Background
Preoperative diagnosis of malignancy within intraductal papillary mucinous neoplasm of the pancreas (IPMN) solely by clinical or radiological findings is not always possible. We sought a ...correlation between preoperative clinico-radiological findings and outcome.
Methods
A prospective database of pancreatic resections for IPMN (2002–2008) and a retrospective pathological revision of all pancreatic cancer specimens (1995–2001) were analyzed. The patients were grouped into asymptomatic with preoperative diagnosis of IPMN (group 1), symptomatic with a preoperative diagnosis of IPMN (group 2), and those with a preoperative diagnosis of pancreatic cancer whose specimen revealed a background of IPMN (group 3). The groups were compared for demographics, clinical presentation, pathological findings, and outcome.
Results
Of the 62 patients with IPMN, 19 were in group 1, 23 in group 2, and 20 in group 3. Their median age (range) was 65.6 (46–80), 67 (50–84), and 73.4 (57–86) years, respectively. The clinical presentation for groups 2 and 3 included abdominal pain (56% vs. 32 %), weight loss (8% vs. 52%), obstructive jaundice (4% vs. 57%), pancreatitis (22% and 5%), and new onset of diabetes (14% and 44%). Invasive cancer was found in one patient in group 1 (5.2%), two patients in group 2 (8.7%), and all patients in group 3. IPMN was present in 23 of 217 (10.6%) of all resected pancreatic cancer specimens. Five year survival for patients with invasive disease was 47% and 92% for patients with noninvasive disease (mean follow-up 37.6 months).
Conclusions
Benign IPMN can usually be differentiated from adenocarcinoma preoperatively. The clinical presentation is highly indicative of disease course.
To measure observer performance at various levels of prevalence.
A multiobserver multiabnormality receiver operating characteristic (ROC) study to assess the effect of prevalence on observer ...performance was conducted. Fourteen observers, including eight faculty members, two fellows, and four residents, interpreted 1,632 posteroanterior chest images with five prevalence levels by using a nested study design. Performance comparisons were accomplished by using a multireader multicase approach to assess the effect of prevalence from 28% (69 of 249) to 2% (31 of 1,577) on diagnostic accuracy. The mean times required to review and report a case were analyzed and compared for different levels of prevalence and readers' experience.
Area under the ROC curve demonstrated that, with the study experimental conditions, no significant effect could be measured as a function of prevalence (P >.05) for any abnormality, group of cases, or readers. There were no significant differences (P >.05) in the mean times required to review and report cases at different prevalence levels and with different groups of readers.
The consistency in the results and the size of this study suggest that with laboratory conditions, if a prevalence effect exists, it is quite small in magnitude; hence, it will not likely alter conclusions derived from such studies.
To review the incidence, cause, and radiologic findings of bowel obstruction in patients who have undergone orthotopic liver transplantation (OLT).
Retrospective review of 4,001 cases of OLT revealed ...48 cases of bowel obstruction in 44 patients. Seventeen computed tomographic (CT) scans and seven barium-enhanced radiographs were reviewed to determine level and cause. Surgical proof was available in 45 cases, while three had characteristic clinical and radiographic features.
Adhesions caused the obstruction in 19 cases in 16 patients; three had bowel ischemia. Internal hernias caused obstruction in 18 patients; all obstructions were transmesenteric or retroanastomotic and occurred with choledochoenteric anastomosis. Seven patients had volvulus; four had bowel ischemia. CT signs of internal hernia included mesenteric vascular abnormalities and clusters of dilated small-bowel segments that displaced the colon away from the abdominal wall. Prospective diagnosis of internal hernia was made in only one case. Incisional or inguinal hernia caused obstruction in seven patients; CT was used just once. Four patients had neoplastic bowel obstruction, three due to posttransplantation lymphoproliferative disorder and one due to colon carcinoma.
Liver transplantation was complicated by bowel obstruction in 48 (1.2%) of 4,001 cases. While adhesions and incisional hernias are common and well recognized, other causes are more challenging to diagnose. The CT findings reported here may allow more accurate diagnosis of internal hernia.
