Technique and impact on first pass effect primary results of the ASSIST global registry

BACKGROUND

Patients treated with mechanical thrombectomy (MT) for acute ischemic strokes from large vessel occlusion (LVO) have better outcomes with effective reperfusion. However, it is unknown which technique leads to better technical and clinical success. We aimed to determine which technique yields the most effective first pass reperfusion during MT.

METHODS

In a prospective, multicenter global registry we enrolled patients treated with operator preferred MT technique at 71 hospitals from January 2019 to January 2022. Three techniques were assessed: SR Classic with stent retriever (SR) and balloon guide catheter (BGC); SR Combination which employed SR with contact aspiration with or without BGC; and direct aspiration (DA) with or without BGC. The primary outcome was achieving an expanded Thrombolysis In Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2.

RESULTS

A total of 1492 patients were enrolled. Patients treated with SR Classic or SR Combination were more likely to achieve first pass eTICI 2c or 3 reperfusion (P=0.01). There was no significant difference in mRS 0-2 (P=0.46) or safety endpoints.

CONCLUSIONS

The use of SR Classic or SR Combination was more likely to achieve first pass eTICI 2c or 3 reperfusion. There were no significant differences in clinical outcomes and safety endpoints.

Sexual harassment at work within Belgian Defence: a prevalence study

INTRODUCTION

Sexual harassment (SH) at work can have an impact on the general health and well-being and on the productivity of the employee. To date, the Belgian Armed Forces do not have any accurate data about SH. Therefore, this study assessed the prevalence of SH within Belgian Defence.

METHODS

The prevalence of SH and staff mental well-being was investigated in a sample of 399 female soldiers. Using quantitative analysis, we measured the impact on mental well-being and the relation to demographic characteristics. Using a qualitative analysis in a subsample of eight female soldiers, we investigated barriers to reporting SH and the impact on professional performance and psychosocial well-being.

RESULTS

The prevalence of non-physical SH is 36.1% over the last 12 months and 64.4% over the course of a career. Physical SH has a prevalence of 16.1% and 43.4%, respectively. Rape prevalence was reported to be 1.4% over the past 12 months, 9% over the course of their career.One in three female soldiers suffer from reduced mental well-being, which was significantly associated with SH. In the interviews, female employees report an impact of SH on professional and personal performance. The willingness to report is low due to misunderstanding, disinformation and psychosocial insecurity.

CONCLUSION

High prevalence numbers were found suggesting an important impact on the professional performance and mental well-being of female military personnel. Organisational changes may create more willingness among victims to report incidents to the designated services.

Transjugular Intrahepatic Portosystemic Shunts in Pediatric Portal Hypertension: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the technical outcome, clinical outcome, and patency of transjugular intrahepatic portosystemic shunt (TIPS) in pediatric portal hypertension (PHT).

METHODS

A systematic search of MEDLINE/PubMed, EMBASE, Cochrane databases and ClinicalTrials.gov, WHO ICTRP registries was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An a priori protocol was registered at the PROSPERO database. Original full-text articles on pediatric patients (sample size ≥ 5 patients with upper age limit of 21 years) and PHT undergoing TIPS creation for any indication were included.

RESULTS

Seventeen studies with 284 patients (average-weighted age of 10.1 years) were included with an average-weighted follow-up of 3.6 years. TIPS was technically successful in 93.3% (95%CI, 88.5% - 97.1%) of patients with a major complication rate of 3.2% (95%CI: 0.7 - 6.9) and adjusted hepatic encephalopathy rate of 2.9% (95%CI, 0.6 - 6.3). The pooled 2-year primary and secondary patency rate was respectively 61.8% (95%CI: 50.0 - 72.4) and 99.8% (95%CI: 96.2% - 100.0%). Stent type (P = .002) and age (P = .04) were identified as a significant source of heterogeneity for clinical success. In subgroup analysis, the clinical success rate was respectively 85.9% (95%CI: 77.8 - 91.4) in studies with a majority of covered stents, and 87.6% (95% CI: 74.1 - 94.6) in studies with a median age ≥ 12 years.

