Development of a consensus document to improve multireader concordance and accuracy of aortic regurgitation severity grading by echocardiography versus cardiac magnetic resonance imaging

Current guidelines recommend a multiparametric echocardiographic assessment of aortic regurgitation (AR). However, the absence of a hierarchical weighting of discordant parameters could cause interobserver variability. In the present study, we sought to define and improve the interobserver variability of AR assessment. Seventeen level 3 readers graded 20 randomly selected patients with AR. The readers also provided a usefulness score for each parameter, depending on its influence on their decision of the AR severity grade. A consensus strategy was subsequently formulated and validated against cardiac magnetic resonance imaging in a separate group of 80 patients. The readers were updated with the consensus document and recalibrated using the same cases. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. At baseline, no uniform approach was used to combine the individual parameters, contributing to the interobserver variability (overall kappa 0.5). A consensus strategy to categorize AR severity was developed in which the left ventricular volume took precedence over the other parameters and was used to differentiate chronic severe AR from less severe categories. Recalibration of the readers using this consensus strategy improved concordance (kappa increased to 0.7). The new strategy also improved the accuracy relative to cardiac magnetic resonance imaging, as evidenced by full agreement on severe AR between the consensus document-based grading and AR severity defined by cardiac magnetic resonance imaging in the separate validation group of 80 patients. In conclusion, grading of chronic AR using a multiparametric approach has suboptimal consistency between readers and a left ventricular volume-based consensus document improved concordance and accuracy.     

Acute renal failure and chronic diarrhea: McKittrick-Wheelock syndrome

In 1954, McKittrick and Wheelock described for the first time a syndrome presenting chronic lost of fluid and electrolytes secondary to chronic diarrhea, associated to large rectal villous adenomas. We report a case of a 75-year-old female who presented chronic diarrhea (3 to 4 depositions per day in the last year), accompanied by acute renal failure. In the rectal tact, we objective the presence of a mass of soft consistency with an irregular surface, occupying approximately two thirds of the circumference, at about 3 cm from the anal margin. It was confirmed by the colonoscopy and the patology was informed as villous adenoma, producing chronic diarrhea or McKittrick-Wheelock syndrome. We decide the surgical approach after the normalization of patient's general status and a proctectomy with coloanal anastomosis was performed. We conclude that we must think about this syndrome in aged patients with chronic diarrhea, alterations of the electrolyte balance and presence of renal failure. Surgery treatment after the replacement of water and electrolytes is the unique curative treatment. The absence of this can cause the death of these patients.     

Ectopic Cushing’s syndrome due to a mesenteric neuroendocrine tumour

INTRODUCTION

Neuroendocrine tumours (NETs) are tumours that commonly involve the gastrointestinal system. Common primary sites in the gastrointestinal system include the small intestine, appendix, rectum and pancreas. Mesenteric NETs are extremely rare entities and are sparsely reported in the literature.

CASE HISTORY

We report the case of a 62-year-old woman with ectopic Cushing’s syndrome due to excessive adrenocorticotropic hormone secretion by a primary mesenteric tumour in the small intestine and its liver metastases.

CONCLUSIONS

Although rare, the mesentery can be a primary site for NETs. It can cause similar symptoms and require similar treatment options. Tumour resection and debulking are acceptable ways to improve both the survival and symptoms.