Novel treatment of gastric outlet obstruction secondary to incarcerated inguinal hernia: percutaneous endoscopic gastrostomy tube

A 93-year-old man presented with gastric outlet obstruction (GOO) secondary to a massive left inguinal hernia with incarcerated antrum. He reported a desire to avoid operative intervention, and given his comorbidities, such an operation carried high risk for perioperative complications. As such, we offered percutaneous endoscopic gastrostomy (PEG) tube placement, as this would allow intermittent decompression of the stomach to reduce the risk of obstruction and strangulation. He tolerated the procedure well and was discharged after several days of observation. He continues to do well at regular outpatient appointments. Although rare, GOO secondary to an incarcerated inguinal hernia is most likely to occur in a patient such as ours: elderly, comorbid and at high risk for perioperative complications. To our knowledge, this is the first documented case to be treated with a PEG tube, which can be a desirable and effective option in this subset of patients.

A Multicenter Assessment of Interreader Reliability of LI-RADS Version 2018 for MRI and CT

Background Various limitations have impacted research evaluating reader agreement for Liver Imaging Reporting and Data System (LI-RADS). Purpose To assess reader agreement of LI-RADS in an international multicenter multireader setting using scrollable images. Materials and Methods This retrospective study used deidentified clinical multiphase CT and MRI and reports with at least one untreated observation from six institutions and three countries; only qualifying examinations were submitted. Examination dates were October 2017 to August 2018 at the coordinating center. One untreated observation per examination was randomly selected using observation identifiers, and its clinically assigned features were extracted from the report. The corresponding LI-RADS version 2018 category was computed as a rescored clinical read. Each examination was randomly assigned to two of 43 research readers who independently scored the observation. Agreement for an ordinal modified four-category LI-RADS scale (LR-1, definitely benign; LR-2, probably benign; LR-3, intermediate probability of malignancy; LR-4, probably hepatocellular carcinoma [HCC]; LR-5, definitely HCC; LR-M, probably malignant but not HCC specific; and LR-TIV, tumor in vein) was computed using intraclass correlation coefficients (ICCs). Agreement was also computed for dichotomized malignancy (LR-4, LR-5, LR-M, and LR-TIV), LR-5, and LR-M. Agreement was compared between research-versus-research reads and research-versus-clinical reads. Results The study population consisted of 484 patients (mean age, 62 years ± 10 [SD]; 156 women; 93 CT examinations, 391 MRI examinations). ICCs for ordinal LI-RADS, dichotomized malignancy, LR-5, and LR-M were 0.68 (95% CI: 0.61, 0.73), 0.63 (95% CI: 0.55, 0.70), 0.58 (95% CI: 0.50, 0.66), and 0.46 (95% CI: 0.31, 0.61) respectively. Research-versus-research reader agreement was higher than research-versus-clinical agreement for modified four-category LI-RADS (ICC, 0.68 vs 0.62, respectively; P = .03) and for dichotomized malignancy (ICC, 0.63 vs 0.53, respectively; P = .005), but not for LR-5 (P = .14) or LR-M (P = .94). Conclusion There was moderate agreement for LI-RADS version 2018 overall. For some comparisons, research-versus-research reader agreement was higher than research-versus-clinical reader agreement, indicating differences between the clinical and research environments that warrant further study. © RSNA, 2023 Supplemental material is available for this article. See also the editorials by Johnson and Galgano and Smith in this issue.

Improved survival following transarterial radioembolization of infiltrative-appearance hepatocellular carcinoma

PURPOSE

Infiltrative-appearance hepatocellular carcinoma presents a challenge to clinicians as diagnostic criteria continue to evolve and evidence-based treatment guidelines have yet to be established. While transarterial radioembolization has shown efficacy in hepatocellular carcinoma, many studies exclude infiltrative-appearance HCC in their analysis. The purpose of this study was to describe imaging features of infiltrative-appearance hepatocellular carcinoma and evaluate effects of radioembolization on survival.

