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BACKGROUND: Whole-body MRI (WB-MRI) could be an alternative to multimodality staging of colorectal cancer, but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in colorectal cancer.METHODS: The Streamline C trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed colorectal cancer. Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or polyp cancer. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs), and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN43958015, and is complete.FINDINGS: Between March 26, 2013, and Aug 19, 2016, 1020 patients were screened for eligibility. 370 patients were recruited, 299 of whom completed the trial; 68 (23%) had metastasis at baseline. Pathway sensitivity was 67% (95% CI 56 to 78) for WB-MRI and 63% (51 to 74) for standard pathways, a difference in sensitivity of 4% (-5 to 13, p=0·51). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (95% [95% CI 92-97]) and standard pathways (93% [90-96], p=0·48). Agreement with the multidisciplinary team's final treatment decision was 96% for WB-MRI and 95% for the standard pathway. Time to complete staging was shorter for WB-MRI (median, 8 days [IQR 6-9]) than for the standard pathway (13 days [11-15]); a 5-day (3-7) difference. WB-MRI required fewer tests (median, one [95% CI 1 to 1]) than did standard pathways (two [2 to 2]), a difference of one (1 to 1). Mean per-patient staging costs were £216 (95% CI 211-221) for WB-MRI and £285 (260-310) for standard pathways.INTERPRETATION: WB-MRI staging pathways have similar accuracy to standard pathways and reduce the number of tests needed, staging time, and cost.FUNDING: UK National Institute for Health Research.

Introduction Colonic stent insertion has been shown to be an effective treatment for patients with acute large bowel obstruction, either as a bridge to surgery or as definitive treatment. However, little is known of the role of secondary stent insertion following primary stent failure in patients considered inappropriate or high risk for emergency surgery. Methods Fourteen patients presenting with acute large bowel obstruction who had previously been treated with colonic stent insertion were studied. All underwent attempted placement of a secondary stent. Results Technical deployment of the stent was accomplished in 12 patients (86%) but only 9 (64%) achieved clinical decompression. Successful deployment and clinical decompression of a secondary stent was associated with older age (p=0.038). Sex, pathology, site of obstruction, duration of efficacy of initial stent and cause of primary failure were unrelated to outcome. No procedure related morbidity or mortality was noted following repeated intervention. Conclusions Secondary colonic stent insertion appears an effective, safe treatment in the majority of patients presenting with acute large bowel obstruction following failure of a primary stent.

AIM To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden. MATERIALS AND METHODS A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as “optimal”, “sub-optimal” or “degraded”. A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression. RESULTS One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as “optimal” quality, 39.5% (n=45) “sub-optimal”, and 14.9% (n=17) as “degraded”. In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan. CONCLUSIONS Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

Summary Background Whole-body magnetic resonance imaging (WB-MRI) could be an alternative to multi-modality staging of non-small-cell lung cancer (NSCLC), but its diagnostic accuracy, effect on staging times, number of tests needed, cost, and effect on treatment decisions are unknown. We aimed to prospectively compare the diagnostic accuracy and efficiency of WB-MRI-based staging pathways with standard pathways in NSCLC. Methods The Streamline L trial was a prospective, multicentre trial done in 16 hospitals in England. Eligible patients were 18 years or older, with newly diagnosed NSCLC that was potentially radically treatable on diagnostic chest CT (defined as stage IIIb or less). Exclusion criteria were severe systemic disease, pregnancy, contraindications to MRI, or histologies other than NSCLC. Patients underwent WB-MRI, the result of which was withheld until standard staging investigations were complete and the first treatment decision made. The multidisciplinary team recorded its treatment decision based on standard investigations, then on the WB-MRI staging pathway (WB-MRI plus additional tests generated), and finally on all tests. The primary outcome was difference in per-patient sensitivity for metastases between standard and WB-MRI staging pathways against a consensus reference standard at 12 months, in the per-protocol population. Secondary outcomes were difference in per-patient specificity for metastatic disease detection between standard and WB-MRI staging pathways, differences in treatment decisions, staging efficiency (time taken, test number, and costs) and per-organ sensitivity and specificity for metastases and per-patient agreement for local T and N stage. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN50436483, and is complete. Findings Between Feb 26, 2013, and Sept 5, 2016, 976 patients were screened for eligibility. 353 patients were recruited, 187 of whom completed the trial; 52 (28%) had metastasis at baseline. Pathway sensitivity was 50% (95% CI 37–63) for WB-MRI and 54% (41–67) for standard pathways, a difference of 4% (−7 to 15, p=0·73). No adverse events related to imaging were reported. Specificity did not differ between WB-MRI (93% [88–96]) and standard pathways (95% [91–98], p=0·45). Agreement with the multidisciplinary team's final treatment decision was 98% for WB-MRI and 99% for the standard pathway. Time to complete staging was shorter for WB-MRI (13 days [12–14]) than for the standard pathway (19 days [17–21]); a 6-day (4–8) difference. The number of tests required was similar WB-MRI (one [1–1]) and standard pathways (one [1–2]). Mean per-patient costs were £317 (273–361) for WBI-MRI and £620 (574–666) for standard pathways. Interpretation WB-MRI staging pathways have similar accuracy to standard pathways, and reduce the staging time and costs. Funding UK National Institute for Health Research.

