Prospective cohort study comparing transient EUS guided elastography to EUS-FNA for the diagnosis of solid pancreatic mass lesions.

BACKGROUND: Semiquantitative EUS-elastography has been introduced to distinguish between malignant and benign pancreatic lesions. This study investigated whether semiquantitative EUS-guided transient real time elastography increases the diagnostic accuracy for solid pancreatic lesions compared to EUS-FNA. PATIENTS AND METHODS: This single centre prospective cohort study included all patients with solitary pancreatic lesions on EUS during one year. Patients underwent EUS-FNA and semiquantitative EUS-elastography during the same session. EUS and elastography results were compared with final diagnosis which was made on the basis of tissue samples and long-term outcome. RESULTS: 91 patients were recruited of which 68 had pancreatic malignancy, 17 showed benign disease and 6 had cystic lesions and were excluded from further analysis. Strain ratios from malignant lesions were significantly higher (24.00; 8.01-43.94 95% CI vs 44.00; 32.42-55.00 95% CI) and ROC analysis indicated optimal cut-off of 24.82 with resulting sensitivity, specificity and accuracy of 77%, 65% and 73% respectively. B-mode EUS and EUS-FNA had an accuracy for the correct diagnosis of malignant lesions of 87% and 85%. When lowering the cut-off strain ratio for elastography to 10 the sensitivity rose to 96% with specificity of 43% and accuracy of 84%, resulting in the least accurate EUS-based method. This was confirmed by pairwise comparison. CONCLUSION: Semiquantitative EUS-elastography does not add substantial value to the EUS-based assessment of solid pancreatic lesions when compared to B-mode imaging.

Consistency and completeness of reported outcomes in randomized trials of primary immunosuppression in kidney transplantation.

Inconsistent and incomplete outcome reporting may make estimates of treatment effects from published randomized trials unreliable. We aimed to determine outcome reporting practices and source of differences in reporting quality among randomized trials of primary immunosuppression in kidney transplantation. We searched the Cochrane Renal Group's Specialized Register, 2000-2012, specified four core outcomes we expected trials to report, and recorded if and how completely each was reported. We identified 179 trials. One hundred sixty-eight (94%) reported death, 145 (81%) as number dead and 119 (66%) as time to death. One hundred sixty-five (92%) reported graft loss, 158 (88%) as number with graft loss and 127 (71%) as time to graft loss. One hundred twenty-one (68%) reported creatinine and 114 (64%) estimated GFR (eGFR). One hundred forty-one (79%) provided complete reports of number dead, 95 (53%) censored and 99 (55%) uncensored number with graft loss. Seventy-three (41%) provided complete reports of time to death, 67 (37%) censored and 31 (17%) uncensored time to graft loss. Complete reporting of graft function was infrequent: 62 (35%) eGFR and 50 (28%) creatinine. All four outcomes were reported in any form in 61 (34%) and completely in 28 (16%) trials. No single trial or journal characteristic was consistently associated with complete outcome reporting. Outcome reporting in kidney transplant trials is inconsistent and frequently incomplete, and published estimates of treatment effects may be unreliable.

Renal medicine in the 'real world'.

The Renal Symposium was held on 12 October 2012 at the Royal College of Physicians of Edinburgh.

Coexistent granulomatous vasculitis and leukaemia cutis in a patient with resolving herpes zoster.

An 80-year-old man presented with a 6-month history of indurated tender purple papules. These had coalesced to form plaques with some central scarring and a dermatomal distribution on the left arm, immediately following herpes zoster (HZ) infection at this site. The patient had a 5-year history of small lymphocytic lymphoma (SLL), which was being managed conservatively under a 'watch and wait' protocol. On histological examination of a skin biopsy, marked interstitial granulomas and prominent granulomatous vasculitis were seen, supporting the clinical impression of a post-HZ granulomatous reaction. In addition, there was a dense monoclonal small B-cell lymphocytic infiltrate indicating koebnerization by SLL (a finding that has not been reported previously with concurrent postherpetic granulomatous vasculitis). Although benign pseudolymphomas occur in postherpetic cases, this case shows that even in association with benign vasculitic features true lymphomas can occur. Furthermore, this case highlights the importance of immunocytochemistry, molecular studies and clinicopathological correlation.

Small bowel infarction in a patient with coeliac disease.

A 40 year old man was admitted with a four week history of intractable diarrhoea and abdominal pain. A clinical diagnosis of inflammatory bowel disease was supported by biopsies of colonic mucosa. There was no response to Mesalazine and over 12 days the patient became critically ill with diarrhoea, hypovolaemia, and peritonism. A laparotomy was performed and 130 cm of infarcted ileum was resected. Extensive investigations excluded thrombophilia and echocardiography excluded intracardiac thrombus. Postoperatively the patient continued to have diarrhoea and he was diagnosed with coeliac disease on the basis of positive antiendomysial and antitissue transglutaminase autoantibodies and duodenal histology. Although there is no proof that mesenteric infarction occurred as a direct consequence of coeliac disease, clinicians should be aware of this possibility.

