Dylan Bartholomeusz

Anorectal Function After Three- Versus Two-Dimensional Radiation Therapy for Carcinoma of the Prostate

PURPOSE To compare the effects of (three-dimensional) 3D vs. two-dimensional (2D) radiation therapy (RT) for carcinoma of the prostate on the prevalence and pathophysiology of anorectal dysfunction. METHODS AND MATERIALS Anorectal symptoms, motility, sensory function, and anal sphincter morphology were evaluated before and up to 2 years after randomly assigned hypofractionated vs. conventionally fractionated RT in 67 patients (median age, 69 years; range, 54-82 years) with localized prostate carcinoma, using either a 3D (n = 29) or 2D (n = 38) treatment technique. RESULTS Anorectal symptoms increased 4 to 6 weeks after RT and persisted in both patient groups. At 2 years, abnormalities included increased stool frequency (55% vs. 53%, p = NS), urgency of defecation (72% vs. 47%, p < 0.05), fecal incontinence (28% vs. 26%, p = NS), and rectal bleeding (38% and 42%, p = NS). Anorectal motility and sensory function deteriorated after RT in both groups with reductions in basal anal pressures, anal pressures in response to squeeze, rectal compliance, and rectal volumes associated with the desire to defecate. External but not internal sphincter thickness changed in the treatment groups although in different directions. However no differences in motility or sensory function were detected between the groups. Baseline anorectal motility but not treatment technique and the hypofracionated schedule were of independent prognostic significance for anorectal motor dysfunction and rectal bleeding respectively at 2 years. CONCLUSION The prevalence and pathophysiology of anorectal dysfunction 2 years after RT for prostate carcinoma was largely independent of the treatment techniques used in this study.

Patient-controlled analgesia with inhaled methoxyflurane versus conventional endoscopist-provided sedation for colonoscopy: a randomized multicenter trial

OBJECTIVE Inhaled methoxyflurane (Penthrox, Medical Device International, Melbourne, Australia) has been used extensively in Australasia (Australia and New Zealand) to manage trauma-related pain. The aim is to evaluate the efficacy, safety, and outcome of Penthrox for colonoscopy. DESIGN Prospective randomized study. SETTING Three tertiary endoscopic centers. PATIENTS Two hundred fifty-one patients were randomized to receive either Penthrox (n = 125, 70 men, 51.4 ± 1.1 years old) or intravenous midazolam and fentanyl (M&F; n = 126, 72 men, 54.9 ± 1.1 years old) during colonoscopy. MAIN OUTCOME MEASUREMENT Discomfort (visual analogue scale [VAS] pain score), anxiety (State-Trait Anxiety Inventory Form Y [STAI-Y] anxiety score), colonoscopy performance, adverse events, and recovery time. RESULTS Precolonoscopy VAS pain and STAI-Y scores were comparable between the 2 groups. There were no differences between groups in (1) pain VAS or STAI Y-1 anxiety scores during or immediately after colonoscopy, (2) procedural success rate (Penthrox: 121/125 vs M&F: 124/126), (3) hypotension during colonoscopy (7/125 vs 8/126), (4) tachycardia (5/125 vs 3/126), (5) cecal arrival time (8 ± 1 vs 8 ± 1 minutes), or (6) polyp detection rate (30/125 vs 43/126). Additional intravenous sedation was required in 10 patients (8%) who received Penthrox. Patients receiving Penthrox alone had no desaturation (oxygen saturation [SaO(2)] < 90%) events (0/115 vs 5/126; P = .03), awoke quicker (3 ± 0 vs 19 ± 1 minutes; P < .001) and were ready for discharge earlier (37 ± 1 vs 66 ± 2 minutes; P < .001) than those receiving intravenous M&F. LIMITATIONS Inhaled Penthrox is not yet available in the United States and Europe. CONCLUSIONS Patient-controlled analgesia with inhaled Penthrox is feasible and as effective as conventional sedation for colonoscopy with shorter recovery time, is not associated with respiratory depression, and does not influence the procedural success and polyp detection.

Disturbed Colonic Motility Contributes to Anorectal Symptoms and Dysfunction After Radiotherapy for Carcinoma of the Prostate

PURPOSE To evaluate the role of colonic motility in the pathogenesis of anorectal symptoms and dysfunction after radiotherapy (RT) for carcinoma of the prostate. PATIENTS AND METHODS Thirty-eight patients, median age 71 (range, 50-81) years with localized prostate carcinoma randomized to one of two radiation dose schedules underwent colonic transit scintigraphy and assessment of anorectal symptoms (questionnaire), anorectal function (manometry), and anal sphincteric morphology (endoanal ultrasound) before and at 1 month and 1 year after RT. RESULTS Whole and distal colonic transit increased 1 month after RT, with faster distal colonic transit only persisting at 1 year. Frequency and urgency of defecation, fecal incontinence, and rectal bleeding increased 1 month after RT and persisted at 1 year. Basal anal pressures remained unchanged, but progressive reductions occurred in anal squeeze pressures and responses to increased intra-abdominal pressure. Rectal compliance decreased progressively in the patients, although no changes in anorectal sensory function ensued. Radiotherapy had no effect on the morphology of the internal and external anal sphincters. Distal colonic retention was weakly related to rectal compliance at 1 month, but both faster colonic transit and reduced rectal compliance were more frequent with increased fecal urgency. At 1 year, a weak inverse relationship existed between colonic half-clearance time and frequency of defecation, although both faster whole-colonic transit and reduced rectal compliance occurred more often with increased stool frequency. CONCLUSION Colonic dysmotility contributes to anorectal dysfunction after RT for carcinoma of the prostate. This has implications for improving the management of anorectal radiation sequelae.

