Hepatic embolotherapy in interventional oncology: technology, techniques, and applications.

Embolotherapy continues to play a growing role in the management of primary and secondary hepatic malignancies. In this review article, we examine the basis of therapy with a focus on neovascularization, which makes treatments via the hepatic artery possible. An overview of the three generations of embolic and therapeutic agents follows. The techniques, technologies, and complications of bland embolization, transarterial chemoembolization, drug-eluting beads, and selective internal radiotherapy are covered to give the reader an overview of this exciting field in interventional radiology.

Pitfalls and artefacts in performance and interpretation of contrast-enhanced MR angiography of the lower limbs.

Peripheral contrast-enhanced MR angiography is widely used for anatomical imaging of the arterial system of the lower limb. There are several pitfalls in the planning, acquisition, and interpretation of these studies that can result in the loss of important diagnostic information, as well as artefacts that can be misinterpreted as disease entities. This review illustrates the range of these potential sources of error and how to avoid them.

Optimized nerve block techniques while performing percutaneous hepatic ablation: Literature review and practical use.

Percutaneous image guided thermal ablation has become a cornerstone of therapy for patients with oligometastatic disease and primary liver malignancies. Evolving from percutaneous ethanol injection (PEI), thermal ablation utilizing radiofrequency ablation (RFA) and microwave ablation (MWA) have become the standard approach in the treatment of isolated lesions that fit within the size criteria for curative intent therapy (typically 3-4cm). With the evolution of more intense thermal ablation, such as MWA, the dramatic increase in both the size of ablation zone and intensity of heat generation have extended the limits of this technique. As a result of these innovations, intra-procedural and post-procedural pain have also significantly increased, requiring either higher levels of intravenous sedation or, in some institutions, general anesthesia. In addition to the increase in therapeutic intensity, the use of intravenous sedation during aggressive ablation procedures carries the risk of over-sedation when the noxious insult (i.e. the ablation) is removed, adding further difficulty to post-procedural recovery and management. Furthermore, high subdiaphragmatic lesions become challenging in this setting due to issues relating to sedation and compliance with breath hold/breathing instructions. Although general anesthesia may mitigate these complications, the added resources associated with providing general anesthesia during ablation is not cost effective and may result in substantial delays in treatment. The reduction of Aerosol Generating Medical Procedures (AGMP), such as intubation due to the COVID-19 Pandemic, must also be taken into consideration. Due to the potential increased risk of infection transmission, alternatives to general anesthesia should be considered when safe and possible. Upper abdominal regional nerve block techniques have been used to manage pain related to trauma, surgery, and cancer; however, blocks of this nature are not well described in the interventional radiology literature. The McGill University group has developed experience in using such blocks as splanchnic, celiac and hepatic hilar nerve blocks to provide peri-procedural pain control [1]. Since incorporating these techniques (along with hydrodissection with tumescent anesthesia), we have also observed in our high volume ablation center a dramatic decrease in the amount of sedatives administered during the procedure, a decrease in patient discomfort during localization and ablation, as well as decreased pain post-procedure. Faster time to discharge and overall reduction in room procedural time serve as added benefits. The purpose of this publication is to outline and illustrate the practical application and use of nerve block/regional anesthesia techniques with respect to percutaneous hepatic thermal ablation.

Current locoregional therapies and treatment strategies in hepatocellular carcinoma.

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Methane from anaerobic fermentation.

Conventional anaerobic digestion is an established technology for wastewater stabilization, but methane production rates and net energy yields are generally too low to make the process competitive as a source of methane. Numerous improvements are being developed to make conversion of plant biomass to methane and simultaneous waste stabilization-methane production practical. Among these improvements are innovative-digester designs and process configurations. Efforts to commercialize modern anaerobic digestion technology are progressing.

Biliary lipids, cholesterol and bile synthesis: different adaptive mechanisms to dietary cholesterol in lean and obese subjects.

BACKGROUND: Increased biliary cholesterol secretion together with elevated cholesterol synthesis may predispose obese subjects to cholesterol gallstone formation. AIM: To investigate whether processing of dietary cholesterol is altered in obesity, we enrolled eight lean and seven obese subjects in a double-blind crossover study. METHODS: Cholesterol consumption was 300 mg/day on low and 1300 mg/day on high cholesterol diet. After 3 weeks on either diet, hepatic bile was collected to determine biliary lipid secretion, and bile salt composition by high-performance liquid chromatography and cholesterol saturation index was calculated. Cholesterol synthesis was measured employing mass isotopomer distribution analysis. Bile acid synthesis via neutral and acidic pathway was assessed by serum levels of 7alpha-hydroxy-4-cholesten-3-one and 27-hydroxycholesterol. RESULTS: Cholesterol synthesis was increased in obese compared with lean and feedback inhibited only in obese. On low cholesterol diet, cholesterol secretion was doubled in obese but bile acid composition and synthesis was similar between the two groups. After high cholesterol diet, cholesterol saturation index and bile secretion were unchanged. In contrast to obese, lean increased bile acid synthesis only via the acidic pathway. CONCLUSIONS: Dietary cholesterol appears to preferentially induce bile acid synthesis via the acidic pathway in lean, whereas cholesterol synthesis was inhibited in obese. Thus, stable cholesterol saturation index may be achieved by different mechanisms.

