Variation in referral practice for patients with colorectal cancer liver metastases.

BACKGROUND: Half of patients with colorectal cancer develop liver metastases. There remains great variability between hospitals in rates of liver resection for colorectal cancer liver metastases (CLM). This study aimed to determine how many patients with potentially resectable CLM are not seen by specialist liver surgeons. METHODS: Patients presenting with new CLM in a cancer network consisting of a tertiary centre and seven attached hospitals were studied prospectively over 12 months. Data were collected retrospectively for patients who did not have a complete data set. Outcomes for patients referred to the liver tertiary centre were collated. The radiology of tumours deemed inoperable by the local colorectal specialist teams was reviewed by specialist liver surgeons and radiologists. RESULTS: In total, 631 patients with CLM were assessed. Prospective data were complete for 241 patients, and 64 (26.6 per cent) of these were referred to the specialist liver team for consideration of resection. No decision was documented for 16 patients (6.6 per cent). Of those not referred, 30 (18.6 per cent) were deemed unfit or refused and 131 (81.4 per cent) were thought inoperable. Referral rates varied between hospitals (13-43.6 per cent). Of 131 patients deemed fit but inoperable by the colorectal specialist teams, 38 (29.0 per cent) were deemed operable and 20 (15.3 per cent) had equivocal imaging when assessed retrospectively by liver specialists. In total, 142 of the 631 patients were referred to liver specialists for consideration of treatments, and 107 (75.4 per cent) treated with curative intent. CONCLUSION: A considerable number of patients with potentially resectable CLM are not assessed by specialist liver teams. Improved referral rates could greatly improve resection rates for CLM, which may improve outcomes for patients with colorectal cancer.

Diffusion-weighted MRI of the liver-Interpretative pearls and pitfalls.

Diffusion-weighted magnetic resonance imaging (DW MRI) is an established technique in neuroradiology and more recently has emerged as a useful adjunct to various oncological applications of MRI. It has an expanding role in the evaluation of liver lesions, offers higher detection rates for small lesions, and can increase confidence in differentiating between benign and malignant lesions. Other applications include assessment of tumour response to therapy, differentiating tumour from bland thrombus, and assessment of liver fibrosis. DW sequences can be performed on most modern MRI machines with relative ease, in a short time period and without the need for contrast medium. DW MRI can be of value in the detection and characterization of hepatic lesions but there are pitfalls, which can potentially cause interpretative difficulty. This article will review the rationale for DW MRI in liver imaging, demonstrate the clinical utility of the technique in a spectrum of hepatic diseases, and illustrate key interpretative pearls and pitfalls.

Optimizing the role of FDG PET-CT for potentially operable metastatic colorectal cancer.

Recent treatment advances now allow a realistic chance of cure in selected patients with metastatic colorectal carcinoma (CRC). Accurate pre-treatment staging is crucial to ensure appropriate management by identification of patients with more advanced disease who will not benefit from surgery. (18)Fluorine 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (PET-CT) has a firmly established role in staging, restaging, and recurrence detection of a range of tumors. This article will review the role of PET-CT in patients with CRC with a particular emphasis on optimizing the technique in patients with potentially operable metastatic disease.

Patient experience, pain, and quality of life after lower limb angioplasty: a multisite prospective cohort study.

PURPOSE: To explore the experience of patients undergoing endovascular lower limb angioplasty and evaluate the improvements in quality of life and disease-related symptoms after the procedure. METHODS: Patients completed a questionnaire before treatment and three questionnaires after the procedure (immediately after the procedure, and again 4 weeks and 3 months later). Anxiety, patient understanding, procedure-related pain, and disease-related pain were assessed by a visual analog score (VAS). Complications, analgesic requirements, and satisfaction were recorded. Changes to quality of life were assessed by the validated SF36 questionnaire. RESULTS: A total of 88 patients (41%) responded. Overall, disease-related pain decreased over 3 months after the procedure. Smokers had more pain both before and after the procedure (P < 0.05). Explanation was considered better if provided by radiologist (P < 0.05). Sixty-nine percent of patients found the procedures less painful (mean VAS 2.5) than they had anticipated (VAS 5.5). Fifty percent of patients experienced adverse effects related to their puncture site, but this was highest among patients who had undergone the procedure before and smokers. The greatest quality-of-life improvements were in emotional and general health. Higher levels of disease-related pain were associated with worse general, emotional, and physical health (P < 0.05). CONCLUSION: Lower limb angioplasty provides symptomatic and quality-of-life improvements. Implementation of simple measures could improve patient satisfaction-for example, treatment should be explained by the radiologist in advance. Routine prescription of analgesics with particular attention to smokers and those undergoing repeat interventions is suggested.

