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Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a potentially curative treatment for patients with colorectal peritoneal metastases (CRPM). Patient selection is key to optimizing outcomes after CRS/HIPEC. The aim of this study was to determine the prognostic value of ascites diagnosed on preoperative imaging.A prospective database of patients eligible for CRS/HIPEC between 2010 and 2020 was retrospectively analyzed. The presence of ascites, postoperative complications, overall survival (OS), disease-free survival (DFS), and completeness of cytoreduction were assessed. Univariable and multivariable logistic regression was performed to identify independent predictors for outcome.Of the 235 included patients, 177 (75%) underwent CRS/HIPEC while 58 (25%) were not eligible for CRS/HIPEC. In 42 of the 177 patients (24%) who underwent CRS/HIPEC, ascites was present on preoperative computed tomography (CT) imaging. Peritoneal Cancer Index (PCI) score was significantly higher in patients with preoperative ascites compared with patients without (11 [range 2-30] vs. 9 [range 0-28], respectively; p = 0.011) and complete cytoreduction was more often achieved in patients without ascites (96.3% vs. 85.7%; p = 0.007). There was no significant difference in median DFS and OS after CRS/HIPEC between patients with and without ascites {10 months (95% confidence interval [CI] 7.1-12.9) vs. 9 months (95% CI 7.2-10.8), and 25 months (95% 9.4-40.6) vs. 27 months (95% CI 22.4-31.6), respectively}.Ascites on preoperative imaging was not associated with worse survival in CRS/HIPEC patients with CRPM. Therefore, excluding patients from CRS/HIPEC based merely on the presence of ascites is not advisable.

Context Subcutaneous adipose tissue (SAT) is not homogeneous, as the fascia scarpa separates the deep SAT (dSAT) from the superficial SAT (sSAT). Objective The aim of this study is to evaluate the sex-specific associations of sSAT and dSAT with hepatic steatosis and metabolic syndrome in overweight individuals. Methods We recruited 285 individuals with a body mass index (BMI) greater than or equal to 27 and aged 55 to 81 years. Abdominal magnetic resonance imaging was performed around level L4 to L5 to measure visceral adipose tissue (VAT), dSAT, and sSAT volumes. The amount of hepatic fat was quantified by MR spectroscopy. Results Men had significantly higher volumes of VAT (122.6 cm3 vs 98.7 cm3, P Conclusion In men, dSAT is associated with hepatic steatosis and adverse metabolic traits, such as lower HDL cholesterol levels, whereas in women with obesity sSAT shows a beneficial relation with respect to hepatic fat content.

Context: No consensus about classification, treatment, and clinical relevance of occipital condyle fractures (OCFs) exists. Aims: The aim of the study was to determine radiological, clinical, and functional outcome of OCFs and thereby determine its clinical relevance. Settings and Design: This was a retrospective analysis of a prospective follow-up study. Materials and Methods: From May 2005 to May 2008, all OCFs were included from a Level-1 trauma center. Patient files were reviewed for patient and fracture characteristics. Fracture classification was done according to the Anderson criteria. Clinical outcome was assessed by completing two questionnaires, radiological outcome by computed tomography imaging, and functional outcome by measuring active cervical range of motion using a Cybex EDI-320. Statistical Analysis Used: A Fisher's exact Test was used in categorical variables and a one-sample t-test for comparing means of active cervical range of motion in occipital fracture patients with normal values. An independent samples t-test was carried out to compare the means of groups with and without accompanying cervical fractures for each motion. Results: Thirty-nine patients were included (4 type I, 16 type II, and 19 type III). Twenty-seven patients completed follow-up, of whom 26 were treated conservatively. Fracture healing was established in 25 of 28 fractures at a median follow-up of 19 months. Eleven patients had none to minimal pain or disability at follow-up, 12 had mild, and two had moderate pain or disability on questionnaires. No statistically significant difference in active cervical range of motion was identified comparing means stratified for accompanying cervical fractures. Conclusions: Conservatively treated patients with an OCF generally show favorable radiological and clinical outcome.

Currently, there are no widely accepted cut-off points to categorize patients as sarcopenic (low skeletal muscle mass) or myosteatotic based on computed tomography (CT) measurements. Moreover, little is known about skeletal muscle mass in healthy subjects, particularly in a Western-European population.Skeletal muscle mass (skeletal muscle index, cmOf the 1073 included patients, 499 (46.5%) were male and the median age and BMI were 51 years and 25.4 kg/mSkeletal muscle density and mass were significantly associated with sex, age, and BMI in a large cohort of healthy Western-European subjects. The newly developed nomograms may be used to calculate the estimated healthy skeletal muscle mass for individuals in patient populations.

Contains fulltext : 193245.pdf (Author’s version postprint ) (Open Access) BACKGROUND: Intestinal failure-associated liver disease is a frequent complication in patients with chronic intestinal failure (CIF), with steatosis as a dominant feature in adults. Proton magnetic resonance spectroscopy (1H-MRS) is a noninvasive method to quantify liver fat content (LFC). In this study, LFC was assessed with 1H-MRS, taking into account the possible accumulation of paramagnetic components of home parenteral nutrition (HPN) that may disturb these measurements. METHODS: LFC was measured in 15 adult CIF patients who had been receiving HPN for >6 months. 1H-MR spectra were obtained with a 3 Tesla magnetic resonance (MR) system, with a method correcting for the presence of paramagnetic ions. Patients with low (/=5%, steatosis) LFC were compared with nonparametric statistical tests. RESULTS: 1H-MRS analysis revealed steatosis in 5 patients (median, 10.3%), while 10 patients had normal LFC (median, 0.9%). In all patients, the 1H-MRS results indicated the presence of various amounts of paramagnetic constituents in the liver. Patients with steatosis had higher alanine aminotransferase values than patients without steatosis (median, 60 vs 28 U/L). Unexpectedly, in the steatosis group, the frequency of HPN use was lower, with significant lower total HPN and carbohydrate calories. In 1 patient, MR spectra were of inferior quality, with broadened resonances after infusion with a ferric compound. CONCLUSION: 1H-MRS enables reliable noninvasive assessment of LFC in patients receiving long-term HPN, if correcting for possible accumulation of paramagnetic components in the liver. However, LFC determination by 1H-MRS is not recommended after a recent ferric compound infusion.

Item does not contain fulltext During the treatment of colorectal liver metastases, evaluation of treatment efficacy is of the utmost importance for decision making. The aim of the present study was to explore the ability of preclinical imaging modalities to detect experimental liver metastases. Nine male Wag/Rij rats underwent a laparotomy with intraportal injection of CC531 tumor cells. On days 7, 10, and 14 after tumor induction, sequential positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging (MRI) scans were acquired of each rat. At each time point, three rats were euthanized and the metastases in the liver were documented histologically. Topographically, the liver was divided into eight segments and the image findings were compared on a segment-by-segment basis with the histopathologic findings. Sixty-four liver segments were analyzed, 20 of which contained tumor deposits. The overall sensitivity of PET, CT, and MRI was 30%, 25%, and 20%, respectively. For the detection of tumors with a histologic diameter exceeding 1 mm (n = 8), the sensitivity of PET, CT, and MRI was 63%, 38%, and 38%, respectively. The overall specificity of PET, CT, and MRI was 98%, 100%, and 93%, respectively. This study showed encouraging detectability and sensitivity for preclinical imaging of small liver tumors and provides valuable information on the imaging techniques for designing future protocols.

