Multidetector CT using virtual gastroscopy and post contrast enhanced multiplanar reformation images can be useful in differentiating between malignant and benign gastric ulcers, according to a recent study conducted by researchers from Kaohsiung Medical University Hospital in Kaohsiung, Taiwan.

“Conventional gastroscopy can diagnose patients with gastric ulcers; however the procedure is invasive and occasionally may miss early stage disease. Our study was designed to determine if MDCT’s multiplanar reformation images plus virtual gastroscopy can help radiologists differentiate cancerous lesions from benign ulcer lesions,” said Chiao-Yun Chen, MD, lead author of the study.

“For virtual gastroscopy, we need to inflate the stomach to perform a CT scan then send all of the raw data to the workstation for post-processing. We can visualize the mucosal surface of the stomach, which traditionally needs to be done by optical gastroscopy,” said Dr. Chen. “However, with virtual gastroscopy alone, no information about the depth of the lesion can be obtained. Therefore, multiplanar reformatted images following intravenous contrast administration plays an important role. We are able to detect each lesion’s depth with CT this way. We can detect enlarged lymph nodes located in the space between the parietal peritoneum and the muscles and bones of the posterior abdominal wall, liver metastasis, etc., that can’t be easily detected using conventional endoscopy,” she said.

The study included 26 patients with gastric cancer (11 with T1 lesions and 15 with T2 lesions) and 26 patients with a benign gastric ulcer. “MDCT had a higher specificity in the diagnosis of malignant gastric ulcers with 77.8% in virtual gastroscopy and 100% in multiplanar reformation images” said Dr. Chen. “High specificity may help avoid delay in the treatment of patients with gastric cancer and thus may improve their survival rate,” she said.

The study appeared in a recent issue of the American Journal of Roentgenology.

Every year, more than 115 million patients enter emergency rooms at hospitals around the nation. And more than three-quarters of them leave with an impression of what happened – or what should happen next – that doesn’t match what their emergency care team would want.

That’s the finding of a new study led by University of Michigan Health System researchers, and published early online in the Annals of Emergency Medicine. The results suggest that emergency room teams need to do a better job of making sure patients go home with clear information and instructions – and that patients and their loved ones shouldn’t leave until they fully comprehend their situation.

The researchers carried out detailed interviews with 140 English-speaking patients who visited one of two emergency departments, and were released to go home. They compared those interviews with the patients’ medical records, and found a serious mismatch between what doctors and nurses found or advised, and what patients comprehended.

What’s worse, patients were pretty sure of what they “knew” 80 percent of the time – even if what they knew wasn’t quite right.

“It is critical that emergency patients understand their diagnosis, their care, and perhaps most important, their discharge instructions," says lead author Kirsten Engel, M.D., a former U-M emergency medicine fellow and Robert Wood Johnson Clinical Scholar who is now at Northwestern University. "It is disturbing that so many patients do not understand their post-emergency department care, and that they do not even recognize where the gaps in understanding are. Patients who fail to follow discharge instructions may have a greater likelihood of complications after leaving the emergency department.”

The study’s senior author agrees. “As a physician, I would like to think I could look someone in the eye and ask: ‘Do you have any questions?,’ and those who were confused or overwhelmed would ask for more help,” says Peter Ubel, M.D., a professor of internal medicine at the U-M Medical School. “This study shows that many patients walk away from important clinical encounters confident that they know what happened and why, but with little reason to be so confident.”

The researchers measured the extent to which patients’ reports agreed with their doctors’ records in four areas: diagnosis, emergency care that was given, post-ER care needs and what kinds of symptoms or signs would require the patient to return to the ER or seek immediate care.

Only 22 percent of patients’ reports were in complete harmony with what their care teams reported on all four counts.

Fifty-eight percent of patients understood at least two of the four areas, but 20 percent were off on three or four areas of their care and follow-up needs.

After asking patients about their diagnosis, care and post-ER instructions, the team also asked them if they were not sure about any of the four areas. Interestingly, patients whose understanding perfectly matched their doctors’ records were just as likely to report being unsure as patients whose understanding was lacking.

“Doctors need to not only ask patients if they have questions, but ask them to explain, in their own words, what they think is wrong with their health and what they can do about it,” says Ubel. “And patients need to ask their doctors more questions, and even need to explain, to their doctors, what they think is going on.”

The biggest area of misunderstanding or lack of comprehension was post-emergency care – that is, what steps the patient needs to take to be seen by their regular doctor or a specialist, how soon to see a doctor, or what medicines or self-care steps they need to take, how to take them, and when.

Ubel, Engel and their colleagues found that 34 percent of the deficiencies in patient comprehension reflected a less-than-complete understanding of what their ER team recommended they do after they left the ER. Meanwhile, 22 percent of the deficiencies in the study had to do with patients’ understanding of what symptoms or changes in their condition should spur them to return to the ER.

Recently, the U-M Health System introduced a program that aims directly at this problem: the Emergency Medicine Consult/Referral Service, run by the Department of Emergency Medicine and the Physician and Consumer Communications division of Public Relations & Marketing Communications.

