Optimal hepatobiliary scintigraphy for gallbladder dyskinesia.

BACKGROUND: The accuracy of hepatobiliary scintigraphy to assess gallbladder function remains controversial. National supply shortages of pharmaceutical-grade cholecystokinin led to the use of an oral fatty meal to stimulate gallbladder contraction during hepatobiliary scintigraphy. The goal of this study was to compare the predictive indices of cholecystokinin and fatty meal ingestion for stimulation of gallbladder contraction. METHODS: Patients evaluated with hepatobiliary iminodiacetic acid scan from 2014 to 2017 were reviewed and grouped based on testing stimulant (fatty meal versus cholecystokinin). Patients who later underwent cholecystectomy were selected for analysis. Hepatobiliary iminodiacetic acid results were correlated with surgical pathology and postoperative resolution of symptoms. Two-way statistical analysis was performed. RESULTS: A total of 359 patients underwent hepatobiliary iminodiacetic acid scan followed by cholecystectomy for biliary dyskinesia. Patients who received fatty meal stimulant (n = 86) were compared to those that received cholecystokinin (n = 273). Mean gallbladder ejection fraction during hepatobiliary iminodiacetic acid was 38% and 44% for the cholecystokinin and fatty meal groups, respectively, P = .073. Predictive metrics were not statistically different between groups with regard to pathology, symptomatic improvement, or accuracy. Symptomatic resolution (cholecystokinin-hepatobiliary iminodiacetic acid 78%, fatty meal-hepatobiliary iminodiacetic acid 68%; P = 0.058) and specificity (cholecystokinin-hepatobiliary iminodiacetic acid 26%, fatty meal-hepatobiliary iminodiacetic acid 44%, P = 0.417) were comparable in both testing groups. CONCLUSION: Stimulation of gallbladder contraction with a fatty meal during hepatobiliary iminodiacetic acid testing is a more affordable and reliable alternative to cholecystokinin for patients undergoing evaluation for gallbladder dysmotility.

Hepatic Steatosis After Neoadjuvant Chemotherapy for Pancreatic Cancer: Incidence and Implications for Outcomes After Pancreatoduodenectomy.

BACKGROUND: This study aimed to determine the incidence of new onset hepatic steatosis after neoadjuvant chemotherapy for pancreatic cancer and its impact on outcomes after pancreatoduodenectomy. METHODS: Retrospective review identified patients who received neoadjuvant chemotherapy for pancreatic adenocarcinoma and underwent pancreatoduodenectomy from 2013 to 2018. Preoperative computed tomography scans were evaluated for the development of hepatic steatosis after neoadjuvant chemotherapy. Hypoattenuation included liver attenuation greater than or equal to 10 Hounsfield units less than tissue density of spleen on noncontrast computed tomography and greater than or equal to 20 Hounsfield units less on contrast-enhanced computed tomography. RESULTS: One hundred forty-nine patients received neoadjuvant chemotherapy for a median of 5 cycles (interquartile range (IQR), 4-6). FOLFIRINOX was the regimen in 78% of patients. Hepatic steatosis developed in 36 (24%) patients. The median time from neoadjuvant chemotherapy completion to pancreatoduodenectomy was 40 days (IQR, 29-51). Preoperative biliary stenting was performed in 126 (86%) patients. Neoadjuvant radiotherapy was delivered to 23 (15%) patients. Female gender, obesity, and prolonged exposure to chemotherapy were identified as risk factors for chemotherapy-associated hepatic steatosis. Compared with control patients without neoadjuvant chemotherapy-associated hepatic steatosis, patients developing steatosis had similar rates of postoperative pancreatic fistula (8% (control) vs. 4%, p = 0.3), delayed gastric emptying (8% vs. 14%, p = 0.4), and major morbidity (11% vs. 15%, p = 0.6). Ninety-day mortality was similar between groups (8% vs. 2%, p = 0.08). CONCLUSION: Hepatic steatosis developed in 24% of patients who received neoadjuvant chemotherapy but was not associated with increased morbidity or mortality after pancreatoduodenectomy.