METHODS

In a retrospective review, infiltrative HCC patients treated from 2008 to 2017 were identified. Patients were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, dates of diagnosis/expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, bilirubin, radiation dose and volume were collected. Patients with bilirubin > 3 were excluded. Mann-Whitney U test and Fisher's exact test assessed differences between groups. Kaplan-Meier survival and Cox proportional hazard analyses were performed.

RESULTS

Fifty-three patients were identified, 15 underwent TARE while 38 served as control. Mean age was 60, 43 patients were male. The mean overall survival was 16.2 months for the TARE group and 5.3 months for the control group (Log-rank p < 0.0001). Cox proportional regression analysis revealed significant associations between survival and albumin (HR 0.210, 0.052-0.839, p = 0.027), Child-Pugh class B (HR 0.196, 0.055-0.696, p = 0.012), sorafenib (HR 0.106, 0.031-0.360, p < 0.001), and number of affected liver lobes (HR 1.864, 1.387-2.506, p < 0.001).

CONCLUSIONS

Transarterial radioembolization for infiltrative HCC improves life expectancy compared to treatment with comfort measures or systemic therapy.

Improved survival following transarterial radioembolization of infiltrative-appearance hepatocellular carcinoma

e15591

Background: Infiltrative-appearance hepatocellular carcinoma (IHCC), also known as diffuse HCC, presents a distinct challenge to clinicians as evidence-based treatment guidelines have yet to be established. While transarterial radioembolization (TARE) has shown efficacy in HCC, many studies exclude IHCC in their analysis. The purpose of this study was to evaluate whether TARE of IHCC improves survival. Methods: With IRB approval, patients with IHCC were identified. Patient were divided into two groups: TARE versus systemic therapy/palliative care. Demographics, date of diagnosis, date of expiry, albumin, international normalized ratio (INR), sodium, alpha-fetoprotein (AFP), creatinine, Child-Pugh class, model for end-stage liver disease (MELD) score, and bilirubin were collected. Patients with bilirubin >3 were excluded. Mann-Whitney U test and Fisher’s exact test assessed for differences between groups. Kaplan-Meier survival analysis and Cox proportional hazard analysis were performed. Results: Forty-one patients were identified, 10 underwent TARE while the remaining 31 served as a control. Mean age was 62, 30 patients were male. The mean overall survival of the TARE treatment group was 16.6 months (506 days) and the mean overall survival of the control group was 5.6 months (170 days) (Log-rank p < 0.004), with a combined overall survival of 8.5 months (259 days). Cox proportional regression analysis revealed statistically significant associations between survival and albumin (hazard ratio 0.12, 0.032-0.41, p < 0.001), Child-Pugh class B (hazard ratio 0.25, 0.064-0.941, p < 0.041), and sorafenib therapy (hazard ratio 0.246, 0.071 – 0.847, p < 0.026). Conclusions: Transarterial radioembolization for patients with IHCC improves life expectancy compared to treatment with comfort measures or systemic therapy.[Table: see text]

The Feasibility of Using Volumetric Phase-Contrast MR Imaging (4D Flow) to Assess for Transjugular Intrahepatic Portosystemic Shunt Dysfunction

PURPOSE

To demonstrate the feasibility of detecting patency, stenosis, or occlusion of transjugular intrahepatic portosystemic shunt (TIPS) with four-dimensional (4D) flow MR imaging.

MATERIALS AND METHODS

Sequential adult patients with TIPS were eligible for enrollment. Volumetric phase-contrast sequence was used to image TIPS. Particle tracing cine images were used for qualitative assessment of stenosis. TIPS was segmented to generate quantitative data sets of peak velocity. Segmentation and quantitative measurement of flow throughout an entire TIPS defined technical success. Doppler US was used for comparison. Venography, when available, and 6-month clinical follow-up were used as reference standards.

RESULTS

4D flow MR imaging was performed in 23 patient encounters and was technically successful in 16/23 (69.6%) encounters. Three cases demonstrated both focal turbulence and abnormal velocities (> 190 cm/s or < 90 cm/s) on 4D flow and had venography-confirmed stenosis (true-positive cases). Seven cases had normal velocities and no turbulence on 4D flow, and all were confirmed negative with clinical follow-up or venography (true-negative cases). Six cases had discordant 4D flow results, with abnormal velocities but no turbulence or focal turbulence but normal velocities. All 6 discordant cases had no evidence of dysfunction during 6-month follow-up.

