Ultrasound-guided day-case wide-bore percutaneous mucin aspiration in advanced pseudomyxoma peritonei.

AIM: To evaluate percutaneous ultrasound-guided day-case mucin aspiration in advanced pseudomyxoma peritonei (PMP) using a wide-bore drain with regards to its safety and efficacy. MATERIALS AND METHODS: All patients who underwent percutaneous mucin aspiration for PMP between 2019-2021 at a single national peritoneal tumour service were included in this study. Under local anaesthesia, a suction-enabled 28-32 F catheter was used for drainage following wire-guided track dilatation. The volume drained and difference in abdominal girth pre- and post-procedure were measured. Patients graded difficulty in breathing and abdominal discomfort pre- and post-procedure. Histology reports were reviewed. RESULTS: Sixteen patients received 56 percutaneous mucin aspirations between 2019-2021. The aetiology was a low-grade appendiceal mucinous neoplasm (LAMN) in 50% of patients. The mean amount of mucin drained was 7,320 ± 3,000ml (range 300-13,500 ml). The mean reduction in abdominal girth post-procedure was 12.2 ± 5 cm (range 0-27 cm). Only grade 1 complications were observed. CONCLUSION: Percutaneous ultrasound-guided day-case aspiration of mucin for advanced and recurrent PMP using a wide-bore drain is a safe and effective procedure. It may be used in the palliative setting or as a bridge to surgery in the very symptomatic patient or if there is a reversible contraindication to surgery.

Transformation of indwelling peritoneal catheter placement for malignant ascites from an inpatient to a day-case service: analysis of patient risk and financial implication.

AIM: To investigate the impact on patient outcomes, costs, and resources/infrastructure of inserting indwelling peritoneal catheters (IPC) during a day-case instead of an inpatient service. MATERIALS AND METHODS: A single-centre, retrospective analysis of patients receiving IPCs over a 4-year period was performed. Patients undergoing a day-case procedure were admitted in the morning for pre-procedural investigations, a 15.5 F PleurX IPC (BD, Wokingham, UK) was inserted, all accessible fluid drained and patients discharged the same day, barring any complications. Using electronic patient records, outcomes and complications (immediate/post-procedural) were recorded. Expenses and re-imbursement tariffs were obtained from the income department. RESULTS: Of 138 IPC procedures, 45.6% were undertaken after formal inpatient admission, 54.3% were undertaken as a day-case. The mean hospital stay was 2.51 bed-days for inpatient procedures (n=63) and 0.31 bed-days for day-case procedures (n=75; p<0.001). Day-case procedures saved 165 bed-days per year. Complication rates were 15.9% and 16% for inpatient and day-case procedures respectively (p=0.98). There was an estimated savings of £1,850.46 per day-case procedure or £138,784.50 annually. CONCLUSION: The placement of IPCs can safely be performed as a day-case procedure. There were substantial economic benefits as well as improved patient satisfaction, with no compromise in patient outcomes. Day-case IPC insertion is now standard practice at The Christie NHS Trust.

Phase I trial of the MEK inhibitor selumetinib in combination with thoracic radiotherapy in non-small cell lung cancer.

