Pancreatic atrophy in patients with chronic graft-versus-host disease.

PURPOSE: To determine if patients with chronic graft-versus-host disease (cGVHD) following allogeneic hematopoietic stem cell transplantation (HSCT) develop greater loss of pancreatic tissue than patients without cGVHD. MATERIALS AND METHODS: This is an IRB-approved, HIPAA-compliant retrospective study of patients receiving allogeneic HSCT at our institution from 01/2006 to 01/2010 with abdominal CT performed within 3 months prior to HSCT and CT performed at least 3 months after HSCT. Measurement of glandular tissue thickness of the head, body, and tail of the pancreas was performed independently by two radiologists blinded to clinical data. Statistical analysis was performed using the Student t-test, and interobserver agreement was evaluated with linear-weighted kappa. RESULTS: 117 patients underwent HSCT during study period, with 36 patients meeting inclusion criteria. 22 subjects (61%) had clinical features of cGVHD, and 14 patients (39%) did not have evidence of cGVHD. Following HSCT, there was a significant decrease in mean total thickness (10.9%, p = 0.002) of the pancreas in the group of patients with cGVHD. The change from pretreatment to the nadir in pancreatic thickness was significantly greater in patient with cGVHD (13.9 ± 12.1 mm), but not in non-cGVHD patients (5.4 ± 4.7 mm) (p = 0.02), with head of the pancreas atrophy accounting for the difference (decrease of 4.8 ± 4.6 mm in cGVHD patients vs. 1.6 ± 2.1 mm in non-cGVHD patients (p = 0.02)). CONCLUSION: Patients with cGVHD develop significantly greater loss of pancreatic glandular tissue than patients without cGVHD following HSCT, with atrophy of pancreatic head being a major contributor.

Responses to exercise in systemic sclerosis-associated interstitial lung disease.

INTRODUCTION: Pulmonary complications in systemic sclerosis (SSc) significantly increase morbidity and mortality. Our aim was to determine the factors limiting exercise capacity in SSc patients with and without interstitial lung disease (ILD), and to identify and quantify abnormalities during exercise that might assist in clinical assessment of this complication. METHODS: Fifteen patients with SSc and ILD (SSc-ILD) were compared with 10 patients with SSc without ILD and 9 age- and sex-matched normal volunteers. Subjects performed symptom-limited incremental treadmill exercise with online measurement of respiratory gas exchange, arterial blood gas sampling and measurement of neurohormones in venous blood. RESULTS: Patients with SSc-ILD had lower exercise capacity than SSc patients without ILD or normal subjects (peak oxygen consumption (PV̇O2 ) (17.1 [4.2] vs. 22.0 [4.7] and 23.0 [5.4] ml kg-1 min-1 , respectively, mean [SD], p < 0.01 ANOVA), but PV̇O2 did not correlate with static pulmonary function measurements. Ventilatory equivalent for CO2 (V̇E/V̇CO2 ; nadir) was higher in SSc-ILD patients than the other two groups (36.6 [8.0] vs. 29.9 [4.4] and 30.0 [2.5], p < 0.005) as were peak exercise dead-space tidal volume ratio (0.44 [0.06] vs. 0.26 [0.09] and 0.26 [0.05], p < 0.001) and peak exercise alveolar-arterial difference (28.9 [16.9] vs. 18.8 [14.0] and 11.5 [6.9] mmHg, p < 0.05). Atrial natriuretic peptide was elevated in both SSc patient groups. CONCLUSIONS: SSc-ILD results in lower exercise capacity than SSc without ILD, and abnormalities of gas exchange are seen. The possible use of cardiopulmonary exercise testing to identify disease and quantify impairment in SSc-ILD merits further study.

In vivo determination of a modified heat capacity of small hepatocellular carcinomas prior to radiofrequency ablation: correlation with adjacent vasculature and tumour recurrence.

PURPOSE: To calculate a modified heat capacity (mHC) of small hepatocellular carcinomas (HCCs) in vivo during radio frequency ablation (RFA) and to determine if mHC correlates with tumour vascularity, adjacent vessels or local recurrence. PATIENTS AND METHODS: This study was IRB approved and informed consent was obtained from all patients. Before formal RFA, ambient HCC temperature and temperature 1 min after heating at constant wattage were measured in 29 patients. From temperature change and wattage, individual mHCs (joules required to increase tumour temperature by 1° Celsius) were calculated. Pre-RFA, three-phase computerised tomography (CT) scans were reviewed blindly for hepatic arteries, hepatic veins and portal veins abutting or within 3 mm of tumour edge from which twelve vascular parameters were quantified. Tumour enhancement (homogeneous or heterogeneous on arterial phase) was also assessed. Multiple regression was used to correlate mHC with vascular parameters and tumour enhancement. Cox proportional hazard model was used to examine the relationship of mHC to local recurrence. RESULTS: There was significant correlation of mHC with lesion enhancement (P = 0.0018), length of hepatic arteries (P < 0.0001) and total hepatic vein volume in contact with tumour (P = 0.016). No correlation was found with any non-abutting vessel or portal vein parameter. The chance of local recurrence increased with increasing mHC. CONCLUSION: Because the modified heat capacity of small HCCs in our study population correlated with HCC enhancement, abutting hepatic arteries, the volume of abutting hepatic veins and local recurrence, it may be an indicator of the heat sink effect (HSE) and supports the HSE as a risk factor for local recurrence.