Aliment Pharmacol Ther 2012; 35: 266–274 Summary Background Polycystic liver disease (PLD) is a phenotypical expression of autosomal dominant polycystic kidney disease and isolated polycystic liver disease. Somatostatin analogues, such as lanreotide, reduce polycystic liver volume. Aim To establish long-term outcome and safety of lanreotide. Methods This was an open-label, observational extension study of a 6-month, randomised, placebo-controlled trial with lanreotide (120 mg/month) in PLD. The length of total treatment was 12 months. Primary endpoint was relative change in liver volume, as determined by CT-volumetry after 12 months of treatment. We offered patients a CT scan 6 months after stopping lanreotide. Results A total of 41/54 (76%) patients participated in the extension study. Liver volume decreased by 4% (IQR −8% to −1%) after 12 months of treatment. The greatest effect was observed during the first 6 months of treatment (decrease of 4% (IQR −6% to −1%)). Liver volume remained unchanged during the following 6 months. We found that liver volume increased by 4% (IQR 0–6%) 6 months after end of treatment (n = 22). Conclusions Lanreotide reduces liver volume within the first 6 months of treatment and the beneficial effect is maintained in the following 6 months. Stopping results in recurrence of polycystic liver growth. This suggests that continuous use of lanreotide is needed to maintain its effect.

Epidemiologic studies of rare diseases may produce surprising findings and raise ethical issues. This is illustrated in this study performed in 171,977 consecutive Taiwanese newborns (including 90,288 boys) from July 2006 through June 2008 by measuring dry blood spot and then leukocyte -galactosidase A ( -Gal A) activities and finally by detecting mutations in the GLA gene involved in Fabry disease. Schematically, two phenotypes of this disease are known: the classic form, with systemic involvement and very low -Gal activity in males; and the later-onset form ( 40 years of age), with some residual -Gal A activity, which is dominated by cardiac involvement. All 11 newborns who had 5% of normal mean -Gal A activity were boys who had GLA mutations. In the group of 66 newborns (64 boys and 2 girls) with -Gal A activities between 5% and 30%, 61 hemizygous boys and 2 heterozygous girls had GLA mutations. Among the group of 12 newborns (11 boys and 1 girl) with -Gal A 30%, only 1 boy had a previously reported mutation, identified in a family with later-onset renal disease. In total, 72 male and 2 female newborns had GLA mutations, an overall frequency of approximately 1 in 1250 boys and approximately 1 in 40,840 girls. Four boys were “predicted” to have the classic phenotype, a frequency of about 1 in 22,570 newborn boys. In contrast, the estimated frequency of the lateronset phenotype is approximately 1 in 1390 male newborns mutations. Three families provided information on other members of the kindreds, two with classic and one with later-onset phenotype. All three families had previously undiagnosed symptomatic family members, including one heterozygous female with ESRD and two males with renal involvement. This is undoubtedly the positive side of such studies. A second study was performed more recently in 110,027 Taiwanese newborns between January 2008 and January 2009 by using a similar protocol (plasma -Gal A activity was measured) (1). The results of this study confirmed those of the previous screening. A high prevalence of the cardiac variant Fabry mutation IVS4 919G3A, first discovered in Japanese patients, was found among newborns (approximately 1 in 1600 boys) in both studies. This splicing mutation was most common (82% of patients). The alternatively spliced transcript was normally present in small amount ( 5% of normal transcript) in most human tissues. However, the G3A transversion enhanced the percent expression of the alternatively spliced -Gal A variant and included a 57-nucleotide intronic sequence that caused a frameshift mutation, resulting in a truncated enzyme polypeptide that had no detectable enzyme activity. The clinical significance of this splicing mutation remains to be fully clarified. Of interest, Lin et al. (1) have investigated 9 grandfathers and 11 grandmothers carrying this mutation, as do their respective grandsons. Among the 9 maternal grandfathers, only 3 had hypertrophic cardiomyopathy, compared with none of the 11 grandmothers. These results should be compared with those reported in 2006 from Torino, Piedmont, Italy, by Spada et al. (2). They screened 37,000 consecutive newborns with similar methods and identified 12 infants with GLA mutations, including 11 who had molecular lesions that expressed residual activity consistent with the later-onset phenotype. The overall frequency of Fabry mutations was approximately 1 in 3100 Caucasian boys. Mutation analysis predicted that one of the newborns had the classic phenotype (1 in approximately 37,000), whereas 11 of the newborns were predicted to have the later-onset phenotype (1 in approximately 3400). The prevalence of the classic form is close to that found in previous estimations, whereas that of the later-onset phenotype seems to be higher than commonly thought. In Taiwan, the frequency was 2.5 times more frequent than in the Italian population. These studies raise many ethical and clinical issues. What can be said to the parents of neonates harboring a GLA mutation suggestive of a later-onset disease? The clinical consequences of some mutations, if any, cannot be predicted. The ethnic background should be taken into account. If clinical consequences can be expected, when to start evaluating the cardiac condition and when to consider enzyme replacement therapy, if necessary? What are the psychologic consequences of the screening on the mutation carrier and his/her family? The ethical issues raised by early detection and prediction of later-onset genetic Published online ahead of print. Publication date available at www.cjasn.org.

Contains fulltext : 89655.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To select parameters that can predict which patients should receive abdominal computed tomography (CT) after high-energy blunt trauma. SUMMARY BACKGROUND DATA: Abdominal CT accurately detects injuries of the abdomen, pelvis, and lumbar spine, but has important disadvantages. More evidence for an appropriate patient selection for CT is required. METHODS: A prospective observational study was performed on consecutive adult high-energy blunt trauma patients. All patients received primary and secondary surveys according to the advanced trauma life support, sonography (focused assessment with sonography for trauma [FAST]), conventional radiography (CR) of the chest, pelvis, and spine and routine abdominal CT. Parameters from prehospital information, physical examination, laboratory investigations, FAST, and CR were prospectively recorded for all patients. Independent predictors for the presence of > or =1 injuries on abdominal CT were determined using a multivariate logistic regression analysis. RESULTS: A total of 1040 patients were included, 309 had injuries on abdominal CT. Nine parameters were independent predictors for injuries on CT: abnormal CR of the pelvis (odds ratio [OR], 46.8), lumbar spine (OR, 16.2), and chest (OR, 2.37), abnormal FAST (OR, 26.7), abnormalities in physical examination of the abdomen/pelvis (OR, 2.41) or lumbar spine (OR 2.53), base excess

