Changes in arterial stiffness but not carotid intimal thickness in acromegaly.

CONTEXT: Acromegaly increases cardiovascular morbidity. We tested the hypothesis that increased arterial stiffness together with left ventricular hypertrophy may be a contributory factor. PATIENTS AND DESIGN: Fifty-six patients (40 males, 54 ± 13 yr; 25 active disease, 31 in remission) and 46 healthy controls (30 males, 52 ± 13 yr) underwent measurements of aortic pulse wave velocity (PWV), carotid Doppler (IMT), echocardiography, and cardiovascular risk factors. RESULTS: Mean serum IGF-I was 323 ± 286 ng/ml (sd score 1.8 ± 1.9) in all patients. Age, body mass index, diastolic blood pressure (BP), and lipid levels were similar comparing patients and controls. Systolic BP (130.8 ± 19.9 vs. 122 ± 14 mm Hg controls, P < 0.01) and PWV (11.7 ± 3.8 vs. 9.7 ± 2.8 m/sec, 95% confidence interval -3.4 to -0.7, P <0.01) were higher in patients than controls. Regression analysis revealed age, presence of acromegaly, systolic BP, and body mass index, inversely, as significantly and independently associated with PWV. No difference in carotid IMT was seen (0.8 ± 0.2 patients vs. 0.7 ± 0.2 mm controls, P = 0.5) or between active/controlled disease. In the subset of participants with echocardiography (n = 32), left ventricular mass was higher by a mean of 38.2 g (95% confidence interval -80.9 to +4.6, P = 0.08). CONCLUSION: In summary, patients with acromegaly had independently and significantly increased aortic PWV as evidence of arterial stiffening but unaltered carotid IMT compared with controls, also influenced by age and systolic BP. Premature cardiovascular disease in patients with acromegaly is likely related to pressure-related arterial and left ventricular stiffening rather than atherosclerotic disease.

A retrospective analysis of selective internal radiation therapy (SIRT) with yttrium-90 microspheres in patients with unresectable hepatic malignancies.

AIM: To evaluate the efficacy and safety of selective internal radiation therapy (SIRT). MATERIALS AND METHODS: A retrospective analysis was undertaken of all patients who underwent SIRT at a single institution. Diagnostic and therapeutic angiograms, computed tomography (CT) images, positron-emission tomography (PET) images, and planar isotope images were analysed. The response to SIRT was analysed using radiological data and tumour markers. Overall survival, complications, and side effects of SIRT were also analysed. RESULTS: The initial 12 patients were included on an intention-to-treat basis, between 21/09/2005 and 07/05/2008. All patients had advanced disease and multiple prior courses of chemotherapy. One patient did not receive yttrium-90 due to complex vascular anatomy; the remaining 11 patients underwent 13 SIRT treatment episodes following work-up angiography. A response was seen using PET in 80% of patients. Using CT, the response of the tumour to therapy in the treated hepatic segments demonstrated a 20% partial response, stable disease in 50%, and progressive disease in 30%. Estimated median survival was 229 days, with 64% of patients still alive at the time of writing. No major complications were observed, although 82% of patients experienced side-effects following SIRT, mainly nausea, vomiting, and abdominal pain. CONCLUSIONS: There have been no complications in the 12 SIRT patients. Tumour response was seen in four out of five patients who underwent PET. Objective CT response rates were mixed and are perhaps partially explained by advanced disease and limitations of using measurements to assess response. This complex and potentially hazardous service has been successfully and safely established.

Nurse-led central venous catheter service: Christie experience.

The aim of this study was to evaluate the success and complication rate of Nurse-led subclavian central venous catheter (CVC) insertion using the landmark technique. A prospective study was performed on all subclavian CVC insertion between 13/01/03 to 01/07/03. Data recorded included indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction. A total of 348 subclavian cuffed tunnelled catheters were inserted over the study period. The age group ranged from 31 years to 84 years with a mean age of 53 years. This included 192 women and 156 men. The majority of CVC insertions were through the right subclavian (79%) and were single lumen (76%). In total, complications were encountered in 48 patients (14%). These included misplaced tip in 29 (8%), arterial puncture in 16 (4%), pneumothorax in 3 (1%) and the procedure failed in 3 (1%). Of these multiple complications were seen in 3 (1%). No interventions were required for the pneumothoraces or for the arterial punctures. In conclusion, nurse-led subclavian CVC placements using the landmark technique are both safe and effective.

The role of ultrasound-guided fine-needle aspiration biopsy in the previously treated patient with thyroid cancer.