CONCLUSIONS

This systematic review and meta-analysis demonstrates that a TIPS is a feasible and safe treatment for pediatric PHT. To improve clinical outcome and patency on the long term, the use of covered stents should be encouraged.

Coil Embolization of True, Common and Proper, Hepatic Artery Aneurysms: Technique, Safety and Outcome

PURPOSE

To retrospectively assess the safety and efficacy of coil embolization for catheter-directed true common and proper hepatic artery aneurysm exclusion.

MATERIALS AND METHODS

Nine consecutive patients (2005-2021) in two university centers presenting with true common and proper hepatic artery aneurysms (> 2 cm in diameter) were treated with 'frontdoor-backdoor' coil embolization. Patients presenting with a hepatic artery pseudoaneurysm, mycotic aneurysm or patients with small (< 2 cm diameter) aneurysms and followed up by imaging were excluded. Technical and clinical success was defined as complete coil-exclusion of the aneurysm on completion angiography and absence of post-embolization adverse events, in particular mass effect or hemorrhage, respectively. Patient characteristics, technical and clinical success, liver function tests and follow-up results were assessed based on the patients' electronic medical records.

RESULTS

Technical and 30-day clinical success was achieved in all procedures (100%). No major procedural complications were reported. Liver function test values were available in 6/9 patients, showing transient elevation of bilirubin in one patient. No end organ ischemia was reported. The mean clinical follow-up period of the study patients was 72 months (12-168 months). Long-term stable occlusion of the hepatic aneurysms was achieved in 9/9 patients (100%). One patient showed late complication (3 years) with coil migration into a bulbar ulcer, without aneurysm recanalization, however with fatal outcome.

CONCLUSION

Coil embolization for the endovascular exclusion of true common and proper hepatic artery aneurysms is safe and effective.

Long COVID in the Belgian Defence forces: prevalence, risk factors and impact on quality of daily functioning

INTRODUCTION

Long COVID (LC) is a medical condition first described and documented through anecdotes on social media by patients prior to being recognised by WHO as a disease. Although >50 prolonged symptoms of LC have been described, it remains a diagnostic challenge for military providers and therefore threatens operational readiness.

METHODS

On 9 September 2021, an online survey was emailed to 2192 Belgian Defence personnel who had previously tested PCR positive for SARS-CoV-2 between 17 August 2020 and 31 May 2021. A total of 718 validated responses were received.Descriptive analyses determined the prevalence of LC and 10 most common symptoms and their duration following infection. In the explanatory analyses, risk factors related to LC were identified. To establish the health-related impact of LC on quality of life (HRQoL), we used the results from the EuroQol 5 Dimension 5 Level questionnaire.

RESULTS

The most frequent symptoms that were reported for >3 months were fatigue, lack of energy and breathing difficulties.47.35% of the respondents reported at least one persistent symptom, while 21.87% reported more than 3 symptoms lasting for at least 3 months after the initial COVID-19 infection. Most patients with LC suffered from symptoms of a neuropsychiatric nature (71.76%).LC was significantly associated with obesity; pre-existing respiratory disease and blood or immune disorders. Physical activity of >3 hours per week halved the risk of LC.The total QoL is reduced in patients with LC. Considering the five dimensions of the questionnaire, only the self-care dimension was not influenced by the presence of LC.

CONCLUSIONS

Almost half of Belgian Defence personnel developed LC after a confirmed COVID-19 infection, similar to numbers found in the Belgian population. Patients with LC would likely benefit from a multidisciplinary rehabilitation approach that addresses shortness of breath, fatigue and mood disturbance.

