Multicenter evaluation of the safety and efficacy of selective internal radiation therapy with yttrium-90 resin microspheres in Taiwan: data from the RESIN registry.

BACKGROUND AND AIM: The REgistry of Selective Internal radiation therapy in AsiaNs (RESIN) was a multicenter, single-arm, prospective, observational study of 90Y resin microspheres in patients with hepatocellular carcinoma (HCC) or metastatic colorectal cancer (mCRC) from Taiwan. RESIN is the first real-life clinical study of this therapy in an Asian cohort. Study objectives were to evaluate the safety and efficacy of 90Y resin microspheres. METHODS: Adults with HCC or mCRC scheduled to receive SIRT with 90Y resin microspheres were included. Primary endpoints were best overall response rate (ORR), adverse events, and changes from baseline in liver function. Secondary efficacy endpoints included overall survival (OS). RESULTS: Of 107 enrolled patients, 83 had HCC, and 24 had mCRC. ORR was 55.41% (HCC) and 33.33% (mCRC). Of 58 HCC patients with 6-month post-SIRT data, 13.79% (n = 8) had resection, transplantation, transarterial chemoembolization, or radiofrequency ablation as the result of down-staging or down-sizing of their lesions. One hundred and ten treatment emergent adverse events (TEAEs) were reported in 51 patients, and five serious adverse events (SAEs) were reported in five patients. The most frequent TEAEs were abdominal pain, nausea and decreased appetite (HCC), and abdominal pain, decreased appetite, fatigue, and vomiting (mCRC). Two deaths due to SAEs (probably related to SIRT) were reported, both in patients with extensive HCC, active hepatitis infection, and other comorbidities. Median OS was 24.07 (HCC) and 12.66 (mCRC) months. CONCLUSIONS: Safety and efficacy outcomes with the routine use of SIRT with 90Y resin microspheres in Taiwan are consistent with published data.

Multiple Synchronous Mucosa-Associated Lymphoid Lymphomas Involving in the Stomach, Duodenum, Ileum, and Sigmoid.

Gastric MALToma is an extra-nodal marginal-type B-cell lymphoma. MALToma may occur secondary to chronic inflammation and autoimmunity. The most common gastrointestinal (GI) site of MALToma is the stomach, with approximately 50% of lesions occurring there. Synchronous upper and lower GI MALTomas rarely occur, with few cases reported. We present the case of a 67-year-old patient who presented asymptomatic and was found to have synchronous multifocal upper and lower GI MALTomas in the stomach, duodenum, terminal ileum, and sigmoid, which did not respond to H. Pylori eradication therapy.

Earthquake Response for Students with Different Severe Degrees of Disabilities: An Investigation of the Special Education Classes in Primary Schools in Taipei.

Taipei has been ranked as the most vulnerable city to a wider combination of risks. Although the Special Education Law addresses the consideration of disaster preparedness for students with disabilities enrolling in Special Education Schools, more attention needs to be given to the far larger number of students with disabilities enrolling in normal schools. These schools need to consider the care for students with different types and severe degrees of disabilities. The aim of the research is to investigate challenges of earthquake preparation and response for students with different severe degrees of disabilities who enrol in the special education classes in general primary schools. The objectives of the research include the following: (1) investigating the challenges and requirements for support of students with different severe degrees of disabilities; (2) examining the need and support for students with different degrees of disabilities during the earthquake response process; and (3) exploring the best practice in the curriculum building for students with different severity of disabilities. The purposive sampling was used to select four primary schools in Taipei as participant groups in the research. The research team used semi-structured interviews to interview eight participants: one special education class teacher and one administrator of each school were invited. Findings include the following: (1) ensuring the appropriate design of physical environment for earthquake response in schools, including rapid response, evacuation, and assembly points for students with different severe degrees of disabilities; (2) proposing suitable staff to student ratio to be planned for the response phase; (3) identifying the appropriate individualised curriculum and learning objectives to suit students with different severe degrees of disabilities.

MRI-based measurements of whole-brain global cerebral blood flow: Comparison and validation at 1.5T and 3T.