BACKGROUND: The RAS/RAF/MEK/ERK signalling pathway has a pivotal role in cancer proliferation and modulating treatment response. Selumetinib inhibits MEK and enhances effects of radiotherapy in preclinical studies. PATIENTS AND METHODS: Single-arm, single-centre, open-label phase I trial. Patients with stage III NSCLC unsuitable for concurrent chemo-radiotherapy, or stage IV with dominant thoracic symptoms, were recruited to a dose-finding stage (Fibonacci 3 + 3 design; maximum number = 18) then an expanded cohort (n = 15). Oral selumetinib was administered twice daily (starting dose 50 mg) commencing 7 days prior to thoracic radiotherapy, then with radiotherapy (6-6.5 weeks; 60-66 Gy/30-33 fractions). The primary objective was to determine the recommended phase II dose (RP2D) of selumetinib in combination with thoracic radiotherapy. RESULTS: 21 patients were enrolled (06/2010-02/2015). Median age: 62y (range 50-73). M:F ratio 12(57%):9(43%). ECOG PS 0:1, 7(33%):14(67%). Stage III 16(76%); IV 5(24%). Median GTV 64 cm3 (range 1-224 cm3). 15 patients comprised the expanded cohort at starting dose. All 21 patients completed thoracic radiotherapy as planned and received induction chemotherapy. 13 (62%) patients received the full dose of selumetinib.In the starting cohort no enhanced radiotherapy-related toxicity was seen. Two patients had dose-limiting toxicity (1x grade 3 diarrhoea/fatigue and 1x pulmonary embolism). Commonest grade 3-4 adverse events: lymphopaenia (19/21 patients) and hypertension (7/21 patients). One patient developed grade 3 oesophagitis. No patients developed grade ≥3 radiation pneumonitis. Two patients were alive at the time of analysis (24 and 26 months follow-up, respectively). Main cause of first disease progression: distant metastases ± locoregional progression (12/21 [57.1%] patients). Six patients had confirmed/suspected pneumocystis jiroveci pneumonia. CONCLUSION: We report poor outcome and severe lymphopenia in most patients treated with thoracic radiotherapy and selumetinib at RP2D in combination, contributing to confirmed/clinically suspected pneumocystis jiroveci pneumonia. These results suggest that this combination should not be pursued in a phase II trial.ClinicalTrials.gov reference: NCT01146756.

An evaluation of MR based deep learning auto-contouring for planning head and neck radiotherapy.

INTRODUCTION: Auto contouring models help consistently define volumes and reduce clinical workload. This study aimed to evaluate the cross acquisition of a Magnetic Resonance (MR) deep learning auto contouring model for organ at risk (OAR) delineation in head and neck radiotherapy. METHODS: Two auto contouring models were evaluated using deep learning contouring expert (DLCExpert) for OAR delineation: a CT model (modelCT) and an MR model (modelMRI). Models were trained to generate auto contours for the bilateral parotid glands and submandibular glands. Auto-contours for modelMRI were trained on diagnostic images and tested on 10 diagnostic, 10 MR radiotherapy planning (RTP), eight MR-Linac (MRL) scans and, by modelCT, on 10 CT planning scans. Goodness of fit scores, dice similarity coefficient (DSC) and distance to agreement (DTA) were calculated for comparison. RESULTS: ModelMRI contours improved the mean DSC and DTA compared with manual contours for the bilateral parotid glands and submandibular glands on the diagnostic and RTP MRs compared with the MRL sequence. There were statistically significant differences seen for modelMRI compared to modelCT for the left parotid (mean DTA 2.3 v 2.8 mm), right parotid (mean DTA 1.9 v 2.7 mm), left submandibular gland (mean DTA 2.2 v 2.4 mm) and right submandibular gland (mean DTA 1.6 v 3.2 mm). CONCLUSION: A deep learning MR auto-contouring model shows promise for OAR auto-contouring with statistically improved performance vs a CT based model. Performance is affected by the method of MR acquisition and further work is needed to improve its use with MRL images.

Abdominal aortitis on PET CT: A case report and review of the literature.

INTRODUCTION: Aortitis often occurs in patients with systemic vasculitis. PRESENTATION OF CASE: We reported a 73 year old man with giant cell arteritis who was presented with abdominal pain and weight loss. DISCUSSION: Aortitis was diagnosed on PET-CT scan performed because initial investigations raised the possibility of pancreatic pathology. CONCLUSION: This case highlights the utility of PET-CT in the diagnosis of abdominal aortitis and the need to consider aortitis as a differential in patients with abdominal pain with a history of vasculitis.

Saving lives, limbs and livelihoods: considerations in restructuring a national trauma service.

STUDY HYPOTHESIS: Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to "best fit" trauma care in a small country (Ireland) to international models. METHODS: The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice. RESULTS: Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km). CONCLUSION: Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.

Thyroid incidentalomas discovered on positron emission tomography CT scanning - Malignancy rate and significance of standardised uptake values.

