Conditional risk of diverticulitis after non-operative management.

BACKGROUND: The objective of this study was to describe conditional recurrence-free survival (RFS) of patients after an index episode of diverticulitis managed without surgery, and to estimate the difference in conditional RFS for diverticulitis according to specific risk factors. METHODS: This was a multicentre retrospective cohort study including all patients managed without surgery for acute sigmoid diverticulitis at two university-affiliated hospitals in Montreal, Quebec, Canada. Conditional RFS for diverticulitis was estimated over 10 years of follow-up. A Cox proportional hazards model was performed at the index episode and again 2 years later. RESULTS: In total, 991 patients were included for analysis. The 1, 2- and 3-year actuarial diverticulitis RFS rates were 81·1, 71·5 and 67·5 per cent respectively. Compared with the 1-year actuarial RFS rate of 81·1 per cent, the 1-year conditional RFS increased with each additional year survived recurrence-free, reaching 96·0 per cent after surviving the first 4 years recurrence-free. A similar phenomenon was observed for 2-year diverticulitis conditional RFS. Lower age (hazard ratio (HR) 0·98, 95 per cent c.i. 0·98 to 0·99), Charlson Co-morbidity Index score of 2 or above (HR 1·78, 1·32 to 2·39) and immunosuppression (HR 1·85, 1·38 to 2·48) were independently associated with recurrence of diverticulitis from the index episode. At 2 years from the index episode, immunosuppression was no longer associated with diverticulitis recurrence (HR 1·02, 0·50 to 2·09). CONCLUSION: The conditional RFS of patients with diverticulitis improved with each year that was survived recurrence-free. Although several factors at index presentation may be associated with early recurrence, the conditional probability of recurrence according to many of these risk factors converged with time.

ANTECEDENTES: El objetivo de este estudio fue describir la supervivencia condicional libre de recidiva de diverticulitis (diverticulitis recurrence-free survival, Div-RFS) en pacientes tras un episodio de diverticulitis tratado de forma conservadora, y calcular la diferencia en la Div-RFS condicional de acuerdo con factores de riesgo específicos. MÉTODOS: Estudio de cohorte retrospectivo multicéntrico que incluyó a todos los pacientes tratados de forma no quirúrgica por diverticulitis sigmoidea aguda en dos hospitales afiliados a la universidad en Montreal, Quebec, Canadá. La supervivencia condicional libre de recidiva de la diverticulitis se calculó durante 10 años de seguimiento. Se realizó un análisis mediante un modelo de riesgos proporcionales de Cox en el episodio índice y nuevamente 2 años después. RESULTADOS: En total, se incluyeron 991 pacientes en el análisis. La Div-RFS actuarial a 1, 2 y 3 años fue del 81,1%, 71,5% y 67,5%, respectivamente. En comparación con la Div-RFS actuarial a 1 año del 81,1%, la Div-RFS condicional a 1 año aumentó con cada año adicional sobrevivido sin recidiva, alcanzando el 96,0% después de sobrevivir los primeros 4 años sin recidiva. Se observó un fenómeno similar para Div-RFS condicional a los 2 años. Una menor edad (cociente de riesgos instantáneos, hazard ratio, HR: 0,98; i.c. del 95%: 0,98 a 0,99), la puntuación de comorbilidad de Charlson ≥ 2 (HR: 1,78; i.c. del 95%: 1,32 a 2,39) y la inmunosupresión (HR: 1,85; i.c. del 95%: 1,38 a 2,48) se asociaron de forma independiente con la recidiva de la diverticulitis desde el episodio índice. En la regresión de Cox a los 2 años del episodio índice, la inmunosupresión ya no se asoció con recidiva de diverticulitis (HR: 1,02; i.c. del 95% 0,50-2,09). CONCLUSIÓN: La Div-RFS condicional mejoró con cada año de supervivencia sin recidiva. Si bien varios factores en la presentación del episodio índice pueden estar asociados con una recidiva precoz, la probabilidad condicional de recidiva en relación con muchos de estos factores de riesgo coincidió con el tiempo.

CT-based adaptive high-dose-rate endorectal brachytherapy in the preoperative treatment of locally advanced rectal cancer: Technical and practical aspects.

