A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization

Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.

High fecundity rates following in-vitro fertilization and embryo transfer in antiphospholipid antibody seropositive women treated with heparin and aspirin

This study was undertaken to explore whether intervention with heparin and aspirin (H/A) in selected patients undergoing in-vitro fertilization (IVF) and embryo transfer could improve fecundity rates. Specifically, it explored the possibility that women diagnosed with organic pelvic disease who demonstrated antiphospholipid antibodies (APA) could benefit from H/A administration in a similar manner to that used in patients with recurrent pregnancy loss. We used an enzyme-linked immunosorbent assay for six different phospholipids to identify patients who expressed APA before they underwent IVF/embryo transfer. This study was confined to the first IVF/embryo transfer cycle that followed assessment of APA status and accordingly, the number of IVF/embryo transfer cycles corresponds with the number of patients treated. APA seropositive patients were treated with aspirin, 81 mg orally q.d., and heparin 5000 IU s.c. b.i.d., beginning on day 1 of controlled ovarian stimulation. The endpoint for success was a live birth or an ultrasound confirming fetal cardiac activity (a viable pregnancy). The prevalence of APA in patients diagnosed with organic pelvic disease (53%) was much higher than in those without female pathology (14%). The administration of H/A to APA seropositive patients significantly (P < 0.05) improved the viable pregnancy rate (49%) compared to the untreated APA seropositive group (16%). The viable pregnancy rate for APA seropositive women treated with H/A was also significantly (P < 0.001) higher than for untreated APA seronegative patients (27%). We conclude that all women undergoing IVF/embryo transfer should be tested for APA prior to initiating ovarian stimulation and those with APA seropositivity should be treated with H/A.

Phase II evaluation of preoperative chemoradiation and postoperative adjuvant chemotherapy for squamous cell and adenocarcinoma of the esophagus

PURPOSE

This phase II trial evaluated continuous-infusion cisplatin and fluorouracil (5-FU) with radiotherapy followed by esophagectomy. The objectives of this trial were to determine the complete pathologic response rate, survival rate, toxicity, pattern of failure, and feasibility of administering adjuvant chemotherapy in patients with resectable cancer of the esophagus treated with preoperative chemoradiation.

PATIENTS AND METHODS

Patients were staged using computed tomography, endoscopic ultrasound, and laparoscopy. The preoperative treatment plan consisted of continuous intravenous infusion of cisplatin and 5-FU and a total dose of 44 Gy of radiation. Esophagogastrectomy was planned for approximately 4 weeks after the completion of chemoradiotherapy. Paclitaxel and cisplatin were administered as postoperative adjuvant therapy.

RESULTS

Forty-two patients were enrolled onto the trial. Of the 39 patients who proceeded to surgery, 29 responded to preoperative treatment: 11 achieved pathologic complete response (CR) and 18 achieved a lower posttreatment stage. Five patients had no change in stage, whereas eight had progressive disease (four with distant metastases and four with increases in the T and N stages). At a median follow-up of 30.2 months, the median survival time has not been reached and the 2-year survival rate is 62%. The median survival of pathologic complete responders has not been reached, whereas the 2-year survival rate of this group is 91% compared with 51% in patients with complete tumor resection with residual tumor (P =.03).

CONCLUSION

An excellent survival rate, comparable to that of our prior preoperative trial, was achieved with lower doses of preoperative cisplatin and 5-FU concurrent with radiotherapy.

Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial

PURPOSE

To prospectively assess the efficacy of percutaneous transabdominal thoracic duct catheterization and embolization in the management of patients with high-output chylothoracic effusions.

MATERIALS AND METHODS

Eleven consecutive patients (four women and seven men; mean age, 53 years) were referred with chylothorax secondary to esophagectomy (n = 4), lobectomy (n = 1), lung transplant (n = 1), coronary artery bypass (n = 1), aortic graft (n = 2), lymphangioleiomyomatosis (n = 1), and gunshot wound (n = 1). Two patients were brought by ambulance and referred back to their hospital on the same day. Pedal lymphography was used to opacify the cisterna chyli or major retroperitoneal lymphatic trunks. When patent, these were punctured under local anesthesia with a fine needle and the thoracic duct was catheterized over a microguide wire with use of a 3-F catheter; the duct was embolized with platinum coils. Patients were followed up for decrease in thoracic drainage output and morbidity.

RESULTS

There were no retroperitoneal ducts suitable for catheterization in six patients because of previous abdominal surgery, trauma, or lymphangioleiomyomatosis; the thoracic duct was successfully catheterized in five patients, a 45% technical success rate. Thoracic duct embolization was performed in four patients, with cure of effusion in two. In the other two patients, one with lymphangioleiomyomatosis and the other with nonchylous pleural fluid, continued effusion was successfully treated by means of pleurodesis. Of two patients with previous thoracic duct ligation, one was found to have the duct incompletely tied. The authors were surprised to find that previous major abdominal surgery, chronic aortic dissection, and lymphangioleiomyomatosis could obliterate major retroperitoneal lymphatic ducts and the cisterna chyli. Percutaneous study of the thoracic duct with aqueous contrast medium was more sensitive than lymphography with iodinated oil. There was no morbidity.