Can FDG-PET be used to predict growth of stage I lung cancer?

AIM: To determine the relationship between the metabolic activity measured by 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET) and computed tomography (CT)-derived tumour growth rates for stage 1 lung cancer. METHODS: Stage I lung cancer patients at our institution who underwent FDG PET, and who had at least two pre-treatment chest CT examinations (n=51), were retrospectively identified. Metabolic activity was defined by maximum lesion standardized uptake value (SUV) and maximum lesion-to-mean background activity (LBR). Growth rates were determined from serial CT volume measurements and the doubling time (DT) was calculated. Tumour growth rates were divided into rapid (DT<180 days), intermediate (DT=180-270 days), and slow (DT>270 days) groups. RESULTS: Rapid, moderate, and slow DT were seen in 22, 19, and 10 patients, respectively. Means (standard deviations) of SUV in the three groups (from rapid to slow growth rate) were 8.2 (4.8), 5.5 (4.5), and 2.2 (1.1), respectively and of LBR were 22.7 (10.1), 15.1 (12.6), and 6 (2.6), respectively. There was a significant relationship between SUV and DT (p<0.05), as well as between LBR and DT (p<0.05). CONCLUSIONS: For stage I lung tumours, there is a significant relationship between growth rates, as measured by serial CT examinations, and the initial pre-treatment metabolic activities, as measured by FDG uptake. This suggests that in patients in whom it is difficult to decide on the aggressiveness on treatment, FDG-PET may be used as additional prognostic tool for determining management.

Positron-emission tomography and computed tomography of cystic pancreatic masses.

AIM: To investigate the sensitivity and specificity of computed tomography (CT), positron-emission tomography (PET), and both methods in combination, for determining whether cystic pancreatic tumours are malignant. MATERIALS AND METHODS: We retrospectively identified all patients with cystic pancreatic tumours who underwent separate PET and contrast-enhanced CT examinations within a 1-month interval. Tumours were classified as benign or malignant on CT (two radiologists, independently), PET [a reported standardized uptake value (SUV) of 2.5 was taken as the cut-off between benign and malignant], and with PET and CT images together (two radiologists, in consensus). Readers were blinded to pathological and other radiological findings. Mean patient age and lesion size were compared between benign and malignant groups using Student's t-test. For CT findings, odds ratios (OR) and confidence intervals (CI) were calculated using multivariate logistic regression models. For CT, PET, and the combined images, sensitivities and specificities were calculated, and compared between groups using Fisher's exact test. RESULTS: Thirty patients were identified. The best CT predictor of malignancy was size; mean diameter was 2.3 cm (benign) and 4.1 cm (malignant) (p<0.01); OR was 2.80 (95% CI, 1.26-6.20). Sensitivities of CT, PET and combined PET/CT images were 67-71, 57, and 86%, respectively. PET/CT was more sensitive than PET (p<0.01) or CT (p<0.01) alone. Specificities of CT, PET, and combined PET/CT images were 87-90, 65, and 91%, respectively. PET/CT was more specific than PET (p<0.01) but not CT (p>0.05). CONCLUSION: The sensitivity and specificity of combined PET and CT images is comparable with or superior to either CT or PET alone in determining malignancy in cystic pancreatic lesions.

The operationalized psychodynamic diagnostics system: clinical relevance, reliability and validity.

In this paper, we present a multiaxial system for psychodynamic diagnosis, which has attained wide usage in Germany in the last 10 years. First we will discuss the 4 operationalized psychodynamic diagnostics (OPD) axes: illness experience and treatment assumptions, relationships, mental conflicts, and structure, then clinical applications will be outlined. Focus psychodynamic formulations can be employed both with inpatients and with outpatients. Studies show good reliability in a research context and acceptable reliability for clinical purposes. Validity will be separately summarized as content, criterion, and construct validity. Validity studies indicate good validity for the individual axes. Numerous studies on the OPD indicate areas of possible improvement, for example for clinical purposes the OPD should be more practically formulated.

Benefits of routine use of coronal and sagittal reformations in multi-slice CT examination of the abdomen and pelvis.

