Gastric ulceration causing thoracic spondylodiscitis: a first case of a rare complication post oesophagectomy.

We report the case of an 84-year-old male, who presented with septicaemia, abdominal and back pain. The patient had a background of oesophageal carcinoma and had undergone previous oesophagectomy and gastric pull-up operation 10 years ago. A computerised topography scan demonstrated a probable gastro-vertebral communication with a destructive process at the T8/T9 vertebral level. Further evaluation with MRI clearly showed the tract between the two structures and confirmed the diagnosis of spondylodiscitis at the adjacent spinal level. The patient was resuscitated, treated with intravenous antibiotics and kept nil by mouth. A subsequent gastroscopy demonstrated an eroding gastric ulcer at the enteric opening of the tract between the tubal stomach and the spinal column. The diagnosis was discussed with the patient, his family and the surgical multidisciplinary team. Given the extent of disease and his multiple medical co-morbidities, the decision was made for conservative management and symptom control. This is the first case of a gastro-vertebral communication causing spondylodiscitis to be described in the literature.

Teaching medical students about radiation protection--what do they need to know?

AIM: To reach a consensus opinion on the competency-based topics in radiation protection that a UK medical student should possess at the time of graduation. MATERIALS AND METHODS: A group of 69 varied, but highly-qualified experts (including 48 radiologists and 21 clinicians), took part in a three-stage e-mail-based Delphi study to establish the competencies in radiology, including knowledge and practice of radiation protection, expected of a medical student at the time of graduation. The information gathered from the first two questionnaires was refined into 57 individual clinical competencies directly relevant to radiation protection. On the final third questionnaire, the expert panel rated these on a seven-point Likert scale from "Definitely not core" to "Definitely core", with an 82% response rate. RESULTS: When 70% of the experts rated a competency>4, it was judged "core". If a competency was rated>4 but by less than 70% of the panel, it was judged "possibly core" due to the lack of consensus. If a competency was rated<4, it was judged "not core". In relation to radiation protection, 32 competencies were judged core, another 19 were considered as possible core and remaining five were considered not core. CONCLUSIONS: This is the first UK study to establish a core curriculum in radiology in relation to radiation protection using a formal consensus method. The consensus of this study is detailed, wide-ranging, and insightful into the teaching of vital issue of radiation protection in radiology to medical students, and provides a valuable resource to enrich radiology teaching.

CT appearances of congential and acquired abnormalities of the superior vena cava.

A wide spectrum of congenital and acquired abnormalities can affect the superior vena cava (SVC). Congenital anomalies can present either as incidental findings or be associated with underlying cardiac abnormalities; these include left-sided or double SVCs and anomalous venous drainages. Acquired conditions involving the SVC, including SVC obstruction syndrome, can be secondary to extrinsic compression or intrinsic occlusion. The CT appearances, the incidence, and associations of these conditions are discussed.

Imaging of implants on chest radiographs: a radiological perspective.

Endovascular and percutaneous techniques have emerged as alternatives to surgical management in the treatment for a wide range of congenital and acquired cardiac, non-vascular and vascular conditions. Consequently, there has been an increasing use of implants such as closure devices, vascular stents (coronary, aortic, pulmonary and superior vena cava) and non-vascular stents like oesophageal and tracheo-bronchial stents. A large number of percutaneously sited implants are used for treating congenital cardiac anomalies such as atrial septal defects (ASD), ventricular septal defects (VSD), and patent ductus arteriosus (PDA). These implants take many shapes and forms. The aim of this review is to demonstrate the radiographic appearances of the various types of cardiovascular, bronchial and oesophageal implants that are visible on plain films. A brief outline of the aims and indications of various implant procedures, the general appearance of the commonest types of implants, and the radiological procedures are discussed. All radiologists are likely to come across implanted devices in plain film reporting. Imaging can be useful in identifying the device, assessing the position, integrity, and for the identification of complications related directly to the implant.

Topical ethyl chloride fine spray. Does it have any antimicrobial activity?

AIM: The aim of this study was to assess whether ethyl chloride fine spray (Cryogesic) has antimicrobial activity. MATERIAL AND METHODS: Blood agar plates supplemented with 5% horse blood were inoculated with five different organisms, coagulase-negative staphylococci (CNS), methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S. aureus (MRSA), Streptococcus pyogenes and Enterococcus faecalis. The plates were assessed for growth inhibition at 24 and 48 h by the microbiologist and compared with the non-sprayed control plates. RESULTS: The model showed a highly significant (p<0.0001) reduction in bacterial count for the plates treated with fine ethyl chloride spray. The estimate of the percentage of bacteria remaining after spraying with ethyl chloride was 42.7%, with a 95% confidence interval of 35.9-50.9%. There was no evidence that the effect of ethyl chloride fine spray was different for the different organisms (p=0.49). CONCLUSION: The use of ethyl chloride shows bacterial count reduction but the clinical implication of this needs to be determined. The authors postulate that any statistically significant reduction can only be helpful in reducing the infection rates. This coupled with the already proven local anaesthetic effects of ethyl chloride will make it an important tool for procedures like arthrocentesis and venepunctures.

Posttransplant lymphoproliferative disorder: a pictorial review.