The management of colorectal cancer increasingly involves multidisciplinary tumor boards. In cases where these occur, the quality can be variable. Despite this, there are no uniform measures to evaluate them. The aim of this study was to evaluate the performance of colorectal cancer tumor boards, via real-time prospective observation. An observational tool, termed Colorectal Multidisciplinary Team Metric for Observation of Decision-Making (cMDT-MODe), was used to assess decision-making in 267 cases. The presentation of case history, radiological and pathological information, as well as contributions to decision making of the various team members were analyzed using descriptive statistics and t-tests. Interobserver agreement was assessed using intraclasscorrelation coefficients. Tumor board meetings lasted 76 min, were attended by approximately 16 specialists each, and reviewed an average of 24 cancer cases (3 min per case review). Regarding the quality of presented information to the team, case history information was rated the highest (mean 4.57), followed by radiological information (mean 4.22) and pathological information (mean 3.81). Regarding each team-member’s contribution to discussion, surgeons were scored the highest (mean 4.81), followed by radiologists (mean 4.41) and meeting chairs (mean 4.13)—all team members except the board coordinators were scored highly. Overall scoring reliability was good (0.79). The cMDT-MODe instrument can be reliably used to prospectively assess decision making in the multidisciplinary management of colorectal patients. By systematically quantifying the quality of a colorectal cancer tumor board, we can identify areas for improving practice so as to optimize decision making for cancer care.

Delays in tissue fixation following tumour vascular clamping and extirpation may adversely affect subsequent protein and mRNA analysis. This study investigated the effect of surgically induced ischaemia in a xenograft model of a colorectal cancer on the expression of a range of prognostic, predictive, and hypoxic markers, with a particular emphasis on thymidylate synthase. Vascular occlusion of human tumour xenografts by D-shaped metal clamps permitted defined periods of tumour ischaemia. Alterations in protein expression were measured by immunohistochemistry and spectral imaging, and changes in mRNA were measured by reverse transcriptase–polymerase chain reaction. Thymidylate synthase expression decreased following vascular occlusion, and this correlated with cyclin A expression. A similar reduction in dihydropyrimidine dehydrogenase was also seen. There were significant changes in the expression of several hypoxic markers, with carbonic anhydrase-9 showing the greatest response. Gene transcriptional levels were also noted to change following tumour clamping. In this xenograft model, surgically induced tumour ischaemia considerably altered the gene expression profiles of several prognostic and hypoxic markers, suggesting that the degree of tumour ischaemia should be minimised prior to tissue fixation.

Otological damage is well-recognized following head injury. The commonest complication is hearing loss. We present a case of bilateral sensorineural hearing loss due to bilateral temporal bone fractures following an epileptic seizure, which is unique in the literature and illustrates the importance of this complication of head injury.

