Multicenter Phase II Clinical Trial of Sorafenib Combined with Transarterial Chemoembolization for Advanced Stage Hepatocellular Carcinomas (Barcelona Clinic Liver Cancer Stage C): STAB Study.

PURPOSE: To evaluate safety and efficacy of combining sorafenib with transarterial chemoembolization in patients with advanced stage hepatocellular carcinomas (HCCs). MATERIALS AND METHODS: Systemic chemotherapy-naïve patients with a Child-Pugh class A liver profile and advanced stage HCCs were enrolled. Sorafenib therapy (daily dose 800 mg) was initiated within 4 weeks after initial conventional transarterial chemoembolization with an allowance of subsequent on-demand conventional chemoembolization. The primary endpoint was rate of protocol treatment completion, which was defined as sorafenib administration for at least 2 months. Secondary endpoints included objective response rate, disease control rate, overall survival, progression-free survival, and incidence of adverse events. Thirty-one patients (24 men, 7 women; median age, 75 years; vascular invasion, n = 19; extrahepatic metastases, n = 18; both, n = 6) who met the inclusion criteria were enrolled. RESULTS: Protocol treatment was completed in 28 patients (90.3%, 28/31) with median protocol treatment duration of 7.0 months (range, 0.5-30 months) and median of 2 (range, 1-4) transarterial chemoembolization sessions. Objective response rate was 77.4% with median overall and progression-free survival of 17.3 months (95% confidence interval, 11.9-22.6 months) and 5.4 months (95% confidence interval, 4.6-6.2 months), respectively. The most common grade 3 or 4 adverse events were self-limiting elevation of aspartate aminotransferase (54.8%, 17/31) and alanine aminotransferase (45.2%, 14/31). CONCLUSIONS: This combination therapy is feasible and promising in patients with advanced stage HCCs.

Hepatic arterial infusion chemotherapy with fine-powder cisplatin and iodized-oil suspension in patients with intermediate-stage and advanced-stage (Barcelona Clinic Liver Cancer stage-B or stage-C) hepatocellular carcinoma: multicenter phase-II clinical study.

PURPOSE: This single-arm, multicenter, phase-II trial evaluated the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) using fine-powder cisplatin and iodized-oil suspension in patients with intermediate- and advanced-stage [Barcelona Clinic Liver Cancer (BCLC) stage-B and stage-C] hepatocellular carcinomas (HCCs). METHODS: The Institutional Review Board approved this study and patients provided written informed consent. Thirty-five patients (24 men and 11 women, mean 74 ± 6 years [range 60-87 years]) with BCLC stage-B (57 %, 20/35) or stage-C (43 %, 15/35) HCCs who were not candidates for other locoregional treatments were enrolled. HAIC was performed using a suspension of fine-powder cisplatin with a maximum dose of 65 mg/m(2) and iodized oil on demand. The primary endpoint was the response rate evaluated based on Response Evaluation Criteria in Solid Tumor (RECIST) and modified RECIST (mRECIST). Secondary endpoints were overall survival, progression-free survival, and safety. RESULTS: The initial and best overall response rates at 4 weeks and 3 months, respectively, were 14 and 17 % based on RECIST, and 57 and 23 % based on mRECIST. The median overall and progression-free survival times were 18 and 4 months, respectively. The most frequent grade-3 or grade-4 adverse events were elevation of serum alanine (23 %) and aspartate aminotransferase (20 %), and thrombocytopenia (17 %). CONCLUSION: This HAIC provides promising therapeutic effects with acceptable safety to patients with intermediate-stage and advanced-stage HCCs.

Lifestyle changes through the use of delivered meals and dietary counseling in a single-blind study. The STYLIST study.