CONCLUSION

4D flow MR imaging can detect TIPS patency and stenosis, but further investigation is required before it can be used to assess for TIPS dysfunction.

MRI of suspected appendicitis during pregnancy: interradiologist agreement, indeterminate interpretation and the meaning of non-visualization of the appendix

OBJECTIVE

To determine the degree of interradiologist agreement between the MRI features of appendicitis during pregnancy, the outcomes associated with an indeterminate interpretation and the negative predictive value of non-visualization of the appendix.

METHODS

Our study was approved by the institutional review board at the Washington University in St. Louis, Missouri (WUStL) and was HIPAA (Health Insurance Portability and Accountability Act of 1996)-compliant. The informed consent requirement was waived. Cases of suspected appendicitis during pregnancy evaluated using MRI were retrospectively identified using search queries. Scans were re-reviewed by two radiologists (7 and 9 years experience, respectively) to evaluate the interradiologist agreement of different MRI features of appendicitis during pregnancy (visualization of the appendix, appendiceal diameter, appendiceal wall thickening, periappendiceal fat stranding, fluid-filled appendix and periappendiceal fluid). The radiologists were blinded to patient outcome, patient intervention, laboratory data, demographic data and the original MRI reports. Clinical outcomes were documented by surgical pathology or clinical observation. Interradiologist agreement was analysed using Cohen's κ, while patient demographic and clinical data was analysed using Student's t-testing.

RESULTS

233 females with suspected appendicitis during pregnancy were evaluated using MRI over a 13-year period (mean age, 28.4 years; range, 17-38 years). There were 14 (6%) positive examinations for appendicitis during pregnancy, including 1 patient whose MRI was interpreted as negative, proven by surgical pathology. The presence of periappendiceal soft-tissue stranding and the final overall impression had the most interradiologist agreement (к = 0.81-1). There were no pregnant patients found to have acute appendicitis who had an indeterminate MR interpretation or when the appendix could not be visualized.

CONCLUSION

The final impression by the two retrospectively reviewing radiologists of MR examinations performed for suspected appendicitis during pregnancy had near-perfect agreement. In patients where the appendix could not be visualized or in patients that were interpreted as indeterminate, no patients had acute appendicitis. Advances in knowledge: MR impression for suspected appendicitis in the pregnant patient has high interradiologist agreement, and a non-visualized appendix or lack of inflammatory findings at the time of MR, reliably excludes surgical appendicitis.

Beyond Histologic Staging: Emerging Imaging Strategies in Colorectal Cancer with Special Focus on Magnetic Resonance Imaging

Imaging plays an increasingly important role in the staging and management of colorectal cancer. In recent years, magnetic resonance imaging (MRI) has supplanted transrectal ultrasound as the preferred modality for the locoregional staging of rectal cancer. Furthermore, the advent of both diffusion-weighted imaging and hepatobiliary contrast agents has significantly enhanced the ability of MRI to detect colorectal liver metastases. In clinical practice, MRI routinely provides prognostic information, helps to guide surgical strategy, and determines the need for neoadjuvant therapies related to both the primary tumor and metastatic disease. Expanding on these roles for MRI, positron emission tomography (PET)/MRI is the newest clinical hybrid imaging modality and combines the metabolic information of PET with the high soft tissue contrast of MRI. The addition of PET/MRI to the clinical staging armamentarium has the potential to provide comprehensive state-of-the-art colorectal cancer staging in a single examination.

Management of complications following radiofrequency ablation of a pedicle osteoid osteoma

Radiofrequency ablation (RFA) has become an accepted first-line treatment for osteoid osteomas. Ablation of spinal osteoid osteomas has presented a particular challenge because of their proximity to delicate neural structures. Although many case series have reported multiple successfully treated spinal osteoid osteomas, there are no reports of thermal injury or insufficiency fracture associated with RFA of spinal osteoid osteomas. We report the management of complications that result from treating a spinal osteoid osteoma within a pedicle.