Radiology of chest wall masses.

OBJECTIVE: The purpose of this article is to highlight the role of radiography, CT, PET/CT, and MRI in the diagnosis and management of chest wall lesions. Chest wall masses are caused by a spectrum of clinical entities. The lesions highlighted in this selection of case scenarios include neoplastic, inflammatory, and vascular lesions. CONCLUSION: Imaging evaluation with radiography, CT, MRI, and PET/CT plays an important role in the accurate diagnosis of chest wall lesions. It can also facilitate percutaneous biopsy, when it is indicated. Imaging enables accurate staging and is a key component of treatment planning for chest wall masses.

Can Doppler sonography discern between hemodynamically significant and insignificant portal vein stenosis after adult liver transplantation?

OBJECTIVE: The purpose of our study was to determine whether Doppler sonography, using a strict reference standard, can specifically identify hemodynamically significant portal vein anastomotic stenosis after liver transplantation in adults. MATERIALS AND METHODS: The duplex and color Doppler examinations of 13 consecutive adult patients who underwent portal venography for suspected portal vein stenosis after liver transplantation were retrospectively examined. Peak systolic velocity (PSV) and change in PSV (ΔPSV) along the portal vein were correlated with portal venography. Stenoses above 50% on the basis of strict venographic criteria were considered hemodynamically significant. The Doppler studies before and after intervention were also assessed. Fourteen randomly chosen subjects with transplants without suspicion of portal anastomotic stenosis acted as controls. RESULTS: Six patients had significant portal vein stenosis (> 50%) and seven had stenosis below 50%. PSV and ΔPSV were significantly greater for patients with > 50% stenosis in comparison with those with ≤ 50% stenosis and control subjects. Optimal threshold values for PSV and ΔPSV were 80 and 60 cm/s, respectively, with either value alone yielding sensitivity of 100% and specificity of 84% for significant stenosis. Threshold values also included cases of stenosis below 50%. Five of six patients with > 50% stenosis underwent stenting, with poststent PSV and ΔPSV significantly declining to match that of control subjects. Three of seven with stenosis below 50% had stents placed but no significant change in the Doppler examination. CONCLUSION: Doppler threshold criteria reliably exclude those without posttransplantation portal vein stenosis and have high sensitivity for detecting portal stenosis. However, these criteria cannot discern the extent of stenosis.

Interns' experiences of disruptive behavior in an academic medical center.

BACKGROUND: The first year of graduate medical education is an important period in the professional development of physicians. Disruptive behavior interferes with safe and effective clinical practice. OBJECTIVE: To determine the frequency and nature of disruptive behavior perceived by interns and attending physicians in a teaching hospital environment. METHOD: All 516 interns at Partners HealthCare (Boston, MA) during the 2010 and 2011 academic years were eligible to complete an anonymous questionnaire. A convenience nonrandom sample of 40 attending physicians also participated. RESULTS: A total of 394 of 516 eligible interns (76.4%) participated. Attendings and interns each reported that their team members generally behaved professionally (87.5% versus 80.4%, respectively). A significantly greater proportion of attendings than interns felt respected at work (90.0% versus 71.5% respectively; P  =  .01). Disruptive behavior was experienced by 93% of interns; 54% reported that they experienced it once a month or more. Interns reported disruptive behavior significantly more frequently than attending physicians, including increased reports of condescending behavior (odds ratio [OR], 5.46 for interns compared with attendings; P < .001), exclusion from decision making (OR, 6.97; P < .001), and berating (OR, 4.84; P  =  .02). Inappropriate jokes, abusive language, and gender bias were also reported, and they were not significantly more frequent among interns than attending physicians. Interns most frequently identified nurses as the source of disruption, and were significantly more likely than faculty to identify nurses as the source of disruptive behavior (OR, 10.40; P < .001). Attendings reported other physicians as the most frequent source of disruption. CONCLUSIONS: Although interns generally feel respected at work, they frequently experience disruptive behavior. Interns described more disruptive behaviors than a convenience sample of attending physicians at our institution.