BACKGROUND: Discussion still remains which polytraumatized patients require radiologic thoracolumbar spine (TL spine) screening. The purpose of this study is to determine whether pelvic fractures are associated with TL spine fractures after a blunt trauma. Additionally, the sensitivity of conventional TL spine radiographs and pelvic radiographs (PXRs) is evaluated. METHODS: We prospectively studied 721 consecutive patients who had sustained a high-energy blunt trauma. The diagnostic workup in these patients included routine conventional radiographs of the pelvis and TL spine followed by a computed tomography (CT) analysis. All patients with pelvic fractures and TL spine fractures identified on conventional radiographs and CT were analyzed. A relative risk (RR) was calculated for the association between pelvic fractures and TL spine fractures. The sensitivity for conventional TL spine radiographs and PXRs in identifying fractures was calculated. RESULTS: Of the 721 patients studied, 620 were included in our diagnostic high-energy trauma protocol. Of these 620 included patients, 86 (14%) suffered a pelvic fracture and 126 (20%) suffered a TL spine fracture. Thirty-three patients (5%) suffered both a pelvic fracture and a TL spine fracture. The RR for a TL spine fracture in the presence of a pelvic fracture identified on PXR is 2.14 (95% confidence interval, 1.54-2.98) and identified on CT this RR is 2.20 (95% confidence interval, 1.59-3.05). However, this association diminishes to a nonsignificant level when the transverse process and spinous process fractures are excluded. Overall sensitivity for conventional TL spine radiographs and PXRs is 22% and 69%, respectively. CONCLUSION: Our data suggest that a pelvic fracture is not a predictor for clinically relevant TL spine fractures. Furthermore, our data confirm the superior sensitivity of CT for detecting TL spine injury and pelvic fractures.

Contains fulltext : 88272.pdf (Publisher’s version ) (Closed access) PURPOSE: Aim was to evaluate the accuracy of computed tomography colonography (CTC) for detection of colorectal neoplasia in a Fecal Occult Blood Test (FOBT) positive screening population. METHODS: In three different institutions, consecutive FOBT positives underwent CTC after laxative free iodine tagging bowel preparation followed by colonoscopy with segmental unblinding. Each CTC was read by two experienced observers. For CTC and for colonoscopy the per-polyp sensitivity and per-patient sensitivity and specificity were calculated for detection of carcinomas, advanced adenomas, and adenomas. RESULTS: In total 22 of 302 included FOBT positive participants had a carcinoma (7%) and 137 had an adenoma or carcinoma >/=10 mm (45%). CTC sensitivity for carcinoma was 95% with one rectal carcinoma as false negative finding. CTC sensitivity for advanced adenomas was 92% (95% CI: 88-96) vs. 96% (95% CI: 93-99) for colonoscopy (P = 0.26). For adenomas and carcinomas >/=10 mm the CTC per-polyp sensitivity was 93% (95% CI: 89-97) vs. 97% (95% CI: 94-99) for colonoscopy (P = 0.17). The per-patient sensitivity for the detection of adenomas and carcinomas >/=10 mm was 95% (95% CI: 91-99) for CTC vs. 99% (95% CI: 98-100) for colonoscopy (P = 0.07), while the per-patient specificity was 90% (95% CI: 86-95) and 96% (95% CI: 94-99), respectively (P < 0.001). CONCLUSION: CTC with limited bowel preparation performed in an FOBT positive screening population has high diagnostic accuracy for the detection of adenomas and carcinomas and a sensitivity similar to that of colonoscopy for relevant lesions. 01 december 2010

Contains fulltext : 80310.pdf (Publisher’s version ) (Closed access) With the increasing possibilities for surgical treatment of colorectal liver metastases, careful selection of patients who may benefit from surgical treatment becomes critical. The addition of PET to (18)F-FDG may significantly improve conventional staging by CT. Up to now, definitive evidence that the addition of (18)F-FDG PET to conventional staging leads to superior clinical results and improved clinical management in these patients has been lacking. In this randomized controlled trial in patients with colorectal liver metastases, we investigated whether the addition of (18)F-FDG PET is beneficial and reduces the number of futile laparotomies. METHODS: A total of 150 patients with colorectal liver metastases selected for surgical treatment by imaging with CT were randomly assigned to CT only (n = 75) or CT plus (18)F-FDG PET (n = 75). Patients were followed up for at least 3 y. The primary outcome measure was futile laparotomy, defined as any laparotomy that did not result in complete tumor treatment, that revealed benign disease, or that did not result in a disease-free survival period longer than 6 mo. RESULTS: Patient and tumor characteristics were similar for both groups. The number of futile laparotomies was 34 (45%) in the control arm without (18)F-FDG PET and 21 (28%) in the experimental arm with (18)F-FDG PET; the relative risk reduction was 38% (95% confidence interval, 4%-60%, P = 0.042). CONCLUSION: The number of futile laparotomies was reduced from 45% to 28%; thus, the addition of (18)F-FDG PET to the work-up for surgical resection of colorectal liver metastases prevents unnecessary surgery in 1 of 6 patients.

Contains fulltext : 81609.pdf (Publisher’s version ) (Closed access) INTRODUCTION: This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients. PATIENTS: For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT. RESULTS: The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87). CONCLUSION: All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.

Contains fulltext : 69921.pdf (Publisher’s version ) (Closed access) PURPOSE: To evaluate the effect of arm position on image quality and effective radiation dose in an automatic exposure-controlled (AEC) multidetector thoracoabdominal computed tomography (CT) protocol in trauma patients. MATERIALS AND METHODS: This retrospective study of the data of 177 trauma patients (117 male; median age, 39 years) was approved by the institutional ethics board, with informed patient consent waived. Patients underwent scanning by using an AEC 16-detector thoracoabdominal CT protocol in which both arms were raised above the shoulder region (standard-position group, 132 patients), one arm was raised and the other was down (one-arm group, 27 patients), or both arms were down (two-arm group, 18 patients). Objective and subjective image quality was assessed. Individual effective radiation dose was calculated from the effective tube current-time product per exposed section. For this purpose, section location-dependent conversion factors were derived by using a CT dosimetry calculator. The effect of arm position on effective dose was quantified by using linear regression analysis with correction for patient volume and attenuation. RESULTS: Compared with the image quality in the standard-position group, the image quality in the one- and two-arm groups was decreased but within acceptable diagnostic limits. The median corrected effective dose in the standard-position group was 18.6 mSv; the dose in the one-arm group was 18% (95% confidence interval: 11%, 25%) higher than this, and that in the two-arm group was 45% (95% confidence interval: 34%, 57%) higher. CONCLUSION: Omitting arm raising results in lower but acceptable image quality and a substantially higher effective radiation dose. Hence, effort should be made to position the arms above the shoulder when scanning trauma patients. Clinical trial registration no. NCT00228111.

Contains fulltext : 69546.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The objective of our study was to evaluate the added value of a low-threshold routine thoracic MDCT algorithm compared with a selective MDCT algorithm in adult blunt trauma patients. SUBJECTS AND METHODS: A prospective cohort study was conducted in 464 consecutive blunt trauma patients who met criteria indicative of severe blunt trauma (66% male; age range, 16-93 years; median injury severity score, 13). After clinical evaluation and conventional radiography of the chest and thoracic spine, all patients underwent routine thoracic MDCT with an IV contrast agent (routine MDCT algorithm). Within this routine MDCT group, a subgroup was prospectively defined with abnormal or inconclusive clinical or conventional radiography evaluation (selective MDCT group). Two investigators determined the type, extent, and clinical impact of additional injuries found on MDCT as compared to conventional radiography for both MDCT groups. RESULTS: Of all 464 patients within the routine MDCT group, 164 patients underwent selective MDCT, which resulted in detection of additional diagnoses compared with conventional radiography in 97 (59%) patients. The routine MDCT algorithm detected additional diagnoses compared with conventional radiography in 201 of 464 patients (43%). Compared with the selective MDCT algorithm, this was an absolute increase of 104 of 464 (22%) extra patients, resulting in a change in patient management in 34 (7%; 95% CI, 5-9.7%), mostly because of additional findings of pulmonary and mediastinal injury. CONCLUSION: Routine MDCT has relatively lower, though still substantial, added diagnostic value compared with selective MDCT of the chest.