Complicated and uncomplicated peptic ulcer disease: altered symptom response to a nutrient challenge linked to gastric motor dysfunction.

Background: Bleeding peptic ulcer (BPU) frequently occurs in the absence of preceding dyspeptic symptoms. We have observed that patients with BPU had a diminished symptom response to nutrient challenge test compared to uncomplicated peptic ulcer disease (uPUD). We postulated that more symptoms are manifest in patients with uPUD than BPU because there are greater derangements in gastric motor function. Aim: To assess gastric emptying in patients with BPU, uPUD and healthy controls (HC). Methods: We studied 17 patients with BPU, 10 with uPUD, and 15 HC. After an 8-hour fast, subjects ingested 200 ml of an enteral feeding solution, containing 5 MBq 99mTc-rhenium sulphide colloid, every 5 min up to a cumulative volume of 800 ml. Gastric emptying was measured by scintigraphy for the total, proximal and distal stomach. Results: Patients with uPUD had significantly higher gastric retention in the proximal and total stomach at 100 min than HC and BPU, while BPU had similar percent retention to HC. Patients with uPUD had significantly higher cumulative symptom response to the nutrient challenge than did HC and BPU, while BPU had similar symptom responses to HC. Conclusions: Patients with uPUD have significantly delayed gastric emptying compared to HC and BPU. Data suggest that in addition to alterations of visceral sensory function, altered gastric motor function occurs during a nutrient challenge in uPUD but not BPU. Gastric motor function may contribute to the manifestation of dyspeptic symptoms in PUD.

Novel use of positron emission tomography/computed tomography in the diagnosis of infected porous orbital implant

We report the use of positron emission tomography/ computed tomography (PET/CT) in the diagnosis of orbital implant infection. A 74-year-old lady presented with a 6-month history of recurrent purulent discharge from her right socket. She has a secondary orbital implant; a 20-mm Vicryl MeshWrapped Aluminum Oxide Implant (FCI Ophthalmics, Marshfield Hills, MA, USA) inserted 9 months earlier. This was complicated with an early pyogenic granuloma that required cautery. Her primary evisceration was performed 50 years ago in Iran for a painful blind eye secondary to penetrating eye injury. On her initial presentation, there was discharge, ocular discomfort but no bleeding. She was systemically well and did not have any comorbidities. On examination, there was mucopurulent discharge, papillary conjunctival inflammation and a central granuloma without implant exposure. Culture of the discharge grew pan-sensitive Pseudomonas aeruginosa and she was managed as chronic conjunctivitis. Over the duration of 3 months, she failed to respond to prolonged courses of various combinations of antibiotics (Tazocin, Ciprofloxacin, Gentamicin and Chloramphenicol), topical corticosteroids (Hydrocortisone) and topical antiseptic (Iodine). A PET/CT of the orbit revealed increased uptake of 18F-fluorodeoxyglucose (FDG) within the implant and posterior peri-implant soft tissue (Fig. 1) suggestive of inflammation. The imaging prompted explantation of the implant for suspected infected orbital implant. The implant was removed, and pus was seen extruding from the implant intraoperatively. Histology of the decalcified implant and the adjacent soft tissue were consistent with chronic inflammation and fibrosis. Culture of the abscess grew population of pan-sensitive P. aeruginosa. She attained complete resolution of symptoms post explantation and extended intravenous Tazocin coverage post explantation. Orbital implant infection is a rare but serious complication of orbital implant. As highlighted in this case, diagnosis is often difficult and can be delayed as symptoms are non-specific and common in implant recipient. Signs and symptoms suggestive of infected orbital implant are purulent or haemorrhagic discharge, socket tenderness, lid oedema, conjunctival chemosis, hyperaemia, discharge and recurrent pyogenic granuloma. Although traditional imaging with magnetic resonance imaging and CT can detect late infected orbital implant with gross collection or structural changes, their role is limited in early, low-grade and chronic infection where no alterations in gross organ and tissue structures have occurred. Therefore, there is the need to complement the anatomic imaging modalities with functional and metabolic imaging techniques. Kristinsson et al. reported the successful use of Technetium 99m-labelled leucocytes in detecting low-grade implant infection that was undetectable with conventional CT. Our case demonstrated that PET/CT appears to be as capable in detecting low-grade chronic orbital implant infection and may have some advantage over conventional imaging and other form of nuclear medicine. Positron emission tomography/computed tomography is faster compared with other nuclear medicine imaging modalities, have high target to background ratio and can achieve resolution down to 4 mm that can improve spatial localization of abnormalities. The uptake of FDG is a reflection of increased glycolysis is metabolically active cells, for example, ocular muscles, brain, neoplasm, infection or inflammation. For this patient, the PET/CT was performed 11 months after her implantation; histology confirms complete fibrovascular ingrowth of the implant. This makes any uptake of FDG because of active fibrovascular ingrowth very unlikely. It would be interesting to compare our PET/CT findings with the PET/CT findings on healthy orbital implants at various stages of fibrovascular ingrowth. Correlation with findings on other

