We performed a comparative assessment of CT and sonographic techniques used to assess appendicitis.
One hundred patients with clinically suspected acute appendicitis were examined with sonography, ...unenhanced focused appendiceal CT, complete abdominopelvic CT using IV contrast material, focused appendiceal CT with colonic contrast material, and repeated sonography with colonic contrast material. Each sonogram was videotaped for subsequent interpretation by three radiologists and two sonographers. The mean sensitivity, specificity, positive and negative predictive values, inter- and intraobserver variability, and diagnostic confidence scores of all observers were used for comparative performance assessments. The three CT examinations were filmed and interpreted separately by four radiologists. Patient discomfort was assessed on a 10-point scale for each radiologic study. Diagnoses were confirmed by pathologic evaluation of resected appendixes or clinical follow-up for a minimum of 3 months after presentation.
Twenty-four of the 100 patients had positive findings for acute appendicitis. Both sonographic techniques had high specificity (85-89%) and comparable accuracy (73-75%) but low sensitivity (33-35%) and inter- and intraobserver variability (kappa = 0.15-0.20 and 0.39-0.42, respectively). Unenhanced focused appendiceal CT, abdominopelvic CT, and focused appendiceal CT with colonic contrast material all significantly outperformed sonography (p <0.0001), with sensitivities of 78%, 72%, and 80%; specificities of 86%, 91%, and 87%; and accuracies of 84%, 87%, and 85%, respectively. Abdominopelvic CT gave the greatest confidence in cases with negative findings (p = 0.001), and focused appendiceal CT with colonic contrast material gave the greatest confidence for cases with positive findings (p = 0.02). In terms of inter- and intraobserver variability, focused appendiceal CT with colonic contrast material yielded the highest, and unenhanced focused appendiceal CT the lowest, agreement (interobserver kappa = 0.45 vs. 0.36 and intraobserver kappa = 0.85 vs. 0.76, respectively) (p <0.05). Colonic contrast material was unsuccessfully advanced into the cecum in 18% of patients and leaked in another 24%. Patient discomfort was greatest with focused appendiceal CT using colonic contrast material and least with unenhanced focused appendiceal CT (p <0.05).
A standard abdominopelvic CT scan is recommended as the initial examination for appendicitis in adult patients. However, focused appendiceal CT with colonic contrast material material should be used as a problem-solving technique in difficult cases.
To describe a patient with a duodenal gastrinoma in a setting of atrophic gastritis and hypergastrinemia.
We present historical features and results of laboratory and genetic evaluation in a woman ...with duodenal gastrinoma and hypergastrinemia due to atrophic gastritis.
In a 46-year-old woman with a history of stable pituitary microprolactinoma, multiple gastrointestinal symptoms developed and prompted the performance of an esophagogastroduodenoscopy in conjunction with small bowel biopsies. A 2-mm duodenal gastrin-producing neuroendocrine tumor was discovered. The tumor stained negative for serotonin and somatostatin and involved the mucosa and submucosa. Immunohistochemical staining of the gastrinoma tissue with a monoclonal antibody to the cholecystokinin-B (gastrin) receptor was negative. The patient's random serum gastrin level was elevated at 990 pg/mL. She had been taking pantoprazole for 4 weeks before that test. After pantoprazole therapy was discontinued, the serum gastrin level remained elevated at 403 pg/mL. There was no family history of multiple endocrine neoplasia type 1, and genetic testing for the MEN1 mutation was negative. An upper endoscopy with measurement of gastric pH and performance of gastric biopsies confirmed the presence of chronic atrophic gastritis. This finding was consistent with the patient's persistently elevated serum gastrin levels.
Patients with atrophic gastritis and associated hypergastrinemia are known to have a high frequency of hypergastrinemia-induced gastric carcinoid tumors, some of which are actual gastrinomas or are thought to arise from the G cells of the stomach. Gastrin is a well-recognized growth factor for many tissues. We postulate that hypergastrinemia in this patient might have had a trophic effect on the duodenal G cells and led to gastrinoma development. No gastrin receptors were detected on the gastrinoma cells; however, that result might have been attributable to technical (fixation or antibody) or tumor (dedifferentiation) problems.