Contains fulltext : 71531.pdf (Publisher’s version ) (Closed access) BACKGROUND AND PURPOSE: Functional outcome in patients with minor head injury with neurocranial traumatic findings on CT is largely unknown. We hypothesized that certain CT findings may be predictive of poor functional outcome. Materials and METHODS: All patients from the CT in Head Injury Patients (CHIP) study with neurocranial traumatic CT findings were included. The CHIP study is a prospective, multicenter study of consecutive patients, > or =16 years of age, presenting within 24 hours of blunt head injury, with a Glasgow Coma Scale (GCS) score of 13-14 or a GCS score of 15 and a risk factor. Primary outcome was functional outcome according to the Glasgow Outcome Scale (GOS). Other outcome measures were the modified Rankin Scale (mRS), the Barthel Index (BI), and number and severity of postconcussive symptoms. The association between CT findings and outcome was assessed by using univariable and multivariable regression analysis. RESULTS: GOS was assessed in 237/312 patients (76%) at an average of 15 months after injury. There was full recovery in 150 patients (63%), moderate disability in 70 (30%), severe disability in 7 (3.0%), and death in 10 (4.2%). Outcome according to the mRS and BI was also favorable in most patients, but 82% of patients had postconcussive symptoms. Evidence of parenchymal damage was the only independent predictor of poor functional outcome (odds ratio = 1.89, P = .022). CONCLUSION: Patients with neurocranial complications after minor head injury generally make a good functional recovery, but postconcussive symptoms may persist. Evidence of parenchymal damage on CT was predictive of poor functional outcome.

Contains fulltext : 51429.pdf (Publisher’s version ) (Closed access) PURPOSE: To prospectively and externally validate published national and international guidelines for the indications of computed tomography (CT) in patients with a minor head injury. MATERIALS AND METHODS: The study protocol was institutional review board approved. All patients implicitly consented to use of their deidentified data for research purposes. Between February 2002 and August 2004, data were collected in consecutive adult patients with blunt minor head injury (Glasgow Coma Scale score of 13-14 or 15) and a risk factor for neurocranial traumatic complications at presentation at four Dutch university hospitals. Primary outcome was any neurocranial traumatic CT finding. Secondary outcomes were clinically relevant traumatic CT findings and neurosurgical intervention. Sensitivity and specificity of each guideline for all outcomes and the number of patients needed to scan to detect one outcome (ie, the number of patients needed to undergo CT to find one patient with a neurocranial traumatic CT finding, a clinically relevant traumatic CT finding, or a CT finding that required neurosurgical intervention) were estimated. RESULTS: Data were available for 3181 patients. Only the European Federation of Neurological Societies guidelines reached a sensitivity of 100% for all outcomes. Specificity was 0.0%-0.5%. The Dutch guidelines had the lowest sensitivity (76.5%) for neurosurgical interventions. The best specificities for traumatic CT findings and neurosurgical interventions were reached with the criteria proposed by the United Kingdom National Institute for Clinical Excellence (NICE) (46.1% and 43.6%, respectively), albeit at relatively low sensitivities (82.1% and 94.1%, respectively). The number of patients needed to scan ranged from six to 13 for traumatic CT findings and from 79 to 193 for neurosurgical interventions. CONCLUSION: All validated guidelines demonstrated a trade-off between sensitivity and specificity. The lowest number of patients needed to scan for either of the outcomes was reached with the NICE criteria. Supplemental material: radiology.rsnajnls.org/cgi/content/full/2452061509/DC1 (c) RSNA, 2007.

Contains fulltext : 154977.pdf (Publisher’s version ) (Open Access) BACKGROUND: An overload of health-related information is available for patients on numerous websites, guidelines, and information leaflets. However, the increasing need for personalized health-related information is currently unmet. OBJECTIVE: This study evaluates an educational e-tool for patients with non-Hodgkin's lymphoma (NHL) designed to meet patient needs with respect to personalized and complete health-related information provision. The e-tool aims to help NHL patients manage and understand their personal care pathway, by providing them with insight into their own care pathway, the possibility to keep a diary, and structured health-related information. METHODS: Together with a multidisciplinary NHL expert panel, we developed an e-tool consisting of two sections: (1) a personal section for patients' own care pathway and their experiences, and (2) an informative section including information on NHL. We developed an ideal NHL care pathway based on the available (inter)national guidelines. The ideal care pathway, including date of first consultation, diagnosis, and therapy start, was used to set up the personal care pathway. The informative section was developed in collaboration with the patient association, Hematon. Regarding participants, 14 patients and 6 laymen were asked to evaluate the e-tool. The 24-item questionnaire used discussed issues concerning layout (6 questions), user convenience (3 questions), menu clarity (3 questions), information clarity (5 questions), and general impression (7 questions). In addition, the panel members were asked to give their feedback by email. RESULTS: A comprehensive overview of diagnostics, treatments, and aftercare can be established by patients completing the questions from the personal section. The informative section consisted of NHL information regarding NHL in general, diagnostics, therapy, aftercare, and waiting times. Regarding participants, 6 patients and 6 laymen completed the questionnaire. Overall, the feedback was positive, with at least 75% satisfaction on each feedback item. Important strengths mentioned were the use of a low health-literacy level, the opportunity to document the personal care pathway and experiences, and the clear overview of the information provided. The added value of the e-tool in general was pointed out as very useful for preparing the consultation with one's doctor and for providing all information on one website, including the opportunity for a personalized care pathway and diary. The majority of the revisions concerned wording and clarity. In addition, more explicit information on immunotherapy, experimental therapy, and psychosocial support was added. CONCLUSIONS: We have developed a personal care management e-tool for NHL patients. This tool contains a unique way to help patients manage their personal care pathway and give them insight into their NHL by providing health-related information and a personal diary. This evaluation showed that our e-tool meets patients' needs concerning personalized health-related information, which might serve as a good example for other oncologic diseases. Future research should focus on the possible impact of the e-tool on doctor-patient communication during consultations.

