Cecal carcinoma: initially diagnosed as Crohn's disease on small bowel follow-through.

Lesions in the terminal ileum are often difficult to visualize on routine small bowel follow-through (SBFT) and may require further investigation to rule out associated abnormalities in the ileocecal valve or cecum. This may be done by peroral pneumocolon at the same sitting as the SBFT, but may require bowel preparation. Two cases of cecal carcinoma that were initially diagnosed as Crohn's disease on SBFT without further investigation of the cecum are reported.

Computer measurement of oral movement in swallowing.

This article describes a computer program that automatically detects and tracks small metal markers affixed to a subject's tongue and teeth in fluoroscopic image sequences of swallowing. The program, written in Microsoft Visual C++ using Windows NT 4.0 and the SAVANT imaging toolkit, involves marker detection and marker tracking. Marker detection is done by template matching. A generic marker template was designed by extracting the grayvalues of pixels within an imaged marker. Template matching with a weighted center-of-mass calculation determined marker location with subpixel accuracy. Marker tracking employed a nearest-neighbor algorithm since (a) the movement of each marker was less than the distance between any two markers and (b) marker trajectories did not overlap. Effects of head motion were attenuated by computing tongue trajectories with respect to a constant frame of reference given by reference markers on the maxillary teeth. Motions were converted from pixels/frame to millimeters/second using a calibration ring secured to the subject's neck. Results for several image sequences showed that our program performs very well in terms of marker detection and trajectory determination. Comparison of automatic and manual tracking of the same image sequences indicated a high degree of correspondence. Automatic tracking of oral movement by computer is a useful tool in kinematic studies of swallowing.

Oropharyngeal dysphagia in esophageal cancer before and after transhiatal esophagectomy.

Although dysphagia is the predominant symptom of esophageal cancer, the nature of the swallowing deficit remains unclear, particularly regarding an oropharyngeal motor component. The present study examined the oropharyngeal swallow in patients with esophageal cancer before and following transhiatal esophagectomy. Videofluoroscopic data were obtained from ten patients with esophageal cancer before and following transhiatal esophagectomy as they swallowed 2-, 5-, and 10-cc aliquots of liquid and puree, and 0.5 and 1 tsp of solid. Each swallow was rated on 36 parameters by three independent judges. Swallow-related hyoid bone movement, computed from digitized segments of the videofluoroscopic data, was compared pre- and postsurgically. All patients showed at least mild abnormality of the oropharyngeal swallow preoperatively. Abnormalities involved all stages of swallowing in nine of the ten patients; however, the oral preparatory/oral stage was relatively more impaired than the pharyngeal stage in the majority of patients. Postsurgically, all patients exhibited at least a mild oropharyngeal swallowing impairment. New or increased postoperative deficits involved the pharyngeal stage of swallowing, whereas oral stage abnormalities were generally improved or unchanged following surgery. Swallow-related hyoid kinematics were highly variable both before and following surgery. Anterior hyoid bone excursion was significantly reduced postoperatively in one patient and significantly increased in one patient. Patients with esophageal cancer exhibit oropharyngeal dysphagia, with different profiles of abnormality before and following esophagectomy.

Stereotaxic core needle biopsy of breast microcalcifications obtained using a standard mammography table with an add-on unit.

OBJECTIVE: To demonstrate the reliability of stereotaxic biopsy of indeterminate microcalcifications using a standard mammography table with an add-on unit. METHODS: In 121 cases of indeterminate microcalcifications, core biopsy was performed using a standard mammography table with an add-on stereotaxic unit. Microcalcifications were identified on radiography of core specimens. RESULTS: Microcalcifications and a definitive histologic diagnosis were obtained in 112 core biopsies (92.6%), with no significant complications. In 23 lesions frank malignancy was diagnosed, and all of these diagnoses were confirmed on surgery. Pathologic examination suggested carcinoma in 4 lesions, and open biopsy confirmed malignancy in 3 of these cases. Four lesions showed atypical ductal hyperplasia. Benign disease was diagnosed in 81 lesions, of which 78 remained stable on mammographic follow-up (mean 16 months later) and 3 were subjected to surgical biopsy (of which 1 was malignant and 2 were benign). Nine cases were technically unsatisfactory because microcalcifications were not sampled. CONCLUSION: Stereotaxic core biopsy performed with an add-on unit is a safe and reliable technique for biopsy of indeterminate microcalcifications. For successful biopsy, microcalcifications must be harvested. Pathologic results should be correlated with mammographic findings. The accuracy rate compares favourably with results reported using prone biopsy tables. In an era of cost containment, this alternative to prone biopsy tables could result in significant savings in terms of capital investment and use of hospital rooms. In this study, surgical biopsy could have been avoided in 64.5% of cases.

Technique for placement of non-end-hole nasojejunal feeding tubes.