CONCLUSIONS

Catheterization of the thoracic duct was possible in all patients who had patent major retroperitoneal lymphatic trunks. Thoracic duct embolization was curative in patients with demonstrable duct leakage. Previous abdominal surgery, aortic dissection, and lymphangioleiomyomatosis can lead to silent occlusion of retroperitoneal lymphatic trunks. Percutaneous thoracic duct catheterization and embolization is safe and can replace surgical ligation in some patients.

Large scale association analysis for identification of genes underlying premature coronary heart disease: cumulative perspective from analysis of 111 candidate genes

BACKGROUND

to date, only three groups have reported data from large scale genetic association studies of coronary heart disease using a case control design.

METHODS AND RESULTS

to extend our initial report of 62 genes, we present data for 210 polymorphisms in 111 candidate genes genotyped in 352 white subjects with familial, premature coronary heart disease (onset age for men, 45; for women, 50) and a random sample of 418 population based whites. Multivariate logistic regression analysis was used to compare the distributions of genotypes between cases and the comparison group while controlling for age, sex, body mass, diabetes, and hypertension. Significant associations were found with polymorphisms in thrombospondin-4 (THBS4), thrombospondin-2 (THBS2) and plasminogen activator inhibitor-2 (PAI2), the strongest being with the A387P variant in THBS4 (p = 0.002). The THBS2 and THBS4 associations have since been replicated. We evaluated polymorphisms in 40 genes previously associated with coronary heart disease and found significant (p<0.05) associations with 10: ACE, APOE, F7, FGB, GP1BA, IL1RN, LRP1, MTHFR, SELP, and THPO. For five of these genes, the polymorphism associated in our study was different from that previously reported, suggesting linkage disequilibrium as an explanation for failure to replicate associations consistently across studies. We found strong linkage disequilibrium between polymorphisms within and between genes, especially on chromosome 1q22-q25, a region containing several candidate genes.

CONCLUSIONS

despite known caveats of genetic association studies, they can be an effective means of hypothesis generation and complement classic linkage studies for understanding the genetic basis of coronary heart disease.

Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction

BACKGROUND

Several risk factors have been shown to increase mortality in cardiac surgery. However, the importance of left ventricular end-diastolic pressure (LVEDP) as an independent risk factor before cardiac surgery is unclear. Method. This observational study investigated 3024 consecutive adult patients who underwent cardiac surgical procedures at the Montreal Heart Institute from 1996 to 2000. The primary outcome was in-hospital mortality with 99 deaths (3.3%) among these patients.

RESULTS

Of the 35 variables subjected to univariate analysis, 23 demonstrated a significant association with mortality. Stepwise multivariate logistic regression identified LVEDP as an independent predictor of mortality after cardiac surgery. The area under the receiver operating characteristic curve of the model predicting mortality was 0.85.

CONCLUSIONS

Elevated LVEDP is an independent predictor of mortality in cardiac surgery. This variable is independent of left ventricular ejection fraction.

Reappraisal of the role of axillary lymph node dissection in the conservative treatment of breast cancer

PURPOSE

The purpose of this study was (1) to review systemic therapy practice patterns to assess how information regarding nodal status currently influences systemic therapy decisions, and (2) to review long-term outcome of patients who do not undergo axillary dissection compared with patients who do.

METHODS AND MATERIALS

For the current practice patterns portion of the study, the records of 292 patients who presented in the past 3 years with invasive breast cancer and underwent conservative surgery were reviewed to determine systemic therapy administered with respect to patient age, primary tumor size, clinical nodal status, and presenting symptoms. For the long-term outcome portion of the study, the records of 955 patients with invasive breast cancer who underwent conservative surgery and radiation therapy before December 1989 were reviewed. Patient characteristics and outcome of those patients who underwent axillary dissection (n = 565, 59%) were compared with a cohort of patients treated during the same era who did not undergo axillary dissection (n = 390, 41%).

RESULTS

For the current practice-patterns cohort, information regarding nodal status appeared to influence adjuvant systemic therapy for those patients less than 50 years of age and for those patients with palpable masses who were older than 50. Patients older than 50 with nonpalpable mammographically detected tumors have a low probability of nodal involvement and information regarding nodal status rarely changed therapy in this group of patients. In the long-term outcome study, there were no significant differences in the rates of distant metastasis, disease-free survival, or overall survival between those patients who underwent lymph node dissection and those who did not.

