John P. McGahan

Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans

Studies in animals have documented that, compared with glucose, dietary fructose induces dyslipidemia and insulin resistance. To assess the relative effects of these dietary sugars during sustained consumption in humans, overweight and obese subjects consumed glucose- or fructose-sweetened beverages providing 25% of energy requirements for 10 weeks. Although both groups exhibited similar weight gain during the intervention, visceral adipose volume was significantly increased only in subjects consuming fructose. Fasting plasma triglyceride concentrations increased by approximately 10% during 10 weeks of glucose consumption but not after fructose consumption. In contrast, hepatic de novo lipogenesis (DNL) and the 23-hour postprandial triglyceride AUC were increased specifically during fructose consumption. Similarly, markers of altered lipid metabolism and lipoprotein remodeling, including fasting apoB, LDL, small dense LDL, oxidized LDL, and postprandial concentrations of remnant-like particle-triglyceride and -cholesterol significantly increased during fructose but not glucose consumption. In addition, fasting plasma glucose and insulin levels increased and insulin sensitivity decreased in subjects consuming fructose but not in those consuming glucose. These data suggest that dietary fructose specifically increases DNL, promotes dyslipidemia, decreases insulin sensitivity, and increases visceral adiposity in overweight/obese adults.

Image-guided Tumor Ablation: Standardization of Terminology and Reporting Criteria—A 10-Year Update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

Image-guided tumor ablation: standardization of terminology and reporting criteria.

The field of interventional oncology with use of image-guided tumor ablation requires standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison between treatments that use different technologies, such as chemical (ethanol or acetic acid) ablation, and thermal therapies, such as radiofrequency (RF), laser, microwave, ultrasound, and cryoablation. This document provides a framework that will hopefully facilitate the clearest communication between investigators and will provide the greatest flexibility in comparison between the many new, exciting, and emerging technologies. An appropriate vehicle for reporting the various aspects of image-guided ablation therapy, including classification of therapies and procedure terms, appropriate descriptors of imaging guidance, and terminology to define imaging and pathologic findings, are outlined. Methods for standardizing the reporting of follow-up findings and complications and other important aspects that require attention when reporting clinical results are addressed. It is the groups intention that adherence to the recommendations will facilitate achievement of the groups main objective: improved precision and communication in this field that lead to more accurate comparison of technologies and results and, ultimately, to improved patient outcomes. The intent of this standardization of terminology is to provide an appropriate vehicle for reporting the various aspects of image-guided ablation therapy.

Hepatic ablation with use of radio-frequency electrocautery in the animal model.

The potential of percutaneous radio-frequency (RF) electrocautery hepatic ablation was evaluated in the animal model. RF hepatic ablation was performed under ultrasound (US) guidance in the liver of 10 swine with use of a specifically designed needle. The needle was placed through the liver capsule, and ablation was performed after isolating the liver at laparotomy. Animals were killed immediately (n = 4), at 1 week (n = 1), 2 weeks (n = 3), or at 5 weeks (n = 2). The US findings were correlated with the pathologic results in the animal livers. RF hepatic ablation was successfully performed in the animal model without complications. Lesions in the animal livers were typically 1 x 2 cm, which initially appeared highly echogenic on US scans. These images corresponded to an area of hepatic necrosis. The lesions became less echogenic shortly after initial treatment but could still be visualized with US at 5 weeks. At histologic study at 5 weeks, the treated livers showed central debris, a larger area of necrotic liver, and a zone of granulation tissue surrounded by a fibrotic capsule. No complications were encountered. RF hepatic ablation shows future promise in treatment of hepatic neoplasms.