AIM: To evaluate the usefulness of coronal and sagittal reformations from isotropic abdomino-pelvic computed tomography (CT) examinations. METHODS: Fifty consecutive abdomino-pelvic CT examinations were reconstructed into two sets of axial source images: 0.9 mm section width with 0.45 mm reconstruction interval (isotropic) and 4 mm section width with 3 mm reconstruction interval. The isotropic dataset was reformatted into coronal and sagittal stacks with 4 mm section widths. Three readers independently reviewed the three image sets with 4 mm section widths. The coronal and sagittal reformations were compared with the axial images, in the same sitting, for depiction of lesions in various abdominal organs. RESULTS: There was better visualization of lesions in the liver, kidneys, mesentery, lumbar spine, major abdominal vessels, urinary bladder, diaphragm and hips on the coronal reformations compared with source axial images (p<0.05). Sagittal reformations scored better than axial source images for showing lesions in the liver, thoracic spine, abdominal vessels, uterus, urinary bladder, diaphragm and hips (p<0.05). The coronal and sagittal series showed significant additional information in 23 and 17% of patients, respectively. CONCLUSION: Radiologists should consider the routine review of at least one additional plane to the axial series in the interpretation of abdomino-pelvic CT studies.

Chemotherapy-induced sclerosing cholangitis.

AIM: To review the computed tomography (CT), magnetic resonance imaging (MRI) and cholangiographic findings of chemotherapy-induced sclerosing cholangitis (CISC). METHODS: Between January 1995 and December 2004, 11 patients in the endoscopic retrograde cholangiography database were identified with CISC. Twelve CT, four MRI, 69 endoscopic and nine antegrade cholangiographic studies in these patients were reviewed. Serial change in appearance and response to endoscopic treatment were recorded. RESULTS: CISC showed segmental irregular biliary dilatation with strictures of proximal extrahepatic bile ducts. The distal 5cm of common bile duct was not affected in any patient. CT and MRI findings included altered vascular perfusion of one or more liver segments, liver metastases or peritoneal carcinomatosis. Biliary strictures needed repeated stenting in 10 patients (mean: every 4.7 months). Cirrhosis (n=1) or confluent fibrosis (n=0) were uncommon findings. CONCLUSION: CISC shares similar cholangiographic appearances to primary sclerosing cholangitis (PSC). Unlike PSC, biliary disease primarily involved ducts at the hepatic porta rather than intrahepatic ducts. Multiphasic contrast-enhanced CT or MRI may show evidence of perfusion abnormalities, cavitary liver lesions, or metastatic disease.

Evaluation of prospective living renal donors for laparoscopic nephrectomy with multisection CT: the marriage of minimally invasive imaging with minimally invasive surgery.

Laparoscopic technique for excision of a kidney from a living donor has advantages over conventional open surgery, but operative visibility and surgical exposure are limited. Preoperative multisection computed tomography (CT) can provide necessary anatomic information in a minimally invasive procedure. A three-phase examination is suggested: (a) imaging from the top of the kidneys to the pubic symphysis with a section width of 2.5 mm and no contrast medium, (b) scanning of the kidneys and upper pelvis during the arterial phase of enhancement with a section width of 1.0 mm, and (c) scanning of the kidneys and upper retroperitoneum during the nephrographic phase of enhancement with a section width of 1.0 mm. Emphasis in this article is placed on analysis of the venous anatomy because most radiologists are unfamiliar with the anatomic variations. Conventional radiography of the abdomen and pelvis is performed after CT to evaluate the collecting system and ureters and to provide a lower total radiation dose than if CT were used. Of several postprocessing techniques that may be used, the authors prefer maximum intensity projection for arterial evaluation and multiplanar reformatting for venous evaluation.

How accurate is helical CT volumetric assessment in renal tumors?