BACKGROUND: Dietary habits are associated with obesity, and both are important contributing factors to lifestyle-related diseases. The STYLIST study examined the effects of dietary counseling by registered dietitians and the delivery of proper calorie-controlled meals (UMIN Registration No: 000006582). METHODS AND RESULTS: Two-hundred adult patients with hypertension and/or diabetes mellitus were randomly divided into 2 groups with/without dietary counseling and consumed an ordinary diet for 4 weeks. Each group was then subdivided into 2 groups with/without dietary counseling and received calorie-controlled lunch and dinner boxes for the next 4 weeks. The calories in the delivered meals were based on the subject's ideal body weight (BW) and physical activity level. BW, waist circumference, blood pressure, and laboratory data, including glycoalbumin, were measured at 0, 4, and 8 weeks. BW and the other parameters were significantly reduced during the study period in patients who received diet counseling in the ordinary diet period and/or delivered meal period but not in patients without dietary counseling, as assessed by linear mixed models for longitudinal data. CONCLUSIONS: The combination of dietary counseling by dietitians and delivery of calorie-controlled meals was effective in reducing BW, as well as blood pressure and glycoalbumin, in patients with hypertension and/or diabetes mellitus.

Impact of Prehospital 12-Lead Electrocardiography and Destination Hospital Notification on Mortality in Patients With Chest Pain　- A Systematic Review.

Background: To achieve early reperfusion therapy for ST-elevation myocardial infarction (STEMI), proper and prompt patient transportation and activation of the catheterization laboratory are required. We investigated the efficacy of prehospital 12-lead electrocardiogram (ECG) acquisition and destination hospital notification in patients with STEMI. Methods and Results: This is a systematic review of observational studies. We searched the PubMed database from inception to March 2020. Two reviewers independently performed literature selection. The critical outcome was short-term mortality. The important outcome was door-to-balloon (D2B) time. We used the GRADE approach to assess the certainty of the evidence. For the critical outcome, 14 studies with 29,365 patients were included in the meta-analysis. Short-term mortality was significantly lower in the group with prehospital 12-lead ECG acquisition and destination hospital notification than in the control group (odds ratio 0.72; 95% confidence interval [CI] 0.61-0.85; P<0.0001). For the important outcome, 10 studies with 2,947 patients were included in the meta-analysis. D2B time was significantly shorter in the group with prehospital 12-lead ECG acquisition and destination hospital notification than in the control group (mean difference -26.24; 95% CI -33.46, -19.02; P<0.0001). Conclusions: Prehospital 12-lead ECG acquisition and destination hospital notification is associated with lower short-term mortality and shorter D2B time than no ECG acquisition or no notification among patients with suspected STEMI outside of a hospital.

Systematic Review and Meta-Analysis of Diagnostic Accuracy to Identify ST-Segment Elevation Myocardial Infarction on Interpretations of Prehospital Electrocardiograms.

Background: The aim of this study was to assess and discuss the diagnostic accuracy of prehospital ECG interpretation through systematic review and meta-analyses. Methods and Results: Relevant literature published up to July 2020 was identified using PubMed. All human studies of prehospital adult patients suspected of ST-segment elevation myocardial infarction in which prehospital electrocardiogram (ECG) interpretation by paramedics or computers was evaluated and reporting all 4 (true-positive, false-positive, false-negative, and true-negative) values were included. Meta-analyses were conducted separately for the diagnostic accuracy of prehospital ECG interpretation by paramedics (Clinical Question [CQ] 1) and computers (CQ2). After screening, 4 studies for CQ1 and 6 studies for CQ2 were finally included in the meta-analysis. Regarding CQ1, the pooled sensitivity and specificity were 95.5% (95% confidence interval [CI] 82.5-99.0%) and 95.8% (95% CI 82.3-99.1%), respectively. Regarding CQ2, the pooled sensitivity and specificity were 85.4% (95% CI 74.1-92.3%) and 95.4% (95% CI 87.3-98.4%), respectively. Conclusions: This meta-analysis suggests that the diagnostic accuracy of paramedic prehospital ECG interpretations is favorable, with high pooled sensitivity and specificity, with an acceptable estimated number of false positives and false negatives. Computer-assisted ECG interpretation showed high pooled specificity with an acceptable estimated number of false positives, whereas the pooled sensitivity was relatively low.

Performance of the 0-Hour/1-Hour Algorithm for Diagnosing Myocardial Infarction in Patients With Chest Pain in the Emergency Department　- A Systematic Review and Meta-Analysis.

