Determination of "borderline resectable" pancreatic cancer - A global assessment of 30 shades of grey.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) is an aggressive cancer with a poor prognosis. Accurate preoperative assessment using computed tomography (CT) to determine resectability is crucial in ensuring patients are offered the most appropriate therapeutic strategy. Despite the use of classification guidelines, any interobserver variability between reviewing surgeons and radiologists may confound decisions influencing patient treatment pathways. METHODS: In this multicentre observational study, an international group of 96 clinicians (42 hepatopancreatobiliary surgeons and 54 radiologists) were surveyed and asked to report 30 pancreatic CT scans of pancreatic cancer deemed borderline at respective multidisciplinary meetings (MDM). The degree of interobserver agreement in resectability among radiologists and surgeons was assessed and subgroup regression analysis was performed. RESULTS: Interobserver variability between reviewers was high with no unanimous agreement. Overall interobserver agreement was fair with a kappa value of 0.32 with a higher rate of agreement among radiologists over surgeons. CONCLUSION: Interobserver variability among radiologists and surgeons globally is high, calling into question the consistency of clinical decision making for patients with PDAC and suggesting that central review may be required for studies of neoadjuvant or adjuvant approaches in future as well as ongoing quality control initiatives, even amongst experts in the field.

Higher Anti-tumor Necrosis Factor-α Levels Correlate With Improved Radiologic Outcomes in Crohn's Perianal Fistulas.

BACKGROUND & AIMS: Higher anti-tumor necrosis factor-α (TNF) drug levels are associated with improved clinical healing of Crohn's perianal fistulas. It is unclear whether this leads to improved healing on radiologic assessment. We aimed to evaluate the association between anti-TNF drug levels and radiologic outcomes in perianal fistulising Crohn's disease. METHODS: A cross-sectional retrospective multicenter study was undertaken. Patients with perianal fistulising Crohn's disease on maintenance infliximab or adalimumab, with drug levels within 6 months of perianal magnetic resonance imaging were included. Patients receiving dose changes or fistula surgery between drug level and imaging were excluded. Radiologic disease activity was scored using the Van Assche Index, with an inflammatory subscore calculated using indices: T2-weighted imaging hyperintensity, collections >3 mm diameter, rectal wall involvement. Primary endpoint was radiologic healing (inflammatory subscore ≤6). Secondary endpoint was radiologic remission (inflammatory subscore = 0). RESULTS: Of 193 patients (infliximab, n = 117; adalimumab, n = 76), patients with radiologic healing had higher median drug levels compared with those with active disease (infliximab 6.0 vs 3.9 µg/mL; adalimumab 9.1 vs 6.2 µg/mL; both P < .05). Patients with radiologic remission also had higher median drug levels compared with those with active disease (infliximab 7.4 vs 3.9 µg/mL; P < .05; adalimumab 9.8 vs 6.2 µg/mL; P = .07). There was a significant incremental reduction in median inflammatory subscores with higher anti-TNF drug level tertiles. CONCLUSIONS: Higher anti-TNF drug levels were associated with improved radiologic outcomes on magnetic resonance imaging in perianal fistulising Crohn's disease, with an incremental improvement at higher drug level tertiles for both infliximab and adalimumab.

Evaluation of the particulate concentration in a gelatin-based phantom for sonographically guided lesion biopsy.

OBJECTIVES: The purpose of this study was to determine the particulate concentration in a gelatin-based ultrasound phantom for lesion biopsy at 6 cm in depth to reduce visualization of the biopsy needle in the near field, simulating subcutaneous fat and tissue echogenicity, and maintain target lesion visualization. METHODS: Four gelatin-based phantoms with cornstarch at concentrations of 4, 8, 12, and 16 g/L and an anechoic gelatin target at 7 cm in depth were rated on a 5-point scale by readers for visibility of the target lesion, similarity of near-field to abdominal subcutaneous fat echogenicity, and visibility of a 22-gauge spinal needle in the phantom. A timed sonographically guided localization task was performed on the anechoic target by 4 radiology residents using the 22-gauge spinal needle. Results were analyzed by comparative statistical analysis. RESULTS: An increasing particulate concentration did not alter the similarity of near-field to abdominal subcutaneous fat echogenicity (P = .6) but did significantly reduce visibility of the anechoic target at a cornstarch concentration of 16 g/L (P = .04) and the 22-gauge needle at 12 g/L (P = .03). Decreased visualization of the needle or target lesion did not affect the time for needle localization of the anechoic target (P = .96). CONCLUSIONS: The optimal ultrasound phantom cornstarch concentration was 12 g/L to reduce visualization of the spinal needle, simulating subcutaneous fat echogenicity while maintaining target lesion visualization.

Role of CT angiography and therapeutic anticoagulation in patients presenting to the emergency department with acute gastrointestinal bleeding.