False-positive uptake on 2-[¹8F]-fluoro-2-deoxy-D-glucose (FDG) positron-emission tomography/computed tomography (PET/CT) in oncological imaging.

With the increasing utilization of integrated positron-emission tomography/computed tomography (PET/CT) using the glucose analogue 2-[¹8F]-fluoro-2-deoxy-D-glucose (FDG) in oncological imaging, it is important for radiologists and nuclear medicine physicians to be aware that FDG uptake is not specific for malignancy, as many different physiological variants and benign pathological conditions can also exhibit increased glucose metabolism. Such false-positive FDG uptake often arises outside the area of primary interest and may mimic malignant disease, thereby confounding accurate interpretation of PET/CT studies. With the use of illustrative clinical cases, this article will provide a systematic overview of potential interpretative pitfalls and illustrate how such unexpected findings can be appropriately evaluated.

Are radiologists able to manage serious anaphylactic reactions and cardiopulmonary arrest?

In this study, we aimed to assess the ability and confidence of radiologists in managing adult life support in cardiopulmonary arrest and acute anaphylaxis reactions. We used a questionnaire survey assessing the knowledge of how to manage and the confidence in managing an adult cardiorespiratory arrest scenario. This was sent to 165 radiology consultants and registrars in 6 NHS trusts in Yorkshire: 105 participated. The questionnaire elicited basic demographic details and included eight questions aimed at assessing recent training, knowledge and confidence in the management of adult resuscitation (Resuscitation Council (UK) 2005 guidelines) and acute anaphylaxis. Despite the fact that 90% of participants stated that they would feel confident to initiate life support, the average score from the questions assessing life support procedure was 2.3 out of 5, with only 13% of participants answering all questions correctly. There was no correlation between grade of radiologist and likelihood of a correct answer, nor was there a correlation between feeling confident and knowing the correct life support procedure. Flaws in training were highlighted, with only 61% of radiologists having attended a life support course in the last 4 years. Those who had attended a course more recently were more likely to perform cardiopulmonary resuscitation correctly (p = 0.02). Individuals who were confident in initialising cardiopulmonary resuscitation were more likely to be confident that other members of staff could assist them (p = 0.028). This study emphasises the need for regular life support training and the need to alter the attitude of radiologists, who must consider it their role to initiate effective life support in the radiology environment.

Congenital talipes equinovarus in Papua New Guinea: a difficult yet potentially manageable situation.

Reports in the literature have suggested a high incidence of congenital deformities, including congenital talipes equinovarus (CTEV), in many Pacific Islands. This study performed a retrospective analysis of cases of CTEV in an isolated region of Papua New Guinea over a 2-year period. Data was collected on the incidence of CTEV, together with an analysis of initial treatment and outcome. The incidence of CTEV was 2.7 per 1,000 live births per year. A peak incidence of CTEV births in September suggested that maternal anaemia secondary to malaria was a significant risk factor. Good functional outcome was confirmed in only 20% of cases following initial treatment. The authors suggest the Ponseti method as a realistic option for treating CTEV in this region and that it could be instigated with minimal resources and training.

Screening for dementia in primary care: a review of the use, efficacy and quality of measures.

BACKGROUND: Despite evidence that early identification of dementia is of growing policy and practice significance in the U.K., limited work has been done on evaluating screening measures for use in primary care. The aim of this paper is to offer a clinically informed synthesis of research and practice-based evidence on the utility, efficacy and quality of dementia screening measures. METHOD: The study has three elements: a review of research literature, a small-scale survey of measures employed in three primary care trusts, and a systematic clinical evaluation of the most commonly used screening instruments. The study integrates data from research and clinical sources. RESULTS: The General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS), and the Mini-Cognitive Assessment Instrument (Mini-Cog) were found to be brief, easy to administer, clinically acceptable, effective, and minimally affected by education, gender, and ethnicity. All three have psychometric properties similar to the Mini-mental State Examination (MMSE). CONCLUSIONS: Although the MMSE is widely used in the U.K., this project identifies the GPCOG, MIS and Mini-Cog as clinically and psychometrically robust and more appropriate for routine use in primary care. A coherent review of evidence coupled with an indepth evaluation of screening instruments has the potential to enhance ability and commitment to early intervention in primary care and, as part of a wider educational strategy, improve the quality and consistency of dementia screening.