The authors describe a simple method for placing a non-end-hole nasojejunal feeding tube with fluoroscopic guidance by using a multipurpose catheter and guide wire. The method was used successfully in 12 patients with no side effects or complications.

A randomized controlled trial to compare the efficacy of cyclical parathyroid hormone versus cyclical parathyroid hormone and sequential calcitonin to improve bone mass in postmenopausal women with osteoporosis.

Short cycles of human (h) PTH-(1-34) may have an anabolic effect to increase bone mass in patients with osteoporosis. As PTH also stimulates bone resorption, it is theoretically possible to enhance the anabolic effects of PTH by using a sequential antiresorptive agent in the treatment cycle. To test this hypothesis, 30 women with osteoporosis, aged 67 +/- 8 yr, completed a 2-yr protocol that comprised 28-day courses of hPTH-(1-34) (800 U) given by daily sc injections; each course was repeated at 3-month intervals. By random allocation, patients either received sequential calcitonin (CT) immediately following the cycle of hPTH-(1-34) (75 U/day, sc; PTH + CT; n = 16) or placebo CT (PTH alone; n = 14) for 42 days. Baseline bone mineral density (BMD) at the lumbar spine site revealed t scores of -3.7 +/- 1.2 (+/-SD) for the PTH alone group and -3.0 +/- 1.4 for the PTH + CT groups, who had 2.0 +/- 2.3 and 1.8 +/- 2.4 vertebral fractures, respectively, at entry to the study. At the end of the 2 yr, the lumbar spine BMD increased from 0.720 +/- 0.130 to 0.793 +/- 0.177 g/cm2 (10.2%) in the PTH group and from 0.760 +/- 0.168 to 0.820 +/- 0.149 g/cm2 (7.9%) in the PTH + CT group. These changes were significant over time in both groups (P < 0.001). Although the final 2-yr lumbar spine BMD was not significantly different between the two treatment groups, those patients receiving sequential CT injections gained bone mass at a consistently slower rate. Changes in BMD at the femoral neck averaged +2.4% and -1.8% in the PTH and PTH + CT groups, respectively, neither of which was significant. In the group receiving only cyclical hPTH-(1-34), the observed 2-yr vertebral fracture incidence was 4.5 compared to 23.0/100 patient yr in the PTH + CT group (P = 0.078). During the first two cycles, changes in biochemical markers of bone formation (serum total alkaline phosphatase, bone-specific alkaline phosphatase, and osteocalcin) and bone resorption (fasting urinary hydroxyproline and N-telopeptide excretion) were significantly increased over pretreatment values after 28 days of hPTH-(1-34) injections (P < 0.05 to P < 0.01 for both groups). Even end of cycle values remained elevated over the study baseline across time (P < 0.01). There were no significant differences for any outcome parameter between the two treatment groups. We conclude that short cycles (28 days) of daily hPTH-(1-34) injections result in significant increases in lumbar spine BMD, without significant changes in cortical bone mass at the femoral neck. Very low incident vertebral fracture rates were documented over 2 yr. However, there is no evidence that sequential antiresorptive therapy with CT is of any benefit over that conferred by cyclical PTH alone.

Recurrent superior mesenteric artery (Wilkie's) syndrome: a case report.

Superior mesenteric artery syndrome (SMAS) is a rare condition. The diagnosis is usually made by exclusion. A previously healthy 20-year-old woman who had recurrent SMAS is described. Diagnosis of the condition was difficult. Initially, small-bowel enteroclysis, upper gastrointestinal series and endoscopy, biopsy of gastric and duodenal mucosa, abdominal computed tomography (CT) and ultrasonography were used to make the diagnosis. Abdominal CT suggested pancreatitis causing compressive obstruction of the superior mesenteric artery. Conservative management was helpful at first, but cramping and projectile emesis recurred. Upper gastrointestinal series suggested duodenal distension and a filling defect in the region of the superior mesenteric artery. Repeat endoscopy showed a lateral pulsatile compression in the region of the distal duodenum and SMAS was diagnosed. Medical therapy was not helpful so duodenojejunostomy was carried out. The operation was successful and the patient was symptom-free for 1 year, when the syndrome recurred, with symptoms of periumbilical pain, intermittent episodes of vomiting and loose stools. At reoperation the duodenojejunal anastomosis was found to be displaced to the left of the superior mesenteric artery pedicle causing recurrent obstruction. The duodenojejunostomy was converted to a Roux-en-Y duodenojejunostomy. The patient has since remained well. A MEDLINE search of the literature for the period 1961 to October 1994 revealed that there were no reported cases of a recurrence of SMAS in an otherwise healthy adult patient. In spite of the difficulty in diagnosing this condition, heightened awareness can lead to early diagnosis and avoid unnecessary suffering for the patient.

Biliary sludge: a risk factor for 'idiopathic' pancreatitis?