Item does not contain fulltext BACKGROUND & AIM: Several trials have demonstrated that somatostatin analogues decrease liver volume in mixed populations of patients with autosomal dominant polycystic kidney disease (ADPKD) and isolated polycystic liver disease. Chronic renal dysfunction in ADPKD may affect treatment efficacy of lanreotide and possibly enhances risk for adverse events. The aim of this open-label clinical trial (RESOLVE trial) was to assess the efficacy of 6-month lanreotide treatment, 120 mg, subcutaneously every 4 weeks in ADPKD patients with symptomatic polycystic liver disease. METHODS: Primary outcome was change in liver volume after 6 months; secondary outcomes were changes in kidney volume, estimated glomerular filtration rate (eGFR), symptom relief and health-related quality of life (Euro-Qol5D). We excluded patients with an eGFR

Contains fulltext : 139472.pdf (Publisher’s version ) (Open Access) BACKGROUND: CT is increasingly used during the initial evaluation of blunt trauma patients. In this era of increasing cost-awareness, the pros and cons of CT have to be assessed. OBJECTIVES: This study was performed to evaluate cost-consequences of different diagnostic algorithms that use thoracoabdominal CT in primary evaluation of adult patients with high-energy blunt trauma. MATERIALS AND METHODS: We compared three different algorithms in which CT was applied as an immediate diagnostic tool (rush CT), a diagnostic tool after limited conventional work-up (routine CT), and a selective tool (selective CT). Probabilities of detecting and missing clinically relevant injuries were retrospectively derived. We collected data on radiation exposure and performed a micro-cost analysis on a reference case-based approach. RESULTS: Both rush and routine CT detected all thoracoabdominal injuries in 99.1% of the patients during primary evaluation (n = 1040). Selective CT missed one or more diagnoses in 11% of the patients in which a change of treatment was necessary in 4.8%. Rush CT algorithm costed euro 2676 (US$ 3660) per patient with a mean radiation dose of 26.40 mSv per patient. Routine CT costed euro 2815 (US$ 3850) and resulted in the same radiation exposure. Selective CT resulted in less radiation dose (23.23 mSv) and costed euro 2771 (US$ 3790). CONCLUSIONS: Rush CT seems to result in the least costs and is comparable in terms of radiation dose exposure and diagnostic certainty with routine CT after a limited conventional work-up. However, selective CT results in less radiation dose exposure but a slightly higher cost and less certainty.

Objective. The objective of this study was to evaluate the diagnostic performance and role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints. Materials and methods. The sonographic report and follow-up data of 494 patients who had undergone a primary sonographic examination were retrospectively reviewed. Sensitivity and specificity of sonography for the diagnosis of an abdominal malignancy-that is, a primary tumor or metastasis-were determined. Multivariate logistic regression analysis was performed to determine the incremental value of sonography, and a prediction rule was derived. Results. An abnormality on sonography-that is, a mass, ascites, pleural effusion, hydronephrosis, or focal intraparenchymal heterogeneity suggestive of a mass-had a sensitivity for abdominal malignancy of 86% and a specificity of 94%. In the multivariate analysis, the sonographic findings were found to have significant incremental value (odds ratio=74) after adjustment for the clinical determinants. In patients younger than 38 years with no previous malignancy, no palpable mass, normal liver function test results, and negative findings on sonographic examination, the risk of an abdominal malignancy was less than 1 in 500. Conclusion. Our results suggest that sonography may be useful in excluding an abdominal malignancy when used in a primary care setting in patients with abdominal complaints who are at low risk for a malignancy.

Contains fulltext : 152411.pdf (Publisher’s version ) (Closed access)

Objective Currently CT is rapidly implemented in the evaluation of trauma patients. In anticipation of a large international multicentre trial, this study9s aim was to evaluate the clinical feasibility of a new diagnostic protocol, used for the primary radiological evaluation in adult blunt high-energy trauma patients, especially for the use of CT. Methods An evidence-based flow chart was created with criteria based on trauma mechanism, physical examination and laboratory analyses to indicate appropriateness of conventional radiography (CR), sonography and CT of head, cervical spine and trunk. To evaluate this protocol, the authors prospectively included 81 consecutive patients. Collected data included protocol adherence and number and type of performed CR and CT scans. The authors also determined the time needed to perform radiological investigations, adverse events in the CT room and clinically relevant missed injuries after 1-month clinical follow-up. Results There was 99% adherence to the protocol concerning CT. Seventy-nine patients (98%) received one or more CT scans: 72 (89%) had thoracoabdominal, 78 (96%) cervical spine and 54 (67%) had cranial CT. In 30 patients, one or more CT scans of body regions could be omitted. In 38%, CR was wrongly omitted or performed incorrectly at a variance with the protocol. No major adverse events occurred in the CT room and no clinically relevant injuries were missed. Conclusions The authors introduced a diagnostic protocol that seems feasible and safe for the evaluation of adult blunt high-energy trauma patients. Implementation of this protocol has the potential to reduce unnecessary radiological investigations, especially CT scans.

During the treatment of colorectal liver metastases, evaluation of treatment efficacy is of the utmost importance for decision making. The aim of the present study was to explore the ability of preclinical imaging modalities to detect experimental liver metastases. Nine male Wag/Rij rats underwent a laparotomy with intraportal injection of CC531 tumor cells. On days 7, 10, and 14 after tumor induction, sequential positron emission tomography (PET), computed tomography (CT), and magnetic resonance imaging (MRI) scans were acquired of each rat. At each time point, three rats were euthanized and the metastases in the liver were documented histologically. Topographically, the liver was divided into eight segments and the image findings were compared on a segment-by-segment basis with the histopathologic findings. Sixty-four liver segments were analyzed, 20 of which contained tumor deposits. The overall sensitivity of PET, CT, and MRI was 30%, 25%, and 20%, respectively. For the detection of tumors with a histologic diameter exceeding 1 mm (n = 8), the sensitivity of PET, CT, and MRI was 63%, 38%, and 38%, respectively. The overall specificity of PET, CT, and MRI was 98%, 100%, and 93%, respectively. This study showed encouraging detectability and sensitivity for preclinical imaging of small liver tumors and provides valuable information on the imaging techniques for designing future protocols.

Item does not contain fulltext BACKGROUND: Patients with diabetes mellitus (DM) have a high prevalence of atherosclerotic vascular lesions. It is therefore reasonable to assume that also the rate of renal artery stenosis (RAS) is higher. The presence of a RAS can have implications for the treatment of patients with diabetes mellitus and hypertension and renal impairment. Therefore it is important to be informed about the chance that a RAS is present among such patients. METHODS: We prospectively studied the prevalence of atherosclerotic renal artery stenosis (RAS) among patients with diabetes mellitus. Patients were included if they were diagnosed with DM and hypertension with or without impairment of renal function. If causes of renal disease other than DM or hypertension were more probable on the basis of biochemical data, then such patients were excluded. A magnetic resonance angiography (MRA) of the renal arteries was made in 54 included successive patients. RESULTS: Patient characteristics: mean age 59+/-8.5years (range 35 to 80). Eight patients had DM 1 and 46 DM 2. Mean BMI was 31.4+/-5.6kg/m(2). A RAS was present in 18 of the 54 (33%) patients, 3 patients had bilateral stenoses. Factors related to the presence of RAS were diastolic blood pressure, glomerular filtration rate and dyslipidaemia. CONCLUSION: In this group of diabetic patients with hypertension and or renal impairment the prevalence of RAS was 33%. 01 oktober 2012

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.