CONCLUSION

For selected patients, axillary lymph node dissection appears to have little influence on subsequent management and long-term outcome. These data suggest that it is time to reassess the role of axillary lymph node dissection in patients who undergo conservative surgery and radiation therapy.

Acquiring basic and advanced laparoscopic skills in novices using two-dimensional (2D), three-dimensional (3D) and ultra-high definition (4K) vision systems: A randomized control study

AIMS

To compare the performance of novices in laparoscopic peg transfer and intra-corporeal suturing tasks in two-dimensional (2D), three-dimensional (3D) and ultra-high definition (4K) vision systems.

METHODS

Twenty-four novices were randomly assigned to 2D, 3D and 4K groups, eight in each group. All participants performed the two tasks on a box trainer until reaching proficiency. Their performance was assessed based on completion time, number of errors and number of repetitions using the validated FLS proficiency criteria.

RESULTS

Eight candidates in each group completed the training curriculum. The mean performance time (in minutes) for the 2D group was 558.3, which was more than that of the 3D and 4K groups of 316.7 and 310.4 min respectively (P < 0.0001). The mean number of repetitions was lower for the 3D and 4K groups versus the 2D group: 125.9 and 127.4 respectively versus 152.1 (P < 0.0001). The mean number of errors was lower for the 4K group versus the 3D and 2D groups: 1.2 versus 26.1 and 50.2 respectively (P < 0.0001).

CONCLUSION

The 4K vision system improved accuracy in acquiring laparoscopic skills for novices in complex tasks, which was shown in significant reduction in number of errors compared to the 3D and the 2D vision systems. The 3D and the 4K vision systems significantly improved speed and accuracy when compared to the 2D vision system based on shorter performance time, fewer errors and lesser number of repetitions.

Increased expression of the epidermal growth factor receptor on human colon carcinoma cells

Epidermal growth factor (EGF) is a small polypeptide hormone that promotes the growth of cells in culture and elicits the differentiation of epithelial tissues in vivo. The effect of EGF is mediated by a transmembrane receptor that is expressed in increased amounts on some tumor cells. We have used a monoclonal antibody to the EGF receptor to detect increased expression of the receptor on human colon carcinoma cells. All eight of the moderately well-differentiated colon carcinoma cell lines tested and several frozen colon carcinoma tissue sections showed increased expression of the EGF receptor, while five poorly differentiated colon carcinoma cell lines and normal colon tissue sections did not. Increased expression of the EGF receptor on moderately well-differentiated colon carcinoma cells but not on poorly differentiated colon carcinoma cells was also demonstrated by western transfer and iodine 125-labeled EGF binding assays. Increased expression of the EGF receptor on moderately well-differentiated colon carcinoma cells seems to be a useful marker for the differentiation of human colon carcinoma cells. In addition, it might provide a site for adjuvant hormonal therapy or immunotherapy.

Intraperitoneal rupture of hydatid cysts

PURPOSE

Hydatid cyst rupture into abdominal cavity is a rare but a serious complication. The rupture can occur after a trauma, or spontaneously as a result of increased intracystic pressure. It is a surgical emergency with high morbidity and mortality rates. Early diagnosis and appropriate surgical management of this complication can be life saving. The objective of the current paper is to evaluate the clinical, and radiographic findings and surgical treatment of this complication.

METHODS

A retrospective study on 12 patients operated in our department for intraperitoneal rupture of hydatid cyst between January 1990 and May 2015. We reviewed age, gender, imaging findings, surgical treatment procedures, mortality, morbidity and recurrence.

RESULTS

Our study includes 12 cases of intraperitoneal rupture of hydatid cysts; eight of the patients were men, and four were women. Four patients had a history of abdominal trauma and the other ruptures occurred spontaneously. All the patients had peritoneal irritation signs at presentation. All them underwent ultrasonography and CT scan. Imaging showed intraabdominal free fluid in all of cases. In 11 cases the cyst was unique and only in one case an associated mesenteric hydatid cyst was noted. Ruptured cysts were located in the right lobe of the liver in nine cases, in the left lobe in the other three cases. All the patients underwent emergency surgery after imaging. The procedure applied was conservative associated with drainage in all the cases. Some associated procedures were performed during the same operation. In only one case total pericystectomy for intraperitoneal cyst was performed. There were no post operative deaths. A total of five morbidities developed in three patients (one case of evisceration, three cases of biliary fistula and a case of pulmonary infection).

CONCLUSIONS

Hydatid cyst rupture in peritoneal cavity is a rare complication. Imaging assessment has an important role in diagnosis but clinical signs are mandatory. A quick diagnosis and emergency surgery can decrease postoperative death. Surgery and postoperative care constitute the basis of treatment.