Idiopathic acute pancreatitis is common. Recent evidence suggests that biliary sludge may be the etiology in many patients with this disorder. In this case-control study, admission ultrasound examinations of patients with idiopathic pancreatitis, patients with acute alcohol-associated pancreatitis and a control group were compared. Biliary sludge was found in seven of 21 patients (33%) with idiopathic pancreatitis, two of 25 (8%) with acute alcohol-associated pancreatitis and one of 63 controls (1.6%). Comparison of idiopathic pancreatitis patients with both acute alcohol-associated pancreatitis patients and controls for the presence of sludge revealed odds ratios of 31.0 (95% CI 3.5 to 273) and 5.8 (95% CI 1.1 to 32.0), respectively. Also observed was a trend towards higher levels of liver enzymes, bilirubin and amylase in patients with idiopathic pancreatitis who had sludge identified. This study provides further evidence linking biliary sludge with a significant proportion of patients with idiopathic acute pancreatitis.

The relative diagnostic impact of screening mammography and physical examination.

OBJECTIVE: To determine the relative diagnostic impact of screening mammography and physical examination. METHODS: Data from the first 3.5 years of operation of the Ontario Breast Screening Program's regional facility in London were analyzed. A total of 14,646 women underwent screening, which involved both mammography and physical examination. The authors examined the relative contribution of the two types of examination according to detection rate, as well as size, stage and histologic type of the identified breast cancers. RESULTS: In total, 135 cancers were detected. Mammography revealed 131 (97.0%) of all cancers, whereas physical examination revealed only 66 (48.9%). Furthermore, the lesions detected by mammography were generally smaller and found at an earlier stage. CONCLUSION: Although most other screening programs involve mammography only, physical examination did make a contribution to the detection rate at the authors' facility. However, in an era of declining resources and cost containment, critical analysis of the value added by physical examination is necessary.

Resident training in breast imaging in Canada: current status.

The authors evaluated the current status of resident training in breast imaging in Canada to provide baseline data for guidelines on the amount and the nature of training necessary. Information was obtained, by means of a questionnaire or a telephone interview, from the directors of all 16 radiology residency programs and the 58 radiology residents in their final year at the time of the study. All programs offer training in breast imaging; the training is mandatory in 11 (69%) and elective in 5 (31%). Of the 58 residents, 52 had had some training in breast imaging at the time of the study. Of these, 24 (46%) had spent a period averaging 3.9 weeks exclusively on breast imaging. Forty-one percent of residents felt that the duration of their breast imaging training was too short, and 35% felt that they could not practise mammography independently after their rotation. The authors found that training in breast imaging across the country is highly variable. Although this training is being upgraded in many programs, deficiencies remain. Guidelines are needed to ensure a minimum standard for training in breast imaging.

Gastroduodenal involvement in chronic granulomatous disease of childhood.

Obstruction of the gastric outlet as a complication of chronic granulomatous disease (CGD) is uncommon. The usual findings in a barium examination of the upper gastrointestinal tract are irregular antral mucosal folds and antral narrowing. There is typically a sharp demarcation of the affected area from the normal proximal stomach. The authors report a case of CGD of childhood in which there was diffuse gastric involvement with extension into the duodenal cap. The patient recovered with conservative therapy after a diagnostic exploratory laparotomy.

Adenocarcinoma of the pancreatic ducts: comparative evaluation with CT and MR imaging at 1.5 T.

A prospective comparison of computed tomography (CT) and magnetic resonance (MR) imaging at 1.5 T was performed in 50 patients with the suspected diagnosis of pancreatic carcinoma. CT scans were obtained before and after administration of contrast material in 41 of 50 patients (82%); 34 of 41 postcontrast scans (83%) were obtained with dynamic CT. MR images were interpreted without knowledge of the results of CT, ultrasound, cholangiography, or endoscopic retrograde cholangiopancreatography in 48 patients (96%). Surgical correlation of findings at CT and MR imaging was performed in 24 patients (48%) at laparotomy and in two patients (4%) at autopsy. On T1-weighted MR images, relatively diminished signal intensity of tumor compared with that of the adjacent pancreas was a consistent finding. MR imaging proved superior to CT in identification of pancreatic carcinoma (particularly in smaller intrapancreatic tumors), peripancreatic extension, vascular and portal vein invasion, and duodenal invasion. These results suggest that MR imaging of the pancreas is superior in many instances to CT in preoperative evaluation of pancreatic carcinoma.

Acquired cystic disease of the kidney in patients on hemodialysis.

Twelve adult patients undergoing hemodialysis for chronic renal failure due to noncystic causes were examined with ultrasonography to assess renal size and cystic changes. Seven of these were examined again one year later. Acquired cystic disease of the kidney was found to be present in ten patients and showed a direct relationship with duration of dialysis. This disease is not a static condition and may show progression or regression over time.