The aim of the present study was to evaluate the effectiveness of ultrasound-guided fine-needle aspiration in detecting locoregional recurrence in previously treated patients with thyroid cancer. A retrospective analysis of ultrasound-guided fine-needle aspiration (FNA) biopsy was carried out for suspected recurrence of thyroid cancer over a 5-year period at a single institution. There were 37 biopsies in 37 patients. Each patient's ultrasound report, cytology report and medical notes were examined to determine the result of the biopsy and the patient's outcome. There were 29 true-positives, 6 true-negatives, 1 false-negative and 1 inadequate biopsy. Ultrasound-guided FNA, therefore, had a sensitivity of 96.7%, specificity of 100% and overall accuracy of 97.2% in detecting recurrence. Ultrasound-guided FNA is an accurate method of identifying suspected recurrence.

To clot or not to clot? That is the question in central venous catheters.

AIM: To establish the relationship between the tip position of tunnelled central venous catheters (CVC) and the incidence of venous thrombosis. MATERIALS AND METHODS: A randomly sampled, retrospective review of 428 CVC inserted into 334 patients was performed. The chest radiograph obtained post-catheter insertion, as well as follow-up radiographs, linograms, venograms and Doppler ultrasounds (US), were reviewed. RESULTS: The median follow-up was 72 days (range 1-720 days), with a total follow-up of 23,040 line days. Venous thrombosis occurred in five out of 191 (2.6%) CVC in a distal position (distal third of the superior vena cava (SVC) or right atrium (RA)), five of 95 (5.3%) in an intermediate position (middle third of the SVC) and 20 of 48 (41.7%) in a proximal position (proximal third SVC or thoracic inlet veins). There was a significant difference in thrombosis rate between lines sited with the tip in a distal compared with a proximal position (p<0.0005). CVC with tips in a proximal position were 16 times more likely to thrombose than those in a distal position. None of the 58 CVC with the tip located in the RA thrombosed or caused complications. CONCLUSION: Distal placement of tunnelled CVC, either in the distal third of the SVC or proximal RA is optimal.

Staging of advanced cervical carcinoma using MRI-predictors of outcome after radical radiotherapy.

AIM: To assess the prognostic significance of imaging findings used in magnetic resonance imaging (MRI) staging of cervical carcinoma by correlation with survival after radiotherapy. MATERIALS AND METHODS: MRI examinations of 99 cervical carcinoma patients were reviewed. Tumour involvement of pelvic structures was assessed. Lymph node sites, short axis diameters and signal characteristics were recorded. MRI staging was compared with clinical [International Federation of Gynaecology and Obstetrics (FIGO)] staging. Univariate analysis was performed for MRI stage, clinical stage, nodal status and pelvic structure involvement against disease-specific (DSS) and disease-free survival (DFS). RESULTS: MRI staging correlated with DSS (p=0.006) and DFS (p=0.007) but clinical staging did not. Pelvic nodes > or = 10 mm and juxtaregional or distant nodes > or = 8 mm short axis were most strongly associated with survival (p=0.014, p=0.011 and p=0.001, respectively, for association with DSS). Tumour involvement of pelvic bowel loops, pelvic sidewall and bladder mucosa were significantly associated with poor DSS and DFS (p<0.05). Tumour dimensions and bladder muscle involvement alone were not associated with poor survival. CONCLUSION: MRI staging is a better predictor of survival than clinical staging in patients receiving radiotherapy for cervical carcinoma. MRI assessment of lymph node enlargement and tumour involvement of pelvic structures gives valuable prognostic information.

Gastrostomy insertion: comparing the options--PEG, RIG or PIG?

AIM: To compare percutaneous endoscopic gastrostomy (PEG) with radiologically inserted gastrostomy (RIG) and assess a hybrid gastrostomy technique (per-oral image-guided gastrostomy, PIG). MATERIALS AND METHODS: Fifty PEGs and 50 RIGs performed in three centres were prospectively compared and the endoscopic findings of 200 PEGs reviewed. A fluoroscopy-guided technique was modified to place 20 F over-the-wire PEG-tubes in 60 consecutive patients. RESULTS: Technical success was 98%, 100% and 100% for PEG, RIG and PIG, respectively. Antibiotic prophylaxis significantly reduced stoma infection for orally placed tubes (p=0.02). Ten out of 50 (20%) small-bore RIG tubes blocked. Replacement tubes were required in six out of 50 PEGs (12%), 10 out of 50 RIGs (20%), but no PIGs (p<0.001). No procedure-related complications occurred. The function of radiologically placed tubes was significantly improved with the larger PIG (p<0.001), with similar wound infection rates. PIG was successful in 24 patients where endoscopic insertion could not be performed. Significant endoscopic abnormalities were found in 42 out of 200 PEG patients (21%), all related to peptic disease. Insignificant pathology was found in 8.5%. CONCLUSION: PIG combines advantages of both traditional methods with a higher success and lower re-intervention rate. Endoscopy is unlikely to detect clinically relevant pathology other than peptic disease. PIG is a very effective gastrostomy method; it has better long-term results than RIG and is successful where conventional PEG has failed.