Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial

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. We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohn's disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in per-patient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed. 284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohn's disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72-86]) and presence (97% [91-99]) were significantly greater than that of ultrasound (70% [62-78] for disease extent, 92% [84-96] for disease presence); a 10% (95% CI 1-18; p=0·027) difference for extent, and 5% (1-9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85-98]) was significantly greater than that of ultrasound (81% [64-91]); a difference of 14% (1-27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86-99) with MRE and 84% (65-94) with ultrasound (difference 12% [0-25]; p=0·054). There were no serious adverse events. Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly. National Institute of Health and Research Health Technology Assessment. [Abstract copyright: Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial

Background 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. Methods We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohn’s disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in perpatient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed. Findings 284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohn’s disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72–86]) and presence (97% [91–99]) were significantly greater than that of ultrasound (70% [62–78] for disease extent, 92% [84–96] for disease presence); a 10% (95% CI 1–18; p=0·027) difference for extent, and 5% (1–9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85–98]) was significantly greater than that of ultrasound (81% [64–91]); a difference of 14% (1–27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86–99) with MRE and 84% (65–94) with ultrasound (difference 12% [0–25]; p=0·054). There were no serious adverse events. Interpretation Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly

Patient preferences for whole-body MRI or conventional staging pathways in lung and colorectal cancer:a discrete choice experiment

OBJECTIVES: To determine the importance placed by patients on attributes associated with whole-body MRI (WB-MRI) and standard cancer staging pathways and ascertain drivers of preference.METHODS: Patients recruited to two multi-centre diagnostic accuracy trials comparing WB-MRI with standard staging pathways in lung and colorectal cancer were invited to complete a discrete choice experiment (DCE), choosing between a series of alternate pathways in which 6 attributes (accuracy, time to diagnosis, scan duration, whole-body enclosure, radiation exposure, total scan number) were varied systematically. Data were analysed using a conditional logit regression model and marginal rates of substitution computed. The relative importance of each attribute and probabilities of choosing WB-MRI-based pathways were estimated.RESULTS: A total of 138 patients (mean age 65, 61% male, lung n = 72, colorectal n = 66) participated (May 2015 to September 2016). Lung cancer patients valued time to diagnosis most highly, followed by accuracy, radiation exposure, number of scans, and time in the scanner. Colorectal cancer patients valued accuracy most highly, followed by time to diagnosis, radiation exposure, and number of scans. Patients were willing to wait 0.29 (lung) and 0.45 (colorectal) weeks for a 1% increase in pathway accuracy. Patients preferred WB-MRI-based pathways (probability 0.64 [lung], 0.66 [colorectal]) if they were equivalent in accuracy, total scan number, and time to diagnosis compared with a standard staging pathway.CONCLUSIONS: Staging pathways based on first-line WB-MRI are preferred by the majority of patients if they at least match standard pathways for diagnostic accuracy, time to diagnosis, and total scan number.KEY POINTS: • WB-MRI staging pathways are preferred to standard pathways by the majority of patients provided they at least match standard staging pathways for accuracy, total scan number, and time to diagnosis. • For patients with lung cancer, time to diagnosis was the attribute valued most highly, followed by accuracy, radiation dose, number of additional scans, and time in a scanner. Preference for patients with colorectal cancer was similar. • Most (63%) patients were willing to trade attributes, such as faster diagnosis, for improvements in pathway accuracy and reduced radiation exposure.</p

Preoperative assessment of skeletal muscle mass during magnetic resonance enterography in patients with Crohn’s disease

