Raymond W. Liu

Safety and Effectiveness of Chemoembolization with Drug-Eluting Beads for Advanced-Stage Hepatocellular Carcinoma

BackgroundAccording to the Barcelona Clinic Liver Cancer (BCLC) algorithm, patients with advanced stage (BCLC-C) hepatocellular carcinoma (HCC) are recommended for systemic treatment or palliative therapy. However, chemoembolization with drug-eluting beads (DEB-TACE) has been shown to be safe in high-risk patients. The purpose of our study was to evaluate the safety and effectiveness of DEB-TACE in patients with an advanced-stage HCC.MethodsIn this institutional review board-approved, retrospective study, 80 patients with advanced-stage HCC underwent DEB-TACE with doxorubicin. Patients were evaluated for median hospital stay, incidence of Grade 3/4 toxicities, 30-day mortality, progression-free survival (PFS), and overall survival (OS) following DEB-TACE. Univariate and multivariate analysis were performed for predictors of better OS.ResultsThe median hospital stay following DEB-TACE was 1xa0day (range: 1–11). The median PFS and OS were 5.1xa0months [95xa0% confidence interval (CI): 4.1–7.7] and 13.3xa0months (95xa0% CI: 10.1–18.6) respectively. On multivariate analysis ECOG PSxa0≤xa01 and >2 DEB-TACE procedures were associated with better OS. Patients with ECOG PSxa0≤xa01 demonstrated a median survival of 17.7xa0months compared with 5.6xa0months for patients with ECOG PSxa0>xa01 (pxa0=xa00.025). Multiple DEB-TACE procedures (>2 procedures) were associated with improved survival (26.8xa0months) compared with patients with one or two procedures (11.4xa0months, pxa0=xa00.01). Portal vein thrombosis or extrahepatic disease had no statistically significant association with OS.ConclusionsDEB-TACE is safe and effective in patients with advanced HCC. ECOG PSxa0≤xa01 and >2 DEB-TACE procedures were associated with better OS.

Venous compression syndromes: clinical features, imaging findings and management

Extrinsic venous compression is caused by compression of the veins in tight anatomic spaces by adjacent structures, and is seen in a number of locations. Venous compression syndromes, including Paget-Schroetter syndrome, Nutcracker syndrome, May-Thurner syndrome and popliteal venous compression will be discussed. These syndromes are usually seen in young, otherwise healthy individuals, and can lead to significant overall morbidity. Aside from clinical findings and physical examination, diagnosis can be made with ultrasound, CT, or MR conventional venography. Symptoms and haemodynamic significance of the compression determine the ideal treatment method.

Segmental Arterial Mediolysis

Segmental arterial mediolysis (SAM) is an uncommon, nonatherosclerotic, noninflammatory, large- to medium-sized arteriopathy first described in 1976. It is characterized histologically by vacuolization and lysis of the outer arterial media leading to dissecting aneurysms and vessel rupture presenting clinically with self-limiting abdominal pain or catastrophic hemorrhages in the abdomen. Patients of all ages are affected with a greater incidence at the fifth and sixth decades. There is a slight male predominance. Imaging findings overlap with inflammatory vasculitis, collagen vascular disease, and fibromuscular dysplasia. The presence of segmental dissections involving the celiac, mesenteric, and/or renal arteries is the key distinguishing features of SAM. Inflammatory markers, genetic tests for collagen vascular disorders, and hypercoagulable studies are negative. Anti-inflammatory agents and immunosuppressants are not effective. A mortality rate of 50xa0% has been attributed to the acute presentation with aneurysmal rupture necessitating urgent surgical or endovascular treatments; in the absence of the acute presentation, SAM is a self-limiting disease and is treated conservatively. There are no established guidelines on medical therapy, although optimal control of blood pressure is considered the main cornerstone of medical therapy. The long-term prognosis is not known.

Yttrium-90 Radioembolization as Salvage Therapy for Liver Metastases From Colorectal Cancer.

Purpose: To report safety and survival outcomes of Yttrium-90 (Y-90) radioembolization when used as salvage therapy for chemotherapy-resistant liver metastases from colorectal cancer. Methods: In this IRB-approved retrospective study, 45 patients with hepatic metastases from colorectal cancer underwent Y-90 radioembolization after failure of systemic chemotherapy. Toxicities were assessed as per NCI-CTCAE and response based on RECIST and PET. Kaplan-Meier survival analysis was performed to calculate median survival, prognostic factors on univariate analysis, and Cox regression analysis for independent predictors of survival. Results: Y-90 radioembolization was technically successful in all (100%). Twenty-three patients (51%) had no toxicities, whereas 6 patients (13%) had grade 3 toxicities, and no patients had grade 4 toxicity. Two patients died within 30 days of treatment from renal failure unrelated to the procedure. Per RECIST, 1 patient (2%) had partial response, 34 (71%) had stable disease, and 6 (13%) had progressive disease. PET response was seen in 46% of patients with 2 patients (4%) demonstrating complete and 22 (42%) demonstrating partial metabolic response. The median survival was 186 days (95% CI, 149-277 d). Response on PET was the only independent predictor of superior overall survival. Patients who had response on PET following Y-90 therapy had a median overall survival of 317 days (10.6 mo) (95% CI, 193-564 d), whereas patients with no response on PET had a median overall survival of 163 days (5.4 mo) (95% CI, 64-283 d). Conclusions: Y-90 radioembolization as a salvage therapy for chemotherapy-resistant hepatic metastases from colon cancer was safe and resulted in disease stability. Response on PET was an independent predictor of superior overall survival.