BACKGROUND: Whole-brain global cerebral blood flow (CBF) determined by MRI techniques, calculated using total CBF (TCBF) from phase-contrast MRI (PC-MRI), and brain parenchyma volume (BPV) from T1 -weighted image, have become increasingly popular in many applications. PURPOSE/HYPOTHESIS: To determine if MRI-based measurements of whole-brain global CBF data obtained across different field strengths could be merged, TCBF and BPV data acquired at 1.5T and 3T were compared. STUDY TYPE: Prospective study. POPULATION: Seventeen healthy subjects (eight females, aged 21-29 years old). FIELD STRENGTH/SEQUENCE: Fast spoiled gradient echo (FSPGR) and PC-MRI at both 1.5T and 3T. ASSESSMENT: TCBF and BPV data acquired at 1.5T and 3T were compared. STATISTICAL TESTS: The relationships of TCBF and whole-brain global CBF between two field strengths were examined by using the Pearson correlation coefficient analysis and intraclass correlation coefficient (ICC). RESULTS: Regression analysis revealed a strong correlation between TCBF at two field strengths (R2 = 0.78, P < 0.001), and the ICC was 0.85, suggesting measurements of TCBF at 1.5T were comparable and correlated with those at 3T. There was a significant difference in BPV between field strengths, where the white matter estimate was significantly larger at 1.5T when compared with that at 3T (P < 0.001). When TCBF was further normalized to the brain parenchyma mass to obtain whole-brain global CBF, it only showed a moderate correlation between measurements at the two field strengths (R2 = 0.46, P = 0.003) and lower ICC of 0.66, reflecting the slightly higher interstrength variability in the whole-brain global CBF measurements. DATA CONCLUSION: TCBF measurements could be performed equally well with comparable results at both field strengths, but specific attention should be given when TCBF is further normalized to BPV to obtain whole-brain global CBF. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2018;47:1273-1280.

The value of Gd-EOB-DTPA-enhanced MR imaging in characterizing cirrhotic nodules with atypical enhancement on Gd-DTPA-enhanced MR images.

PURPOSE: To evaluate the utility of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) in characterizing atypically enhanced cirrhotic nodules detected on conventional Gd-DTPA-enhanced MR images. MATERIALS AND METHODS: We enrolled 61 consecutive patients with 88 atypical nodules seen on conventional Gd-DTPA-enhanced MR images who underwent Gd-EOB-DTPA-enhanced MRI within a 3-month period. Using a reference standard, we determined that 58 of the nodules were hepatocellular carcinoma (HCC) and 30 were dysplastic nodules (DNs). Tumor size, signal intensity on precontrast T1-weighted images (T1WI), T2-weighted images (T2WI) and diffusion-weighted images (DWI), and the enhancement patterns seen on dynamic phase and hepatocyte phase images were determined. RESULTS: There were significant differences between DNs and HCC in hyperintensity on T2WI, hypointensity on T1WI, hypervascularity on arterial phase images, typical HCC enhancement patterns on dynamic MR images, hypointensity on hepatocyte phase images, and hyperintensity on DWI. The sensitivity and specificity were 79.3% and 83.3% for T2WI, 50.0% and 80.0% for T1WI, 82.8% and 76.7% for DWI, 17.2% and 100% for dynamic MR imaging, 93.1% and 83.3% for hepatocyte phase imaging, and 46.8% and 100% when arterial hypervascularity was combined with hypointensity on hepatocyte-phase imaging. CONCLUSION: Gd-EOB-DTPA-enhanced hepatocyte phase imaging is recommended for patients at high risk for HCC who present with atypical lesions on conventional Gd-DTPA-enhanced MR images.

Computed tomographic imaging in determining the need of embolization for high-grade blunt renal injury.

BACKGROUND: It is well documented that transarterial embolization (TAE) can successfully stop bleeding in renal trauma patients and reduce the failure rate of conservation treatment. However, there is no consensus on the indications for TAE. The aim of this study was to evaluate the criteria for computed tomography (CT) to predict the need for TAE for patients with high-grade blunt renal trauma. METHODS: Of the 137 patients with blunt renal trauma between 2005 and 2010, 81 had a high-grade injury (grade ≥ 3) with stable hemodynamics, who were treated conservatively, were included in the study. CT criteria included contrast extravasation (CE), perirenal hematoma rim distance (PRD), and extent of hematoma. The patients were divided into two groups according to the extent of hematoma on CT, as either Group 1 with localized hematomas or Group 2 with extensive hematomas. We compared the CT and angiographic findings and examined the correlation between patient management and outcome. The CT criteria, alone or in combination, for predicting the subsequent requirement for TAE were evaluated. RESULTS: Of the 81 patients, 35 were in Group 1 and 46 were in Group 2, with 35 having CE. The 22 patients who received TAE were all in Group 2 and had CE. Mean PRD was larger for the patients who received TAE than for those who did not. CE, extent of hematoma, and PRD correlated significantly with the need for TAE (all p < 0.001). Overall, the combination of CT criteria for CE and extent of hematoma showed the highest accuracy for predicting the need for TAE. CONCLUSION: CE, extent of hematoma, and PRD were simple and sensitive indicators of patients who required TAE. The combination of CE criteria and extent of hematoma markedly increased the predictive value for predicting the need for TAE. LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV.

Celiac artery compression syndrome: an experience in a single institution in taiwan.