Item does not contain fulltext BACKGROUND: It is unknown whether if a plain X-ray of the iliac arteries (pelvic X-ray) is a reliable tool to detect calcifications and predict vascular complications. METHODS: In a prospective study, a pelvic X-ray was performed before transplantation in patients without evidence of peripheral vascular disease (n = 109) and vascular calcifications were scored. Vascular calcifications in the iliac arteries and complications were scored by the transplant surgeon during the operation (gold standard). RESULTS: Vascular calcifications were found on the pelvic X-ray in 33 patients (30.2%). The transplant surgeon identified vascular calcifications in 35%. Sensitivity and specificity of the pelvic X-ray for vascular calcifications in the iliac arteries were 48 and 82%, respectively. Technical problems with the arterial anastomosis due to vascular calcifications were observed in five patients. The negative predictive value and positive predictive value of a pelvic X-ray for complications with the arterial anastomosis were 99 and 14%, respectively. CONCLUSIONS: A pelvic X-ray is not a reliable tool to detect vascular calcifications. Technical problems with the arterial anastomosis due to calcifications are infrequent in the absence of vascular calcifications on the pelvic X-ray.

Contains fulltext : 87934.pdf (Publisher’s version ) (Closed access) OBJECTIVE: [F-18]-Fluorodeoxyglucose-positron emission tomography (FDG-PET) is used increasingly in the work-up to surgery for patients with potentially resectable colorectal liver metastases. This study evaluates the clinical effectiveness, impact on health care resources and cost-effectiveness of adding FDG-PET to the diagnostic algorithm alongside a randomized clinical trial from a health care perspective. METHODS: In a randomized clinical trial, the net monetary benefit (NMB) of FDG-PET added to conventional diagnostic work-up (CWU) was determined in patients with colorectal liver metastases. Seventy-five patients were included in each arm. Change in clinical management, futile laparotomies, preoperative findings and all relevant health care consumption were prospectively documented during 3 years. To assess health-related quality of life European Quality of Life-5 Dimensions was administered at the time of randomization, 3 and 6 weeks postoperatively, and every 3 months postoperatively for 3 years. Quality-adjusted life years (QALYs) were calculated based on European Quality of Life-5 Dimensions outcomes. RESULTS: In adding FDG-PET, diagnostic performance increased and futile laparotomies were reduced by 38%. Both health-related quality of life and QALYs showed no significant difference between the CWU and PET groups. For CWU and PET groups costs were euro 92,836 and euro 81,776, respectively, accumulated in 3 years after randomization. NMB ranged from euro 1004 to euro 11,060 depending on the monetary value given to a QALY. When costs for chemotherapy were disregarded, costs amounted to euro 15,874 for CWU and euro 18,664 for PET group. CONCLUSION: Additional costs of FDG-PET in the diagnostic work-up of patients with potentially resectable colorectal liver metastases were compensated by a reduction in futile laparotomies. The NMB analysis showed savings over a relevant range of willingness to pay for a QALY. 01 november 2010

Contains fulltext : 88949.pdf (Publisher’s version ) (Closed access) PURPOSE: To compare the cost-effectiveness of using selective computed tomographic (CT) strategies with that of performing CT in all patients with minor head injury (MHI). MATERIALS AND METHODS: The internal review board approved the study; written informed consent was obtained from all interviewed patients. Five strategies were evaluated, with CT performed in all patients with MHI; selectively according to the New Orleans criteria (NOC), Canadian CT head rule (CCHR), or CT in head injury patients (CHIP) rule; or in no patients. A decision tree was used to analyze short-term costs and effectiveness, and a Markov model was used to analyze long-term costs and effectiveness. n-Way and probabilistic sensitivity analyses and value-of-information (VOI) analysis were performed. Data from the multicenter CHIP Study involving 3181 patients with MHI were used. Outcome measures were first-year and lifetime costs, quality-adjusted life-years, and incremental cost-effectiveness ratios. RESULTS: Study results showed that performing CT selectively according to the CCHR or the CHIP rule could lead to substantial U.S. cost savings ($120 million and $71 million, respectively), and the CCHR was the most cost-effective at reference-case analysis. When the prediction rule had lower than 97% sensitivity for the identification of patients who required neurosurgery, performing CT in all patients was cost-effective. The CHIP rule was most likely to be cost-effective. At VOI analysis, the expected value of perfect information was $7 billion, mainly because of uncertainty about long-term functional outcomes. Conclusion: Selecting patients with MHI for CT renders cost savings and may be cost-effective, provided the sensitivity for the identification of patients who require neurosurgery is extremely high. Uncertainty regarding long-term functional outcomes after MHI justifies the routine use of CT in all patients with these injuries. 01 februari 2010

Contains fulltext : 87857.pdf (Publisher’s version ) (Closed access) PURPOSE: The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury. METHODS: This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre. RESULTS: We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant. CONCLUSION: Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected. 01 april 2010

Contains fulltext : 88962.pdf (Publisher’s version ) (Closed access) BACKGROUND: Multidetector-row computed tomography (MDCT) is a more sensitive modality as compared with conventional radiography (CR) in detecting pulmonary injuries. MDCT often detects pulmonary contusion that is not visualized by CR, defined as occult pulmonary contusion (OPC). The aim of this study was to investigate whether OPC on MDCT has implications for the outcome in blunt trauma patients. METHODS: We used prospectively collected data from 1,040 adult high-energy blunt trauma patients who were primarily presented at our emergency department and who underwent CR and MDCT of the chest. All patients with pulmonary contusion were identified and divided into two groups: The "CR/computed tomography (CT) group" consisted of patients with pulmonary contusion visible on both CR and MDCT. The "CT-only" group consisted of patients with OPC, visible exclusively on MDCT. The control group consisted of blunt trauma patients without pulmonary contusion. These groups were compared with respect to difference in mortality and other outcome measures. In addition, a multivariate analysis was performed. RESULTS: Two hundred fifty-five patients suffered pulmonary contusion: The CT-only group consisted of 157 and the CR/CT group of 98 patients. The CT-only group did not differ from the control group with respect to mortality rate and other outcome measures. However, compared with the CR/CT group, mortality rate was significantly lower (8% versus 16%, p = 0.039) and most other outcome measures were significantly better in the CT-only group. CONCLUSION: OPC on MDCT is not associated with a worse outcome as compared with patients without pulmonary contusion. OPC has a better outcome as compared with pulmonary contusion visible on both CR and MDCT. 01 februari 2010

Contains fulltext : 81608.pdf (Publisher’s version ) (Closed access) BACKGROUND: Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm. MATERIALS: This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup. RESULTS: Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm. CONCLUSIONS: Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.

Contains fulltext : 80538.pdf (Publisher’s version ) (Closed access) AIM: To identify and to evaluate predictors that determine whether chest computed tomography (CT) is likely to reveal relevant injuries in adult blunt trauma patients. METHODS: After a comprehensive literature search for original studies on blunt chest injury diagnosis, two independent observers included studies on the accuracy of parameters derived from history, physical examination, or diagnostic imaging that might predict injuries at (multidetector row) CT in adults and that allowed construction of 2x2 contingency tables. For each article, methodological quality was scored and relevant predictors for injuries at CT were extracted. For each predictor, sensitivity, specificity, positive and negative likelihood ratio and diagnostic odds ratio (DOR) including 95% confidence intervals were calculated. RESULTS: Of 147 articles initially identified, the observers included 10 original studies in consensus. Abnormalities at physical examination (abnormal respiratory effort, need for assisted ventilation, reduced airentry, coma, chest wall tenderness) and pelvic fractures were significant predictors (DOR: 2.1-6.7). The presence of any injuries at conventional radiography of the chest (eight articles) was a more powerful significant predictor (DOR: 2.2-37). Abnormal chest ultrasonography (four articles) was the most accurate predictor for chest injury at CT (DOR: 491-infinite). CONCLUSION: The current literature indicates that in blunt trauma patients with abnormal physical examination, abnormal conventional radiography, or abnormal ultrasonography of the chest, CT was likely to reveal relevant chest injuries. However, there was no strong evidence to suggest that CT could be omitted in patients without these criteria, or whether these findings are beneficial for patients.

