Agreement and consistency in the triaging of musculoskeletal primary care referrals by vetting clinicians using a knowledge-based triage tool

BACKGROUND

Primary care referrals received by secondary care services are vetted or triaged to pathways best suited for patients' needs. If knowledge-based triaging is used by vetting clinicians, accuracy is required to avoid incorrect decisions being made. With limited evidence to support best practice, we aimed to evaluate consistency across vetting clinicians' decisions and their agreement with a criterion decision.

METHODS

Twenty-nine trained vetting clinicians (18 female) representative of pay grades independently triaged five musculoskeletal physiotherapy referral cases into one of 10 decisions using an internally developed triage tool. Agreement across clinicians' decisions between and within cases was assessed using Fleiss's kappa overall and within pay grade. Proportions of triage decisions consistent with criterion decisions were assessed using Cochran's Q test.

RESULTS

Clinician agreement was fair for all cases (κ = 0.385) irrespective of pay grade but varied within clinical cases (κ = -0.014-0.786). Proportions of correct triage decisions were significantly different across cases [Q(4) = 33.80, P < 0.001] ranging from 17% to 83%.

CONCLUSIONS

Agreement and consistency in decisions were variable using the tool. Ensuring referrer information is accurate is vital, as is developing, automating and auditing standards for certain referrals with clear pathways. But we argue that variable vetting outcomes might represent healthy pathway abundance and should not simply be automated in response to perceived inefficiencies.

Educating Women About Pelvic Floor Disorders During Pregnancy From the First to the "Fourth Trimester": A Randomized Clinical Trial

IMPORTANCE

Pregnancy and childbirth are risk factors for developing pelvic floor disorders (PFDs), and this continues postpartum ("fourth trimester"). Knowledge of PFDs among women of childbearing age is lacking and presents an opportunity for education.

OBJECTIVES

The aim of this study was to compare the increase in knowledge of PFDs in patients who received written handouts versus interactive workshops as measured by the Prolapse and Incontinence Knowledge Questionnaire (PIKQ).

STUDY DESIGN

This was a randomized clinical trial of pregnant patients 18 years or older. Patients either received written handouts only or received handouts and attended an interactive workshop. Handouts were created in collaboration with communication specialists focusing on risk factors and prevention strategies. The primary outcome was the change in PIKQ score. Secondary outcomes were Pelvic Floor Distress Inventory score and postpartum phone interviews of workshop group participants. Questionnaires were assessed at recruitment and 6 weeks postpartum. The nonparametric Wilcoxon test compared continuous variables, and the Fisher exact test compared categorical variables.

RESULTS

One hundred twenty patients were randomized. Demographics were similar between groups. Median PIKQ score change showed no difference between groups (P = 0.37). Pelvic Floor Distress Inventory-20 scores were similar between groups at baseline (P = 0.78) and postpartum (P = 0.82). Quantile regression showed posteducation PIKQ scores were significantly higher in the workshop (21.00 vs 17.00; P = 0.011) and written (21.00 vs 17.00; P < 0.001) groups. Phone interviews showed consistent themes: (1) greater awareness of PFDs, (2) more likely to discuss PFDs, and (3) relief that PFDs are treatable. Fifty-nine percent of patients preferred learning through workshops compared with the handouts.

CONCLUSIONS

Both groups showed improvement in knowledge of PFDs. Well-written, illustrated handouts were effective in increasing patient knowledge of PFDs.

47 FRAILTY: A QUALITATIVE STUDY EXPLORING THE PERCEPTIONS OF CCCUPATIONAL THERAPISTS IN IRELAND

Background

Ireland’s ageing population has resulted in an increasing number of frail older adults presenting to health and social care settings nationwide. Despite growing attention towards older adults’ and health professionals’ perspectives of frailty, the evidence base pertaining to occupational therapists is limited. This study aims to explore occupational therapists’ perceptions of frailty within an Irish context and to investigate whether their perceptions subsequently impact their approach to the assessment and management of frailty.

Methods

A qualitative descriptive design was undertaken to explore the perceptions of frailty of occupational therapists working with older adults. Qualitative data was collected from nineteen (n=19) occupational therapists working across Ireland in various clinical settings participating in four online focus groups. Data were analysed using thematic analysis.

Results

Perceptions of occupational therapists were constructed into three main themes; 1) Conceptualising frailty; 2) Management of frailty; 3) Advancing frailty practice. Occupational therapists in Ireland shared similar perceptions of frailty as a multidimensional concept. Findings suggest that although occupational therapists are well-equipped in the provision of care for frail older adults, participants believed that the profession’s scope is not optimised in the assessment and management of frailty.

Conclusion

This study is the first of its kind to be conducted in Ireland, therefore contributing to the growing frailty research field. Development of community services, the enhancement of undergraduate frailty education, and a movement towards a shared understanding of frailty between clinicians and patients are recommended to progress occupational therapy in the context of frailty management.

Exploring young people's perspectives of inequalities in health: a qualitative study

Background

Reducing inequalities in health is an enduring global public health challenge. Worryingly in England, inequalities across some groups and places are worsening, highlighted and exacerbated by the Covid-19 pandemic. While there has been growing interest in exploring public understandings of health inequalities, few studies have explored the views of young people. Our study seeks to redress this by exploring young people's perspectives of inequalities in health.

Methods

Working with existing youth organisations, we recruited young people (aged 13-21) from six youth groups in areas of high deprivation across three geographical locations in England. Each group took part in three interlinked focus groups (n = 18), the majority of which were run online using video conferencing platforms. Focus groups were co-delivered with partnering youth organisations during 2021. They involved participatory concept mapping activities, and the discussion of health related news articles.