Diagnosis of Deep-Vein Thrombosis Using Duplex Ultrasound

PURPOSE To critically evaluate the accuracy, advantages, and drawbacks of duplex ultrasound as a diagnostic test for proximal deep-vein thrombosis. DATA IDENTIFICATION An English-language search using MEDLINE (1980 to 1988) and bibliographies from articles, and a hand search of pertinent radiology and ultrasound journals from 1988. STUDY SELECTION All series comparing duplex ultrasound to the reference standard, contrast venography, were reviewed and classified into levels based on the quality of study design. DATA EXTRACTION Results of duplex ultrasound compared with venography in the proximal deep venous system, technical problems encountered, frequency of diagnosis of other causes of leg swelling, and frequency of unsuccessful or inconclusive studies were collated. RESULTS OF DATA SYNTHESIS Four well-designed studies reported similar results. The sensitivity of duplex ultrasound in detecting proximal thrombi ranged from 92% to 95% with a combined sensitivity of 93% (CI, 88% to 98%), and the specificity ranged from 97% to 100% with a combined sensitivity of 98% (CI, 96% to 100%). Similar findings were noted in nine other studies that had minor methodologic flaws. Four studies reported that ultrasound was able to identify a nonthrombotic cause of leg swelling in 5% to 15% of cases. Four studies found that duplex ultrasound was inconclusive in 1% to 6% of cases, with a combined frequency of 2%. CONCLUSIONS Duplex ultrasound appears to be very accurate in the detection of acute proximal deep-vein thrombosis. This test has major advantages as well as certain limitations compared with other diagnostic methods.

Fractures of the scapula.

One hundred thirty-seven fractures of the scapula in 121 patients were reviewed. The average age at the time of injury was 35 years, with fractures predominant in males (64%). The majority of cases (43%) involved fractures of the body of the scapula, with fractures of the scapular neck being second most common (26%). Automobile accidents produced the most injuries (52%), followed by auto-pedestrian (18%), falls (12%), and motorcycle accidents (11%). Associated bony or major soft-tissue trauma was present in all but 15 of the 121 patients, the most common being fractured ribs in 44%. Other associated injuries included fractures of the clavicle (26%), fractured skull (24%), cerebral contusion (20%), neurologic deficit (13%), and pulmonary contusion or hemo-pneumothorax (16%). Patients with injuries involving the acromion process or acromioclavicular joint had a significantly higher incidence of associated peripheral nerve injuries than those with other fractures of the scapula, indicating that special attention should be given to the neurologic examination of patients with these fractures. Careful neurovascular examination is mandatory. Treatment was usually conservative, independent of the location of the fracture, with satisfactory long-term results. We recommend simple immobilization followed by early active range of motion exercise.

Use of ultrasonography in the patient with acute abdominal trauma

The purpose of this study was to assess the use of ultrasonography in patients with acute abdominal trauma. Five hundred prospective patients, who came to the Emergency Department with acute trauma, were evaluated with ultrasonography and included in this study. The ultrasonographic examination focused on detection of free fluid but included evaluation of parenchymal organs for injury. The physical examination was not used in the statistical analysis of the sonographic findings. In comparing ultrasonography to computed tomography, diagnostic peritoneal lavage, or operative findings, we obtained 24 true positive, 79 true negative, four false positive, and 14 false negative results. Sensitivity of ultrasonography in detecting free fluid in comparison to computed tomography, diagnostic peritoneal lavage, and surgery was 63%, specificity was 95%, accuracy was 85%, positive predictive value was 86%, and negative predictive value was 85%. The most common reason for false negative sonographic results was identification of free fluid in the pelvis on computed tomograms but not on ultrasonograms owing to lack of a full bladder. In none of these instances were the sonographic false negative results of clinical significance. Ultrasonography allowed detection of solid organ injury of the liver in one of seven cases, of the kidney in one of four cases, and in the bowel in zero of three cases. In the three instances of bowel injury, free fluid was noted on ultrasonograms. Ultrasonography fared better in cases of splenic laceration, permitting detection in nine of 14 cases. The emergent ultrasonogram may be used to detect free fluid in the abdomen of the acutely traumatized patient. However, sonography is limited in detecting free fluid in the pelvis using the present technique and does not allow visualization of organ injury. Limitations of this examination should be recognized for appropriate triage of the acutely traumatized patient.