90Y Radioembolization versus Drug-eluting Bead Chemoembolization for Unresectable Hepatocellular Carcinoma: Results from the TRACE Phase II Randomized Controlled Trial

Background Transarterial chemoembolization (TACE) is the recommended treatment for intermediate hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer guidelines. Prospective uncontrolled studies suggest that yttrium 90 (⁹⁰Y) transarterial radioembolization (TARE) is a safe and effective alternative. Purpose To compare the efficacy and safety of TARE with TACE for unresectable HCC. Materials and Methods In this single-center prospective randomized controlled trial (TRACE), ⁹⁰Y glass TARE was compared with doxorubicin drug-eluting bead (DEB) TACE in participants with intermediate-stage HCC, extended to Eastern Cooperative Oncology Group performance status 1 and those with early-stage HCC not eligible for surgery or thermoablation. Participants were recruited between September 2011 and March 2018. The primary end point was time to overall tumor progression (TTP) (Kaplan-Meier analysis) in the intention-to-treat (ITT) and per-protocol (PP) groups. Results At interim analysis, 38 participants (median age, 67 years; IQR, 63-72 years; 33 men) were randomized to the TARE arm and 34 (median age, 68 years; IQR, 61-71 years; 30 men) to the DEB-TACE arm (ITT group). Median TTP was 17.1 months in the TARE arm versus 9.5 months in the DEB-TACE arm (ITT group hazard ratio [HR], 0.36; 95% CI: 0.18, 0.70; P = .002) (PP group, 32 and 34 participants, respectively, in each arm; HR, 0.29; 95% CI: 0.14, 0.60; P < .001). Median overall survival was 30.2 months after TARE and 15.6 months after DEB-TACE (ITT group HR, 0.48; 95% CI: 0.28, 0.82; P = .006). Serious adverse events grade 3 or higher (13 of 33 participants [39%] vs 19 of 36 [53%] after TARE and DEB-TACE, respectively; P = .47) and 30-day mortality (0 of 33 participants [0%] vs three of 36 [8.3%]; P = .24) were similar in the safety groups. At the interim, the HR for the primary end point, TTP, was less than 0.39, meeting the criteria to halt the study. Conclusion With similar safety profile, yttrium 90 radioembolization conferred superior tumor control and survival compared with chemoembolization using drug-eluting beads in selected participants with early or intermediate hepatocellular carcinoma. Clinical trial registration no. NCT01381211 © RSNA, 2022 Online supplemental material is available for this article.

Clinical outcomes of biliary drainage of malignant biliary obstruction due to colorectal cancer metastases: A systematic review

BACKGROUND AND AIMS

Malignant biliary obstruction is an ominous complication of metastatic colorectal cancer (mCRC). Biliary drainage is frequently performed to relieve symptoms of jaundice or enable palliative systemic therapy, but effective drainage can be difficult to accomplish. The aim of this study is to summarize literature on clinical outcomes of biliary drainage in mCRC patients with malignant biliary obstruction.

METHODS

We searched Medline and EMBASE for studies that included patients with malignant biliary obstruction secondary to mCRC, treated with endoscopic and/or percutaneous biliary drainage. We summarized available data on technical success, clinical success, adverse events, systemic therapy administration and survival after biliary drainage.

RESULTS

After screening 3584 references and assessing 509 full-text articles, seven cohort studies were included. In these studies, rates of technical success, clinical success and adverse events varied between 63%-94%, 42%-81%, and 19%-39%, respectively. Subsequent chemotherapy was administered in 17%-56% of patients. Overall survival varied between 40 and 122 days across studies (278-365 days in patients who received subsequent chemotherapy, 42-61 days in patients who did not).

CONCLUSIONS

Successful biliary drainage in mCRC patients can be challenging to achieve and is frequently associated with adverse events. Overall survival after biliary drainage is limited, but is significantly longer in patients treated with subsequent systemic therapy. Expected benefits of biliary drainage should be carefully weighed against its risks.

Percutaneous stenting in malignant biliary obstruction caused by metastatic disease: clinical outcome and prediction of survival according to tumor type and further therapeutic options

BACKGROUND AND STUDY AIMS

Obstructive jaundice caused by metastatic disease leads to deterioration of general condition and short survival time. Successful decompression can offer symptom control and enable further treatment with chemotherapy, which can improve survival.

PATIENTS AND METHODS

Ninety-nine percutaneous transhepatic cholangiography (PTC) procedures with metallic stent placement were performed in 93 patients between 2007 and 2013. Files were retrospectively studied and a review of patients' demographics, clinical and laboratory parameters, treatment and survival was performed. Kaplan-Meier survival analysis with log-rank test was done in function of bilirubin level, tumor type and treatment with chemotherapy.

