Magnetic resonance enterography (MRE) and ultrasound are used to image Crohn's disease, but their comparative accuracy for assessing disease extent and activity is not known with certainty. Therefore, we did a multicentre trial to address this issue.
This case report highlights an unusual presentation of acute adrenal infarction in a Covid-19 patient who presented with abdominal symptoms and hyponatraemia. We discuss the recent literature reviewing how Covid-19 creates a hypercoaguable state, with acute adrenal infarction as a possible prothrombotic complication.
Abstract Background Colorectal cancer is associated with secondary sarcopenia (muscle loss) and myosteatosis (fatty infiltration of muscle) and patients who exhibit these host characteristics have poorer outcomes following surgery. Furthermore, patients who undergo curative advanced rectal cancer surgery such as pelvic exenteration, are at risk of skeletal muscle loss due to immobility, malnutrition and a post-surgical catabolic state. Neuromuscular electrical stimulation (NMES) may be a feasible adjunctive treatment to help ameliorate these adverse side-effects. Hence, the purpose of this study is to investigate NMES as an adjunctive pre- and post-operative treatment for rectal cancer patients in the radical pelvic surgery setting and to provide early indicative evidence of efficacy in relation to key health outcomes. Method In a phase II, Double-blind, randomised controlled study, 58 patients will be recruited and randomised (1:1) to either a treatment (NMES plus standard care) or placebo (sham-NMES plus standard care) group. The intervention will begin two weeks pre-operatively and continue for eight weeks after exenterative surgery. The primary outcome will be change in mean skeletal muscle attenuation, a surrogate marker of myosteatosis. Sarcopenia, quality of life, inflammatory status and cancer specific outcomes will also be assessed. Discussion This pilot study will provide study important preliminary evidence of the potential for this adjunctive treatment. It will provide guidance on subsequent development of phase 3 studies on the clinical benefit of NMES for rectal cancer patients in the radical pelvic surgery setting. Trial Registration ClinicalTrials.gov Identifier: NCT04065984; Registered August 22, 2019; Recruiting.
We present the case of a 16 year old girl who developed an aggressive colitis in the context of a prior biopsy proven autoimmune pancreatitis, which presented with obstructive jaundice at the age of 13 year. This history prompted prospective investigation and the discovery of compelling evidence to make a diagnosis of IgG4-related sclerosing disease with extra-pancreatic colonic involvement on the basis of raised serum IgG4 levels and a florid colonic IgG4 plasma cell infiltrate with over 20 IgG4 positive plasma cells/hpf. The colitis was resistant to conventional therapy but responded dramatically to treatment with the anti-TNFα monoclonal antibody, adalimumab. This is the first case to report both the effectiveness of adalimumab in treating IgG4 positive colitis in a patient with IgG4-related sclerosing disease, and to prospectively record resolution of an IgG4 positive colonic infiltrate with immunosuppression.
Introduction: Maintaining adequate nutritional status can be a challenge for patients with small bowel neuroendocrine tumours (NETs). Surgical resection could result in short bowel syndrome (SBS), whilst without surgical resection there is a considerable risk of ischemia or developing an inoperable malignant bowel obstruction (IMBO). SBS or IMBO are forms of intestinal failure (IF) which might require treatment with home parenteral nutrition (HPN). Limited data exist regarding the use of HPN in patients with small bowel neuroendocrine tumours, and it is not frequently considered as a possible treatment. Methods: A systematic review was performed regarding patients with small bowel NETs and IF to report on overall survival and HPN-related complications and create awareness for this treatment. Results: Five articles regarding patients with small bowel NETs or a subgroup of patients with NETs could be identified, mainly case series with major concerns regarding bias. The studies included 60 patients (range 1–41). The overall survival time varied between 0.5 and 154 months on HPN. However, 58% of patients were alive 1 year after commencing HPN. The reported catheter-related bloodstream infection rate was 0.64–2 per 1000 catheter days. Conclusion: This systematic review demonstrates the feasibility of the use of HPN in patients with NETs and IF in expert centres with a reasonable 1-year survival rate and low complication rate. Further research is necessary to compare patients with NETs and IF with and without HPN and the effect of HPN on their quality of life.
In the UK, the prevalence of home parenteral nutrition (HPN) for patients with incurable palliative malignancy has historically been lower than countries with comparable health economies, but there is evidence to suggest a significant increase in the prevalence within the UK. Despite this increase, there has been lack of clarity regarding patient survival and quality of life, optimisation of patient selection and associated health economics. This thesis examined the complex issues involved in the use of HPN for Intestinal Failure in the palliative phase of malignancy deriving information from: a systematic review of the existing medical literature on these topics; novel data generated through meta-analysis of survival data; a national questionnaire of clinician’s attitudes to PN use in this context; analysis of a retrospective case series from University Hospital Southampton; identification of patient factors which effect survival; validation of newly developed survival prognostic tools; and a health economic assessment of this therapy. Meta-analysis of survival data for palliative malignancy patients treated with HPN showed that survival was short, 55% and 74% mortality at 3- and 6-months respectively, with only 2% of patients alive at one year. There were insufficient and poor quality data on quality of life (QoL), although the available data indicate a probable positive impact of HPN treatment in this highly symptomatic patient group. The attitudes of UK based IF clinicians are increasingly positive towards HPN therapy for palliative malignancy, with an emphasis of treatment for improving QoL. Patient performance status at commencement of HPN is the best predictor of survival. Newly developed survival prognostication tools lack sensitivity and specificity. The cost of HPN treatment in the palliative malignancy patient group is high, with low cost effectiveness (£176,587 per quality adjusted life year), although comparable to HPN treatment for non-malignancy patients. The cost effectiveness dramatically improves when patient selection favours better performance status with consequent longer survival, at a higher QoL. The results presented in this thesis provide clinically relevant information that can help with informed decision making by clinicians and patients when considering commencing HPN therapy during the palliative phase of malignant disease. This thesis also presents the first health economic assessment of this treatment, which can aid commissionaires when planning funding of services to meet the increasing demands for this treatment.
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