Results

Key themes emerged around young people's perspectives of: i) factors influencing health within their local area; ii) understandings of inequalities in health; and iii) key messages to convey to those with a role in addressing health inequalities at a place level.

Conclusions

Our study highlights the importance of exploring and understanding young people's perspectives of inequalities in order to better shape policies which are supported by the communities and people they impact.

Key messages

Young people have a nuanced, experiential understanding of key factors influencing their health and inequalities in health within their local areas. Building upon young people’s understandings of inequalities in health provides opportunities to mobilise support for policies seeking to change the distribution of key social determinants.

Reducing inequalities in child health: a case study in an English local authority

Background

Many health outcomes for children and young people in England, UK remain poor compared to international peers, with persistent inequalities across the country. Our study sought to understand, from the perspectives of local stakeholders, the key factors affecting the development and implementation of policy to improve child health and reduce inequalities.

Methods

We carried out a detailed case study in an English local authority area. Our fieldwork comprised: documentary review of local policies, observation of key strategic and operational meetings and semi-structured interviews with local stakeholders. We followed Jessop's (2016) approach in using specific policy areas and policies (mental health, obesity and the early years) as 'entry points' to understand the local context.

Results

First, and most importantly, there was an overriding consensus that local action to reduce inequalities in child health is hampered by a persistent unequal distribution of the social determinants of health. Second, local stakeholders highlighted the damaging impact of austerity measures and poverty in the UK, which, they argued, had impacted most upon the most vulnerable. Third, while national policies often provided a framework and incentive for local action, there was an emphasis on the importance of local knowledge and place-based approaches, developed through close work with communities.

Conclusions

Our study highlights the need for progressive policies to begin to reduce the uneven distribution of the social determinants of health to enable local stakeholders to make progress in tackling inequalities in child health. It emphasises the futility of funding national policies to improve child health and reduce inequalities in the context of greatly reduced budgets for local authorities. National policy should also facilitate the mobilisation of context specific knowledge, produced in conjunction with community members.

Key messages

Our work evidences the pressing need to address structural inequalities and adequately resource and facilitate work to reduce inequalities at a local level. National policy should facilitate the mobilisation of context specific knowledge, produced in conjunction with community members.

An observational study to compare the utilisation of computed tomography colonography with optical colonoscopy as the first diagnostic imaging tool in patients with suspected colorectal cancer

AIM

To evaluate the clinical and cost implications of using computed tomography colonography (CTC) compared to optical colonoscopy (OC) as the initial colonic investigation in patients with low-to-intermediate risk of colorectal cancer (CRC).

MATERIALS AND METHODS

A non-randomised, prospective single-centre study recruited 180 participants to compare the cost implications of two clinical pathways used in the diagnosis of low-to-intermediate risk of CRC that differ in the initial diagnostic test, either CTC or OC. Costs were compared using generalised linear models (GLM) and combined with quality-adjusted life years (QALYs, based on the EQ-5D-5L) to estimate cost-effectiveness at 6 months post-recruitment. Secondary outcomes assessed access to care and patient satisfaction.

RESULTS

Mean (SD, n) cost at 6 months post-recruitment per participant was £991 (£316, n=105) for the OC group and £645 (£607, n=68) for the CTC group, leading to an estimated cost difference of -£370 (95% CI: -£554, -£185, p<0.001). Assuming a £20,000 willingness-to-pay per QALY threshold, there was a 91.4% probability of CTC being cost-effective at month 6. The utilisation of CTC led to improved access to care, with a shorter mean time from referral from primary care to results (6.3 days difference, p=0.005). No differences in patient satisfaction were detected between both groups.

CONCLUSION

The utilisation of CTC as the first-line investigation for patients with low-to-intermediate risk of CRC has the potential to release OC capacity, of pivotal importance for patients more likely to benefit from an invasive diagnostic approach.

Prediction of a positive circumferential resection margin at surgery following neoadjuvant chemotherapy for adenocarcinoma of the oesophagus

Background

A positive circumferential resection margin (CRM) has been associated with higher rates of locoregional recurrence and worse survival in oesophageal cancer. The aim of this study was to establish if clinicopathological and radiological variables might predict CRM positivity in patients who received neoadjuvant chemotherapy before surgery for oesophageal adenocarcinoma.

Methods

Multivariable analysis of clinicopathological and CT imaging characteristics considered potentially predictive of CRM was performed at initial staging and following neoadjuvant chemotherapy. Prediction models were constructed. The area under the curve (AUC) with 95% confidence intervals (c.i.) from 1000 bootstrapping was assessed.

Results

A total of 223 patients were included in the study. Poor differentiation (odds ratio (OR) 2·84, 95 per cent c.i. 1·39 to 6·01) and advanced clinical tumour status (T3-4) (OR 2·93, 1·03 to 9·48) were independently associated with an increased CRM risk at diagnosis. CT-assessed lack of response (stable or progressive disease) following chemotherapy independently corresponded with an increased risk of CRM positivity (OR 3·38, 1·43 to 8·50). Additional CT evidence of local invasion and higher CT tumour volume (14 cm3) improved the performance of a prediction model, including all the above parameters, with an AUC (c-index) of 0·76 (0·67 to 0·83). Variables associated with significantly higher rates of locoregional recurrence were pN status (P = 0·020), lymphovascular invasion (P = 0·007) and poor response to chemotherapy (Mandard score 4-5) (P = 0·006). CRM positivity was associated with a higher locoregional recurrence rate, but this was not statistically significant (P = 0·092).