RESULTS

Hyperbilirubinemia resolved in 73% of procedures. Median survival time after the procedure was 48 (95%CI 34.8 - 61.1) days. If additional chemotherapy was possible, a median survival of 170 (95%CI 88.5 - 251.4) days was noted versus 32 (95%CI 22.4 - 41.5) days without chemotherapy (p < 0.01). Survival rates greatly differed between primary tumor type, with the largest benefit of PTC in colorectal cancer. In 35 % of the procedures minor or more severe complications were noted. The 30-day mortality was 33%, with 3 procedure related deaths.

CONCLUSION

PTC with metallic stenting can bring symptom relief and enable further treatment with chemotherapy, which can lead to a longer survival time, especially in colorectal cancer. However, in patients in whom palliative stenting failed to resolve the hyperbilirubinemia survival is short.

Pathophysiology, diagnosis and treatment of varicoceles: a review

In this article we reviewed the pathophysiology, diagnosis and treatment of varicoceles. The etiology and pathogenesis of varicoceles cannot be explained by one theory. Valve dysfunction, ontogenetic collateral formation and the nutcracker phenomenon seem to act synergistically. Hyperthermia, elevated hydrostatic pressure and antisperm agents are suggested as possible causes for the pathophysiology how varicoceles induce infertility. However the combination of patient's lifestyle, genetic factors and the consequences of reflux into the pampiniform plexus are believed to contribute to the infertility. Although venography stays the gold standard, the combination of physical examination, color Doppler ultrasound and thermography has the highest sensitivity and specificity to diagnose a varicocele. Regarding infertility, we are still searching for strict criteria or grading, to decide which patients with a varicocele may or may not have benefit from treatment. Treatment of varicoceles can be performed by different open surgical or percutaneous techniques. Treatment of varicoceles for infertility or to prevent infertility remains controversial, because the majority of men with varicoceles are still fertile. At the moment, inguinal or subinguinal microscopic surgery gave the highest pregnancy rates, the lowest recurrence and lowest complication rates. But retrograde superselective glue embolization or sclerosing of the ISV are the best percutaneous alternative and can be performed on an outpatient basis under local anesthesia and with faster return to normal activities than surgery.

Upper gastrointestinal tract bleeding management: Belgian guidelines for adults and children

Upper gastrointestinal bleeding (UGIB) remains a common disease affecting 100 to 170 per 100 000 adults per year and causing thereby a significant burden to healthcare resources. Despite the improvements in the management of this disorder, the associated mortality ranges from 5 to 14%. Since the general management of UGIB is not uniform, the main objective of this work is to provide guidelines for the care of adults and children presenting with bleeding caused by gastro-duodenal ulcer or variceal rupture.

METHODS

In the absence of evidence-based recommendations, these guidelines were proposed after expert opinions reconciliation and graded accordingly. They are based on the published literature up to September 2010 and graded according to the class of evidence.

RESULTS

The current guidelines for the management of UGIB include recommendations for the diagnostic process, general supportive care, pharmacological therapy aiming at bleeding control, specific and endoscopic treatment of acute bleeding and follow-up for both gastro-duodenal ulcers and portal hypertension-induced bleeding.

Nora's lesion, a distinct radiological entity?

OBJECTIVE

To describe the radiological findings of "Bizarre parosteal osteochondromatous proliferation"(BPOP)-otherwise known as Nora's lesion, to describe the natural evolution of BPOP and to assess radiologically if BPOP is indeed part of a spectrum of reactive lesions including florid reactive periostitis and turret exostosis.

DESIGN

Four experienced musculoskeletal radiologists studied plain radiographs and other imaging documents of histologically-proven Nora's lesions, looking for soft-tissue changes, periosteal reaction/calcification and calcified/ossified pseudotumours, and compared those findings with findings on pathology reviewed by a peer group of pathologists.

PATIENTS

Twenty-four Nora's lesions originating from a series of 200 consecutive, histologically-verified bone (pseudo)tumours of the hand, seen by the "Netherlands Committee on Bone Tumours" for review and second opinion.