The aim of this study was to evaluate the accuracy of tumor size measurement on CT studies of renal tumors. Sixteen patients with tumors of the kidneys were imaged by helical CT prior to surgery. Assessment of tumor volume was made by two radiologists on the CT images with the summation of area method, then compared with the resected specimen water displacement volume. Intra- and interobserver agreement for CT measurements were also assessed. There were substantial differences between the CT volume measurement compared with the tumor post-operative volume (mean of differences 30.05+/-91.6, 95%CI: 31.45-91.55). The inter- and intraobservation agreements for tumor measurement by CT was found to be satisfactory (ANOVA: p < 0.0001; t-test: p < 0.05). The CT volumetric measurement by area summation is a method with good inter- and intraexamination reproducibility but not an accurate technique for tumor volume assessment.

Increasing examiner involvement in an objective structured clinical examination by integrating a structured oral examination.

INTRODUCTION: The role of physician examiners in an objective structured clinical examination (OSCE) is relatively passive. In our institution examiners criticized the passive nature of their role. This study evaluates the reliability and viability of adding a structured oral examination to an OSCE. METHOD: Ten 24-minute stations consisted of three parts. Part I: 12 minutes-patient encounter. Part II: 6 minutes-oral presentation covering findings, differential diagnosis, and management plan. Part III: 6 minutes-structural oral examination (SOE), containing 5 predetermined questions. RESULTS: Over 6 consecutive days, 72 graduates were assessed. Overall average score: 72.02 (SD 5.05); reliability 0.84. Part I of the OSCE average score: 69.2 (SD 7.4); reliability 0.69. Part II oral presentation average score 64 (SD 5.8) reliability 0.87. SOE average score 77.7 (SD 6.3); reliability 0.64. Eighty-nine percent of the examiners indicated satisfaction with the new format. CONCLUSIONS: The SOE was a reliable component of an OSCE and contributed to the overall reliability. Examiners reported a higher degree of satisfaction with the examination.

Using a video conference to teach clinical clerks in a one-week cardiothoracic clerkship.

BACKGROUND: Students report that their operating room experience during specialty clerkships has been less than satisfactory. To deal with this and other problems in a 1-week cardiothoracic clerkship, a video conference system was introduced. METHODS: Three teaching strategies were used: a seminar dealing with the disease process and a description of the operative procedure; bedside pre-operative assessment of the patient, with a tutor; and a live video conference of the operation. The tutor observed the live video presentation with the students, initiating interaction with the operating surgeon and facilitating questions and discussion. Video quality was maintained by one camera connected to the headlight of the surgeon and another placed above the operative field. RESULTS: Both students and staff expressed a high degree of satisfaction in debriefing sessions and on a standard faculty evaluation form. CONCLUSIONS: This innovation in surgery specialty teaching contributes to the acquisition of educational objectives in the operating room and in a cardiothoracic clerkship.

[Mammary gland carcinoma treated by large-dose medroxyprogesterone acetate of which pulmonary metastases disappeared and a selection of hormone, chemoimmunological treatment].

A patient who underwent radical mastectomy was treated by tegafur and tamoxifen. Pulmonary metastases were found four months after operation. Lymphokine activated killer (LAK) and auxiliary interleukin-2 (IL-2) administration was performed, with no change (NC). However, administration of large-dose medroxyprogesterone acetate induced complete disappearance of pulmonary metastases after more than nine months.

[Possibilities of whole-body hyperthermia]. / Möglichkeiten der Ganzkörperhyperthermie.

Significant modifications in tissues, even death of cells, are caused by hyperthermia of few degrees centigrade. The extent of these modifications depends on the temperature applied. In a whole-body treatment, only not directly cytotoxic temperatures can be tolerated. The authors compare the methods of induction of whole-body hyperthermia with respect to expenditure, temperature applied, and side effects. Total-body hyperthermia aims at a reinforcement of other tumoricide therapies (radiotherapy, chemotherapy). - A pilot study performed with patients suffering from microcellular bronchial carcinomas, extensive disease, showed that the results of ACO and total-body hyperthermia (41 degrees C) are encouraging as compared with single ACO therapy: complete remission 8/15, partial remission 5/15, no change and progressive disease 2/15, 53-week survival rate 0,5, one-year survival rate 0,53, two-year survival rate 0,18.