Conclusion

The presence of advanced cT status, poor tumour differentiation, and CT-assessed lack of response to chemotherapy, higher tumour volume and local invasion can be used to identify patients at risk of a positive CRM following neoadjuvant chemotherapy.

Patterns of recurrence in oesophageal cancer following oesophagectomy in the era of neoadjuvant chemotherapy

Background

Tumour recurrence following oesophagectomy for oesophageal cancer is common despite neoadjuvant treatment. Understanding patterns of recurrence and risk factors associated with locoregional and systemic recurrence might influence future treatment strategies.

Methods

This was a cohort study involving patients undergoing resection for adenocarcinoma or squamous cell carcinoma of the oesophagus between 2000 and 2014. Clinicopathological factors associated with locoregional and systemic recurrence were analysed using multivariable logistic regression to determine odds ratios (ORs) and 95 per cent confidence intervals.

Results

Some 698 patients were identified. Lymphovascular invasion (OR 2·09, 95 per cent c.i. 1·18 to 3·71) and preoperative stenting (OR 3·70, 1·34 to 10·23) were independent risk factors for isolated locoregional recurrence. Pathological nodal disease in patients with pT1–2 (pN1: OR 2·72, 1·35 to 5·48; pN2–3: OR 5·00, 2·35 to 10·66) or pT3–4 (pN1: OR 3·03, 1·51 to 6·07; pN2–3: OR 5·75, 3·15 to 10·49) disease predisposed to systemic recurrence. Poor or no response to chemotherapy was also an independent risk factor for isolated systemic recurrence (OR 1·85, 1·05 to 3·26). A positive resection margin (R1 resection) was not associated with a significantly increased risk of isolated locoregional recurrence (OR 1·37, 0·81 to 2·33).

Conclusion

These findings confirm that oesophageal adenocarcinoma is frequently a systemic disease. Understanding the key predictors of local and systemic recurrence may facilitate the tailoring of oncological therapies to the individual patient.

Malignancy and mesenteric panniculitis

AIM

Mesenteric panniculitis (MP) is a chronic inflammatory process of the small bowel mesentery that has been reported in conjunction with malignancy. The objectives of the present study were to identify the frequency and type of cancers that may coexist with MP and whether these can be seen on the initial diagnostic computerised tomography (CT).

METHOD

A prospective database was kept of patients diagnosed with MP in the Canterbury region of New Zealand between 1 January 2003 and 31 December 2014. CT scans were independently reviewed. Clinical records were reviewed and family doctors were contacted for additional information.

RESULTS

There were 302 patients with possible MP identified and 259 in whom it was confirmed on review. Seventy-eight patients had a diagnosis of malignancy, with 54 having a current cancer (59 total cancers), 33 a past cancer and nine both. Of the 59 current cancers the most common primary sites were colorectum (19), lymph nodes (17), kidney (six) and prostate (four). Fifty-four were at sites included on an abdominal CT scan. At all sites [except prostate (0/4)] there were high rates of detection on CT with 44/54 cancers visible including 20/23 gastrointestinal tract, 14/17 lymphomas and 9/9 non-prostate urogenital tract malignancies. Six people were subsequently diagnosed with cancer after the index CT.

CONCLUSION

When MP occurs in association with malignancy, the commonest primary sites are large bowel, the lymph nodes and the urogenital tract. In those with MP on imaging, any cancer except prostate can usually be seen on the index CT. Further extensive investigation in asymptomatic patients is therefore likely to be of low yield.

Reassessment of Crohn's disease treated with at least 12 months of anti-TNF therapy: how likely is treatment withdrawal?

OBJECTIVE

To assess methods of disease reassessment and rates of treatment withdrawal in patients with Crohn's disease (CD) treated with biologics and to report retrospective risk stratification for treatment withdrawal as suggested by the STORI trial in the context of this cohort.

DESIGN

A retrospective observational cohort study of all patients with CD treated with antitumour necrosis factor (anti-TNF) therapy for >12 months in 2011.

SETTING

Tertiary care.

PATIENTS

Patients with CD treated with anti-TNF therapy.

MAIN OUTCOME MEASURES

Method and outcome of reassessment and whether patient was withdrawn from therapy; also, whether patients met low-risk criteria for withdrawal as identified by the STORI trial, and outcome of those meeting low-risk criteria.

RESULTS

73 patients (infliximab n=48, adalimumab n=25) underwent disease reassessment. Nine patients were deemed to have achieved remission and were withdrawn from treatment: 6 (67%) maintained remission at 12 months, three patients relapsed and were successfully retreated. 52 patients had sufficient data available for STORI criteria to be applied retrospectively. 37% (19/52) fulfilled low-risk criteria for withdrawal-of these, 26% (5/19) were withdrawn from anti-TNF therapy and three had sustained clinical remission at 1 year. Reasons for non-withdrawal included ongoing endoscopic activity (n=8), radiological activity (n=2) and clinical concern due to previous disease behaviour (n=4).

CONCLUSIONS

Relatively few patients were deemed in sufficient depth of remission to warrant a trial of withdrawal of anti-TNF therapy. Many patients were not withdrawn, despite meeting STORI low-risk criteria, due to ongoing disease activity highlighting the limitations of applying such criteria in a 'real world' setting.