Posttransplant lymphoproliferative disorder (PTLD) is a serious and potentially fatal complication after solid organ and haemopoietic stem cell transplantation. The frequency of PTLD varies with the type of organ transplant but overall it affects 2-10% of all solid organ transplant recipients. Most cases develop within 1 year after the transplant, although occasional cases present 5-10 years later. Posttransplant lymphoproliferative disorder is clinically and pathologically heterogeneous - the majority are of the non-Hodgkin's lymphoma type, whereas Hodgkin's lymphoma arising after transplantation is rare. We have retrospectively reviewed patients with a histological diagnosis of PTLD after a solid organ transplant. We present the imaging features and a clinical review of this condition. Early diagnosis of PTLD may alter the management and outcome of the disease. The radiologist can play a vital role in establishing the diagnosis by imaging features supplemented with percutaneous biopsy and also in monitoring the disease response to treatment.

Cardiac pacing systems and implantable cardiac defibrillators (ICDs): a radiological perspective of equipment, anatomy and complications.

Cardiac pacing is a proven and effective treatment in the management of many cardiac arrhythmias. Implantable cardiac defibrillators (ICDs) are beneficial for certain patient groups with a history of serious, recurrent ventricular dysrhythmias, with a high risk of sudden cardiac death. Pacemaker devices take many forms and are highly visible on the chest radiograph. The radiographic appearances of ICDs and pacemakers can be similar and are subject to similar complications. The anatomical approach to the implantation, the type of device used and anatomical variations will all affect the appearance of these devices on the chest film. Pacemaker complications identified radiographically include pneumothorax, lead malpositioning, lead displacement or fracture, fracture of outer conductor coil, loose connection between the lead and pacemaker connector block, lack of redundant loops in paediatric patients and excessive manipulation of the device by the patient (Twiddler's syndrome). This pictorial review highlights the role of chest radiography in the diagnosis of post-cardiac pacing and ICD insertion complications, as well as demonstrating the normal appearances of the most frequently implanted devices.

Radiological features of hepatocellular carcinoma in Southern Pakistan.

We describe the radiological features of 201 patients diagnosed as having hepatocellular carcinoma (HCC) in Southern Pakistan. The cases of biopsy-proven HCC were analysed retrospectively for years 1994-1998. Age, sex, underlying cirrhosis, hepatitis markers, and radiological description were recorded. The mean age was 56 years. There were 149 males and 52 females. 82% patients had underlying cirrhosis. The tumour size was measured in at least two dimensions, and the maximum mean tumour size at the time of diagnosis was 8.3 +/- 4.0 cm. Of the tumours 79.5% were more than 5 cm; 56% of primary HCC were multifocal; 51% involved the right lobe only; 15% involved the left lobe; 34% involved both lobes of liver. Portal vein thrombosis was detectable in 17%. There were no significant differences in the radiological patterns amongst patients who had hepatitis B virus related and hepatitis C virus-related HCC except for age.

Colonic mucosal prostaglandin E2 and cyclooxygenase expression before and after low aspirin doses in subjects at high risk or at normal risk for colorectal cancer.

UNLABELLED: Development of potential cancer chemopreventive drugs involves the systematic evaluation of these drugs in preliminary Phase I and II studies in human beings to identify the optimal drug dose, drug toxicity, and surrogate end point biomarker modulation. OBJECTIVES: We tested the hypothesis that aspirin, at a single, once-daily 81-mg dose, will reduce colonic mucosal concentration of prostaglandin estradiol (E2) in individuals at high risk for colorectal cancer development similar to our prior observations in a young normal-risk population. METHODS: Aspirin was administered at a dose of 81 mg once daily for 28 days in a cohort of 92 matched high-risk and normal-risk colorectal cancer subjects. Prostaglandin E2 and cyclooxygenase expression were assayed from distal sigmoid biopsies from all of the subjects before and after treatment. RESULTS: The mean prostaglandin E2 for normal-risk subjects before aspirin treatment was 11.3 +/- 1.7 pg/microg (mean +/- SE) tissue protein and after aspirin treatment was 4.9 +/- 0.91 pg/microg tissue protein (P < 0.0001). In high-risk subjects, mean pretreatment prostaglandin E2 was 14.4 +/- 1.7 pg/microg tissue protein and after aspirin treatment was 4.7 +/- 0.70 pg/microg tissue protein (P < 0.0001). Aspirin treatment did not alter cyclooxygenase-1 protein expression. CONCLUSIONS: Aspirin treatment at a dose of 81 mg reduces colorectal mucosal prostaglandin E2 concentration after 28 daily doses. Risk for colorectal carcinoma did not modify colorectal mucosal baseline or post-aspirin prostaglandin E2, or cyclooxygenase expression. Colorectal mucosal prostaglandin concentration may be used as a "drug-effect surrogate biomarker," that is, a surrogate to assess sufficient delivery and tissue effect of a chemopreventive agent.

Adherence to single daily dose of aspirin in a chemoprevention trial. An evaluation of self-report and microelectronic monitoring.

A consecutive sample of 64 healthy adults (33 female and 31 male) were recruited at the University of Michigan Medical Center, Ann Arbor. Data were available for analysis on 57 subjects. The participants were asked to take a single daily dose of aspirin ranging from 0 to 640 mg. Adherence to the daily aspirin ingestion was measured by self-report and the Medication Event Monitoring System (MEMS, Aprex Corp, Fremont, Calif); adherence rate for the study population was 35%. The adherence rates for all dosing errors between self-report and Medication Event Monitoring System were significantly different (P = .002). There was no significant gender difference in adherence rates. Adherence to regular aspirin ingestion was poor in healthy, paid subjects despite explicit, written and verbal instructions. Patient self-report alone is not a reliable measure of adherence.