Background: This study assessed the diagnostic performance of the 0-hour/1-hour (0/1-h) algorithm to rule in and rule out acute myocardial infarction (MI) in patients presenting to the emergency department (ED) for suspected acute coronary syndrome without ST-segment elevation, as recommended in the 2015 European Society of Cardiology (ESC) guideline. Methods and Results: Following the Preferred Reporting Items for a Systematic Review and Meta-analysis of Diagnostic Test Accuracy (PRISMA-DTA) guidelines, a systematic review was conducted using the PubMed database from inception to March 31, 2020. We included any article published in English investigating the diagnostic performance of the ESC 0/1-h algorithm for diagnosing MI in patients with chest pain visiting the ED. Of 651 studies identified as potentially available for the study, 7 studies including 16 databases were analyzed. A meta-analysis of the diagnostic accuracy of the 0/1-h algorithm using high-sensitivity cardiac troponin I (hs-cTn) with 6 observational databases showed a pooled sensitivity of 99.3% (95% confidence interval [CI] 98.5-99.7%) and a pooled specificity of 90.1% (95% CI 80.7-95.2%). A meta-analysis of the diagnostic accuracy of 10 observational databases of the ESC 0/1-h algorithm using hs-cTn revealed a pooled sensitivity of 99.3% (95% CI 96.9-99.9%) and a pooled specificity of 91.7% (95% CI 83.5-96.1%). Conclusions: Our results demonstrate that the ESC 0/1-h algorithm can effectively rule in and rule out patients with non-ST-segment elevation MI.

Effects of Door-In to Door-Out Time on Mortality Among ST-Segment Elevation Myocardial Infarction Patients Transferred for Primary Percutaneous Coronary Intervention　- Systematic Review and Meta-Analysis.

Background: Primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is now widely accepted. Recent guidelines have focused on total ischemic time, because shorter total ischemic time is associated with a more favorable prognosis. The door-in to door-out (DIDO) time, defined as time from arrival at a non-PCI-capable hospital to leaving for a PCI-capable hospital, may affect STEMI patient prognosis. However, a relevant meta-analysis is lacking. Methods and Results: We searched PubMed for clinical studies comparing short-term (30-day and in-hospital) mortality rates of STEMI patients undergoing primary PCI with DIDO times of ≤30 vs. >30 min. Two investigators independently screened the search results and extracted the data. Random effects estimators with weights calculated by the inverse variance method were used to determine pooled risk ratios. The search retrieved 1,260 studies; of these, 2 retrospective cohort studies (15,596 patients) were analyzed. In the DIDO time ≤30 and >30 min groups, the primary endpoint (i.e., in-hospital or 30-day mortality) occurred for 51 of 1,794 (2.8%) and 831 of 13,802 (6.0%) patients, respectively. The incidence of the primary endpoint was significantly lower in the DIDO time ≤30 min group (odds ratio 0.45; 95% confidence interval 0.34-0.60). Conclusions: Our findings suggest that a DIDO time ≤30 min is associated with a lower short-term mortality rate. However, further larger systematic reviews and meta-analyses are needed to validate our findings.

Supplemental Oxygen and Acute Myocardial Infarction　- A Systematic Review and Meta-Analysis.

Background: In Japan, oxygen is commonly administered during the acute phase of myocardial infarction (MI) to patients without oxygen saturation monitoring. In this study we assessed the effects of supplemental oxygen therapy, compared with ambient air, on mortality and cardiac events by synthesizing evidence from randomized controlled trials (RCTs) of patients with suspected or confirmed acute MI. Methods and Results: PubMed was systematically searched for full-text RCTs published in English before June 21, 2020. Two reviewers independently screened the search results and appraised the risk of bias. The estimates for each outcome were pooled using a random-effects model. In all, 2,086 studies retrieved from PubMed were screened. Finally, 7,322 patients from 9 studies derived from 4 RCTs were analyzed. In-hospital mortality in the oxygen and ambient air groups was 1.8% and 1.6%, respectively (risk ratio [RR] 0.90; 95% confidence interval [CI] 0.38-2.10]); 0.8% and 0.5% of patients, respectively, experienced recurrent MI (RR 0.44; 95% CI 0.12-1.54), 1.5% and 1.6% of patients, respectively, experienced cardiac shock (RR 1.10; 95% CI 0.77-1.59]), and 2.4% and 2.0% of patients, respectively, experienced cardiac arrest (RR 0.91; 95% CI 0.43-1.94). Conclusions: Routine supplemental oxygen administration may not be beneficial or harmful, and high-flow oxygen may be unnecessary in normoxic patients in the acute phase of MI.