Rectal tumour volume (GTV) delineation using T2-weighted and diffusion-weighted MRI: Implications for radiotherapy planning

PURPOSE

To compare the rectal tumour gross target volume (GTV) delineated on T2 weighted (T2W MRI) and diffusion weighted MRI (DWI) images by two different observers and to assess if agreement is improved by DWI.

MATERIAL AND METHODS

27 consecutive patients (15 male, range 27.1-88.8 years, mean 66.9 years) underwent 1.5T MRI prior to chemoradiation (45Gy in 25 fractions; oral capecitabine 850mg/m(2)), including axial T2W MRI (TR=6600ms, TE=90ms) and DWI (TR=3000ms, TE=77ms, b=0, 100, 800s/mm(2)). 3D tumour volume (cm(3)) was measured by volume of interest (VOI) analysis by two independent readers for the T2W MRI and b800 DWI axial images, and the T2W MRI and DWI volumes compared using Mann-Whitney test. Observer agreement was assessed using Bland-Altman statistics. Significance was at 5%.

RESULTS

Artefacts precluded DWI analysis in 1 patient. In the remaining 26 patients evaluated, median (range) T2W MRI MRI and DWI (b=800s/mm(2)) 3D GTVin cm(3) were 33.97 (4.44-199.8) and 31.38 (2.43-228), respectively, for Reader One and 43.78 (7.57-267.7) and 42.45 (3.68-251) for Reader Two. T2W MRI GTVs were slightly larger but not statistically different from DWI volumes: p=0.52 Reader One; p=0.92 Reader Two. Interobserver mean difference (95% limits of agreement) for T2W MRI and DWI GTVs were -9.84 (-54.96 to +35.28) cm(3) and -14.79 (-54.01 to +24.43) cm(3) respectively.

CONCLUSION

Smaller DWI volumes may result from better tumour conspicuity but overall observer agreement is not improved by DWI.

Facing the future: the effects of the impending financial drought on NHS finances and how UK radiology services can contribute to expected efficiency savings

The recent turmoil within the banking sector has led to the development of the most significant recession since the "great depression" of the 1930s. Although the coalition government has promised to "guarantee that health spending increases in real terms in each year of Parliament", this may still not be enough to meet future needs over the coming years due to increasing demand and cost pressures. The expected mismatch between actual National Health Service (NHS) funding post-2011 and that required to satisfy increasing demand has been estimated by the Department of Health to require efficiency savings representing up to one-fifth of the overall NHS budget. This paper explains the reasons behind the anticipated slowdown in the growth of real NHS funding, and how, as a discipline, radiology can increase the efficiency of the services it provides in anticipation of future financial austerity within the NHS.

Vascular invasion in hepatocellular carcinoma: is there a correlation with MRI?

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the commonest malignancies worldwide. Prognosis is predicted by size at diagnosis, vascular invasion and tumour proliferation markers. This study investigates if MRI features of histologically proven HCCs correlate with vascular invasion.

METHODS

Between 2006 and 2008, 18 consecutive patients, with a total of 27 HCCs, had comprehensive MRI studies performed at our institution within a median of 36 days of histology sampling. Each lesion was evaluated independently on MRI by 3 radiologists (blinded to both the radiology and histopathology reports) using a 5-point confidence scale for 23 specific imaging features. The mean of the rating scores across readers was calculated to determine interobserver consistency. The most consistent features were then used to examine the value of features in predicting vascular invasion, using a χ(2 )test for trend, having eliminated those features without sufficient variability.

RESULTS

22 of the 23 imaging features showed sufficient variability across lesions. None of these significantly correlated with the presence of vascular invasion, although a trend was identified with the presence of washout in the portal venous phase on MRI and the median size of lesions, which was greater with vascular invasion.

CONCLUSION

This study suggests that no single MRI feature accurately predicts the presence of vascular invasion in HCCs, although a trend was seen with the presence of washout in the portal venous phase post gadolinium. Larger prospective studies are required to investigate this further.

Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation

AIM

To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for hepatocellular carcinoma (HCC) in cirrhotic patients undergoing liver transplantation. Secondary aims were to examine the effect of radiologist experience and lesion size on diagnostic accuracy.

MATERIALS AND METHODS

Thirty-nine patients (72% male with a mean age of 56.5 years) underwent liver transplantation following preoperative triple-phase MDCT examination of the liver. MDCT examinations were retrospectively independently reviewed by three radiologists for the presence and location of suspected HCCs, with the diagnostic confidence recorded using a five-point confidence scale. MDCT examinations were compared with explant specimens for histopathological correlation.

RESULTS

Histopathological results demonstrated 46 HCCs in 29 of the 39 patients. Analysis demonstrated a sensitivity of 65-75% and specificity of 47-88% for detection of HCC lesions. The sensitivity dropped to 48-57% for lesions of size ≤20mm. As the diagnostic confidence increased, there was a further decrease in the sensitivity (4-26%). The radiologist with the greatest number of years experience was found to have a significantly higher accuracy of detection of HCC lesions compared with the least experienced radiologist.

CONCLUSION

Larger lesion size of HCC and greater number of years experience of the radiologist resulted in significantly higher accuracy of HCC lesion detection. The overall sensitivity and specificity results for MDCT detection of HCC are comparable to previous helical CT imaging.

Accuracy of hepatocellular carcinoma detection on multidetector CT in a transplant liver population with explant liver correlation

AIM

To evaluate the diagnostic accuracy of multidetector computed tomography (MDCT) for hepatocellular carcinoma (HCC) in cirrhotic patients undergoing liver transplantation. Secondary aims were to examine the effect of radiologist experience and lesion size on diagnostic accuracy.