The CORE-OM in an older adult population: psychometric status, acceptability, and feasibility.

There is a need to extend and test the feasibility and acceptability of mental health outcome measures in the older population (i.e., aged 65-100). We present data on the CORE-OM (Clinical Outcomes in Routine Evaluation-Outcome Measure) on a sample of 118 people aged 65-97 presenting for mental health treatment and 214 people aged 65-94 drawn from a non-clinical population. Results show the CORE-OM to be a reliable measure in both samples when the overall mean item is used but the reliability is not as high for the specific domains as psychometrically stable structures. The CORE-OM showed large overall differences between the non-clinical and clinical samples indicating that it is equally as sensitive to these differing populations across this older age band as with working-age adults. However, the norms for the clinical sample were consistently lower than the equivalent clinical norms for a working-age sample. These findings suggest that the collection and compilation of age-specific norms is crucial in ensuring that appropriately referenced norms are used rather than assuming that norms are generalizable across the whole adult life-span.

Pragmatic randomized trial of antenatal intervention to prevent post-natal depression by reducing psychosocial risk factors.

BACKGROUND: Social support theory and observational risk factor studies suggest that increased antenatal psychosocial support could prevent post-natal depression. We used empirical knowledge of risk and protective factors for post-natal depression not employed previously in order to develop and evaluate an antenatal preventive intervention. METHODS: We conducted a pragmatic randomized controlled trial in antenatal clinics. We screened 1300 primiparous women and 400 screened positive, 69 screen-positive women were untraceable or not eligible. Of 292 women who completed baseline assessment, 209 consented to randomization, of these 190 provided outcome data 3 months post-natally. 'Preparing for Parenthood', a structured antenatal risk factor reducing intervention designed to increase social support and problem-solving skills, was compared with routine antenatal care only. We compared the percentage depressed at 3 months after childbirth using the self-completion General Health Questionnaire Depression scale and Edinburgh Post-natal Depression Scale (EPDS), and the Schedules for Clinical Assessment in Neuropsychiatry a systematic clinical interview. RESULTS: Assignment to the intervention group did not significantly impact on post-natal depression (odds ratio for GHQ-Depression 1.22 (95% CI 0.63-2.39), P = 0.55) or on risk factors for depression. Forty-five per cent of the intervention group women attended sufficient sessions to be likely to benefit from intervention if effective. Attenders benefited no more than non-attenders. CONCLUSIONS: Prevention services targeting post-natal depression should not implement antenatal support programmes on these lines until further research has demonstrated the feasibility and effectiveness of such methods. The development of novel, low cost interventions effective in reducing risk factors should be completed before further trial evaluation.

Outcomes of time-limited psychotherapy in applied settings: replicating the Second Sheffield Psychotherapy Project.

In a replication and extension of the Second Sheffield Psychotherapy Project (SPP2), a collaborative psychotherapy project (CPP) was carried out at 3 sites within the National Health Service of the United Kingdom. Clients (N = 36) stratified at 3 levels of severity of depression were randomly assigned to one of 2 treatment approaches (psychodynamic-interpersonal or cognitive-behavioral) of 2 time-limited durations (8 or 16 sessions). Gains in both treatment approaches were approximately equivalent and were similar for CPP and SPP2 clients when measured at the end of treatment. However, CPP patients did not maintain their gains to the extent that the SPP2 clients did at 3-month and 1-year follow-up assessments. In the CPP, clients given 16 sessions showed a statistically significant advantage over clients given 8 sessions on some measures at some assessments; in the SPP2, similar effects were noted only among some subgroups of clients.

Tissue-specific expression of neural cell adhesion molecule (NCAM) may allow differential diagnosis of neuroblastoma from embryonal rhabdomyosarcoma.