Prehospital Administration of Aspirin and Nitroglycerin for Patients With Suspected Acute Coronary Syndrome　- A Systematic Review.

Background: Recent guidelines for acute coronary syndrome (ACS) recommend prehospital administration of aspirin and nitroglycerin for ACS patients. However, there is no clear evidence to support this. We investigated the benefits and harms of prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals in patients with suspected ACS. Methods and Results: We searched the PubMed database and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence. Three retrospective studies for aspirin and 1 for nitroglycerin administered in the prehospital setting to patients with acute myocardial infarction were included. Prehospital aspirin administration was associated with significantly lower 30-day and 1-year mortality compared with aspirin administration after arrival at hospital, with odds ratios (OR) of 0.59 (95% confidence interval [CI] 0.35-0.99) and 0.47 (95% CI 0.36-0.62), respectively. Prehospital nitroglycerin administration was also associated with significantly lower 30-day and 1-year mortality compared with no prehospital administration (OR 0.34 [95% CI 0.24-0.50] and 0.38 [95% CI 0.29-0.50], respectively). The certainty of evidence was very low in both systematic reviews. Conclusions: Our systematic reviews suggest that prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals is beneficial for patients with suspected ACS, although the certainty of evidence is very low. Further investigation is needed to determine the benefit of the prehospital administration of these agents.

Prehospital Activation of the Catheterization Laboratory Among Patients With Suspected ST-Elevation Myocardial Infarction Outside of a Hospital　- Systematic Review and Meta-Analysis.

Background: In the management of patients with ST-elevation myocardial infarction (STEMI), system delays for reperfusion therapy are still a matter of concern. We investigated the impact of prehospital activation of the catheterization laboratory in the management of STEMI patients. Methods and Results: This is a systematic review of observational studies. A search was conducted of the PubMed database from inception to July 2020 to identify articles for inclusion in the study. The critical outcomes were short- and long-term mortality. The important outcome was door-to-balloon time. The GRADE approach was used to assess the certainty of the evidence. Seven studies assessed short-term mortality; 1,541 were assigned to the prehospital activation (PH) group and 1,191 were assigned to the emergency department activation (ED) group. There were 26 fewer deaths per 1,000 patients in the PH group. Three studies assessed long-term mortality; 713 patients were assigned to the PH group and 1,026 were assigned to the ED group. There were 54 fewer deaths per 1,000 patients among the PH group. Five studies assessed door-to-balloon time; 959 were assigned to the PH group and 631 to the ED group. Door-to-balloon time was 33.1 min shorter in the PH group. Conclusions: Prehospital activation of the catheterization laboratory resulted in lower mortality and shorter door-to-balloon time for patients with suspected STEMI outside of a hospital.

Characterization of atrial activation (A-A) intervals during atrial fibrillation due to a single driver: do they reflect atrial effective refractory periods?

BACKGROUND: The mean, median, and minimum local atrial activation (A-A) intervals have been used to determine the local atrial effective refractory period (AERP) during atrial fibrillation (AF), the underlying assumption being that AF is due to multiple reentrant wavelets. OBJECTIVE: We tested the hypothesis that when AF is due to a single, rapid, stable reentrant circuit (driver), the minimum and mean local A-A intervals will be similar at sites in the reentrant circuit, but will vary widely at sites with fibrillatory conduction, making these latter intervals unreliable indicators of AERP. METHODS: During sustained AF due to a left atrial (LA) driver in 6 sterile pericarditis dogs, electrograms were recorded from 186 bipolar electrodes from both atria. A-A intervals were measured from each recording site during 1.2 seconds of AF. Minimum A-A intervals as well as temporal (within site) and spatial (between sites) variability were determined from all sites. RESULTS: A-A intervals from each site during AF demonstrated that (1) 90-100% of right atrial (RA) sites and 18-39% of LA sites showed considerable (SD > 6 ms) temporal variability; (2) RA and LA sites with fibrillatory conduction (SD > 6 ms) showed considerable (a) spatial variability (RA: 9-36 ms; LA: 5-27 ms) and (b) variability of the minimum A-A intervals (RA: 14-35 ms; LA 11-28 ms). CONCLUSION: During AF due to a driver, areas with fibrillatory conduction manifested considerable variability in the mean and the minimum A-A intervals. Therefore, it is unlikely that any of the A-A intervals reflect AERP.

