Diagnosis and treatment in intestinal carcinoid tumors

Conclusions Patients with carcinoid tumors may present with a wide variety of symptoms depending on tumor localization, grade of malignancy, hormone production, and tumor symptoms. All of these factors must be taken into account in choice of the best-tailored treatment.     

Slowing the progression of adult chronic kidney disease: therapeutic advances

When kidney disease of any aetiology results in substantial loss of nephrons, a common clinical syndrome, characterised by hypertension, proteinuria and a progressive decline in renal function, ensues. This observation suggests that common mechanisms may contribute to progressive renal injury and that therapeutic interventions that inhibit these common pathways may afford renal protection. Research to date has identified several mechanisms that may contribute to progressive renal injury including glomerular haemodynamic changes, multiple effects of angiotensin II and detrimental effects of excessive filtration of plasma proteins by injured glomeruli. Clinical trials over the past decade have identified several interventions that are effective in slowing the rate of progression of chronic kidney disease (CKD). The use of ACE inhibitors, angiotensin receptor antagonists or a combination of the two should be regarded as fundamental to any therapy for slowing the rate of CKD progression. Hypertension should be treated aggressively to achieve a blood pressure target of < 130/80 mm Hg. Reduction of proteinuria to < 0.5 g/day should be regarded as an independent therapeutic goal. Although inconclusive, there is some evidence to support moderate dietary protein restriction to 0.6 g/kg/day in appropriate patients. Hyperlipidaemia may contribute to CKD progression and should be treated to reduce cardiovascular risk and potentially improve renal protection. Smoking cessation should be encouraged and, where necessary, assisted. Among diabetic patients tight glycaemic control should be achieved (glycosylated haemoglobin < 7%). These interventions are simple and relatively inexpensive. If applied to all patients with CKD they will result in substantial slowing of renal function decline in many patients and thereby reduce the number who progress to end-stage renal disease and require renal replacement therapy.     

Role of natriuretic peptides in the diagnosis and treatment of patients with carcinoid heart disease

Carcinoid heart disease (CHD) occurs in 20-70% of the patients with metastatic well-differentiated neuroendocrine tumours (NET). We evaluated whether natriuretic peptides (ANP or NT-proBNP) are useful in early detection of CHD. Blood samples from 32 patients with NET were compared with cardiac ultrasound follow-up. CHD was defined as thickening of the tricuspid valve in the presence of grade III-IV/IV tricuspid valve regurgitation. CHD was found in nine out of 32 patients (28%), all with symptoms of the carcinoid syndrome compared to 65% in the 23 patients without CHD (P=0.04). Median levels of NT-proBNP and 5-HIAA were significantly higher in patients with CHD (894 ng l(-1) and 815 micromol 24 h(-1)) compared to those without (89 and 206 ng l(-1), P<0.001 and P=0.007). No significant differences were detected in ANP levels (P=0.11). Dilatation of the right atrium and ventricle as well as thickening of the tricuspid valve and degree of regurgitation were statistically significant correlated with NT-proBNP levels. The accuracy of NT-proBNP in the diagnosis of CHD was higher than that of ANP. A significantly better survival was observed in case of normal NT-proBNP values. In conclusion, NT-proBNP is helpful as a simple marker in the diagnosis of CHD. Survival is better in patients with normal levels of NT-proBNP.     

Sensitivity to change of AIMS2 and AIMS2-SF components in comparison to M-HAQ and VAS-pain