RESULTS

Nora's lesions have a recognised presentation on radiographs without specific MR characteristics. Natural evolution could be assessed retrospectively in four cases. Recurrent lesions were seen in seven cases and are difficult to differentiate from primary lesions.

CONCLUSIONS

Nora's lesion, defined as a "well-marginated mass of heterotopic mineralization arising from the periosteal aspect of an intact cortex, without medullary changes" has a distinct radiological presentation and is part of a spectrum of reactive lesions which includes florid reactive periostitis and turret exostosis. As it has a distinct radiological appearance, differential diagnosis of malignant lesions such as osteosarcoma and chondrosarcoma should be clear. It does not require immediate biopsy unless the natural evolution is unspecific.

Accuracy of radiography in grading and tissue-specific diagnosis--a study of 200 consecutive bone tumors of the hand

OBJECTIVE

To determine the usefulness of radiography and magnetic resonance imaging in differentiating benign from malignant bony tumors of the hand and in making a tissue-specific diagnosis.

DESIGN

Two hundred consecutive bony tumors of the hand, the details of which originated from a national databank, were studied in a prospective way by radiography (100%) and by MRI (25%). All tumors were graded on a five-point scale, from certainly benign to certainly malignant, using location and morphology as diagnostic parameters. For all tumors a tissue-specific diagnosis was made, by the proposal of three possibilities in decreasing order of probability. Histological diagnosis was made by peer review, according to the WHO classification.

RESULTS

By the combining of "certainly" and "probably" benign (grades I and II) and "certainly" and "probably" malignant (grades IV and V), a correct grading was obtained in 165 (82.5%) of the cases (154 of the 173 benign and 11 of the 27 malignant tumors). A correct tissue-specific diagnosis was included in the three proposed differentials in 87.5%. MRI confirmed a correct diagnosis made on radiography in 72% and improved the grading capability by correctly upgrading malignant tumors and downgrading benign tumors in, respectively, 8% and 12%. The capability to obtain a tissue-specific diagnosis improved with change of an incorrect diagnosis on radiography to a correct one on MRI in 12 cases (24%).

CONCLUSION

Subjective (semiquantitative) grading on radiography by an expert group proved to be excellent when compared with the results of a quantitative analysis of individual grading parameters. Multiple logistic regression analysis of these parameters resulted in a grading formula containing only six variables. The additional value of MRI in grading was amply demonstrated. Already high accuracy of radiography, in making a tissue-specific diagnosis, improved substantially after the performance of MRI.

Impaired microcirculation in heart failure

The aim of the present study was to examine the nailfold capillary morphology and dynamics in treated chronic heart failure (CHF) in relation to parameters of left ventricular structure and function. Twenty patients with CHF class II according to the New York Heart Association underwent a capillaroscopic examination at the finger nailfold using a computerized videophotometric system (Capiflow) at rest and after 1 min arterial occlusion. Study parameters ere number, length and diameter of the capillaries as well as capillary blood velocity (CBV). Further experiments included echocardiography and determination of left ventricular ejection fraction by Tc scintigraphy. Nailfold capillaries in established CHF are enlarged and the CBV is dramatically decreased. The reactive hyperemic response to 1 min arterial occlusion is attenuated. CBV correlates positively with left ventricular ejection fraction (r = 0.61, p = 0.01) and inversely with left ventricular end-diastolic (r = -0.56, p = 0.04) and end-systolic (r = -0.69, p = 0.01) diameters. The time-to-peak flow after 1 min arterial occlusion is positively related (r = 0.68, p < 0.05) to the duration of CHF. Our data indicate that finger microcirculation in CHF deteriorates as a function of the severity and duration of heart failure.

Superior vena cava syndrome after implantation of a transvenous cardioverter defibrillator

Superior vena cava syndrome is a rare, but nevertheless well known complication of permanent pacemaker implantation. Nowadays cardioverter defibrillators are also routinely implanted transvenously. A superior vena cava syndrome occurred in a 48-year-old female 2 years after implantation of cardioverter defibrillator. The clinical problem, in the presence of a predisposing thrombophilic condition (circulating lupus anticoagulant), resolved only partially after treatment with thrombolytics and oral anticoagulation. This syndrome should be recognized as a possible important complication of defibrillator therapy and requires lifelong anticoagulation.