Intraneuronal Abeta, non-amyloid aggregates and neurodegeneration in a Drosophila model of Alzheimer's disease.

We have developed models of Alzheimer's disease in Drosophila melanogaster by expressing the Abeta peptides that accumulate in human disease. Expression of wild-type and Arctic mutant (Glu22Gly) Abeta(1-42) peptides in Drosophila neural tissue results in intracellular Abeta accumulation followed by non-amyloid aggregates that resemble diffuse plaques. These histological changes are associated with progressive locomotor deficits and vacuolation of the brain and premature death of the flies. The severity of the neurodegeneration is proportional to the propensity of the expressed Abeta peptide to form oligomers. The fly phenotype is rescued by treatment with Congo Red that reduces Abeta aggregation in vitro. Our model demonstrates that intracellular accumulation and non-amyloid aggregates of Abeta are sufficient to cause the neurodegeneration of Alzheimer's disease. Moreover it provides a platform to dissect the pathways of neurodegeneration in Alzheimer's disease and to develop novel therapeutic interventions.

Accuracy of thin section magnetic resonance using phased-array pelvic coil in predicting the T-staging of rectal cancer.

Magnetic resonance (MR) imaging may contribute to staging rectal cancer and inform the decision regarding administration of pre-operative radiotherapy. The accuracy of MR has been debated. The aim of the present study was to determine the accuracy of thin section T2-weighted MR images in rectal cancer patients. MR results were compared with histological assessment of resection specimens. Over a 2-year period, 42 patients were studied. Histological staging was pT2 n = 13, pT3 n = 25 and pT4 n = 4. MR diagnostic accuracy was 74%. MR sensitivity and specificity was 62% and 79% for pT2 lesions, 84% and 59% for pT3 lesions and 50% and 76% for pT4 lesions. Estimation of tumour penetration by thin section MR imaging of rectal cancers using pelvic phased-array coil has moderate diagnostic accuracy. The limitations of MR should be acknowledged when selecting rectal cancer patients for pre-operative radiotherapy.

The impact of involvement of biomedical scientists in specimen dissection and selection of blocks for histopathology: a study of time benefits and specimen handling quality in Ayrshire and Arran area laboratory.

AIMS: To assess possible time benefits of specimen dissection by biomedical scientists (BMSs) and the quality of specimen handling by BMSs, in a department where BMSs trim those specimens requiring simple descriptions, from which standard blocks are taken. METHODS: Specimen handling by BMSs and consultant pathologists was compared. Time taken for each specimen trimmed was recorded prospectively. To determine specimen handling quality, adherence to dissection standard operating procedures (SOPs) was assessed by recording retrospectively whether or not each action in the SOP had been performed. Information on subsequently required extra levels or blocks was recorded. RESULTS: Analysis of data from 672 specimens trimmed by consultants showed that any given action in the SOPs was performed on average on 60.2% of applicable/assessable specimens; for 660 similar specimens trimmed by BMSs, each action was performed on average on 80.1% of specimens. Of the specimens where data on extra blocks were recorded, extra blocks were required in 3% of those trimmed by pathologists and in 4% of those trimmed by BMSs. Extra levels were required in 12% of those trimmed by pathologists and in 16% of those trimmed by BMSs. BMS trimming saves 16 hours of consultant time each month. The difference between pathologists and BMSs in time for each specimen trimmed is negligible. CONCLUSIONS: The advantages of increased adherence to trimming SOPs and saving consultant time outweigh the relatively small number of extra blocks and levels required when BMSs trim. There is no reduction in quality of dissection.

When typical is atypical: mycobacterial infection mimicking cutaneous vasculitis.

Patients with systemic lupus erythematosus (SLE) who present with skin disease pose the clinician with diagnostic challenges. The skin disease can reflect an increase in systemic disease activity suggested by other features of active lupus and, as such, usually responds well to more aggressive immunosuppressive therapy. Other possibilities of skin disease include drug eruptions, skin disease unrelated to SLE and, more rarely, opportunistic skin infection. In patients who show a poor response to more aggressive immunosuppressive therapy, consideration must be given to the possibility of opportunistic infection. A high index of suspicion will allow prompt treatment. We describe two patients with SLE who developed cutaneous atypical mycobacterial infection during immunosuppressive therapy. The diagnosis of cutaneous vasculitis was considered in both cases, but subsequent skin biopsy revealed the correct diagnosis. This report illustrates the importance of skin biopsy in patients with suspected cutaneous lupus who are not responding to immunosuppressive therapy.