AIMS: Increasing use of 18F-Fluorodeoxy glucose (FDG) Positron Emission Tomography Computed Tomography (PET CT) has resulted in an increased frequency of incidentally discovered areas of focally increased FDG uptake within the thyroid gland - thyroid incidentalomas. We aimed to compare radiological characteristics of thyroid incidentalomas with cytology, histology and ultrasound findings. MATERIALS AND METHODS: We examined all FDG PET CT scan reports for all patients undergoing this investigation over a 6 year period in a single tertiary cancer centre. All PET CT scans followed an agreed proforma allowing reports mentioning "thyroid" to be identified. Reports commenting on a positive finding within the thyroid gland were investigated further manually. Incidental mentions of thyroid with no underlying abnormality were discounted from analysis. RESULTS: In the study period, 7221 patients underwent FDG PET CT scanning in our unit. Within this group 75 (1%) showed diffuse FDG uptake and 81 (1.1%) showed focal uptake (thyroid incidentalomas). Only 30 patients (37%) with incidentalomas had further investigation and malignancy rate was 23% (7/30). Median Standardised Uptake Values (SUV) in malignant lesions was 9.9 (range 3.5-17.8) whilst in benign lesions and diffuse lesions it was 5.4 (2.8-32) and 4.2 (2.1-25.6) respectively (p = 0.0013, Kruskal Wallis). CONCLUSION: There remains a need to develop a standardised approach to the investigation and management of thyroid incidentalomas discovered on FDG PET CT scanning. Up to 1 in 4 of these patients will harbour thyroid malignancy.

Disc-retained tubes for radiologically inserted gastrostomy (RIG): not up to the job?

AIM: To assess the insertion procedure and performance of disc-retained gastrostomy tubes, recording complications and accidental displacements by prospective audit, and to determine whether primary placement of the tube off-licence was feasible. MATERIALS AND METHODS: Disc-retained 12 F single-lumen Monarch gastrostomy tubes (Enteral UK, Selby, UK) were inserted by three gastrointestinal interventional radiologists in a supra-regional cancer centre. The 12 F tubes required a 20 F peel-away sheath with four-point gastropexy fixation and were placed under conscious sedation, using electrocardiogram (EEG) bispectral index monitoring. Follow-up was performed in an in-house gastrostomy drop-in clinic at 1 week and 1 month, supplemented with weekly telephone follow-up. Patients also had open access to the gastrostomy drop-in clinic for immediate advice and complication management. RESULTS: Eighteen patients underwent primary insertion of a Monarch gastrostomy tube over 5 months. A total of 6/18 (33%) tubes displaced; 4/18 (22%) completely, 2/18 (11%) occult into the peritoneum. Four of 18 (22%) patients developed infection at the stoma site. Due to the unexpectedly poor performance of the tube, the study was terminated early. CONCLUSION: Initial experience with the Monarch disc-retained gastrostomy tube demonstrates it unsuitable for primary placement with current protocols. In view of the potentially serious complications, the Medicines and Healthcare Products Regulatory Agency (MHRA) has been informed. A request has been made to the distributer to reassess the tube design and/or review the procedure promoted for primary placement.

Multicentre survey of radiologically inserted gastrostomy feeding tube (RIG) in the UK.

AIMS: To evaluate the variance in current UK clinical practice and clinical outcomes for direct percutaneous radiologically inserted gastrostomy (RIG). MATERIALS AND METHODS: A prospective UK multicentre survey of RIG performed between October 2008 and August 2010 was performed through the British Society of Gastrointestinal and Abdominal Radiology (BSGAR). RESULTS: Data from 684 patients were provided by 45 radiologists working at 17 UK centres. Two hundred and sixty-three cases (40%) were performed with loop-retained catheters, and 346 (53%) with balloon-retained devices. Sixty percent of all patients experienced pain in the first 24 h, but settled in the majority thereafter. Early complications, defined as occurring in the first 24 h, included minor bleeding (1%), wound infection (3%), peritonism (2%), and tube misplacement (1%). Late complications, defined as occurring between day 2 and day 30 post-procedure, included mild pain (30%), persisting peritonism (2%), and 30 day mortality of 1% (5/665). Pre-procedural antibiotics or anti-methicillin-resistant Staphylococcus aureus (MRSA) prophylaxis did not affect the rate of wound infection, peritonitis, post-procedural pain, or mortality. Ninety-three percent of cases were performed using gastropexy. Gastropexy decreased post-procedural pain (p < 0.001), but gastropexy-related complications occurred in 5% of patients. However, post-procedure pain increased with the number of gastropexy sutures used (p < 0.001). The use of gastropexy did not affect the overall complication rate or mortality. Post-procedure pain increased significantly as tube size increased (p < 0.001). The use of balloon-retention feeding tubes was associated with more pain than the deployment of loop-retention devices (p < 0.001). CONCLUSION: RIG is a relatively safe procedure with a mortality of 1%, with or without gastropexy. Pain is the commonest complication. The use of gastropexy, fixation dressing or skin sutures, smaller tube sizes, and loop-retention catheters significantly reduced the incidence of pain. There was a gastropexy-related complication rate in 5% of patients. Neither pre-procedural antibiotics nor anti-MRSA prophylaxis affected the rate of wound infection.