We systematically reviewed randomized controlled trials (RCTs) assessing the effectiveness of computerized decision support systems (CDSSs) featuring rule- or algorithm-based software integrated with ...electronic health records (EHRs) and evidence-based knowledge. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Abstracts of Reviews of Effects. Information on system design, capabilities, acquisition, implementation context, and effects on mortality, morbidity, and economic outcomes were extracted. Twenty-eight RCTs were included. CDSS use did not affect mortality (16 trials, 37395 patients; 2282 deaths; risk ratio RR = 0.96; 95% confidence interval CI = 0.85, 1.08; I(2) = 41%). A statistically significant effect was evident in the prevention of morbidity, any disease (9 RCTs; 13868 patients; RR = 0.82; 95% CI = 0.68, 0.99; I(2) = 64%), but selective outcome reporting or publication bias cannot be excluded. We observed differences for costs and health service utilization, although these were often small in magnitude. Across clinical settings, new generation CDSSs integrated with EHRs do not affect mortality and might moderately improve morbidity outcomes.
A 62-yr-old man was referred for management of GI polyposis. Large bowel polyps were initially diagnosed >25 yr ago, and the patient had undergone multiple colonoscopies and polypectomies. Personal ...and family history were notable for thyroid goiter and hypothyroidism. Physical examination was notable for lingular papillomatosis. No cutaneous lesions were seen. Upper endoscopy revealed esophageal glycogen acanthosis. There were multiple polyps throughout the stomach and the small and large intestines. Histology of these polyps showed multiple cell types including juvenile polyps, inflammatory polyps with fibromuscular proliferation and lamina propria ganglion cells, and focal adenomatous change. A clinical diagnosis of Cowden syndrome was made. Mutation analysis revealed a variant in exon 8 of the PTEN gene. Direct sequencing revealed a germline heterozygous C.892-895InsA, which is predicted to result in a truncated PTEN protein. Cowden syndrome is an underdiagnosed, underrecognized, autosomal dominant, inherited syndrome. For the gastroenterologist, esophageal acanthosis and multiple hamartomatous polyps should suggest the diagnosis. Sensitive molecular diagnostic tests looking for mutations in the appropriate genes are clinically available. Together with genetic counseling, molecular diagnostic testing will allow more accurate risk assessment and surveillance for cancer for both the patient and family members.
Dans cet article, nous proposons une lecture des modalités de représentation de l’espace urbain dans le roman de banlieue Les Saisons de Louveplaine, de Cloé Korman (2013). En tenant compte de la ...critique de la vie urbaine développée par Michel de Certeau, nous envisageons la banlieue imaginaire de Louveplaine comme un espace qui ne cesse d’être lu et écrit par ses habitants. Cette énonciation de l’espace prend la forme tantôt du récit d’enquête, tantôt du récit fantastique, et résulte strictement liée aux trajets piétons accomplis par les personnages du roman.
Esthesioneuroblastoma (ENB) is an uncommon neuroectodermal tumor that originates from the olfactory mucosa and often recurs locally. Distant metastases of ENB have been described, but there are few ...reports of intramedullary metastases to the spinal cord.
Here we report a case of a patient presenting with a progressive paraparesis and magnetic resonance imaging findings of multiple drop metastases to thoracic and lumbar regions of the spinal cord, 17 years after diagnosis and treatment for an intracranial ENB with subsequent neck nodal metastases. The dorsal symptomatic lesion was treated with resection, radiotherapy, and adjuvant chemotherapy.
The implications of spinal metastases for the clinical prognosis of this disease are discussed, with a review of the few reported cases of spinal ENB metastases in the literature.
Through the presentation of this case we hope to further contribute to a better understanding of this rare disease's prognosis.
Summary Squamous cell carcinoma (SCC) is an uncommon and frequently aggressive subtype of gallbladder cancer known for its poor outcomes compared with other gallbladder tumours. Gallbladder SCC ...typically presents as higher grade and more advanced than adenocarcinoma, resulting in lower estimated survival. Early recognition of these tumours is ideal, but infrequently achieved. Herein is a case of a male patient in his 80s with new onset abdominal pain who was initially diagnosed with cholecystitis, but diagnostic imaging revealed a gallbladder mass. Surgical resection and pathology revealed pure SCC of the gallbladder without local organ invasion or metastatic disease. Pure SCC histology of the gallbladder is rare, with limited studies on clinical presentation, natural history, and optimal treatment.
PDF