Contains fulltext : 80986.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The purpose of this study was to evaluate the effectiveness of CT colonography (CTC) as a triage technique in faecal occult blood test (FOBT)-positive screening participants. METHODS: Consecutive guaiac (G-FOBT) and immunochemical (I-FOBT) FOBT-positive patients scheduled for colonoscopy underwent CTC with iodine tagging bowel preparation. Each CTC was read independently by two experienced observers. Per patient sensitivity, specificity and positive and negative predictive values (PPV and NPV) were calculated based on double reading with different CTC cut-off lesion sizes using segmental unblinded colonoscopy as the reference standard. The acceptability of the technique to patients was evaluated with questionnaires. RESULTS: 302 FOBT-positive patients were included (54 G-FOBT and 248 I-FOBT). 22 FOBT-positive patients (7%) had a colorectal carcinoma and 211 (70%) had a lesion >or=6 mm. Participants considered colonoscopy more burdensome than CTC (por=6 mm. The PPV of CTC was 87% (95% CI 80% to 93%) and NPV 77% (95% CI 69% to 85%). Using CTC as a triage technique in 100 FOBT-positive patients would mean that colonoscopy could be prevented in 28 patients while missing >or=10 mm lesions in 2 patients. CONCLUSION: CTC with limited bowel preparation has reasonable predictive values in an FOBT-positive population and a higher acceptability to patients than colonoscopy. However, due to the high prevalence of clinically relevant lesions in FOBT-positive patients, CTC is unlikely to be an efficient triage technique in a first round FOBT population screening programme.

Contains fulltext : 80007.pdf (Publisher’s version ) (Closed access) BACKGROUND & AIMS: Therapy for polycystic liver is invasive, expensive, and has disappointing long-term results. Treatment with somatostatin analogues slowed kidney growth in patients with polycystic kidney disease (PKD) and reduced liver and kidney volume in a PKD rodent model. We evaluated the effects of lanreotide, a somatostatin analogue, in patients with polycystic liver because of autosomal-dominant (AD) PKD or autosomal-dominant polycystic liver disease (PCLD). METHODS: We performed a randomized, double-blind, placebo-controlled trial in 2 tertiary referral centers. Patients with polycystic liver (n = 54) were randomly assigned to groups given lanreotide (120 mg) or placebo, administered every 28 days for 24 weeks. The primary end point was the difference in total liver volume, measured by computerized tomography at weeks 0 and 24. Analyses were performed on an intention-to-treat basis. RESULTS: Baseline characteristics were comparable for both groups, except that more patients with ADPKD were assigned to the placebo group (P = .03). The mean liver volume decreased 2.9%, from 4606 mL (95% confidence interval (CI): 547-8665) to 4471 mL (95% CI: 542-8401 mL), in patients given lanreotide. In the placebo group, the mean liver volume increased 1.6%, from 4689 mL (95% CI: 613-8765 mL) to 4895 mL (95% CI: 739-9053 mL) (P < .01). Post hoc stratification for patients with ADPKD or PCLD revealed similar changes in liver volume, with statistically significant differences in patients given lanreotide (P < .01 for both diseases). CONCLUSIONS: In patients with polycystic liver, 6 months of treatment with lanreotide reduces liver volume.

Contains fulltext : 52652.pdf (Publisher’s version ) (Closed access) BACKGROUND: Selection of patients for hepatic resection of colorectal liver metastases is still limited. After conventional work up by computed tomography (CT) scan, 60% of patients will develop recurrent disease in the early years after resection. The aim of the present study was to evaluate whether an additional fluorine-18-deoxyglucose positron emission tomography (FDG-PET) improves patient selection and therefore adds value to select patients for curative liver resection. METHODS: Data from 203 patients selected for surgical treatment of colorectal liver metastases between 1995 and 2003 were collected in a prospective database. Group A consisted of 100 consecutive patients selected for hepatic surgery by conventional diagnostic imaging (CT chest and abdomen) only. Group B consisted of 103 consecutive patients selected for hepatic surgery by conventional diagnostic methods plus an additional FDG-PET. RESULTS: The number of patients with futile surgery, in which further treatment was considered inappropriate at laparotomy, was 28.0% in group A and 19.4% in group B. The reason for unresectable disease differed between groups. In group A, 10/100 (10.0%) patients showed extrahepatic abdominal disease versus 2/103 patients (1.9%) in group B (P = .017). In all other cases, resection was not performed because liver disease proved too extensive at laparotomy. For patients ultimately undergoing surgical treatment of the metastases, survival was comparable between groups. Overall survival at 3 years was 57.1% in group A versus 60.1% in group B. Disease-free survival at 3 years was 23.0% in group A and 31.4% in group B. CONCLUSIONS: In patients with colorectal liver metastases, FDG-PET may reduce the number of negative laparotomies. However, the effect size on the selection of these patients seems not sufficient enough to affect the overall and disease-free survival after treatment.

Contains fulltext : 52750.pdf (Publisher’s version ) (Closed access) BACKGROUND: Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients. METHODS: Clinical and radiologic data from 106 consecutive blunt trauma patients were reviewed. Diagnoses revealed by conventional work-up of the chest, abdomen, pelvis, and thoracolumbar spine were compared with that detected by CT scan of the chest and abdomen. Unexpected findings by CT scan and rejected diagnoses by CT scan were collected. Therapeutic consequences of these diagnoses were determined both theoretically and collected from the medical records. RESULTS: In 74% (95% confidence interval [CI] 65-82) of the 106 patients, 1 or more diagnoses were demonstrated by chest or abdominal CT scan, whereas they had not been revealed by preceding conventional work-up. This resulted in an actual change of treatment in 34% (95% CI 25-43) of the patients. CT scan of the chest resulted in a change of treatment in 33% (95% CI 23-44) and abdominal CT scan in 16% (95% CI 9-24). CONCLUSIONS: CT scan of the chest and abdomen has a high diagnostic value in the evaluation of blunt trauma patients, when it is selectively performed in addition to the early conventional radiologic work-up. Unexpected pathologic findings are detected by CT scan in the majority of the patients. These findings result in an adaptation of treatment in a substantial number of the patients.