INTRODUCTION: Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment. METHODS: Retrospective single-centre study over a 2-year period. RESULTS: A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782). CONCLUSIONS: The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.

A rare case of MRI of myxoid hepatocellular adenoma with gadoxetic acid uptake.

This is the first case report of 43-year-old lady with a myxoid hepatic adenoma which demonstrated significant contrast uptake during hepatobiliary phase imaging. This highlights the potential for a missed diagnosis and likely subsequent malignant transformation in a young patient in whom it was initially presumed to be focal nodular hyperplasia with no further surveillance.

Mass lesions in chronic pancreatitis: benign or malignant? An "evidence-based practice" approach.

The diagnosis of a pancreatic mass lesion in the presence of chronic pancreatitis can be extremely challenging. At the same time, a high level of certainty about the diagnosis is necessary for appropriate management planning. The aim of this study was to establish current best evidence about which imaging methods reliably differentiate a benign from a malignant lesion, and show how that evidence is best applied. A diagnostic algorithm based on Bayesian analysis is proposed.

Liver disease severity predicts carcinogenesis of dysplastic liver nodules in cirrhosis.

While dysplastic liver nodules in cirrhosis are pre-malignant, little is known about the predictors of hepatocarcinogenesis of these lesions. This was a retrospective observational study of subjects with cirrhosis who had at least one hypervascular, non-malignant intrahepatic nodule on imaging while undergoing outpatient management by a tertiary hepatology referral centre between Jan 2009 and Jan 2019. Clinical and biochemical parameters were collected. The primary endpoint was transformation to hepatocellular carcinoma (HCC) as determined by Liver Imaging Reporting and Data System. During the study period, 163 non-malignant hypervascular nodules were identified in 77 patients; 147 had at least 6 months of follow up imaging and 16 received upfront radiofrequency ablation upon detection. During a median follow up of 38.5 months (IQR 16.5-74.5), 25 (17%) of the 147 hypervascular nodules being monitored transformed to HCC. On multivariate analysis, Child-Pugh grade was found to be the only independent predictor of nodule transformation into HCC (p = 0.02). Those with Child-Pugh B and C liver disease had a 10.1 (95% CI 1.22-83.8; p = 0.03) and 32.6-fold (95% CI 2.3-467; p = 0.01) increased risk respectively for HCC transformation compared to Child-Pugh A subjects. This large, single centre study demonstrates that around 20% of dysplastic nodules in cirrhotic patients undergo hepatocarcinogenesis during follow up, and that Child Pugh grade is the only independent predictor of transformation to HCC. Additional prospective studies are warranted to better understand the risk profile of these nodules, and how best they should be managed.

Gastric adenocarcinoma causing biliary obstruction without ductal dilatation: a case report.

INTRODUCTION: Gastric adenocarcinoma is a known complication of partial gastrectomy. Jaundice from gastric adenocarcinoma usually occurs in the setting of hepatic nodal or parenchymal metastasis. This case demonstrates an unusual level of biliary obstruction from gastric adenocarcinoma. CASE PRESENTATION: An 84-year-old Caucasian man was diagnosed as having a new gastric adenocarcinoma at the level of the gastroenteric anastomosis of a prior Billroth II gastrectomy after presenting with painless jaundice. He had a non-dilated biliary tree on radiographic imaging despite evidence of large bile duct obstruction on liver biopsy. The obstruction was managed with endoscopic wire-guided stenting of the malignant tumor. CONCLUSIONS: The unusual finding of a non-dilated biliary tree in the face of obstructive jaundice is likely to have resulted from the unusual post-surgical anatomy and hence distal level of obstruction. Endoscopic duodenal stenting is a novel method of managing obstructive jaundice in gastric adenocarcinoma.

Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar.

BACKGROUND: The Roll Back Malaria strategy recommends a combination of interventions for malaria control. Zanzibar implemented artemisinin-based combination therapy (ACT) for uncomplicated malaria in late 2003 and long-lasting insecticidal nets (LLINs) from early 2006. ACT is provided free of charge to all malaria patients, while LLINs are distributed free to children under age 5 y ("under five") and pregnant women. We investigated temporal trends in Plasmodium falciparum prevalence and malaria-related health parameters following the implementation of these two malaria control interventions in Zanzibar. METHODS AND FINDINGS: Cross-sectional clinical and parasitological surveys in children under the age of 14 y were conducted in North A District in May 2003, 2005, and 2006. Survey data were analyzed in a logistic regression model and adjusted for complex sampling design and potential confounders. Records from all 13 public health facilities in North A District were analyzed for malaria-related outpatient visits and admissions. Mortality and demographic data were obtained from District Commissioner's Office. P. falciparum prevalence decreased in children under five between 2003 and 2006; using 2003 as the reference year, odds ratios (ORs) and 95% confidence intervals (CIs) were, for 2005, 0.55 (0.28-1.08), and for 2006, 0.03 (0.00-0.27); p for trend < 0.001. Between 2002 and 2005 crude under-five, infant (under age 1 y), and child (aged 1-4 y) mortality decreased by 52%, 33%, and 71%, respectively. Similarly, malaria-related admissions, blood transfusions, and malaria-attributed mortality decreased significantly by 77%, 67% and 75%, respectively, between 2002 and 2005 in children under five. Climatic conditions favorable for malaria transmission persisted throughout the observational period. CONCLUSIONS: Following deployment of ACT in Zanzibar 2003, malaria-associated morbidity and mortality decreased dramatically within two years. Additional distribution of LLINs in early 2006 resulted in a 10-fold reduction of malaria parasite prevalence. The results indicate that the Millennium Development Goals of reducing mortality in children under five and alleviating the burden of malaria are achievable in tropical Africa with high coverage of combined malaria control interventions.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies showing their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patients' records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department (Southern General Hospital, Glasgow, UK) rarely yield bacterial growth, and over 2 years only four cultures seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Do peripheral blood cultures taken in the emergency department influence clinical management?