PURPOSE: During the last decade due to the availability of a CT scan in the brachytherapy suite, high-dose-rate endorectal brachytherapy (HDREBT) has evolved as a CT-based daily adaptive treatment. An update of the technical and practical aspects of HDREBT is provided. METHODS AND MATERIALS: Description of technical and practical aspects of HDREBT focused on the preoperative treatment of locally advanced rectal cancer. During preoperative HDREBT, 26 Gy is delivered in four daily applications of 6.5 Gy prescribed to the 100% isodose, covering the clinical target volume. Daily CT scans are obtained and used for plan optimization, leaving patient positioning unchanged between CT scan and treatment delivery. RESULTS: All steps of HDREBT treatment procedure are discussed in detail: flexible proctosigmoidoscopy and clipping; patient setup; applicator placement; target delineation; treatment planning and delivery; and patient care. Afterward, treatment results are reviewed. CONCLUSIONS: CT-based adaptive preoperative HDREBT is a practical and feasible therapy for locally advanced rectal cancer, offering excellent local control with a favorable toxicity profile.

Noninvasive multidetector computed tomography enterography in patients with small-bowel Crohn's disease: is a 40-second delay better than 70 seconds?

BACKGROUND: Multidetector computed tomography (MDCT) enterography combines neutral enteric contrast with intravenously administered contrast material. The optimal intravenous (IV) contrast material protocol has still not been established. PURPOSE: To determine the optimal delay time to image patients with small-bowel Crohn's disease during MDCT enterography. MATERIAL AND METHODS: After oral administration of 1350 ml of neutral contrast medium, 26 patients with small-bowel Crohn's disease underwent MDCT enterography;scans were obtained 40 s (enteric phase) and 70 s (parenchymal phase) after IV administration of 100 ml of iodinated contrast material. Three radiologists, blinded to clinical and pathological findings, independently and retrospectively evaluated each scan in two separate reading sessions for the presence or absence of CT features of Crohn's disease activity. The interobserver agreement was evaluated, and the efficacy of each phase in detecting active disease in the terminal ileum for each reader was determined. The gold standard was pathology (n=13), endoscopy (n=3), and clinical evaluation (n=10). RESULTS: No statistically significant difference was present between the enteric and the parenchymal phase for each reader in each segment regarding the presence or absence of CT features of Crohn's disease. The interobserver agreement for the presence of five main features of active Crohn's disease in the terminal ileum ranged from poor to excellent.The sensitivity, specificity, negative predictive value, positive predictive value, and accuracy for active Crohn's disease in the terminal ileum ranged from 40 to 90%, 88 to 100%, 70 to 94%, 44 to 100%, and 69 to 96%, respectively. There was no statistical difference between the two phases for each reader. CONCLUSION: MDCT enterography in patients with suspected active Crohn's disease can be obtained at either 40 s or 70 s after IV contrast material.

Extraarticular snapping hip: sonographic findings.

OBJECTIVE: The aim of the study was to determine the sonographic findings of snapping hip and to correlate the findings with the presence or absence of pain. MATERIALS AND METHODS: Twenty patients with snapping hip were examined with sonography. Conventional and dynamic sonographic examinations of both hips were performed using a 5.0- or 7.0-MHz transducer. RESULTS: Conventional sonographic studies allowed identification of various structural abnormalities (tendinitis, bursitis, synovitis) and helped to document tenderness along the course of specific tendons. Dynamic sonographic studies revealed 26 cases of snapping hip. In 24 of these 26 cases, the underlying cause was clearly identified. Twenty-two snapping hips were caused by an abnormal movement of the iliopsoas tendon, and two were caused by iliotibial band friction over the greater trochanter. One patient reported a bilateral snapping sensation that could not be documented on sonography. Snapping hip was elicited by a wide variety of hip movements. Sonography established an immediate temporal correlation between the jerky tendon motion and the painful snap reported by the patient. Only 14 cases of snapping hip were painful. CONCLUSION: Conventional sonographic studies can identify signs of tendinitis, bursitis, or synovitis. Dynamic sonographic studies revealed the cause of snapping hip in most patients. Snapping hip is characterized on sonography by a sudden abnormal displacement of the snapping structure. In our study, a significant proportion of the cases of snapping hip were not painful.