A retrospective comparative study of epirubicin-lipiodol emulsion and cisplatin-lipiodol suspension for use with transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma.

Transcatheter arterial chemoembolization (TACE) is widely used to treat unresectable hepatocellular carcinoma (HCC). Recently, a fine-powder formulation of cisplatin (DDP-H) was developed in Japan. We aimed to compare clinical outcomes after TACE using epirubicin or DDP-H in patients with HCC. We evaluated 202 patients who were treated with TACE alone, using either epirubicin-lipiodol emulsion or DDP-H-lipiodol suspension. Of these, epirubicin and DDP-H treatment groups comprised 106 and 96 patients, respectively. The median follow-up time was 32 months (range: 1-45 months). The progression free survival rate in the DDP-H­lipiodol group was significantly higher than in the epirubicin-lipiodol group (log-rank test, P =0.0164). Moreover, the DDP-H­lipiodol group showed significantly better overall survival than the epirubicin-lipiodol group (log-rank test: P =0.0052). The overall survival rate at 1, 2, and 3 years was 88.5, 71.8 and 62.4%, respectively, for the DDP-H-lipiodol group and 83.0, 57.9 and 36.5%, respectively, in the epirubicin-lipiodol group. In a multivariate analysis, the independent factors affecting overall survival were drug (epirubicin vs. DDP-H; hazard ratio 0.44, P= 0.0001), clinical stage (I/II vs. III/IV; hazard ratio 1.93, P = 0.0026), and Child-Pugh score (A vs. B/C; hazard ratio 3.15, P < 0.0001). TACE using a gelatin sponge and lipiodol with DDP-H showed better progression-free survival and overall survival rates than TACE with the epirubicin-lipiodol emulsion in patients with HCC. The improvement of overall survival in patients with HCC receiving this treatment warrants further investigation as a randomized control trial.

Angiotensin II type 1 receptor blockers do not promote coronary collateral circulation in patients with coronary artery disease.

We previously reported that angiotensin-converting enzyme inhibitors (ACE-Is) promote collateral circulation in patients with coronary artery disease (CAD). There have been many reports on the beneficial effects of angiotensin II type 1 receptor blockers (ARBs) on the cardiac microvasculature. Therefore, the following studies were performed to evaluate the association between treatment with an ARB and the enhancement of coronary collateral circulation as assessed by the Rentrop Score (RS) (Study 1) and to compare these results to those obtained with an ACE-I (Study 2). The subjects were 456 patients with angina who underwent coronary angiography. Study 1: Those who had one (1-V), two (2-V) or three significantly stenosed vessels (3-V) and who received only an ARB without any other anti-hypertensive medication were defined as the ARB group (n=81), and age-, sex- and body mass index-matched subjects (n=146) were selected as a comparative group. There were no significant differences in the percentage of patients with RS>or=1 between the two groups. Study 2: Those who received an ACE-I as the only anti-hypertensive treatment were defined as the ACE-I group (n=67), which was matched to the ARB group in Study 1. The percentage of patients with RS>or=1 in the ACE-I group was significantly higher than that in the ARB group as assessed by a Cochran-Mantel-Haenszel analysis. In addition, patients with 3-V disease who were treated with an ACE-I, but not an ARB, were most likely (odds ratio [confidence Interval]): 27.7 [4.8-161.0]) to show enhanced collateral circulation, as assessed by a multiple logistic regression analysis. These results suggest that treatment with an ACE-I, but not treatment with an ARB, was associated with the enhancement of collateral circulation in patients with CAD.