Improving performance using indicators. Recent experiences in the United States, the United Kingdom, and Australia

This article describes recent national performance improvement initiatives in the United States, United Kingdom, and Australia. This comparison is of particular interest because each of these three countries faces similar challenges in delivering health care and improving health. Each has elevated a focus on safety and quality improvement to a national level. Marked differences in the organization and financing of health care across these three countries provide a unique opportunity to compare and contrast approaches. Drawing on the experience of the authors in each of the three countries and publicly available data sources about specific national initiatives, we describe the national context for improvement and outline recent performance improvement initiatives and emerging issues and challenges. Similarities and differences in the current evolution of national performance initiatives are described and conclusions are drawn about challenges that all three countries face, particularly in terms of developing meaningful sets of national indicators of health system performance. The challenges for future work include the importance of information infrastructure, the paucity of accurate and accessible clinical data, the need for effective performance measurement processes at a local level to capture useful data, and the tensions of balancing accountability and improvement agendas for measurement.

Arts, health and wellbeing: a third way for health?

The principle of a Third Way is to balance the autonomous needs of the individual with the need for community. Elevating Arts into a pivotal role across the spectrum of healthcare may provide a third way. Ill health is not isolated from society. A holistic approach sees health as successful adaptation to environment; Unemployment, social exclusion and bereavement become as much health concerns as diabetes. The health perspective should widen from the narrow scientific to a broader humanistic approach: changing professional medical education; introducing arts in healthcare settings and understanding the community impact of participation in the arts. Harnessing disparate perspectives present a challenge. Professional medical education should change to bridge the gap between science and society. Evidence suggests that the healthcare settings that support and reflect the perspectives offered by Dance, Music, Literature, Museums and Galleries lead to health gain and are in the long term cost-effective. Over the last decade a number of studies and grassroots projects have demonstrated the therapeutic value of arts in treating and preventing illness, yet there is a need to fully exploit this potential; health planners should provide leadership and support. The potential for arts to inform and facilitate individual expression is enourmous and should be further explored. A third way for health requires fundamental reassessment: what is health? What is a health centre: Arts should provide a third way to a dynamic engagement between the NHS and its constituents.

Lack of evidence for antisense suppression in the fungal plant pathogen Ustilago maydis

Modulation of the expression of the Ustilago maydis Pyr3 gene, encoding dihydroorotase (DHOase), through antisense RNA regulation has been explored. This was done by placing the gene in sense and antisense orientations under the control of an hsp70-like gene promoter in a high-copy number autonomously replicating expression vector. Cells transformed with the antisense vector contained similar levels of DHOase activity to those found in cells harboring the expression vector alone. Transformants containing the antisense vector did not exhibit uridine-dependent growth, which would be expected for a Pyr3-deficient phenocopy. This was despite detection of high levels of antisense RNA transcripts in cells transformed with the Pyr3 antisense vector.

Trends in health services management

This paper describes how the NHS in the United Kingdom needs to continue to adapt and evolve in response to six major pressures, and how the corresponding challenge facing managers in the NHS is how to cope, adapt and tackle those pressures. The foundation was laid in 1984 with the introduction of general management from central government down to the sub-units of the nine District Health Authorities in Wales. This signalled a change in the service from one merely administered to one which was actively managed. The NHS manager must now concentrate on a number of fronts, notably planning, performance objectives, policy management, resource allocation and positive management of change. The Corporate Management Programme for Wales published in 1988 reinforces fundamental management principles and describes an agenda of management initiatives and objectives for the NHS in Wales over the next five years. The Programme has initiated the process of Corporate Planning. The future trend in health services management is interwoven with the programme of reform of the NHS introduced by the Government's White Paper 'Working for Patients' published in 1989. Initiatives introduced in Wales which will assist this programme of reform are described.