To evaluate computed tomography (CT) and magnetic resonance imaging (MRI) utilization patterns before and after the implementation of a preauthorization program based on the ACR Appropriateness ...Criteria((R)) and the guidelines of the Royal College of Radiologists.
All CT and MRI requests received at the preauthorization center and CT and MRI examinations actually performed were identified by our health care service's centralized computerized database between January 1, 2000, and December 31, 2003. The obligatory preauthorization of CT and MRI requests was established for CT in September 2001 and for MRI in February 2002. All ambulatory CT and MRI examination requests sent for approval during the study period by most of our health care physicians were included in the study. The preauthorization program model is presented, and multiple parameters were evaluated from January 2000 to December 2003, before and after preauthorization was established.
Before preauthorization was required, the CT and MRI utilization rates were constantly increasing by 20% and 5% per year for CT and MRI, respectively. After preauthorization was implemented, CT and MRI annual performance rates decreased from 25.9 and 7 examinations per 1,000, respectively, in 2000 to 17.3 and 5.6 examinations per 1,000, respectively, in 2003. The decreases in the utilization of MRI and CT imaging between 2001 and 2003 were 9% (12,129 compared with 11,070 MRI examinations) and 33% (81,223 compared with 57,204 CT examinations), respectively, resulting in substantial, statistically significant cost savings. The deferral rate ranged from 7.5% to 12.2% (mean = 9.8%) for CT and 13.9% to 21.4% (mean = 17%) for MRI. Deferred cases in CT were most commonly in neuroradiology, musculoskeletal radiology, and CT angiography (ranges of deferred cases 9% to 12%, 11% to 12%, and 10% to 12%, respectively). Deferred cases in MRI were most commonly in abdominal and chest radiology (ranges of deferred cases 32% to 37% and 20% to 31%, respectively). Computed tomography was more commonly utilized inappropriately by pediatric professions, and MRI was more commonly utilized inappropriately by medical subspecialty professions.
Preauthorization of CT and MRI requests results in a substantial decrease in utilization of these modalities with reduction in imaging costs.
To define the incidence, clinical presentation, radiologic findings and principles of diagnosis, and management of acute graft pancreatitis occurring more than 3 months after transplantation.
Acute ...graft pancreatitis is a frequent late complication after simultaneous pancreas-kidney transplantation (SPKT) with enteric drainage that is not well understood.
We performed a retrospective analysis of data from patients who underwent SPKT with enteric drainage at our institution. All recipients who experienced episodes that met the clinical criteria for late graft pancreatitis were included. We excluded events proven to be anastomotic or duodenal stump leaks. Clinical presentation, laboratory findings, radiologic imaging, course of management, and graft and patient outcome were evaluated and analyzed.
Of 79 SPKTs (1995-2007), 11 (14%) recipients experienced 31 episodes of late graft pancreatitis (average number per patient, 3; range, 1-13), occurring an average of 28 months after transplantation (range, 3 months to 8 years). All patients presented with right lower quadrant abdominal peritonitis, fever, and findings compatible with pancreas graft inflammation on computed tomography or ultrasound imaging. Mild hyperamylasemia (>110 IU/L) was found in 82% of cases. Treatment was conservative, including bowel rest, antibiotics, and percutaneous sampling and drainage of abscesses as necessary. Excellent graft and patient survival were achieved.
The diagnosis of late acute graft pancreatitis is clinical, with confirmatory computed tomography or ultrasound imaging. Conservative treatment yields excellent graft and patient survival.