AbstractMeasurement of the psoas muscle area has been applied to estimate lean muscle mass as a surrogate marker of sarcopenia, but there is a paucity of evidence regarding the influence of sarcopenia on clinical outcomes following inflammatory bowel disease surgery. The aim of this study was to evaluate the association between MRI enterography defined sarcopenia and postoperative complications in patients undergoing elective ileocaecal resection for Crohn’s disease. To obtain cross sectional area measurement of the psoas muscle, the freehand area tool was used to trace the margin of each psoas muscle at the level of L4, with the sum recorded as Total Psoas Area (TPA). The total cross sectional muscle area of the abdominal wall was recorded as Skeletal Muscle Area (SMA), while myosteatosis was measured by normalising the psoas muscle intensity with the mean intensity of the cerebrospinal fluid. The primary outcome was the incidence of 30-day postoperative complications in patients in the lowest quartile of TPA and SMA. 31 patients were included and ten patients (32.25%) developed postoperative complications within 30 days of surgery. The cut-off values for the lowest quartile for TPA were 11.93 cm2 in men and 9.77 cm2 in women, including a total of 8 patients (25.8%) with 5 patients in this group (62.5%) developing postoperative complications and 3 patients (37.5%) Clavien-Dindo class ≥ 3 complications. The cut-off values for the lowest quartile for SMA were 73.49 cm2 in men and 65.85 cm2 in women, with 4 patients out of 8 (50%) developing postoperative complications. Psoas muscle cross sectional area and skeletal mass area can be estimated on Magnetic Resonance Enterography as surrogate markers of sarcopenia with high inter-observer agreement.</jats:p

Proposed randomised controlled feasibility trial of a novel polyvinylideneflouride (PVDF) mesh (Dynamesh®-HIATUS) cruroplasty versus suture-only repair of large hiatus hernia: the DYNAMIC Study

Background - Gastro-oesophageal reflux disease (GORD) is a significant health problem affecting up to 25% of adults. Keyhole surgical treatment of chronic GORD has become an alternative to medical treatment over the past 20 years. However, patients with large hiatus hernias more than 5cm in size appear to have poorer results with recurrence in up to half of the patients. The use of mesh reinforcement has been considered to improve this, as this has been efficacious in other hernia repairs. However, with hiatal hernia repair there have been concerns about risks of mesh erosion and infection, and results to date have been equivocal.Aim - A feasibility randomised controlled trial (RCT) comparing suture versus mesh+suture repair (with blinded patient and assessor) for large hiatus hernias more than 5cm.Methods - This feasibility study utilises a novel permanent synthetic circumferential mesh tailored specifically for hiatal hernia repair. The material PVDF is unique with less risk of shrinkage or erosion. It is MRI visible uniquely allowing study of its position in vivo. Forty patients will be randomised in theatre with outcome data to 3 years including GERD-QOL, EQ50, evidence of recurrent reflux or hiatus hernia on barium swallow, and utilising a new classification of mesh position on MRI correlating this to outcome.This study will commence in November 2018 with recruitment phase over one year, and follow-up to three years. A multidisciplinary team including academics, patients and clinicians have produced a new protocol that sets the standard for future RCTs in hiatal hernia surgery

Diagnostic accuracy of magnetic resonance enterography and small bowel ultrasound for the extent and activity of newly diagnosed and relapsed Crohn's disease (METRIC): a multicentre trial

Background 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. Methods We recruited patients from eight UK hospitals. Eligible patients were 16 years or older, with newly diagnosed Crohn’s disease or with established disease and suspected relapse. Consecutive patients had MRE and ultrasound in addition to standard investigations. Discrepancy between MRE and ultrasound for the presence of small bowel disease triggered an additional investigation, if not already available. The primary outcome was difference in perpatient sensitivity for small bowel disease extent (correct identification and segmental localisation) against a construct reference standard (panel diagnosis). This trial is registered with the International Standard Randomised Controlled Trial, number ISRCTN03982913, and has been completed. Findings 284 patients completed the trial (133 in the newly diagnosed group, 151 in the relapse group). Based on the reference standard, 233 (82%) patients had small bowel Crohn’s disease. The sensitivity of MRE for small bowel disease extent (80% [95% CI 72–86]) and presence (97% [91–99]) were significantly greater than that of ultrasound (70% [62–78] for disease extent, 92% [84–96] for disease presence); a 10% (95% CI 1–18; p=0·027) difference for extent, and 5% (1–9; p=0·025) difference for presence. The specificity of MRE for small bowel disease extent (95% [85–98]) was significantly greater than that of ultrasound (81% [64–91]); a difference of 14% (1–27; p=0·039). The specificity for small bowel disease presence was 96% (95% CI 86–99) with MRE and 84% (65–94) with ultrasound (difference 12% [0–25]; p=0·054). There were no serious adverse events. Interpretation Both MRE and ultrasound have high sensitivity for detecting small bowel disease presence and both are valid first-line investigations, and viable alternatives to ileocolonoscopy. However, in a national health service setting, MRE is generally the preferred radiological investigation when available because its sensitivity and specificity exceed ultrasound significantly.</p