Comparative study between 68Ga-prostate-specific membrane antigen positron emission tomography and conventional imaging in the initial staging of prostate cancer

The management of prostate cancer has undergone significant advances since the introduction of 68Ga‐prostate‐specific membrane antigen (68Ga‐PSMA) positron emission tomography (PET) scans. Data on the use of 68Ga‐PSMA PET scans in the setting of biochemical recurrence is widely available. Data on the use of 68Ga‐PSMA PET as an initial staging modality, however, is limited. The aim of this retrospective study was to compare the staging of patients with newly diagnosed prostate cancer between 68Ga‐PSMA PET and current conventional imaging modalities. The potential impact of any change in stage will be analysed.

Hybrid 99m Tc-magnetite tracer for dual modality sentinel lymph node mapping

AbstractAccuracy of sentinel lymph node identification using radioactive tracers in non-superficial cancers can be limited by radiation shine through and low spatial resolution of detection systems such as intraoperative gamma probes. By utilising a dual radioactive/magnetic tracer, sensitive lymphoscintigraphy can be paired with high spatial resolution intraoperative magnetometer probes to improve the accuracy of sentinel node detection in cancers with complex multidirectional lymphatic drainage. Dextran-coated magnetite nanoparticles (33 nm mean hydrodynamic diameter) were labelled with 99mTc and applied as a lymphotropic tracer in small and large animal models. The dual tracer could be radiolabelled with 98 ± 2% efficiency after 10 min of incubation at room temperature. Biodistribution studies of the tracer were conducted in normal rats (subdermal and intravenous tail delivery, n = 3) and swine (subdermal hind limb delivery, n = 5). In rats the dual tracer migrated through four tiers of lymph node, 20 min after subdermal injection. Results from intravenous biodistribution test for radiocolloids demonstrated no aggregation in vivo, however indicated the presence of some lower-molecular weight radioactive impurities (99mTc-dextran). In swine, the dual tracer could be effectively used to map lymphatic drainage from hind hoof to popliteal and inguinal basins using intraoperative gamma and magnetometer probes. Of the eight primary nodes excised, eight were positively identified by gamma probe and seven by magnetometer probe. The high-purity dual tracer shows early promise for sentinel node identification in complex lymphatic environments by combining sensitive preoperative lymphoscintigraphy with a high-resolution intraoperative magnetometer probe.

P409 More targeted evaluation of nutrition in inflammatory bowel disease (IBD) reveals opportunities to optimise care: body mass index, body composition and iron deficiency

(42%), and 5 indeterminate colitis (11%); 67% of pts (30/45) were previously evaluated by a gastroenterologist while the remaining 33% (15/45) only by their general practitioner (GP). At final analysis only 60% of pts (27/45) reported a good overall satisfaction from their previous medical experiences. A complete dissatisfaction was observed in 11/30 pts (37%) previously evaluated by a gastroenterologist and in 7/15 pts (47%) evaluated only by their GP. Overall satisfaction rate before MI was significantly lower in pts affected by indeterminate colitis (p = 0.004) and in pts <40 years old (p = 0.02). Physicians’ communication skills were reported quite satisfactory by female (p = 0.01) while poorly satisfactory in pts with family history of IBD (p < 0.001), in pts <40 years old (p < 0.001), and in pts affected by indeterminate colitis (p = 0.05). Concerning physician empathy perceived by pts it was strongly in female pts (p < 0.001) and lack in those with family history of IBD (p < 0.001). At multivariable analysis only good physician empathy perceived by female resulted significant (p = 0.002). After MI counselling all pts (100%) reported a good overall satisfaction without lack of empathy (71% marked “excellent empathy”) due to the fact that they felt they had complete answers to their questions. All pts appreciated the use of explanatory pictures. The mean duration of the visit was 41.5±8.7 minutes. Conclusions: MI is very well appreciated by IBD pts. It is a quite time-consuming technique but considerably useful at the first visit and in younger pts. Explanatory pictures help pts to better understand their clinical condition. MI can help physicians, especially gastroenterologists, to move from “cure” to “care” with their IBD patients.