MATERIALS AND METHODS

Thirty-nine patients (72% male with a mean age of 56.5 years) underwent liver transplantation following preoperative triple-phase MDCT examination of the liver. MDCT examinations were retrospectively independently reviewed by three radiologists for the presence and location of suspected HCCs, with the diagnostic confidence recorded using a five-point confidence scale. MDCT examinations were compared with explant specimens for histopathological correlation.

RESULTS

Histopathological results demonstrated 46 HCCs in 29 of the 39 patients. Analysis demonstrated a sensitivity of 65-75% and specificity of 47-88% for detection of HCC lesions. The sensitivity dropped to 48-57% for lesions of size ≤20mm. As the diagnostic confidence increased, there was a further decrease in the sensitivity (4-26%). The radiologist with the greatest number of years experience was found to have a significantly higher accuracy of detection of HCC lesions compared with the least experienced radiologist.

CONCLUSION

Larger lesion size of HCC and greater number of years experience of the radiologist resulted in significantly higher accuracy of HCC lesion detection. The overall sensitivity and specificity results for MDCT detection of HCC are comparable to previous helical CT imaging.

Two-year audit of computed tomographic colonography in a teaching hospital: are we meeting the standard?

OBJECTIVE

We aimed to determine whether adopting the published recommendations has led to successful implementation of computed tomographic colonography (CTC) in a teaching hospital setting outside the context of a clinical trial.

METHOD

An audit of all the CTC examinations between April 2005 and June 2007 was conducted to determine the following: adequacy of bowel preparation, CTC indications and findings (compared with available colonoscopy), complications and experience of reporting radiologist.

RESULTS

The most common indications for the 111 CTC patients reviewed included exclusion of synchronous colonic tumours, incomplete colonoscopy and altered bowel habit. Only 16% of ascending colon/caecal segments was clear of faecal or fluid contamination. The rectum and sigmoid colon were free of contamination in 78% and 74% of cases respectively. Appropriately trained radiologists reported 91% of studies. Thirty-two percent of studies were normal. The most common positive findings were diverticular disease or a rectal tumour. Sensitivity, specificity and positive predictive value were 89%, 94% and 90% respectively (all polyps) with a sensitivity of 98.5% for lesions > 5 mm in size. Twenty-five percent of patients had extra colonic abnormalities. There were no recorded complications.

CONCLUSION

Our CTC practice is within accepted published guidelines. Bowel preparation is suboptimal in a significant proportion of cases and faecal tagging is being implemented.

The radiological manifestations of intramuscular haemangiomas in adults: magnetic resonance imaging, computed tomography and ultrasound appearances

OBJECTIVE

Intramuscular haemangiomas in adults may appear similar to soft tissue sarcomas on imaging. This study evaluates the imaging characteristics of intramuscular haemangiomas on magnetic resonance imaging (MRI), computed tomography (CT) and ultrasound.

SUBJECTS AND METHODS

Retrospective review of medical records, imaging and pathology details of 34 patients presenting with intramuscular haemangiomas was performed. Age of patient, size, site of lesion and type of imaging was recorded. Lesions were evaluated for calcification, presence of fat, outline, texture, vascularity, enhancement and involvement of local structures.

RESULTS

There were 12 male and 22 female patients aged between 9 years and 90 years (mean 39 years). Twenty-two lesions involved muscles of the extremities and 12 involved muscles of the trunk. Mean duration of the lesions was long: 59.3 months (range 3-240 months), with an average size of 7.5 cm (1.5-15 cm). Imaging comprised 27 MR studies, seven CT scans, 19 ultrasounds, and eight plain films. All lesions were well defined, lobulated and heterogeneous. None showed local invasion. On MRI and CT, 93-100% showed the presence of fat and 100% showed vascular channels and enhancement on MRI, CT and ultrasound. Phleboliths were seen on four plain films (50%) and on the corresponding MR images. On MRI, 70% of lesions had mildly hyperintense signal on T1-weighted sequences and 96% had hyperintense signal on T2-weighted sequences (relative to skeletal muscle). Histopathology confirmed diagnosis in all cases, showing the presence of fat, medium/large vessels and skeletal muscle.

CONCLUSION

Intramuscular haemangiomas have characteristic appearances on MRI, CT and ultrasound. Long history, presence of fat, calcification and internal vessels should alert the radiologist to this diagnosis prior to biopsy.

Computed tomography findings in fibrosing mediastinitis

AIM

To describe the CT features of fibrosing mediastinitis.

MATERIALS AND METHODS

The clinical notes, histology, and CT images from 12 patients with fibrosing mediastinitis were reviewed. Clinical data regarding the presentation and suspected aetiology were correlated with location of mediastinal disease, calcification, effect on mediastinal structures, and additional pulmonary findings on computed tomography (CT).

RESULTS

The mean age was 40.5 years, with seven female and five male patients. The most common presenting symptom was shortness of breath. Fibrosing mediastinitis diffusely infiltrated the mediastinum in five patients and was localized in seven. Calcification was present in two cases. Eleven of 12 cases had narrowing of mediastinal structures, including five with pulmonary artery narrowing, five with superior vena cava obstruction, four with bronchial narrowing, three with tracheal narrowing, and one with narrowing of the pulmonary vein. The disease was considered idiopathic in seven cases with a demonstrable aetiology in five cases. Eight out of 12 patients had additional pulmonary findings, including all patients with a known aetiology.