Upper airway obstruction due to inoperable intrathoracic goitre treated by tracheal endoprosthesis

Thyroidectomy is the treatment of choice in patients with thyroid enlargement complicated by compression or displacement of the trachea because of the risk of complete airway obstruction due to sudden enlargement of the goitre by, for example, haemorrhage. In patients who are medically inoperable an endoscopically inserted tracheal endoprosthesis may provide longstanding airway patency, as reported here.

A simplified insertion technique for tracheobronchial silicone stents

In many patients with central airway obstruction due to extrinsic compression or malacia, insertion of tracheobronchial stents can provide effective and permanent relief. Of the various types of prostheses described, the silicone Dumon-Artemis stents (Medicore, Brussels, Belgium) are probably the most efficient. The use of an elegant and safe specially designed stent introducer system combined with a special bronchoscope is proposed for insertion by Dumon. This combined stent insertion system, however, is relatively expensive and cumbersome, especially for centers where relatively limited numbers of patients are treated. We propose an alternative, simplified insertion technique of silicone Dumon-Artemis stents, which was proven safe and efficient in our series of patients.

Successful management of recurrent pneumothorax in cystic fibrosis by localized apical thoracoscopic talc poudrage

Thoracoscopic talc poudrage of the entire pleural surface constitutes successful treatment of recurrent pneumothorax in cystic fibrosis (CF); however, subsequent lung transplantation is seriously jeopardized due to the development of extensive pleural adhesions. We describe a 27-year-old patient with CF with recurrent right-sided pneumothorax, refractory to chest tube drainage and to chemical (tetracycline) pleurodesis, who was successfully treated with a localized, apical thoracoscopic talc poudrage, thereby preserving the possibility of subsequent lung transplantation.

Prosthetic valve endocarditis due to Listeria monocytogenes. A case report with review of the literature

We report the case of a 71-year-old man with a prosthetic aortic valve endocarditis caused by Listeria monocytogenes. He was successfully treated with a combination of ampicillin and amikacin, and valve replacement surgery. This case and previously reported cases are discussed.

Long-term functional results of the non-surgical treatment of common bacterial infections of joints

Thirty patients with acute bacterial infection of a peripheral joint were treated with intravenous antibiotics, daily closed needle aspiration and early mobilization therapy. Joint mobility, expressed as a percentage of normal mobility, was evaluated at the end of the reconvalescence period and again after 42 to 65 months (mean: 50 months). The functional outcome was excellent and joint mobility normal in 2/3 of the cases as revealed by the short- and long-term evaluation results. Factors that affected joint mobility were: delayed treatment, joint disorders prior to treatment, and ease of access to the joint for needle aspiration. Poor results were found in the presence of hip infections. In the long term, deterioration of joint mobility can occur in the same aggravating conditions. Treatment of septic arthritis with daily needle aspiration and early mobilization gave very good functional results.

Levamisole as basic treatment of rheumatoid arthritis: longterm evaluation

We evaluated longterm levamisole treatment of 201 rheumatoid patients. Fifty-nine patients in their 1st yr of treatment were not analyzed; of the remaining 142, 69 (49%) still took levamisole with benefit. Levamisole was stopped in 32 patients (22%) for inefficacy and for reversible adverse reactions in 37 (26%). Leukotoxic side-effects were the commonest cause of withdrawal (23 patients = 16%). Since June 1977, we administer levamisole on a 1 d/wk schedule (150 mg), with determination of white blood cells 10 h after intake to detect high-risk patients for agranulocytosis. With disease exacerbation during treatment or lack of response after 6 months, the drug is given on a 2nd non-consecutive day. Since June 1977, cases of agranulocytosis have not been observed. Allergic vasculitis did not occur with a 1 d/wk schedule. The absence of nephrotoxicity and hepatotoxicity is stressed. Only 4 patients (3%) were lost to follow-up. Comparison is made with longterm use of gold and D-penicillamine. We conclude that levamisole is a useful slow acting antirheumatic drug.