Celiac artery compression syndrome (CACS) or median arcuate ligament (MAL) syndrome is a rare vascular disease. The clinical manifestations of CACS include the triad of postprandial pain, vomiting, and weight loss. The pathogenesis of CACS is the external compression of celiac artery by the MAL or celiac ganglion. Moreover, some authors also reported the compression with different etiologies, such as neoplasms of pancreatic head, adjacent duodenal carcinoma, vascular aneurysms, aortic dissection, or sarcoidosis. In the literature, most cases of CACS were reported from Western countries. In contrast, this disease was seldom reported in Oriental countries or regions, including Taiwan. Superior mesenteric artery syndrome (SMAS) is also a rare disease characterized by compression of the third portion of the duodenum by the SMA. The clinical features of SMAS are postprandial pain, vomiting, and weight loss. To date, there are no guidelines to ensure the proper treatment of patients with CACS because of its low incidence. Thus, tailored therapy for patients with CACS remains a challenge as well as the prediction of clinical response and prognosis. The aim of our present study was to investigate the clinical features, the association with SMAS, treatments, and outcomes of patients with CACS in a single institution in Taiwan.

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.

BACKGROUND: Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan. METHODS: From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success. RESULTS: A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma. CONCLUSIONS: Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

Role of arterial embolization on blunt hepatic trauma patients with type I contrast extravasation.

BACKGROUND: Our aim was to evaluate the clinical effectiveness of transcatheter arterial embolization (TAE) in the management of hemodynamically stable blunt hepatic trauma (BHT) patients with contrast material extravasation into the peritoneal cavity, known as type I contrast material extravasation, on computed tomography (CT) scan. METHODS: Adult patients who sustained BHT and who were hemodynamically stable after initial resuscitation underwent abdominal CT scan. If the abdominal CT scan revealed type I contrast material extravasation, patients who remained hemodynamically stable were sent for angiography. RESULTS: During a 30-month period, 8 patients were identified with type I contrast material extravasation. Three received immediate celiotomy because of hemodynamic instability. Five patients received angiography and subsequent TAE. One patient received celiotomy after TAE. The success rate of TAE was 50% (4/8). CONCLUSION: With TAE, nonoperative management of hemodynamically stable BHT patients with type I contrast material extravasation on CT scan was achieved in half patients.

Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients.

BACKGROUND: Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE. MATERIALS AND METHODS: Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability. RESULTS: There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE. CONCLUSION: Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.

Photophysical mechanisms of collagen modification by 80 MHz femtosecond laser.

Photophysical mechanisms of collagen photomodification (CFP) by the use of a 80 MHz, 780 nm femtosecond titanium-sapphire laser were investigated. Our observation that the decrease in collagen second harmonic generation and increase in two-photon autofluorescence intensity occurred primarily at sites where photoproducts were present suggested that the photoproducts may act to facilitate the CFP process. Laser power study of CFP indicated that the efficiency of the process depended on the sixth power of the laser intensity. Furthermore, it was demonstrated that CFP can be used for bending and cutting of collagen fibers and creating 3D patterns within collagen matrix with high precision (~2 µm).

Evaluation of need for operative intervention in blunt splenic injury: intraperitoneal contrast extravasation has an increased probability of requiring operative intervention.

BACKGROUND: Angioembolization is an effective adjunct to the management of blunt splenic injuries (BSI) that are not surgically treated. However, in some cases patients are unable to undergo angioembolization due to changes in their hemodynamic condition. In this study we attempt to define the characteristics of patients who need angioembolization in high-grade BSI. METHODS: We retrospectively reviewed the charts of patients with BSI between January 2004 and June 2008. Patients with contrast extravasation (CE) on computed tomography (CT) scan were enrolled. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale (AIS), the amount of blood transfused, and the type of CE were analyzed. RESULTS: A total of 69 patients were enrolled. Patients with intraperitoneal CE in BSI required a higher rate of immediate operation due to changed hemodynamics. Furthermore, these patients displayed higher ISS and higher blood transfusion amounts. CONCLUSIONS: In BSI patients, intraperitoneal CE is associated with a higher possibility of requiring surgical intervention. Early surgical intervention should be considered in BSI patients with intraperitoneal CE or with ISS ≥ 25.

Evaluation of need for angioembolization in blunt renal injury: discontinuity of Gerota's fascia has an increased probability of requiring angioembolization.

BACKGROUND: Angioembolization is an effective adjunct in the management of high-grade renal injuries not surgically treated. However, in some cases, the bleeding may stop spontaneously, without the need for embolization. The aim of this study was to define the characteristics of patients who need angioembolization for high-grade blunt renal injuries (BRIs). METHODS: Patients with BRIs between January 2004 and May 2008 were retrospectively reviewed. Patients with contrast extravasation on computed tomographic scans who then underwent angiography were enrolled. Demographics, injury severity scores, abbreviated injury scale scores, amounts of blood transfused, and need for angioembolization were analyzed. RESULTS: Twenty-six patients were enrolled. Patients with discontinuity of Gerota's fascia and pararenal hematoma expansion in BRIs required angioembolization at a higher rate. Furthermore, these patients displayed higher injury severity scores and abbreviated injury scale scores. Five patients experienced complications. CONCLUSIONS: In patients with BRIs, discontinuity of Gerota's fascia and pararenal hematoma expansion seemed to be associated with the need for angioembolization. Early angioembolization should be considered in patients with severe associated trauma with BRIs.