CONCLUSIONS

In the present series of patients, fibrosing mediastinitis more commonly presented as a localized mediastinal mass than as diffuse mediastinal disease, with the anterior mediastinal compartment most frequently involved. Most cases were idiopathic compared with the majority of previous cases at this institution being ascribed to tuberculosis. There is a high incidence of concomitant pulmonary findings, in particular when an identifiable aetiology is present. Obstruction of vital structures frequently gives rise to complications.

Eisenmenger syndrome and idiopathic pulmonary arterial hypertension: do parenchymal lung changes reflect aetiology?

AIM

To document the pulmonary vascular changes on thin-section computed tomography (CT) in patients with Eisenmenger syndrome and idiopathic pulmonary arterial hypertension, and to determine whether there is any correlation with pulmonary arterial pressures or the aetiology of pulmonary hypertension.

MATERIAL AND METHODS

From the National Pulmonary Hypertension Database, we identified eight patients with idiopathic pulmonary arterial hypertension and 20 patients with Eisenmenger syndrome (secondary to a ventriculoseptal defect) who had also undergone contrast-enhanced thin-section CT. CT studies were reviewed for the presence of centrilobular nodules, mosaicism, neovascularity, and bronchial artery hypertrophy. Haemodynamic data were also reviewed.

RESULTS

Centrilobular nodules, mosaicism, and neovascularity were seen in both patient groups (p>0.05). A significantly higher number of enlarged bronchial arteries were seen in patients with Eisenmenger syndrome. There was no correlation with pulmonary arterial pressures.

CONCLUSION

Patients with idiopathic pulmonary arterial hypertension and Eisenmenger syndrome demonstrated similar pulmonary vascular changes on CT. These changes did not predict the underlying cause of pulmonary hypertension or its severity.

Imaging features of isolated unilateral pulmonary artery agenesis presenting in adulthood: a review of four cases

AIM

To highlight the variation in clinical manifestations, imaging and management of four cases of unilateral pulmonary artery agenesis presenting in adulthood.

METHOD

Four patients with unilateral pulmonary artery agenesis were referred to our institution between 1995 and 2005. They underwent a series of investigations, including chest radiography, echocardiography, ventilation perfusion scintigraphy, angiography, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

Two of the four patients had absence of the right main pulmonary artery, whilst the remaining two patients had absence of the left main pulmonary artery. One patient showed a restrictive defect on pulmonary function tests. Two patients who had ventilation perfusion scintigraphy showed absent perfusion and reduced ventilation on the affected side. Angiography (where performed), CT and MRI confirmed the anatomy and the presence of multiple collaterals. Bronchiectasis was demonstrated on CT in two patients, with one also demonstrating a mosaic attenuation pattern. One patient had an incidental lung tumour on the side of the agenesis, which was diagnosed as a chondroid hamartoma on histology. Three of the four patients eventually underwent resection of the affected lung.

CONCLUSION

Isolated unilateral pulmonary artery agenesis has a non-specific presentation. Awareness of this condition can lead to earlier diagnosis, with cross-sectional imaging making an important contribution.

Quality of life in patients with chronic anal fissure

OBJECTIVE

Little is known about the quality of life in patients with the distressing symptoms of chronic anal fissure. This was a prospective study assessing the physical and mental health of fissure patients before and after topical treatment.

PATIENTS AND METHODS

New patients attending the fissure clinic were recruited prospectively into the study over a 2-month period. On first appointment, patients were given 2 questionnaires to complete: the Short-Form 36 Health Survey (SF-36) and a general questionnaire recording patients' demographic details, previous treatment, site and duration of fissure and symptoms on a visual analogue scale (VAS). Following an 8-week course of topical treatment, patients repeated the SF-36 and symptoms were again recorded on a VAS. Healing of fissure was noted.

RESULTS

Fifty-four patients entered the study, of which 39 returned for follow-up; 16 male, 23 female; mean age 38.6 years (range 17-80 years). Median duration of fissure was 6 months (3 months - 10 years). Higher VAS ratings for fissure pain were associated with worse scores for all aspects of health-related quality of life, including mental health (P < 0.001), bodily pain (P < 0.001), vitality (P < 0.006) and social functioning (P < 0.001). Compared to age and gender matched norms for the SF-36, fissure patients had more bodily pain (P < 0.001, Wilcoxon) and poorer health perceptions (P < 0.02, Wilcoxon). Gender did not affect any of the SF-36 subscales. However, females did report significantly more bleeding (P = 0.05). On follow-up, healing was complete in 27 patients (69%). Symptoms of pain, bleeding and irritation were all significantly reduced in this group. Repeating the SF-36 showed an improvement in bodily pain, role-physical functioning and vitality (P < 0.05).

CONCLUSION

Successful nonsurgical treatment of chronic anal fissure leads to symptomatic improvement and beneficially affects health-related quality of life.

L-arginine-induced relaxation of the internal anal sphincter is not mediated by nitric oxide

BACKGROUND

Topical application of L-arginine, the precursor of nitric oxide, reduces resting anal pressure without significant side-effects and may therefore be of benefit in the treatment of anal fissure. This in vitro study investigated the effect of L-arginine on sheep and human isolated internal anal sphincter (IAS) to ascertain the role played by nitric oxide and guanosine 3',5'-cyclic monophosphate.

METHODS

Strips of sheep and human IAS were mounted in isolated organ baths. The effects on myogenic tone of increasing concentrations of L-arginine, D-arginine and other amino acids were evaluated.