It is staffed by referral coordinators who follow up with ER patients by phone within 24 hours of their ER visit, to help schedule appointments with U-M physicians for specialty care if the patients’ insurance allows it or make sure they know that they need to schedule an appointment elsewhere.

More than 12,000 follow-up appointments have been scheduled for recent U-M ER patients since the program began in February 2007, and 81 percent of those patients have arrived for their scheduled appointments, up from 59 percent before the program began. Appointment cancellations are also down.

Before the program began, 24 percent of U-M ER patients who needed a follow-up appointment never scheduled one. And many patients and clinicians who did try to arrange follow-up care went through a frustrating and confusing process that is repeated every day in hospitals around the country. The new call center offers a standardized, centralized way to make sure patients get scheduled to see the provider they need soon after their ER visit.

The new study involved patients from ages 18 to 83 years, 59 percent of whom were women. Nineteen percent of patients were African-American, and 68 percent were white, with the remaining percentage being other races or without a race recorded on their record. Thirty-five percent had a high school education or less. Patients were given a brief cognition test before being interviewed, to make sure their thinking and understanding abilities were normal. In some cases, caretakers were also interviewed.

In addition to Engel and Ubel, who directs the Program for Behavioral and Decision Sciences in Medicine, the new study’s authors include Michele Heisler, M.D., MPA, Dylan Smith, Ph.D., Claire Robinson, MPH, and Jane Forman, M.D. The study was funded by the Robert Wood Johnson Foundation and the U-M Clinical Scholars Program.

Reference: Annals of Emergency Medicine, doi:10.1016/j.annemergmed.2008.05.016

Researchers have determined a novel mechanism through which organ transplantation often leads to cancer, and their findings suggest that targeted therapies may reduce or prevent that risk.

In the July 15, 2008, issue of Cancer Research, researchers at Harvard Medical School found in animal and laboratory experiments that the anti-rejection, immunosuppressive drug cyclosporine ramps up expression of vascular endothelial growth factor (VEGF), which signals the growth of new blood vessels that can feed tumors.

They also found that simultaneously administering an anti-VEGF therapy with cyclosporine in mice repressed this tumor growth. Several inhibitors of VEGF are already in use in human cancer therapy.

The findings could offer some good news for the 15 to 20 percent of transplant patients who develop cancer within a decade of receiving new organs, according to the study’s senior investigator, Soumitro Pal, Ph.D., an assistant professor at Harvard Medical School’s Transplantation Research Center at Children’s Hospital in Boston.

“It may be that anti-VEGF agents given judiciously after transplantation can reduce future cancer occurrence,” he said.

VEGF expression is markedly increased in patients post-transplantation, and this can aid in the development of a blood supply to a transplanted organ, helping it survive and thrive. “But once the organ has stabilized, it may be possible to lower the level of VEGF expression to prevent tumor growth,” he said. “We would need to figure out how to balance benefit and risk to keep cancer at bay.”

Tumors that develop after transplantation may have three potential sources: they may have pre-existed or could have been a recurrence of previous cancer – and in both of these cases, a patient’s pre-transplant immune system might have kept these cancers in check – or cancer-causing viruses could have come from the donor organ. Physicians have long observed that immunosuppressive agents, such as the class of calcineurin inhibitors that includes cyclosporine, appear to promote cancer development, often in organs that are not transplanted, but the cause of this was unclear. The Harvard team tested the ability of cyclosporine to promote growth of pre-existing tumors in mice implanted with human renal (kidney) cancer cells. Mice treated with the agent formed tumors faster than untreated mice, but anti-VEGF therapy substantially reduced that excessive growth.

Digging deeper into the biological pathway of VEGF activation, the scientists found that cyclosporine activates two of the three forms of the common protein catalyst, protein kinase C, which leads to increased expression of VEGF.

“We think PKC-mediated VEGF transcriptional activation is a key component in the progression of cyclosporine-induced post-transplantation cancer,” Pal said. “It is likely not the whole story, but this gives us a clue that we might be able to use existing or novel therapies to reduce cancer risk in transplanted patients.”

The mission of the American Association for Cancer Research is to prevent and cure cancer. Founded in 1907, AACR is the world’s oldest and largest professional organization dedicated to advancing cancer research. The membership includes more than 28,000 basic, translational and clinical researchers; health care professionals; and cancer survivors and advocates in the United States and 80 other countries. AACR marshals the full spectrum of expertise from the cancer community to accelerate progress in the prevention, diagnosis and treatment of cancer through high-quality scientific and educational programs. It funds innovative, meritorious research grants. The AACR Annual Meeting attracts more than 17,000 participants who share the latest discoveries and developments in the field. Special conferences throughout the year present novel data across a wide variety of topics in cancer research, treatment and patient care. AACR publishes five major peer-reviewed journals: Cancer Research; Clinical Cancer Research; Molecular Cancer Therapeutics; Molecular Cancer Research; and Cancer Epidemiology, Biomarkers & Prevention. Its most recent publication and its sixth major journal, Cancer Prevention Research, is dedicated exclusively to cancer prevention, from preclinical research to clinical trials. The AACR also publishes CR, a magazine for cancer survivors and their families, patient advocates, physicians and scientists. CR provides a forum for sharing essential, evidence-based information and perspectives on progress in cancer research, survivorship and advocacy.