The effect of total hip replacement on driving reactions

The driving reactions of 25 patients were assessed before and after operation for hip replacement. Driving reactions were tested by monitoring the delay and force of brake application after an emergency signal, using a simulated driving control system. Fifteen normal subjects were also tested. Statistical analysis demonstrated significant differences between patients with either left or right hip replacement and between pre- and postoperative testing. Most patients improved by the eighth week, but some had deteriorated and did not recover until re-tested eight months after operation. It is concluded that for most patients eight weeks' delay for return to driving is appropriate, but for a minority of patients with right hip replacement recovery of reaction speed requires longer rehabilitation.

Early experience with closed interlocking medullary nailing of the femur

We report on the first 14 patients treated with the Grosse Kempf femoral locking nail in our hospital. As with simple closed nailing of the femur attention to detail in the operating theatre is important. To date there have been only a few minor complications with the procedure, apart from one non-union. It allows stabilization of complicated fractures of the femoral shaft particularly in patients with multiple and often bilateral injuries caused by high velocity. It is concluded that it is an excellent procedure for complicated unstable fractures of the femoral shaft which would otherwise be treated on traction, and that the procedure can be safely performed in any centre where closed intramedullary nailing is commonly practised.

Radiologic evaluation of complications after esophagogastrectomy

The use of surgical stapling devices has caused renewed interest in the performance of esophagogastrectomy by reducing complications to an acceptable level. This has resulted in a more complicated radiographic appearance of the procedure. Since complications can be devastating, prompt recognition by the radiologist is critical. Sixty consecutive patients undergoing esophagogastrectomy were examined 7 days postoperatively with esophagrams. Forty-seven had been performed using the end-to-end anastomosis stapler. The spectrum of normal postoperative appearances is described. Follow-up examinations were performed in 29 patients. Postoperative complications included leak at a staple line (four), gastric outlet obstruction (two), gastric necrosis (two), and position-dependent problems with gastric emptying (five). Leaks were manifested by pleural effusions and by contrast extravasation, generally at the anastomosis or the distal gastric margin of resection. Late complications included benign strictures (eight), recurrent malignancy (seven), tracheal aspiration (one), reflux esophagitis (two), and bronchoesophageal fistula (two). The presence of a mass greater than 1.5 cm, particularly one extending across the anastomosis, correlated highly with recurrent malignancy.

Computed tomography in the staging of esophageal carcinoma

The computed tomographic (CT) findings in 52 patients with histologically proved esophageal carcinoma were reviewed. In 30 of these patients, the CT findings were correlated with findings at surgery or autopsy. CT was found to be highly accurate in predicting tumor size and assessing invasion of the tracheobronchial tree and spread to the liver, adrenals, and celiac and left gastric nodes. By quantifying the contact between the tumor and aorta, it was found that the CT appearance correctly predicted the presence or absence of aortic invasion in 24 of 25 cases (five cases were indeterminate). CT was insensitive in detecting metastatic spread to local periesophageal nodes; in these cases the tumor tended to involve the nodes without enlarging them. CT is an accurate method for assessing the spread of esophageal carcinoma. Its use can prevent unnecessary surgery in patients with inoperable tumors.

Pharmacy services for diabetic patients in South Carolina: a survey of physician and patient attitudes

Diabetic patients and physicians in South Carolina were surveyed to gauge their attitudes to 13 potential pharmacy services. Approximately 33% of the physician sample and 42% of the patient sample responded to a self-administered, mailed questionnaire. The results indicated that both groups held favorable attitudes toward services aimed at improving the patient's knowledge of diabetes but reacted negatively to services in which the pharmacist would be involved in the collection of information relating to diabetic control. Although the attitudes of patients and physicians were highly congruent, patients typically held more favorable attitudes than physicians when significant differences were found. It also was found that patient and physician characteristics were incapable of segregating respondents into groups with varying attitudes.

Deep infection after total hip replacement

Sixty-eight patients suffering deep infection from a consecutive series of 1746 total hip replacement operations are reviewed. The infection rate has been reduced considerably by improved technique and multiple antibiotic prophylaxis without the use of a special operation enclosure. Factors affecting deep infection are analysed and discussed.