BACKGROUND: Blood cultures are routinely used to investigate suspected sepsis in the emergency department despite several studies demonstrating their limited influence on patient management. OBJECTIVES: To quantify the use and clinical relevance of blood cultures obtained in the emergency department. METHODS: A retrospective study of blood cultures taken in the emergency department between 1 January 2003 and 31 December 2004. Microbiology results and patient records were reviewed to determine the influence of positive cultures on subsequent patient management. RESULTS: 2213 blood cultures were taken in the emergency department over the study period. 132 (6%) yielded a positive result. Three positive cultures cases had incomplete information. Of the remaining 129 positive cultures, 30 (1.4% of all cultures) were "true positives" and 4 (0.18%) influenced subsequent patient management. CONCLUSIONS: Blood cultures taken in our emergency department rarely yield bacterial growth and over 2 years, only four seemed to directly influence patient management. Better guidelines are required for targeted use of blood cultures in the emergency department.

Evaluation of the incidence of pulmonary embolus in the early postoperative period following cemented hemiarthroplasty.

PURPOSE: Little is known regarding the incidence of early postoperative pulmonary embolus (PE) following hip fracture surgery. Clinical suspicion of PE mandates therapeutic anticoagulation, adding a further insult to those of trauma and surgery in a physiologically frail population. The aim of the study was to evaluate for the presence of PEs by performing postoperative CT pulmonary angiography (CTPA) in patients who demonstrated intraoperative, or early postoperative cardiorespiratory lability following surgery with a cemented prosthesis for intracapsular hip fracture. METHODS: All patients undergoing cemented hemiarthroplasty for displaced intracapsular neck of femur fracture were recruited during a 6-month period, and signed consent obtained from the patient or their next of kin for CTPA in the event of any cardiorespiratory instability. Patient demographics, comorbidities were reviewed, and premorbid mobility status documented. RESULTS: 18 of the 66 patients in the study having cemented hemiarthropalsty demonstrated intra- or early postoperative lability, all had early postoperative CTPA scans. 6 of the 18 were noted to have PE. All had more than 1 risk factor for VTE on admission (excluding their injury). Patients diagnosed with PE had a higher ASA grade, and lower mobility scores than those who did not have a PE. CONCLUSIONS: Clinical suspicion alone is inadequate to diagnosis PE in patients undergoing cemented hip arthroplasty. Only 1 in 3 patients suspected of PE on account of intraoperative or immediate postoperative cardiorespiratory lability was found to have a PE based on CTPA. Early postoperative CTPA is helpful to prevent unnecessary anticoagulation for suspected PE.

"EcoRadiology"--pulling the plug on wasted energy in the radiology department.

RATIONALE AND OBJECTIVES: We sought to evaluate the power consumption of various devices around the radiology department, audit our use of recycling, and review efforts by vendors to reduce the environmental impact of their products. MATERIALS AND METHODS: Using a readily available power monitor, we calculated the power consumption of different devices around our department. In particular, we calculated the financial and environmental cost of leaving equipment on overnight and/or at weekends. When it was not possible to measure energy usage directly, we obtained and reviewed relevant technical manuals. We contacted vendors directly to document how the environmental impact of new technology and decommissioning aging technology is being tackled. RESULTS: We found that 29 of 43 desktop computers and 25 of 27 picture archiving and communications system (PACS) reporting stations were left on needlessly overnight and/or at weekends, resulting in estimated electrical running costs while not in use of approximately $7253 per year, and CO2 emissions equivalent to the annual emissions of over 10 passenger cars. We discovered that none of our PACS reporting stations supported energy-saving modes such as "sleep" or "hibernate." Despite encouraging staff to turn off computers when not in use, a reaudit found no improvement in results. CONCLUSIONS: Simple steps such as turning off computers and air-conditioning units can produce very significant financial and environmental savings. Radiology can lead the way in making hospitals more energy efficient.