RESULTS

L-Arginine, D-arginine and other basic amino acids (L-lysine and L-ornithine) all caused a concentration-dependent reduction in myogenic tone. L-Arginine was the most effective and produced a mean(s.e.m.) maximal reduction in myogenic tone of 78.2(7.1) and 40.2(9.3) per cent in sheep and human tissue respectively. These responses were not affected by N(G)-nitro-L-arginine methyl ester, a nitric oxide synthase inhibitor, or 1H-[1,2,4]oxadiazolo[4,3-a]-quinoxalin-1-one, an inhibitor of soluble guanylyl cyclase. Changes in pH per se were unable to explain the relaxation fully, but an equiosmolar sodium chloride solution produced a concentration-response relationship similar to that of L-arginine.

CONCLUSION

The ability of L-arginine to reduce myogenic tone is independent of nitric oxide. This effect may be partially pH dependent but the osmolality of the solution appears to be a major factor. Hyperosmolar solutions might be worthy of further investigation as agents that affect anal tone.

The role of topical diltiazem in the treatment of chronic anal fissures that have failed glyceryl trinitrate therapy

OBJECTIVE

The treatment of anal fissures has evolved over the last 5 years with the development of topical treatments aimed at reducing sphincter hypertonia. This is thought to improve anal mucosal blood flow and promote healing of the fissure. This study reports the use of topical diltiazem in patients with chronic anal fissures that have failed previous treatment with topical 0.2% glyceryl trinitrate (GTN).

PATIENTS AND METHODS

Forty-seven patients with chronic anal fissure who had previously failed at least one course of topical GTN were recruited prospectively from a single centre. Patients were instructed to apply 2 cm (approximately 0.7 g) of 2% diltiazem cream to the anal verge twice daily for eight weeks. Symptoms of pain, bleeding and itching were recorded on a linear analogue score prior to starting the cream and then repeated at 2 weekly intervals. Patients were asked to report side-effects throughout the study period. Healing of the fissure was assessed after 8 weeks of treatment.

RESULTS

Forty-six patients completed treatment; of these, 22 had healed fissures (48%). Ten of the 24 patients with persistent fissures were symptomatically improved and wished no further treatment. Of the 14 patients who remained symptomatic, one was given a repeat course of 0.2% glyceryl trinitrate with subsequent healing of the fissure, 10 were recruited into an ongoing study involving injections of botulinum toxin into the internal anal sphincter and three were referred for surgery.

CONCLUSION

This study shows that topical 2% diltiazem is an effective and safe treatment for chronic anal fissure in patients who have failed topical 0.2% GTN. The need for sphincterotomy can be avoided in up to 70% of cases.

Topical L-arginine gel lowers resting anal pressure: possible treatment for anal fissure

PURPOSE

Exogenous nitric oxide donors, such as glyceryl trinitrate, have been used as treatment for anal fissures; however, headaches develop in 60 percent of patients. Nitric oxide produced from the cellular metabolism of L-arginine mediates relaxation of the internal anal sphincter. This study investigated whether topical L-arginine gel reduces maximum anal resting pressure in volunteers.

METHOD

In a two-center study, volunteers received a single topical dose of L-arginine or placebo (Aquagel ). Anal manometry was performed for two hours after application of 400 mg of L-arginine gel or placebo gel to the anal verge in 25 volunteers. Side effects were recorded after single application and also after repeated dosing for three days.

RESULTS

L-Arginine reduced maximum anal resting pressure by 46 percent from a median of 65 cm of water to a minimal value of 35 cm of water ( P< 0.001, Wilcoxon's signed-rank test). The difference between L-arginine and placebo using repeated-measures testing was significant at P< 0.005. No side effects occurred with either gel; in particular, no episodes of headache were recorded.

CONCLUSION

Topical L-arginine gel significantly lowers maximum anal resting pressure; its onset of action is rapid, and duration is at least two hours ( P< 0.01). L-arginine may have therapeutic potential, but further evaluation is needed before it can be used as a possible alternative treatment for chronic anal fissure.

Requirement for B cell linker protein (BLNK) in B cell development

Linker proteins function as molecular scaffolds to localize enzymes with substrates. In B cells, B cell linker protein (BLNK) links the B cell receptor (BCR)-activated Syk kinase to the phosphoinositide and mitogen-activated kinase pathways. To examine the in vivo role of BLNK, mice deficient in BLNK were generated. B cell development in BLNK-/- mice was blocked at the transition from B220+CD43+ progenitor B to B220+CD43- precursor B cells. Only a small percentage of immunoglobulin M++ (IgM++), but not mature IgMloIgDhi, B cells were detected in the periphery. Hence, BLNK is an essential component of BCR signaling pathways and is required to promote B cell development.

Antibodies raised by gastrimmune inhibit the spontaneous metastasis of a human colorectal tumour, AP5LV