Contains fulltext : 53711.pdf (Publisher’s version ) (Closed access) OBJECTIVE: A history of loss of consciousness (LOC) or post-traumatic amnesia (PTA) is commonly considered a prerequisite for minor head injury (MHI), although neurocranial complications also occur when LOC/PTA are absent, particularly in the presence of other risk factors. The purpose of this study was to evaluate whether known risk factors for complications after MHI in the absence of LOC/PTA have the same predictive value as when LOC/PTA are present. METHODS: A prospective multicentre study was performed in four university hospitals between February 2002 and August 2004 of consecutive blunt head injury patients (> or = 16 years) presenting with a normal level of consciousness and a risk factor. Outcome measures were any neurocranial traumatic CT finding and neurosurgical intervention. Common odds ratios (OR) were estimated for each of the risk factors and tested for homogeneity. RESULTS: 2462 patients were included: 1708 with and 754 without LOC/PTA. Neurocranial traumatic findings on CT were present in 7.5% and were more common when LOC/PTA was present (8.7%). Neurosurgical intervention was required in 0.4%, irrespective of the presence of LOC/PTA. ORs were comparable across the two subgroups (p>0.05), except for clinical evidence of a skull fracture, with high ORs both when LOC/PTA was present (OR = 37, 95% CI 17 to 80) or absent (OR = 6.9, 95% CI 1.8 to 27). LOC and PTA had significant ORs of 1.9 (95% CI 1.0 to 2.7) and 1.7 (95% CI 1.3 to 2.3), respectively. CONCLUSION: Known risk factors have comparable ORs in MHI patients with or without LOC or PTA. MHI patients without LOC or PTA need to be explicitly considered in clinical guidelines.

Contains fulltext : 51516.pdf (Publisher’s version ) (Closed access) BACKGROUND: Prediction rules for patients with minor head injury suggest that the use of computed tomography (CT) may be limited to certain patients at risk for intracranial complications. These rules apply only to patients with a history of loss of consciousness, which is frequently absent. OBJECTIVE: To develop a prediction rule for the use of CT in patients with minor head injury, regardless of the presence or absence of a history of loss of consciousness. DESIGN: Prospective, observational study. SETTING: 4 university hospitals in the Netherlands that participated in the CT in Head Injury Patients (CHIP) study. PATIENTS: Consecutive adult patients with minor head injury (> or =16 years of age) with a Glasgow Coma Scale (GCS) score of 13 to 14 or with a GCS score of 15 and at least 1 risk factor. MEASUREMENTS: Outcomes were any intracranial traumatic CT finding and neurosurgical intervention. The authors performed logistic regression analysis by using variables from existing prediction rules and guidelines, with internal validation by using bootstrapping. RESULTS: 3181 patients were included (February 2002 to August 2004): 243 (7.6%) had intracranial traumatic CT findings and 17 (0.5%) underwent neurosurgical intervention. A detailed prediction rule was developed from which a simple rule was derived. Sensitivity of both rules was 100% for neurosurgical interventions, with an associated specificity of 23% to 30%. For intracranial traumatic CT findings, sensitivity and specificity were 94% to 96% and 25% to 32%, respectively. Potential CT reduction by implementing the prediction rule was 23% to 30%. Internal validation showed slight optimism for the model's performance. LIMITATION: External validation of the prediction model will be required. CONCLUSION: The authors propose the highly sensitive CHIP prediction rule for the selective use of CT in patients with minor head injury with or without loss of consciousness.

Contains fulltext : 52091.pdf (Publisher’s version ) (Closed access) BACKGROUND: For patients with colorectal liver metastases, resection is the treatment of choice. Careful selection of these patients is crucial in order to reduce the chance of unexpected findings at laparotomy and abandoning further surgical intervention. Here, we evaluate the predictive value of CT and FDG-PET of the liver and extrahepatic findings compared to findings during laparotomy and 6 months follow-up. METHODS: 131 consecutive patients, selected for hepatic surgery for colorectal liver metastases by CT and FDG-PET, were evaluated prospectively. During surgery, the liver was assessed by intra-operative ultrasound, palpation and histology. RESULTS: In 127 patients (97%), CT was true-positive for liver metastases. In 3 patients, CT was false-positive and in 1 patient false-negative. In 126 patients (96%), FDG-PET was true-positive for liver metastases, in 2 patients FDG-PET was false-negative, in 3 patients true-negative (negative FDG-PET, false-positive CT). At laparotomy a total of 363 liver metastases was identified: 63 lesions 20 mm [124 (97%) CT-positive, 121 (95%) FDG-PET-positive]. CT and FDG-PET missed approximately 30% of the smaller liver lesions, resulting in a significant change in clinical management during surgery in only nine patients. CONCLUSIONS: CT and FDG-PET have a similar diagnostic yield for the identification of liver metastases; both modalities being adequate on a patient-basis but inadequate to detect the smallest of liver lesions. However, the clinical relevance of the latter is limited.

Contains fulltext : 53230.pdf (Publisher’s version ) (Closed access) Recently, a new oral liver-specific manganese-based MR agent (CMC-001) has been introduced. This contrast medium is delivered to the liver in high concentrations in the portal vein and very low doses in the hepatic artery, as only small amounts of manganese enter the general circulation. It is taken up by the hepatocytes and excreted in the bile. Our initial experience with the new MR contrast medium in a variety of patients is reported. A total of 20 patients (11 males and 9 females) were studied with MR imaging 2 h after oral ingestion of the contrast agent. Sixteen patients were referred for evaluation of focal liver lesion(s), whereas in the remaining four patients, evaluation of the biliary tract was requested. In the 17 patients without biliary obstruction, there was an increased signal intensity of the liver parenchyma, whereas in the three patients with biliary obstruction, the uptake was delayed. There was excellent visualization of the biliary system on the T1-weighted images in the 16 patients without biliary obstruction referred for evaluation of a focal liver lesion. In seven patients, the uptake was patchy. In patients with focal liver lesions or biliary tract diseases, it is possible to increase the signal intensity of the liver parenchyma after the oral intake of CMC-001. In patients without biliary tract obstruction, the biliary system is easily visualized. Oral manganese seems to be useful in hepatobiliary MRI. Further research is strongly warranted.

Background Patient education should be part of improvement strategies to increase guideline adherence by professionals. Objectives This study evaluates an e-tool designed in response to patients’ need for more complete information regarding diagnostics, therapy and after-care (based on previous research). The e-tool aims to inform patients about non-Hodgkin’s lymphoma (NHL)-care and gives patients the possibility to check their own care pathway and register personal experiences. Methods The e-tool was developed in consultation with the Dutch Lymphoma Patients Organization and evaluated by NHL-patients, professionals and laymen. Feedback was asked concerning lay-out, user convenience, information provision and general strengths and weaknesses of the e-tool. The effect of the e-tool is now tested in 9 Dutch hospitals. Patients are included from November 2012 to November 2013. All patients receive patient information and an informed consent form. The process of inclusion is continuously monitored. Results In the development phase, 18 out of 26 feedback forms were filled out. Information needs were satisfactory and clearness of navigation and information on new therapies were improved after feedback. In the first 3 months of the testing phase, 25 of the historically estimated 50 patients received patient information, 12 consented and 8 used the e-tool. Discussion The e-tool seems feasible to empower patients regarding their NHL-care pathway. However, distribution of patient information is not yet optimal. Patients’ experiences with the e-tool and possible effects on quality of care is tested in a randomised controlled trial. Implications Educational e-tools for patients may help to improve guideline development and adherence.