The challenge of patients' unmet palliative care needs in the final stages of chronic illness.

BACKGROUND: There is consensus in the literature that the end of life care for patients with chronic illness is suboptimal, but research on the specific needs of this population is limited. AIM: This study aimed to use a mixed methodology and case study approach to explore the palliative care needs of patients with a non-cancer diagnosis from the perspectives of the patient, their significant other and the clinical team responsible for their care. Patients (n = 18) had a diagnosis of either end-stage heart failure, renal failure or respiratory disease. METHODS: The Short Form 36 and Hospital and Anxiety and Depression Questionnaire were completed by all patients. Unstructured interviews were (n = 35) were conducted separately with each patient and then their significant other. These were followed by a focus group discussion (n = 18) with the multiprofessional clinical team. Quantitative data were analysed using simple descriptive statistics and simple descriptive statistics. All qualitative data were taped, transcribed and analysed using Colaizzi's approach to qualitative analysis. FINDINGS: Deteriorating health status was the central theme derived from this analysis. It led to decreased independence, social isolation and family burden. These problems were mitigated by the limited resources at the individual's disposal and the availability of support from hospital and community services. Generally resources and support were perceived as lacking. All participants in this study expressed concerns regarding the patients' future and some patients described feelings of depression or acceptance of the inevitability of imminent death. CONCLUSION: Patients dying from chronic illness in this study had many concerns and unmet clinical needs. Care teams were frustrated by the lack of resources available to them and admitted they were ill-equipped to provide for the individual's holistic needs. Some clinicians described difficulty in talking openly with the patient and family regarding the palliative nature of their treatment. An earlier and more effective implementation of the palliative care approach is necessary if the needs of patients in the final stages of chronic illness are to be adequately addressed.

Involvement of endothelin (ET)A and ETB receptors in the hypertrophic effects of ET-1 in rabbit ventricular cardiomyocytes.

The question was addressed whether endothelin-1 (ET-1) exerts hypertrophic effects in cardiomyocytes isolated from ventricles of adult rabbits and maintained in short-term (24 h) serum-free primary culture providing mechanical quiescence. ET-1 (> or =100 pM) increased significantly total mass of cellular protein and incorporation of L-U-[(14)C]phenylalanine and 2-[(14)C]uridine into cellular protein and RNA, respectively. Cycloheximide (35 microM), an inhibitor of protein synthesis, significantly reduced the incorporation of L-U-[(14)C]phenylalanine and 2-[(14)C]uridine into cellular protein and RNA, respectively, under control conditions and in response to ET-1. Actinomycin D (5 microM), a selective inhibitor of transcription, abolished the incorporation of 2-[(14)C]uridine into cellular RNA and significantly reduced the incorporation of L-U-[(14)C]phenylalanine into cellular protein under control conditions and in response to ET-1. The selective antagonists at the ET(A) receptor [BQ123 (100 nM) and PD155080 (100 nM)] and the selective antagonist at the ET(B) receptor [BQ788 (100 nM)] significantly reduced the incorporation of L-U-[(14)C]phenylalanine into cellular protein in response to ET-1 (10 nM). The selective inhibitor of protein kinase C (PKC), bisindolylmaleimide (BIM) (5 microM), reduced markedly the incorporation of 2-[(14)C]uridine into cellular RNA and, to a lesser degree, the incorporation of L-U-[(14)C]phenylalanine into cellular protein in response to ET-1 (100 pM to 10 nM). ET-1 exerts hypertrophic effects directly in vitro in ventricular cardiomyocytes isolated from the hearts of adult rabbits. These effects are (a) due to de novo synthesis since total mass of cellular protein and incorporation of L-U-[(14)C]phenylalanine and 2-[(14)C]uridine into cellular protein and RNA, respectively, were increased; (b) mediated by both the ET(A) and ET(B) receptor subtypes; and (c) may be associated, at least partly, with the activation of PKC.