Sustainable growth rate 2013: time for definitive intervention

Federal healthcare spending has been a subject of intense concern as the US Congress continues to search for ways to reduce the budget deficit. The Congressional Budget Office (CBO) estimated that, even though it is growing more slowly than previously projected, federal spending on Medicare, Medicaid and the State Childrens Health Insurance Program (SCHIP) will reach nearly

An anatomic study of the distal femoral epiphysis.

900 billion in 2013. In 2011 the Medicare program paid

Pelvic Incidence and Acetabular Version in Slipped Capital Femoral Epiphysis.

68 billion for physicians and other health professional services, 12% of total Medicare spending. Since 2002 the sustainable growth rate (SGR) correction has called for reductions to physician reimbursements; however, Congress has typically staved off these reductions, although the situation remains precarious for physicians who accept Medicare. The fiscal cliff agreement that came into focus at the end of 2012 averted a 26.5% reduction to physician reimbursements related to the SGR correction. Nonetheless, the threat of these devastating cuts continues to loom. The Administration, Congress and others have devised many options to fix this unsustainable situation. This review explores the historical development of the SGR, touches on elements of the formula itself and outlines current proposals for fixing the SGR problem. A recent CBO estimate reduces the potential cost of a 10-year fix of SGR system to

The episode, the PTAC, cost, and the neurointerventionalist

138 billion. This has provided new hope for resolution of this long-standing issue.

Catheter-Directed Intraarterial Thrombolysis as Part of a Multidisciplinary Management Protocol of Frostbite Injury

Background: The anatomy of the undulating distal femoral physis may be relevant to growth disturbance after physeal fractures and screw fixation about the physis. The surface anatomy of this physis has not been well described. Methods: We performed an anatomic study on 26 cadaveric distal femoral epiphyses in specimens 3 to 18 years of age. High-resolution 3-dimensional surface scans were obtained and analyzed to determine the heights, approximate surface areas, and locations of the major undulations. Results: Gross examination revealed lateral and anteromedial peripheral notches at the metaphyseal-epiphyseal junction, which deepen with advancing skeletal maturity. Within the epiphysis, there are 3 major undulations: a central ridge, lateral ridge, and medial peak, with mean heights of 5.5 mm (range, 2.9 to 9.8 mm), 2.5 mm (1.0 to 5.7 mm), and 2.9 mm (0.9 to 4.7 mm), respectively. The normalized height and surface area of each undulation decreased with increasing age, most dramatically in the central ridge. With respect to a line connecting the medial and lateral aspects of the physis, we found that the central peak passes more superior with younger age, and tends to be more posteriorly located. The lowest point of the physis is located either anteromedial or posterolateral. Conclusions: The central ridge, lateral ridge, and medial peak are the 3 major undulations in the distal femoral physis. The central ridge has the greatest height and most dramatic decrease in relative size with increasing age, suggesting structural importance. This anatomic data can guide metaphyseal and epiphyseal screw fixation. Clinical Relevance: This study provides quantitative data on the topographic anatomy of the distal femoral physis, which can guide screw placement about the physis. These data may help identify fractures patterns with a greater risk of growth disturbance and key radiographic landmarks for guiding fracture reduction.

Multidetector CT for GI bleeding: first-line diagnostic study?

Background: The etiology of slipped capital femoral epiphysis (SCFE) is multifactorial, but the role of sagittal balance of the pelvis as a contributing factor to its development has not been well studied. Our primary purpose was to determine whether a smaller pelvic incidence (PI), a position-independent anatomic parameter that regulates pelvic orientation, could be a factor that increases shear stress in the epiphyseal growth plate and potentially contributes to the development of SCFE. We also set out to determine whether acetabular retroversion was associated with SCFE. Methods: We obtained 14 cadaveric pelvi from the Hamann-Todd Osteological Collection whose femurs showed evidence of post-SCFE deformity. Two hundred age-matched, sex-matched, and race-matched pelvi were used as controls. PI and acetabular version were measured using standardized lateral photographs and goniometers, respectively. T tests were performed to evaluate for differences in measured parameters between groups. Results: The mean PI was 40.6±6.1 degrees for SCFE specimens and 47.4±9.9 degrees for normal specimens (P=0.01). The mean version of SCFE and normal acetabula was 15±7 and 17±6 degrees, respectively (P=0.39). There was also no significant difference in version between SCFE acetabula and the contralateral, uninvolved acetabular of the same specimen (15±7 vs. 17±8 degrees, P=0.33). Conclusions: Specimens with SCFE deformity demonstrated a smaller PI than a large cohort of normal control specimens. We found no significant difference between acetabular version of specimens with and without SCFE deformity. Contralateral or unaffected acetabuli of SCFE specimens were not more retroverted than the affected side of the same specimen. Clinical Relevance: Sagittal balance of the pelvis, and particularly decreased PI, may play an important role in the development of SCFE. The influence of mechanical factors beyond the hip joint in the development of SCFE should be considered by clinicians.