Effects of prednisolone on the differentiation of mouse lung adenomas in culture.

Explants of pulmonary adenomas, induced in mice by urethan, were cultured with or without prednisolone for 72 hr. After this time, the cuboidal epithelial cells of the tumor contained many more lamellar bodies than the nonsteroid control cultures. Incorporation of labeled palmitic acid into saturated phosphatidylcholine was not significantly increased in these short-term steroid-treated cultures. The results indicate that steroid enhances the maturation of cultured pulmonary adenoma cells into cells morphologically indistinguishable from type II alveolar epithelial cells of normal lung.

Bacterial phagocytosis and intracellular killing by alveolar macrophages in BB rats.

Diabetic patients and animals show an increased susceptibility to bacterial infections due to impaired bactericidal function of various host-defense mechanisms. In our study, we examined the ability of alveolar macrophages (AMs) of the diabetic BB rat to phagocytize and kill Staphylococcus aureus bacteria. Groups of spontaneously diabetic BB rats with variable severity of diabetes were used and compared with non-diabetes-prone BB rats. AMs obtained from diabetic insulin-deficient BB rats showed a markedly decreased capacity to phagocytize and kill bacteria, a defect that was partially corrected after a period of aggressive insulin treatment. Glucose-intolerant BB rats and diabetes-prone BB rats who did not develop diabetes showed a normal AM function compared to non-diabetes-prone BB rats. The impaired phagocytotic and bactericidal functions of AMs appeared to be caused by a cellular abnormality associated with the degree of insulin deficiency.

Ward treatment milieu and posthospital functioning.

Two units of seven and 14 state hospital wards were used in a study to explore possible relationships between some socio-cultural aspects of ward environments and outcome of treatment as assessed by time out of the hospital after discharge. Confounding variables such as pretreatment characteristics, length of hospitalization, and community of discharge make conclusions from many such studies tenuous. Methods were derived and are here described in detail that reduce the influence of some of these variables. Within unit 2 (14 wards), a vector of social structure that differentiated the wards and consisted of two highly correlated factors on the Ward Atmosphere Scale was found to be significantly associated with outcome. Those wards seen by both patients and staff as lower in the allowance of expression of anger and aggression and higher in order and organization (only staff's perception) had better outcomes. The wards of unit 1 were homogeneous both in outcome and in staff and patients' assessments of order and organization and freedom to express anger and aggression.

Blood levels of neuroleptic drugs in nonresponding chronic schizophrenic patients.

Blood levels of butaperazine were measured in schizophrenic patients who were chronic nonresponders to their psychotropic medication. The blood levels were compared with those in patients who had shown a better clinical response to this neuroleptic. Nonresponders had two to seven times lower levels of butaperazine in plasma and RBCs after a single dose or chronic dosing. Some of the patients later treated with thioridazine or haloperidol had lower plasma levels of these neuroleptics also. No significant differences were found between nonresponders and relative responders in either the alpha- or beta-phase half-life of butaperazine in plasma and RBCs after administration of a single dose of the drug. Butaperazine and thioridazine levels were not related to previously administered amounts of neuroleptic drugs. These findings do not support the hypothesis that low blood levels are the result of faster systemic metabolism of the drug after it reaches the central circulation. Our results suggest that low blood levels of neuroleptics may be one important factor in the poor clinical response of some chronic schizophrenic patients.

Supervision and the professional development of the psychiatric resident.

The authors used a questionnaire survey to study the way psychiatric residents experience their psychotherapy supervisors at two points in their training. Results show that second-year residents were more critical in their evaluations of supervisors than first- or third-year residents and that there appeared to be a characteristic progression in the experience of residents from year to year. The authors believe that the resident's experience of supervision reflects a developmental process, which others have described and viewed as important in the formation of identity as a psychiatrist.

Alteration in the recommended dosing schedule for risperidone.