Common epidermal lesions of the bowhead whale, Balaena mysticetus.

Samples of common skin abnormalities from 23 subsistence-harvested bowhead whales (Balaena mysticetus) were examined. Most lesions fell into three broad classes: shallow lacerations, circular depressions, and epidermal sloughing. Both circular depression lesions and epidermal sloughing lesions may be divided into more than one subgroup based on morphological criteria. Examination of each of the subgroups using light and scanning electron microscopy suggests relationships among the subgroups of a class. These proposed relationships are discussed, as are some possible etiologies. Scanning electron microscopy reveals abundant bacteria and diatoms present in association with each lesion class but no evidence of a particular association characteristic of a lesion class. The microflora were especially abundant wherever the stratum spinosum was exposed at the skin surface.

Ventricular fibrillation during coronary angiography: the precatheterization QT interval.

Ventricular fibrillation during coronary angiography is associated with contrast-induced changes in repolarization and thus pre-catheterization abnormalities could predispose to this event. We retrospectively examined angiograms, pre-catheterization electrocardiograms and records of 26 consecutive patients who had ventricular fibrillation during coronary angiography, and compared these patients to controls matched for age, sex, and left ventricular function. Diatrizoate meglumine was used as the angiographic contrast agent in all instances. Catheterization findings and the prevalence of prior myocardial infarction were similar in both groups. However, pre-catheterization QT intervals in the ventricular fibrillation group (0.43 +/- 0.05 sec) were significantly longer than in control patients (0.39 +/- 0.04 sec, P less than 0.005) as were their QT intervals corrected for heart rate (QTc) (0.47 +/- 0.04 vs 0.42 +/- 0.03 sec; P less than 0.001). Only seven of the 16 patients (44%) with ventricular fibrillation who had a precatheterization QTc greater than 0.44 sec had the arrhythmia during angiography of a critically stenosed (greater than 75%) coronary artery, whereas VF followed injection of critically stenosed vessels in eight of 10 (80%) of those with a normal QTc (p NS). After a follow-up period of 24 to 54 months (mean 39), two ventricular fibrillation patients have died (one suddenly), as compared to five in the control group (two suddenly) (p NS). Therefore, pre-catheterization QT prolongation was associated with ventricular fibrillation during coronary angiography, but ventricular fibrillation did not necessarily portend a worse long-term prognosis.

Pacemaker therapy.

This article reviews the indications for pacemaker implantation and the techniques and devices currently in use. The management of patients who require permanent pacemakers and the potential complications involved are discussed. The article concludes with a brief synopsis of temporary pacing.

Masked primary (or tertiary) hyperparathyroidism.

Two patients are described in whom the preliminary clinical and laboratory investigations suggested a diagnosis of osteomalacia, from gluten-sensitive enteropathy in one and from anticonvulsant therapy in the other. However, when the primary disease was corrected by diet and extra vitamin D, respectively, both patients developed hypercalcaemia. A standard hydrocortisone test in the second patient failed to reduce the hypercalcaemia. In both patients parathyroid tumours were found at operation. It is suggested that both patients had tertiary hyperparathyroidism in which the normally tell-tale hypercalcaemia was at first masked by the other abnormalities, and that this masking may account for some cases reported as having normocalcaemic primary (or tertiary) hyperpatathyroidism. Interpretation of total plasma-calcium is likely to be unreliable unless the 25-hydroxyvitamin-D levels can be shown or assumed to be normal.

Earthquake waves and the geomagnetic dynamo.

It is proposed that earthquake waves energize the geomagnetic dynamo. Fluid motions generated by earthquakes may have enough energy to be in equipartition with fields as large as 100 gauss. Seismic waves from meteoritic impacts with energies sufficient to reverse the field occur every 170,000 years.