The Acute Effect of Exercise on Executive Function and Attention: Resistance Versus Aerobic Exercise

Acute aerobic exercise was shown to enhance such cognitive functions as executive function (EF) and attention. Acute resistance exercise was also shown to enhance cognitive functions, however, only few studies directly compared these two exercise modalities. The aim of this study was to evaluate the acute effect of a typical moderate intensity resistance exercise session as compared to a typical moderate intensity aerobic session, on executive function and attention. A counterbalanced repeated measures experimental design was applied. Forty physical education students (21 women; 19 men, age = 25.7±2.84 years) were tested before and after three sessions: aerobic, resistance, and control. Each session consisted of 30 minutes of exercise or a rest. Executive function and attention were assessed by components of the computerized Stroop Catch game and Go-NoGo cognitive tests. A two-way ANOVA showed a greater increase in attention scores after the resistance sessions (p < .05) compared to the control condition. Attention scores in the aerobic sessions showed a trend toward improvement but did not reach statistical significance. Scores of EF significantly increased, both after the resistance session and the aerobic session (p < .05), but not after rest in the control condition. Our findings show that an acute session of resistance exercise increased both Attention and EF test scores, while an aerobic exercise session improved only the EF scores.

Hyperparathyroidism in pregnancy

Primary hyperparathyroidism in pregnancy is uncommon and easily overlooked. It is associated with a complication rate of up to 80 per cent--mainly stillbirths, abortions and neonatal tetany. Surgical treatment during pregnancy offers the best chance for fetal and neonatal survival.

Emergency geriatric surgical admissions

The emergency surgical work load created by patients aged 80 and over in a district hospital was assessed and the results of treatment examined. Over one year 248 patients aged 80 or over were admitted as emergencies, and the overall mortality rate was 21.8%. When terminal disease was excluded mortality rate was 12.5%. These elderly patients had an average length of stay in the acute surgical ward of 14.7 days compared with a mean of 8.4 days for all patients, and all but seven patients were discharged to their original place of referral.Elderly patients do exacerbate the bed shortage in acute surgical wards because they tend to stay longer than younger patients, but these elderly surgical patients imposed only a small load on the inpatient geriatric services, as 78% were discharged straight to their own homes and a further 17% went home after a period on the surgical convalescent wards.

[A rare aetiology of the post-partum fever: ovarian vein thrombophlebitis]

OBJECTIVES

To clarify the contribution of the doppler and the CT in the balance aetiology of a fever of the post-partum and to connect it with a thrombophlebitis of ovarian vein.

PATIENTS AND METHODS

Five patients presented there post-partum a fever with pointed abdominal painful syndrome. A doppler and a CT were performed.

RESULTS

Doppler showed a hypoechoic tubular structure located forward and laterally with regard to the psoas with a flat spectre in pulsed Doppler in every case. CT confirmed the diagnosis of a thrombophlebitis of the right ovarian vein in three cases and left in two cases. Evolution after anticoagulation and an antibiotic therapy was favourable with regression of clinical signs and doppler evaluation.

CONCLUSION

In front of any fever of the post-partum, it is necessary to evoke a thrombophlebitis of the vein ovarian, although it is about a rare aetiology. In spite of the superiority of the CT-scan and RP imaging for such a diagnosis, doppler is a simple and reproducible diagnostic tool for the monitoring which must be practised in first intention.

Increased erythrocyte stearic acid desaturation in rats with chemically induced colorectal carcinomas

Our previous studies have demonstrated a desaturation of stearic acid related to oleic acid in the lipid layer of erythrocytes in patients with malignancies. This study investigated the stearic acid desaturation in red blood cell membranes of rats during the induction of colorectal tumours. Male Sprague-Dawley rats were injected weekly with dimethylhydrazine (DMH) and sacrificed at 4-week intervals. Blood was withdrawn via heart puncture, collected in EDTA bottle and erythrocytes separated by centrifugation. Total lipid extraction was carried out and analysed with gas liquid chromatography. In the control rats (injected with normal saline) the mean of the stearic to oleic acid ratio in erythrocyte membranes was 2.0 +/- 0.3 (n = 28, range 1.51-2.62) compared to a mean of 0.94 +/- 0.16 (n = 0.5-1.23) in tumour bearing rats (p less than 0.001). The increased desaturation occurred in parallel with appearance of tumours. These data suggest the regulation of stearic acid desaturation is an important adaptive mechanism of membrane fluidity and could be a useful chemical marker for malignancy.

Hemodynamic compromise associated with air trapping following coronary artery bypass surgery

Cardiovascular collapse due to pulmonary hyperinflation was noted in a patient with chronic obstructive pulmonary disease following median sternotomy for cardiac surgery. Treatment included bronchodilator therapy to reduce airway obstruction, limitation of minute ventilation, and increasing time available for exhalation. High inspiratory flow rates and expiratory retard may be beneficial.