OBJECTIVE: The authors' goal was to study the recommended dose schedule for risperidone. METHOD: They obtained computerized pharmacy data on 1,283 inpatients with the diagnoses of schizophrenia or schizoaffective disorder who were treated with risperidone. Continuance on risperidone was defined as remaining on the drug for 16 days or until discharge. RESULTS: The majority of the patients (84%) continued on resperidone. Use of the recommended dose schedule decreased greatly over time. Patients were more likely to continue on risperidone if they had a higher maximum dose (5.7 mg/day versus 4.7 mg/day), a longer number of days to maximum dose (5.7 days versus 3.9 days), and a maximum rise in dose of 0.5-2 mg/day. CONCLUSIONS: These findings suggest that the recommended dose schedule should be altered to one that recommends a less rapid titration (over 6 days to a week) and that the dose increments consist of 0.5-2 mg/day.

Electrophysiological (H-reflex) studies of patients with tardive dyskinesia.

The authors studied the H-reflex recovery curves of 31 schizophrenic patients with tardive dyskinesia in response to acute administrations of apomorphine, amphetamine, or physostigmine and compared them with curves of chronic schizophrenic patients without tardive dyskinesia and normal volunteers. Their most unexpected finding was the absence of an H-reflex in 9 of the 31 patients with tardive dyskinesia. They also found a relationship between severity of tardive dyskinesia and the value of the facilitatory peak Hchi: patients with more severe tardive dyskinesia symptoms had significantly higher values for Hchi.

Midline theta rhythm.

Thirty-six patients had a midline theta rhythm in the electroencephalogram that consisted of a train of rhythmic waveforms in the theta frequency range (4 to 7 Hz), which occurred as a focal rhythm in the midline leads and was usually most prominent in the central vertex lead. The activity consisted of sinusoidal or arciform waveforms that waxed and waned. There was variable reactivity of the midline rhythm to eye opening, alerting, and limb movement. Of the 36 patients, 28 had a seizure disorder, while the other eight had various conditions unassociated with epilepsy. The pattern was not associated with epileptiform activity, mu activity, a drowsy pattern, or medication effect. Although its mechanism of origin is uncertain, the midline theta rhythm appears to represent a nonspecific electroencephalographic pattern that can occur in a mixed group of patients with various diagnoses.

Computed tomography and EEG in cerebrovascular disease.

In three patients with cerebrovascular diseases, the EEG showed active dysfunction of varied extent and severity in one cerebral hemisphere, but computed tomography showed no demonstrable abnormalities in the corresponding areas. These patients had occlusion or severe stenosis of one or both internal carotid arteries, either extracranially or intracranially. Both clinical symptoms and the EEG abnormalities resolved or improved after surgical anastomosis of the superficial temporal artery to the middle cerebral artery.

Transient global amnesia and epilepsy. Electroencephalographic distinction.

Electroencephalographic recordings were obtained during 13 episodes of transient global amnesia in 13 patients. Eight were entirely normal; none showed seizure discharges or other epileptiform activity. Electroencephalographic recordings were also obtained after 103 episodes of amnesia in 96 patients with transient global amnesia (TGA) alone, five patients who had both TGA and epilepsy independently, and three patients with amnesia related to epilepsy. The majority (60.8%) of waking records were normal during or after episodes of TGA. Mild or moderate and nonfocal abnormalities were found in a minority. Genuine epileptiform activity was observed only among patients who had seizure disorders. Amnestic episodes attributable to seizures were more brief and more apt to be repeated than TGA and usually responded to anticonvulsant drugs. Differentiation of TGA from epilepsy is essential for appropriate management.

Periodic sharp waves in baclofen-induced encephalopathy.

Acute encephalopathy and an abnormal electroencephalogram with a periodic sharp wave pattern developed in a 58-year-old woman shortly after she received a few doses of baclofen. The clinical and electroencephalographic abnormalities improved promptly after the medication was discontinued.

Localized EEG abnormalities in acute carbon monoxide poisoning.

The EEG of a patient with acute carbon monoxide poisoning was characterized by lateralized sharp waves and a focal electrographic seizure discharge within hours of the exposure. These findings were associated with coma and focal motor seizures. The patient made a full clinical recovery, and the EEG was normal two months after the exposure. The association of a primarily diffuse cerebral insult after CO poisoning, with prominent lateralized epileptiform discharges in the EEG, is a distinctly unusual phenomenon.

Triphasic waves in cerebral carcinomatosis. Another nonmetabolic cause.

A 59-year-old woman with a metastatic adenocarcinoma of unknown origin and no metabolic abnormalities developed a diffuse encephalopathy, with generalized triphasic waves seen on the electroencephalogram. Postmortem examination revealed widespread, multifocal perivascular carcinomatosis of the cerebral cortices. Triphasic waves have been described with dementing processes, subdural hematomas, and cerebrovascular disease, but they are more commonly seen with metabolic encephalopathies. This case demonstrates an additional nonmetabolic cause of triphasic waves.