Abstract only
1564
Background: Cancer is a leading cause of mortality worldwide. Screening is a key strategy for reducing cancer morbidity and mortality. We aimed to evaluate the utility of cancer ...screening in an asymptomatic population at an integrated cancer prevention center. Methods: One-thousand consecutive asymptomatic, apparently healthy adults, aged 20-80 years, were screened for early detection of 11 common cancers by routine screening tests. Results: Malignant and benign lesions were found in 2.4% and 7.1% of the screenees, respectively. The most common malignant lesions were in the gastrointestinal tract and breast followed by gynecological and skin. The compliance rate for the different screening procedures was considerably higher than the general Israeli population – 78% compared to 60% for mammography (p<0.001) and 39% compared to 16% for colonoscopy (p<0.001). Advanced age, family history and certain lifestyle parameters were associated with increased risk for cancer. Moreover, polymorphisms in the APC and CD24 genes indicated high cancer risk. When two of the polymorphisms existed in an individual, the risk for a neoplastic lesion was extremely high (OR 2.3 95% CI 0.94-5.9). Conclusions: A significant number of neoplastic lesions were diagnosed at an early stage. Polymorphisms in the APC and CD24 genes may identify individuals at an increased risk for cancer. Cancer may be diagnosed at an early stage using the screening facilities of a multidisciplinary outpatient clinic.
To prospectively evaluate the clinical response and hemodynamic changes in cavernosal arteries after oral administration of sildenafil without and with audiovisual sexual stimulation and to compare ...those responses with responses from intracavernosal injections of vasoactive agents.
Institutional review board approval and written informed consent were obtained. Thirteen consecutive patients (age range, 22-77 years; mean, 60.4 years) with erectile dysfunction were evaluated with clinical assessment and cavernosal duplex ultrasonography (US). The patients were examined at two sessions 3 weeks apart. First, each patient received 100 mg of sildenafil citrate orally and was examined 60 minutes later without any sexual stimulation. Each patient then underwent repeat clinical and duplex US assessment after audiovisual sexual stimulation. Three weeks later, the patients underwent identical clinical evaluation and duplex US after intracavernosal injection of a commercially available combination of papaverine, prostaglandin E1, and phentolamine. Clinical and duplex US data (ie, peak systolic velocity PSV) were examined by using the Wilcoxon signed rank test for matched pairs.
At rest, the overall mean cavernosal artery PSV was 1.08 cm/sec and remained unchanged after intake of sildenafil without any audiovisual stimulation, with no clinical evidence of erection. With the addition of audiovisual sexual stimulation, eight (62%) of 13 patients had penile congestion or erection, and six (46%) had a PSV greater than 25 cm/sec. With intracavernosal injection of the combination of three drugs, all 13 patients achieved congestion or erection, and 10 (77%) had a PSV greater than 25 cm/sec. Both clinical and duplex US responses to intracavernosal injection were significantly greater than they were to sildenafil with audiovisual sexual stimulation (P = .04 and .003, respectively).
Oral sildenafil with audiovisual sexual stimulation led to a significant clinical response and increment in blood flow in the cavernosal arteries. However, more patients responded to intracavernosal injection of the combination of three drugs than to sildenafil, and the clinical response was significantly better.
Abstract Background Cancer is a leading cause of mortality worldwide. Screening is a key strategy for reducing cancer morbidity and mortality. Methods We aimed to describe the experience of an ...integrated cancer prevention center in screening an asymptomatic population for the presence of neoplasia. One-thousand consecutive asymptomatic, apparently healthy adults, aged 20–80 years, were screened for early detection of 11 common cancers that account for 70–80% of cancer mortality. Results Malignant and benign lesions were found in 2.4% and 7.1% of the screenees, respectively. The most common malignant lesions were in the gastrointestinal tract and breast followed by gynecological and skin. The compliance rate for the different screening procedures was considerably higher than the actual screening rate in the general Israeli population — 78% compared to 60% for mammography (p < 0.001) and 39% compared to 16% for colonoscopy (p < 0.001). Advanced age, family history of cancer and certain lifestyle parameters were associated with increased risk. Moreover, polymorphisms in the APC and CD24 genes indicated high cancer risk. When two of the polymorphisms existed in an individual, the risk for a neoplastic lesion was extremely high (OR 2.3 95% CI 0.94–5.9). Conclusions One stop shop screening for 11 common cancers in the setting of a multidisciplinary outpatient clinic is feasible and can detect cancer at an early stage.