Percutaneous ultrasound-guided radiofrequency electrocautery ablation of prostate tissue in dogs

RATIONALE AND OBJECTIVES We investigated the feasibility of percutaneous radiofrequency (RF) electrocautery in ablation of prostate tissue in dogs. METHODS We used six dogs in whom a specially designed needle was placed percutaneously into the prostate. RF electrocautery was applied to the needle and treatment was monitored with ultrasound. Animals were sacrificed and gross examination of the prostate and surrounding tissues was performed. Histopathologic examinations of the prostate were also performed. RESULTS The treatment zone appeared as an elliptical echogenic focus on ultrasound that increased in size with the application of current. Gross and histopathologic correlation demonstrated that the treatment area included a central area of char with a surrounding area of coagulation. There were no deleterious effects to surrounding tissues. CONCLUSION Our results demonstrate the feasibility of percutaneous ultrasound-guided RF electrocautery ablation of canine prostate tissue.

Maximum-tolerated dose, toxicity, and efficacy of (131)I-Lym-1 antibody for fractionated radioimmunotherapy of non-Hodgkin's lymphoma.

PURPOSE Lym-1, a monoclonal antibody that preferentially targets malignant lymphocytes, has induced remissions in patients with non-Hodgkins lymphoma (NHL) when labeled with iodine 131 ((131)I). Based on the strategy of fractionating the total dose, this study was designed to define the maximum-tolerated dose (MTD) and efficacy of the first two, of a maximum of four, doses of (131)I-Lym-1 given 4 weeks apart. Additionally, toxicity and radiation dosimetry were assessed. MATERIALS AND METHODS Twenty patients with advanced NHL entered the study a total of 21 times. Thirteen (62%) of the 21 entries had diffuse large-cell histologies. All patients had disease resistant to standard therapy and had received a mean of four chemotherapy regimens. (131)I-Lym-1 was given after Lym-1 and (131)I was escalated in cohorts of patients from 40 to 100 mCi (1.5 to 3.7 GBq)/m2 body surface area. RESULTS Mean radiation dose to the bone marrow from body and blood (131)I was 0.34 (range, 0. 1 6 to 0.63) rad/mCi (0.09 mGy/MBq; range, 0.04 to 0.17 mGy/ MBq). Dose-limiting toxicity was grade 3 to 4 thrombocytopenia with an MTD of 100 mCi/m2 (3.7 GBq/m2) for each of the first two doses of (131)I-Lym-1 given 4 weeks apart. Nonhematologic toxicities did not exceed grade 2 except for one instance of grade 3 hypotension. Ten (71 %) of 14 entries who received at least two doses of (131)I-Lym-1 therapy and 11 (52%) of 21 total entries responded. Seven of the responses were complete, with a mean duration of 14 months. All three entries in the 100 mCi/m2 (3.7 MBq/m2) cohort had complete remissions (CRs). All responders had at least a partial remission (PR) after the first therapy dose of (131)I-Lym-1. CONCLUSION (131)I-Lym-1 induced durable remissions in patients with NHL resistant to chemotherapy and was associated with acceptable toxicity. The nonmyeloablative MTD for each of the first two doses of (131)I-Lym-1 was 100 mCi/m2 (total, 200 mCi/m2) (3.7 GBq/m2; total, 7.4 GBq/m2).

Hepatic ablation using bipolar radiofrequency electrocautery.

RATIONALE AND OBJECTIVES Percutaneous methods have been used to treat primary and secondary hepatic neoplasms. In the current study, we evaluated the potential of bipolar radiofrequency (RF) electrocautery to increase in vitro liver tissue destruction when compared with monopolar RF electrocautery. METHODS Two needles (electrodes) were placed into fresh bovine liver tissue for use with bipolar electrocautery. Needle tip exposure was kept constant at 3 cm while other parameters, including treatment time, power (wattage), interneedle distance, and needle tip temperature, were changed. Pathologic and histologic correlation was performed, and tissue necrosis was weighed in grams for individual parameters. RESULTS There was a minimal threshold of approximately 45 degrees C where tissue coagulation occurred. Tissue coagulation increased the longer treatment went on. Increasing temperature, wattage, or both increased tissue coagulation such that necrosis was too rapid and char formation occurred, which prevented further coagulation. For all wattages and temperatures, there was increasing tissue necrosis with increasing needle separation, until a point at which further needle separation produced less tissue necrosis. Optimizing parameters allowed tissue coagulation of greater than 30 g. CONCLUSION Bipolar RF electrocautery shows promise for increasing the tissue coagulation in fresh bovine liver compared with the previously described monopolar technique.