The demand that providers of mental health services be accountable for the services they provide has highlighted the importance of identifying and tracking the relationship between service, cost, and outcome in the current context of managed behavioural health care. In order to meet this demand, it is imperative that clinicians, researchers, and administrators have reliable and valid measures with which to document and track treatment outcomes. In the arena of child and adolescent care, there is a gap between traditional diagnostic measures and measures specifically designed to track outcomes. This study reports the comprehensive development and testing of a new outcome measure, the Youth Outcome Questionnaire, designed cooperatively by clinicians, researchers, and managed care administrators in order to meet the needs of all three. Multiple clinical samples and normative groups were assessed and results suggest that the instrument meets recommended standards of reliability, validity, and sensitivity to change. The process of development and testing serve as an illustration of the types of issues which must be addressed by those charged with the responsibility for documenting treatment outcomes. Copyright © 2001 John Wiley & Sons, Ltd.

The majority of superficial temporal artery (STA) aneurysms are due to trauma and are, in reality, false aneurysms. However, true STA aneurysms are extremely rare. Here, we present two cases of spontaneous superficial temporal artery aneurysms arising without any previous history of trauma.

Background The aim of this study was to investigate the use of magnetic resonance imaging (MRI) for non-invasive measurement of rectal cancer angiogenesis and hypoxia. Methods Fifteen patients with rectal adenocarcinoma underwent preoperative dynamic contrast-enhanced (DCE) and blood oxygenation level-dependent (BOLD) MRI. Microvessel density (CD31 level), and expression of vascular endothelial growth factor (VEGF) and carbonic anhydrase (CA) 9 were measured immunohistochemically in histological tumour sections from 12 patients. Serum VEGF levels were also measured in 14 patients. Correlations between quantitative imaging indices and immunohistochemical variables were examined. Results There was good correlation between circulating VEGF and CD31 expression (rs = 0·88, P < 0·001). CD31 expression did not correlate with any dynamic MRI parameter, except transfer constant, with which it correlated inversely (rs = −0·65, P = 0·022). Tissue and circulating VEGF levels did not correlate, and neither correlated with any tumour DCE MRI parameter. No relationship was seen between BOLD MRI and CA-9 expression. Conclusion The negative correlation between transfer constant (reflecting tumour blood flow and microvessel permeability) with CD31 expression is paradoxical. DCE MRI methods for assessing tissue vascularity correlate poorly with histological markers of angiogenesis and hypoxia, suggesting that DCE MRI does not simply reflect static histological vascular properties in patients with rectal cancer.

Otological damage is well-recognized following head injury. The commonest complication is hearing loss. We present a case of bilateral sensorineural hearing loss due to bilateral temporal bone fractures following an epileptic seizure, which is unique in the literature and illustrates the importance of this complication of head injury.

Orthogonal wavelets have been applied to communications since the early 90s. We prove that the Hilbert transform of a wavelet is orthogonal to its time shifts and it is also orthogonal to the corresponding wavelet and its time shifts. On the other hand, since the Hilbert transform only shifts the phase of the wavelet function by 90-degree, the magnitude spectrums of the wavelet and its transform are the same. Therefore they are located on the same frequency band. In order to utilize the above properties, we propose to use the wavelet and its Hilbert transform for waveform encoding of data bits. With this, we are able to double the bit rate without increasing the bandwidth or affecting the bit error rate (BER). Daubechies (1992) wavelets are used in the analyses of the proposed system.

Compositionality is the ability of a Vocabulary System to record non-atomic strings. In this manuscript we define the types of composition, which can occur. We will then propose methods for both server based and client-based composition. We will differentiate the terms Pre-Coordination, Post-Coordination, and User-Directed Coordination. A simple grammar for the recording of terms with concept level identification will be presented, with examples from the Unified Medical Language System's (UMLS) Metathesaurus. We present an implementation of a Window's NT based client application and a remote Internet Based Vocabulary Server, which makes use of this method of compositionality. Finally we will suggest a research agenda which we believe is necessary to move forward toward a more complete understanding of compositionality. This work has the promise of paving the way toward a robust and complete Problem List Entry Tool.