Paradoxical nocturnal elevation of sympathetic tone and spontaneous ventricular fibrillation in Brugada syndrome.

BACKGROUND: Nocturnal dominance of the incidence of spontaneous ventricular tachyarrhythmias has been reported in patients with Brugada syndrome (BrS). The purpose of the present study is to analyze the QT dynamics and autonomic balance as well as their diurnal variations in BrS patients. METHODS: Of the 33 consecutive patients with BrS included in the study, 14 had a history of cardiopulmonary arrest due to spontaneous ventricular fibrillation (VF) episodes (VF-BrS) and 19 had asymptomatic BrS (A-BrS). QT dynamics and heart rate variability were analyzed using 24-h Holter electrocardiogram recordings. RESULTS: Of the total 14 first cardiopulmonary arrest episodes due to spontaneous VF, 11 (79%) occurred in VF-BrS patients during the nighttime or at rest. The QT/RR slope during daytime was significantly steeper than that during nighttime in the A-BrS patients (p=0.031), but not in the VF-BrS patients (p=1.0). There were significant diurnal differences pertaining to the high-frequency (HF) and low-frequency (LF)/HF ratios in the A-BrS patients (p=0.019 and p=0.019, respectively), but not in the VF-BrS patients (p=1.0 and p=1.0, respectively). The VF-BrS patients were characterized by relatively high LF/HF ratios, whereas the A-BrS patients were characterized by relatively low LF/HF ratios throughout the daytime and nighttime. Furthermore, the LF/HF ratios during the nighttime in the VF-BrS patients were significantly higher than those in the A-BrS patients (p=0.021). CONCLUSIONS: Most first episodes of spontaneous VF in the VF-BrS patients occurred during the nighttime or at rest. The autonomic imbalance of paradoxical nocturnal elevation of the sympathetic tone along with an underlying persistent sympathetic tone throughout the day may play a key role for spontaneous VF initiation in BrS patients.

Effect of statin on restenosis after radius stent implantation in patients with acute coronary syndrome.

Despite reports that statin treatment reduces the rate of coronary restenosis with a balloon expandable stent, there is no evidence that statins affect the incidence of restenosis with a self-expanding Radius stent. Ninety-five patients with acute coronary syndrome who had been implanted with a Radius stent were classified into two groups: those with hyperlipidemia and initial statin treatment (statin group, n = 38) and those without statin treatment (comparative group, n = 57). At six months after stent implantation, the rate of coronary restenosis was significantly lower in the statin group (10.5%) than control group (28.1%) (p = 0.033), while there were no differences in morphology, maximal inflation pressure or stent size between the two groups. Interestingly, there was no difference in the serum lipid profile between the two groups at the 6-month follow-up, although the statin group had a significantly lower rate of restenosis. In conclusion, initial statin therapy reduced the rate of coronary restenosis even when a Radius stent was implanted.

Changes in the expression of leukocyte adhesion molecules throughout the acute phase of myocardial infarction.

Since increased leukocytes within days after the onset of acute myocardial infarction (AMI) may reflect an increased expression of the adhesion molecules necessary for effective endothelial transmigration, we evaluated the expression of adhesion molecules on leukocytes throughout the acute phase of MI. We measured the number of leukocytes and enzymes and the expression levels of CD11a, CD18, very-late-after-activation antigen-4 alpha, intracellular adhesion molecule-1 (ICAM-1) and L-selectin by flow cytometry before and after coronary intervention, and at 6, 12, 18, 48 and 72 hours of MI in 5 patients (AMI group). As controls, we measured these parameters in 5 patients who had been diagnosed with angina pectoris and underwent coronary intervention (AP group). In the AMI group the expression of monocyte CD11a was significantly increased after 6 hours, and CD18 and ICAM-1 expression were also significantly increased after 12 hours, whereas that of monocyte L-selectin was increased after 72 hours. In addition, the increased monocyte CD11a was accompanied by an increased number of monocytes and a greater expression of CD11a per cell in the AMI group. In conclusion, since CD11a and CD18 are expressed on the cell surface as a heterodimer and ICAM-1 is a ligand for CD11a/CD18, their increased expression may contribute to their adhesion to endothelium in ischemic regions and may lead to the formation of microaggregates.