Both precursor forms of gastrin and mature amidated gastrin peptides can enhance proliferation of colorectal tumours and may regulate growth in an autocrine manner. The purpose of this study was to evaluate the effect of neutralization of precursor and amidated gastrin on primary and secondary in vivo growth of a human colorectal tumour. The human colorectal cell line, AP5LV, when injected into the muscle layer of the abdominal wall of severe combined immunodeficient (SCID) mice, grows as a well-vascularized primary tumour and metastasis to the lung. AP5LV expressed the precursor gastrin forms; progastrin and glycine-extended gastrin and gastrin/CCKB receptors, as assessed by immunocytochemistry. Gastrimmune is a gastrin immunogen in which the amino terminus of the gastrin-17 molecule is linked to diphtheria toxoid and induces antibodies which neutralise the amidated and glycine-extended forms of gastrin-17. Rabbit antiserum, raised against Gastrimmune, was administered intravenously into SCID mice bearing AP5LV tumours. Control animals were treated with antiserum raised against diphtheria toxoid only. Antibodies raised against Gastrimmune significantly limited the growth of primary AP5LV tumours, as assessed by median cross-sectional area (controls = 244 mm2; antibody-treated = 179 mm2; P = 0.033). In addition Gastrimmune-induced antiserum limited the growth of lung metastasis as assessed by nodule number (controls = 3.5; antibody-treated = 1.0; P = 0.0001) and nodule cross-sectional as assessed by image analysis (controls = 11.9 mm2; antibody-treated = 3.75 mm2; P = 0.0064). In conclusion in vivo neutralization of gastrin forms, which may potentially be fueling growth by an autocrine pathway, inhibited both primary growth and, to a greater degree, lung metastasis of a human colorectal tumour cell line. Immunization against tumour-associated gastrin forms may provide an effective therapy for advanced colorectal cancer.

Gastric carcinoid expresses the gastrin autocrine pathway

BACKGROUND

In gastric adenocarcinoma the gastrin autocrine-paracrine pathway is activated. As enterochromaffin-like (ECL) cells originate from the same stem as epithelial cells, the aim of this study was to determine if the gastrin autocrine pathway is present in gastric carcinoid.

METHODS

Samples from ten patients with gastric carcinoid were assessed by immunocytochemistry using primary antibodies directed against gastrin precursors and the gastrin/cholecystokinin B receptor and detected using the avidin-biotin immunoperoxidase system.

RESULTS

A high level of expression of precursor and mature gastrin peptides, together with the gastrin receptor, was seen in all carcinoids screened.

CONCLUSION

In common with the glandular epithelium of the stomach the gastrin gene is activated during the neoplastic process in ECL cells. This finding may explain why some carcinoids do not regress after surgical procedures that lower serum gastrin. Antigastrin agents may be a useful treatment for carcinoid either in their own right or as an adjunct to surgery.

Recurrent corneal infections in a patient with the acquired immunodeficiency syndrome

A 29-year-old female intravenous drug abuser infected with the human immunodeficiency virus suffered recurrent, bilateral corneal infections over an 11-month period. Multiple infectious organisms were responsible, including capnocytophaga species, Candida albicans, Staphylococcus aureus, coagulase-negative staphylococcus, and a-streptococcus. One eye was eviscerated because of corneal perforation and loss of vision; the second eye has maintained good vision. Predisposing factors usually associated with corneal infections were absent. Treatment was complicated by extremely poor patient compliance, ongoing intravenous drug abuse, and concurrent multiple extraocular medical problems.

Flow cytometric studies of ploidy and proliferative indices in the Yorkshire trial of adjuvant progestogen treatment of endometrial cancer

OBJECTIVE

To estimate whether flow cytometric indices provide independent measures of prognosis or predict response to prophylactic progestogens in endometrial cancer.

DESIGN

Endometrial tumour specimens were retrieved and analysed by flow cytometry from 257 women who had been randomly allocated in a previous trial to receive prophylactic progestogen in addition to conventional therapy for endometrial carcinoma.

SETTING

Fourteen district and two teaching hospitals in West Yorkshire.

SUBJECTS

Women developing primary endometrial cancer between 1975 and 1983.

MAIN OUTCOME MEASURES

Tumour ploidy status and proliferative indices and the relation of these to tumour stage and grade, to prognosis and to response to progestogens.

RESULTS

Ploidy status and proliferative indices were related to tumour stage, grade and patient survival but were not independent predictors of survival. They did not predict patients who would respond to progestogens although there was a nonsignificant trend towards patients with diploid tumours surviving longer after progestogen treatment.

CONCLUSIONS

Flow cytometry adds little to established prognostic indicators for endometrial cancer.

Direct pituitary inhibition of prolactin secretion by dopamine and noradrenaline in sheep

The effects of dopamine, noradrenaline and 3,4-dihydroxyphenylacetic acid (DOPAC) on the release of prolactin were examined in ovariectomized ewes. Infusion of dopamine (0.5 or 1 microgram/kg per min for 2 h i.v.) reduced plasma prolactin concentrations in a dose-dependent manner, whereas DOPAC (5 or 10 micrograms/kg per min for 2 h i.v.) had no effect. In a further series of experiments, ovariectomized hypothalamopituitary disconnected ewes were given dopamine or noradrenaline (each at 0.5 or 1 microgram/kg per min for 2 h i.v.), and both amines reduced mean plasma concentrations of prolactin with similar potency in a dose-dependent manner. These effects were blocked by treatment with pimozide and prazosin respectively. During the infusion of dopamine, the peripheral plasma concentrations of DOPAC and 3,4-dihydroxyphenylethyleneglycol (DHPG) were increased (DOPAC, 22 +/- 7 (S.E.M.) to 131 +/- 11 nmol/l; DHPG, 2.9 +/- 0.3 to 6.4 +/- 0.2 nmol/l), but plasma concentrations of dopamine and noradrenaline did not change. Finally, administration of domperidone, a specific dopamine receptor antagonist that does not cross the blood-brain barrier, resulted in a sustained increase in plasma prolactin concentrations in ovariectomized ewes. We conclude that the secretion of prolactin from the pituitary gland is under dual inhibitory regulation by both dopamine and noradrenaline in the sheep.