Magnetic resonance enterography compared with ultrasonography in newly diagnosed and relapsing Crohn's disease patients: the METRIC diagnostic accuracy study

Magnetic resonance enterography and enteric ultrasonography are used to image Crohn's disease patients. Their diagnostic accuracy for presence, extent and activity of enteric Crohn's disease was compared. To compare diagnostic accuracy, observer variability, acceptability, diagnostic impact and cost-effectiveness of magnetic resonance enterography and ultrasonography in newly diagnosed or relapsing Crohn's disease. Prospective multicentre cohort study. Eight NHS hospitals. Consecutive participants aged ≥ 16 years, newly diagnosed with Crohn's disease or with established Crohn's disease and suspected relapse. Magnetic resonance enterography and ultrasonography. The primary outcome was per-participant sensitivity difference between magnetic resonance enterography and ultrasonography for small bowel Crohn's disease extent. Secondary outcomes included sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease extent, and sensitivity and specificity for small bowel Crohn's disease and colonic Crohn's disease presence; identification of active disease; interobserver variation; participant acceptability; diagnostic impact; and cost-effectiveness. Out of the 518 participants assessed, 335 entered the trial, with 51 excluded, giving a final cohort of 284 (133 and 151 in new diagnosis and suspected relapse cohorts, respectively). Across the whole cohort, for small bowel Crohn's disease extent, magnetic resonance enterography sensitivity [80%, 95% confidence interval (CI) 72% to 86%] was significantly greater than ultrasonography sensitivity (70%, 95% CI 62% to 78%), with a 10% difference (95% CI 1% to 18%;  = 0.027). For small bowel Crohn's disease extent, magnetic resonance enterography specificity (95%, 95% CI 85% to 98%) was significantly greater than ultrasonography specificity (81%, 95% CI 64% to 91%), with a 14% difference (95% CI 1% to 27%). For small bowel Crohn's disease presence, magnetic resonance enterography sensitivity (97%, 95% CI 91% to 99%) was significantly greater than ultrasonography sensitivity (92%, 95% CI 84% to 96%), with a 5% difference (95% CI 1% to 9%). For small bowel Crohn's disease presence, magnetic resonance enterography specificity was 96% (95% CI 86% to 99%) and ultrasonography specificity was 84% (95% CI 65% to 94%), with a 12% difference (95% CI 0% to 25%). Test sensitivities for small bowel Crohn's disease presence and extent were similar in the two cohorts. For colonic Crohn's disease presence in newly diagnosed participants, ultrasonography sensitivity (67%, 95% CI 49% to 81%) was significantly greater than magnetic resonance enterography sensitivity (47%, 95% CI 31% to 64%), with a 20% difference (95% CI 1% to 39%). For active small bowel Crohn's disease, magnetic resonance enterography sensitivity (96%, 95% CI 92% to 99%) was significantly greater than ultrasonography sensitivity (90%, 95% CI 82% to 95%), with a 6% difference (95% CI 2% to 11%). There was some disagreement between readers for both tests. A total of 88% of participants rated magnetic resonance enterography as very or fairly acceptable, which is significantly lower than the percentage (99%) of participants who did so for ultrasonography. Therapeutic decisions based on magnetic resonance enterography alone and ultrasonography alone agreed with the final decision in 122 out of 158 (77%) cases and 124 out of 158 (78%) cases, respectively. There were no differences in costs or quality-adjusted life-years between tests. Magnetic resonance enterography and ultrasonography scans were interpreted by practitioners blinded to clinical data (but not participant cohort), which does not reflect use in clinical practice. Magnetic resonance enterography has higher accuracy for detecting the presence, extent and activity of small bowel Crohn's disease than ultrasonography does. Both tests have variable interobserver agreement and are broadly acceptable to participants, although ultrasonography produces less participant burden. Diagnostic impact and cost-effectiveness are similar. Recommendations for future work include investigation of the comparative utility of magnetic resonance enterography and ultrasonography for treatment response assessment and investigation of non-specific abdominal symptoms to confirm or refute Crohn's disease. Current Controlled Trials ISRCTN03982913. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 42. See the NIHR Journals Library website for further project information

Localization of enkephalin immunoreactivity in the spinal cord of the long-tailed ray Himantura fai

Enkephalin-like immunoreactivity (ENK-LI) was found throughout the spinal cord of the long-tailed ray Himantura fai. The densest ENK-LI was in the superficial portion of lamina A of the dorsal horn. Lamina B and the deeper parts of lamina A contained radially oriented, labelled fibres. Laminae C, D, and E contained many longitudinally orientated fascicles which were surrounded by a reticulum of transversely orientated, labelled fibres, some of which projected into the ventral and lateral funiculi. Labelled fibres were found in the dorsal commissure and around the central canal, but the later did not cross the midline. One-third of all enkephalinergic cells were found throughout laminae A and B, while two-thirds were located in the medial half of C, D, and E. Occasionally a labelled cell was located in the lateral funiculus. The ventral horn (laminae F and G) contained many enkephalinergic fibres but no labelled nuclei. A few dorsal column axons contained ENK-LI. In the lateral funiculus there were two groups of labelled axons, a superficial, dorsolateral group, and a deeper group, occupying a crescent-shaped region. The ventral funiculus also contained many labelled axons. The central projection of the dorsal root passed through the substantia gelatinosa and divided into rostrally and caudally projecting fascicles within lamina C. The root, and these fascicles, both lacked ENK-LI. In contrast, the fascicles in laminae D and E did contain enkephalinergic fibres. The origin of the various fibre systems and the role of enkephalin in the regulation of sensory processing and motor output are discussed

The academic environment: the students' perspective

Dental education is regarded as a complex, demanding and often stressful pedagogical procedure. Undergraduates, while enrolled in programmes of 4-6 years duration, are required to attain a unique and diverse collection of competences. Despite the major differences in educational systems, philosophies, methods and resources available worldwide, dental students' views regarding their education appear to be relatively convergent. This paper summarizes dental students' standpoint of their studies, showcases their experiences in different educational settings and discusses the characteristics of a positive academic environment. It is a consensus opinion that the 'students' perspective' should be taken into consideration in all discussions and decisions regarding dental education. Moreover, it is suggested that the set of recommendations proposed can improve students' quality of life and well-being, enhance their total educational experience and positively influence their future careers as oral health physicians. The 'ideal' academic environment may be defined as one that best prepares students for their future professional life and contributes towards their personal development, psychosomatic and social well-being. A number of diverse factors significantly influence the way students perceive and experience their education. These range from 'class size', 'leisure time' and 'assessment procedures' to 'relations with peers and faculty', 'ethical climate' and 'extra-curricular opportunities'. Research has revealed that stress symptoms, including psychological and psychosomatic manifestations, are prevalent among dental students. Apparently some stressors are inherent in dental studies. Nevertheless, suggested strategies and preventive interventions can reduce or eliminate many sources of stress and appropriate support services should be readily available. A key point for the Working Group has been the discrimination between 'teaching' and 'learning'. It is suggested that the educational content should be made available to students through a variety of methods, because individual learning styles and preferences vary considerably. Regardless of the educational philosophy adopted, students should be placed at the centre of the process. Moreover, it is critical that they are encouraged to take responsibility for their own learning. Other improvements suggested include increased formative assessment and self-assessment opportunities, reflective portfolios, collaborative learning, familiarization with and increased implementation of information and communication technology applications, early clinical exposure, greater emphasis on qualitative criteria in clinical education, community placements, and other extracurricular experiences such as international exchanges and awareness of minority and global health issues. The establishment of a global network in dental education is firmly supported but to be effective it will need active student representation and involvement