OBJECTIVE: To examine sensitivity to change of Dutch versions of AIMS2 (arthritis impact measurement scales-2) and AIMS2-SF (short form) components, in comparison with M-HAQ (modified health assessment questionnaire) and the 100 mm visual analogue scale for pain (VAS-pain) in patients with rheumatoid arthritis. METHODS: 218 patients participated in a study on patient education. Participants completed the Dutch AIMS2, M-HAQ, and VAS-pain at baseline and after one year; 165 completed both assessments. The education programme did not have any effect on health status. Patients were classified according to change over one year in their responses to the AIMS2 question about general health perception: improved health (n = 32), no change (n = 101), and poorer health (n = 32). Changes in scores over one year were tested with paired t tests, and standardised response means were calculated for AIMS2 and AIMS2-SF components, M-HAQ total score, and VAS-pain in the three classifications of change in health perception. RESULTS: AIMS2 and AIMS2-SF physical, symptom, and affect components showed similar sensitivity to change. The physical and symptom components performed better than M-HAQ and VAS-pain. AIMS2 and AIMS2-SF social interaction and role components were not sensitive to changes in general health perception. The role component was only applicable in 63 patients, because the others were unemployed, disabled, or retired. CONCLUSIONS: AIMS2-SF is a good alternative to the AIMS2 long form for the assessment of health status in rheumatoid arthritis, and is preferable to M-HAQ and VAS-pain. Use of the AIMS2-SF makes it easier and less costly to collect data and reduces the burden on patients.     

Eating in larger groups increases food consumption

OBJECTIVE: To determine whether children's food consumption is increased by the size of the group of children in which they are eating. DESIGN: Crossover study. SETTING: University based preschool. PARTICIPANTS: 54 children, aged 2.5-6.5 years. INTERVENTIONS: Each child ate a standardised snack in a group of three children, and in a group of nine children. MAIN OUTCOME MEASURES: Amount each individual child consumed, in grams. RESULTS: Amount eaten and snack duration were correlated (r = 0.71). The association between group size and amount eaten differed in the short (<11.4 min) versus the long (> or =11.4 min) snacks (p = 0.02 for the interaction between group size and snack duration). During short snacks, there was no effect of group size on amount eaten (16.7 (SD 11) g eaten in small groups vs 15.1 (6.6) g eaten in large groups, p = 0.42). During long snacks, large group size increased the amount eaten (34.5 (16) vs 26.5 (13.8), p = 0.02). The group size effect was partially explained by a shorter latency to begin eating, a faster eating rate and reduced social interaction in larger groups. CONCLUSIONS: Children consumed 30% more food when eating in a group of nine children than when eating in a group of three children during longer snacks. Social facilitation of food consumption operates in preschool-aged children. The group size effect merits consideration in creating eating behaviour interventions.     

Volumetric rendering of MR images

The authors developed new techniques for three-dimensional display of magnetic resonance (MR) images that preserve soft-tissue definition, are fully automatic, and work with routinely used section thicknesses. MR images are segmented, selectively enhanced, and displayed by means of a volumetric rendering algorithm. These techniques were used to illustrate normal anatomy of the brain, knee, and liver. Three-dimensional rendering of balanced spin-echo images shows the ventricles and extracerebral veins and of T1-weighted images, the sulci and gyri. The large hepatic and portal vessels can be seen with these enhancement techniques. Three-dimensional views of the knee reveal articular surfaces of the tibia and clearly depict menisci and posterior and anterior cruciate ligaments. These techniques make it possible to image multiple soft tissues simultaneously while preserving the detail contained in the original images. Three-dimensional presentation of complex, overlapping anatomic regions is helpful in surgical planning and should lead to improved diagnosis.     

Digital beam attenuator technique for compensated chest radiography

The feasibility of producing patient-specific beam attenuators for chest radiography has been investigated using an anthropomorphic phantom and a human volunteer. A low-dose test exposure is digitized, processed, and used to print a small cerium filter, which is placed in the x-ray beam near the collimator. The final radiograph is recorded on film. The technique results in relatively uniform film exposure, so that structures in all regions of the chest are simultaneously displayed with optimal film contrast. The equalized exposure improves image quality in the normally underpenetrated regions and reduces the role of cross-scatter from the lungs. The image is analogous to optical or computer-processed unsharp masking techniques, but the processing is accomplished in the x-ray beam and results in an improved exposure distribution, giving advantages that cannot be achieved with image processing techniques alone.