The MSD1 region of neural cell adhesion molecule (NCAM) was originally described as being spliced into the 120-kDa isoform of NCAM isolated from muscle. The 105 bp region is inserted between exons 12 and 13 and actually consists of three separate exons, MSD1a, MSD1b and MSD1c of 15, 48, 42 bp, respectively. In addition, a further exons consisting of a single triplet has been designated MSD1d, making the full insert size 108 bp. As the MSD1 region was originally described as being selectively expressed in muscle tissue, we have investigated whether it is also present on tumours of rhabdoid origins and whether its presence can be used as the diagnostic marker to distinguish other small round cell tumours of childhood, such as neuroblastoma. Using a variety of human tumour cell lines, we demonstrated the presence of the MSD1 region on all rhabdomyosarcomas investigated. However, neuroblastoma cell lines only expressed subcompartments of the MSD1 region. The MSD1c exon was not spliced into the NCAM molecules isolated from any of the neuroblastoma cell lines investigated. On the basis of this finding, it appears that neuroblastoma and rhabdomyosarcoma can be distinguished by the expression of MSD1c mini-exon. Further studies are underway to attempt to define a monoclonal antibody that recognises the region, using mice immunised with synthetic peptides, and to confirm the finding using fresh biopsy material.

Vase mini-exon usage by NCAM is not restricted to tumours of neuroectodermal origin.

The neural cell adhesion molecule (NCAM) plays an important role in normal development. Many variants of NCAM are generated through post-transcriptional and post-translational modifications. These variants are tissue-specific and their expression is developmentally regulated. NCAM is also re-expressed in a number of human tumours, including neuroblastoma, rhabdomyosarcoma, Wilms' tumour and Ewing's sarcoma. We have characterized the NCAM variants associated with rhabdomyosarcoma. Polysialylated NCAMs are present in this tumour and, after neuraminidase treatment, they resolve into 2 bands of 140 and 120 kDa. These data were corroborated by Northern-blot analysis where mRNA species of 6.7 and 5.5 kb are detected. These mRNA code for the 140- and 120-kDa NCAM proteins respectively. PCR analysis shows that the previously described VASE mini-exon is also present in NCAM found in rhabdomyosarcoma. The VASE mini-exon, spliced at exon 7-8 junctions, has previously been detected in neural and heart NCAM, as well as in NCAMs found in human small-cell lung carcinoma (SCLC). DNA sequencing confirmed that the VASE mini-exon in rhabdomyosarcoma is identical to that found in neuroblastoma and SCLC.

The California Psychotherapy Alliance Scales: a pilot study of dimensions and elements.

The reliability and clinical utility of the rater form of the California Psychotherapy Alliance Scales (CALPAS-R) was investigated on a sample of 12 one-hour audiotapes representing differing therapeutic dyads and sampled from sessions two to six of a relationship-oriented (exploratory) therapy within pilot cases of a large outcome study. Both global dimensions and element-based ratings were used to test the feasibility of employing the elements as a way of obtaining a finer-grained analysis of the therapeutic alliance. Results are reported in terms of the interrater reliability of the dimensions and elements, and show element ratings to yield dimensional measures similar or superior to global ratings in reliability. In addition, CALPAS-R ratings were analysed in conjunction with client ratings of session depth and smoothness as well as helpfulness.

Splicing of the VASE exon of neural cell adhesion molecule (NCAM) in human small-cell lung carcinoma (SCLC).

Expression of the neural cell adhesion molecule (NCAM) on small-cell lung carcinoma (SCLC) cell lines and tumour tissue has been investigated. Cell lines were found to express highly sialylated NCAM. Neuraminidase treatment revealed the presence of the 140- and 120-kDa isoforms with differential expression of a 95-kDa protein. Similar data were obtained with SCLC tumour tissues. These results were corroborated by Northern blotting where mRNA of 6.7 and 5.5 kb coding for the 140- and 120-kDa isoforms, respectively, were identified. In a few tumours, a weaker band of 7.4-kb mRNA coding for the 180-kDa NCAM was also identified. This result could not be confirmed biochemically due to shortage of material. Finally, a 5-kb transcript was identified in all SCLC samples examined. The NCAM isoform coded by this mRNA remains unknown. Using the polymerase chain reaction (PCR), we have demonstrated the presence of the VASE mini-exon in some isoforms of SCLC NCAM. The VASE mini-exon sequence in human SCLC differs from the published murine sequence by only one base change. This substitution does not result in altered amino-acid sequence.