This research is concerned with the development of a neural system for robust projective-invariant recognition of multiple targets which may be partially occluded in a cluttered background based on single gray-level images. For this purpose we have developed in the research a new method for affine-invariant iconic representation and recognition of targets using a novel set of Gabor/Fourier kernels with multi-dimensional indexing in the frequency domain. An affine-invariant representation of local image patches is extracted in the form of spectral signatures, by directly convolving the image with our novel configuration of these kernels. We achieved 100% correct recognition rates with a model library of 26 models over a wide range of viewing poses and distances (360 of rotation and tilt and 82 of slant and 4 octaves of scale). The system also maintains its 100% recognition rate in high levels of noise/clutter (up to -17 dB) and to resolution degradation (1:5 reduction). A novel method for representation and recognition of 3D Object/Targets based on 3D frequency domain representation was also developed and tested.

Arthur Levin {#article-title-2} Founder of the Wellington Hospital and pioneer of day surgery ( b 1913; q Cambridge/St Bartholomew's 1939), d 29 April 1999. Early in the war he was appointed to the Royal Masonic Hospital, which was an officers' hospital. Later he served with the Royal Army Medical Corps in India and the Far East. After the war he entered general practice and was medical adviser to several large companies, including Rolls Royce and British Aerospace. In 1960 Arthur became one of the original trustees of the Charles Wolfson Charitable Trust and over the next nearly 40 years was influential in the development of many medical projects. In 1970 he realised that there was a need to create a modern flagship private hospital. The result was the Wellington Hospital in London, which opened in 1974. It was funded by the British and Commonwealth Shipping Company, of which he had been chief medical officer. He remained executive medical director until 1988, developing the second building, Humana Hospital, for which he laid the foundation stone in 1982. In 1981 he began plans for a day surgery centre in Harley Street and the Wellington Day Surgery Centre opened the following year with 20 beds and five operating theatres. While at the Wellington Arthur Levin founded the Wellington Foundation to further postgraduate education for doctors and nurses and research into patient care and the Wellington Society, which organises lectures and conferences. He was chairman of both. In 1984 he was appointed an honorary fellow of King's College London and was involved in planning the largest day surgery centre for the NHS at King's College Hospital. This now treats 12 000 patients a year. Arthur believed in the cross fertilisation of ideas between the private and state funded sectors in medicine, and he used his intelligence and charm …

An apparatus previously used to evaluate the rheological properties of weak milk gels has proved suitable for studying the creep compliance—time behaviour of fruit yoghurt, mayonnaise and fruit jams. All samples exhibited viscoelastic properties. The equipment is recommended for its simplicity of design and operation, and because of its ability to test foods containing fruit pieces. The size and weight of the fruit must be known since these quantities influence the creep compliance behaviour.

The determination of the K∑N coupling constant g ∑ 2 has received much less attention than its companion g ∧ 2 (1, 2). Early applications of Kaon-nucleon dispersion relations (3) provided values of g ∑ 2 based on K±n analysis. However, these calculations are now considered unreliable as they are based on crude parametrizations of the low energy \(\bar K\)N scattering amplitude. The lack of real part data in these dispersion relations made the use of a threshold subtraction necessary so that the results were highly model dependent. One must also note that K±n data are in general not as good as K±p data because of the problems related to the deuteron structure. Thus for many years it has become usual to determine the value of an effective coupling G2 = g ∧ 2 + 0.84 g ∑ 2 making use of K±p analyses.

Surface demineralization of bone in vivo induces new cartilage and bone formation locally. We studied the effects of local surface demineralization of the tibia in the rat on the process of fracture healing. We found that demineralization for 20 minutes with 0.5N HCl induced in the first 10 days following fracture less cartilaginous callus, with less calcium and magnesium, as compared to controls. However, from the second week on, the amount of cartilaginous callus in HCl-treated and control fractured bones was similar. Bony callus was greater in HCl-treated bones throughout the experiment, but X-rays showed poor bone union 5-8 weeks following fracture. Surface demineralization of bone in vitro induces local cartilage and bone formation, but inhibits good fracture healing.