Prognosis of patients with intermediate-stage hepatocellular carcinomas based on the Child-Pugh score: subclassifying the intermediate stage (Barcelona Clinic Liver Cancer stage B).

PURPOSE: Retrospective evaluation of intermediate-stage hepatocellular carcinoma (HCC) patient survival after undergoing chemoembolization based on the Child-Pugh score. MATERIALS AND METHODS: Data of intermediate-stage HCC patients undergoing chemoembolization were gathered from 43 centers in Japan. Overall survival rates were compared with Child-Pugh scores. RESULTS: Of the 329 patients examined in this study, Child-Pugh scores were 5 (CP-5) in 136 patients (41.3%), 6 (CP-6) in 101 patients (30.7%), 7 (CP-7) in 58 (17.7%), 8 (CP-8) in 22 (6.7%), and 9 (CP-9) in 12 (3.6%). Two-year survival rates were 77.5% in CP-5 patients (p = 0.047 vs. CP-6), 65.1% in CP-6 patients (p = 0.038 vs. CP-7), 51.3% in CP-7 patients (p = 0.30 vs. CP-8, p = 0.034 vs. CP-9), 50.3% in CP-8 patients (p = 0.0065 vs. CP-9), and 16.7% in CP-9 patients. Two-year survival rates were 77.2% in 139 patients meeting the 4 tumors of 7 cm criterion with Child-Pugh class A (B1) (p < 0.0001 vs. B2), 59.5% in 178 patients other than B1 and B3 (B2) (p = 0.0014 vs. B3), and 16.7% in 12 patients with Child-Pugh score 9 (B3). CONCLUSION: The Child-Pugh score is a useful prognostic factor to stratify intermediate-stage HCC patients.

Subgrouping of intermediate-stage (BCLC stage B) hepatocellular carcinoma based on tumor number and size and Child-Pugh grade correlated with prognosis after transarterial chemoembolization.

PURPOSE: To find a subgroup that benefits most from transarterial chemoembolization (TACE) in terms of tumor number and size and liver profile in patients with intermediate-stage hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Data of 325 intermediate-stage HCC patients who received TACE as the initial treatment were gathered. Four tumor numbers (3-6 tumors) and five maximum tumor diameters (3-7 cm) as well as all of their combinations but one (3 tumors and 3 cm) and Child-Pugh grade were used as variables to ascertain prognostic factors. RESULTS: The respective 1-, 3-, and 5-year overall survival rates in all patients were 86.5, 47.0, and 23.7%, respectively. Tumor numbers of 4 (P = 0.00145) and 5 (P = 0.036), and tumor size of 7 cm (P = 0.015), and 12 other combinations of tumor number and size, and Child-Pugh grade (P = 0.0015) were identified as significant prognostic factors in univariate analysis, and 4 tumors of 7 cm (P = 0.0008) and Child-Pugh grade (P = 0.0036) remained significant in the stepwise Cox proportional hazard model. The overall survival was significantly better in a patient subgroup having two factors other than patient subgroups having one or no prognostic factors. CONCLUSION: A patient subgroup having two prognostic factors benefited most from TACE in intermediate-stage HCC patients.

Percutaneous cardiopulmonary support for pulmonary thromboembolism caused by large uterine leiomyomata.

OBJECTIVE: Acute pulmonary thromboembolism (PTE) is a common illness that causes death and disability. Deep vein thrombosis (DVT) is often found in patients with a large myomatous uterus, and can occasionally result in acute PTE. Here, we describe the achievement of a favorable outcome in a case of acute PTE. CASE REPORT: The patient presented with acute PTE caused by a large uterine leiomyoma, without DVT of the lower extremities. Percutaneous cardiopulmonary support (PCPS) was used as an adjunct to thrombolytic therapy to treat the right ventricular thrombus with acute PTE. According to emergency practice, PCPS was initiated, and the patient was successfully treated with thrombolytic and anticoagulant therapy associated with total abdominal hysterectomy. CONCLUSIONS: This case suggests that PCPS can lead to favorable clinical outcomes in patients with large uterine leiomyomata and severe PTE.