Early derangement of INR predicts liver failure after liver resection for hepatocellular carcinoma.

BACKGROUND: Surgical resection, where appropriate, remains one of the best treatment options for hepatocellular carcinoma (HCC), however outcomes can be compromised by the development of liver failure. We reviewed our experience of liver resection for HCC patients to identify factors that may predict the development of post-hepatectomy liver failure (PHLF) and survival. METHODS: A single centre retrospective cohort study. Data was collected between 1999 and 2017 from all patients undergoing HCC resection in a tertiary university hospital from electronic medical records. PHLF was defined as per the International Study Group for Liver Surgery criteria. Variables with p < 0.15 on univariate analysis were included in a multivariate binary logistic regression model. Kaplan-Meier analyses were used to determine correlations with overall survival (OS) and disease-free survival (DFS), and variables with p < 0.15 on univariate analysis selected for a step-down Cox proportional hazard regression model. RESULTS: Overall, 120 patients underwent liver resection within the study period, of which 22 (18%) developed PHLF. Patients with normal INR ≤1.20 at day 2 did not develop PHLF whereas patients with INR >1.60 were at significant risk. Resection of multiple tumours (odds ratio 21.63, p = 0.002) and deranged postoperative day 2 INR>1.6 (odds ratio 21.05, p < 0.0001) were identified as independent prognostic markers of PHLF. CONCLUSION: The use of INR measurement at day 2 predicts PHLF and may enable us to objectively identify and stratify patients who may be eligible for enhanced recovery programs from those who will merit close monitoring in high dependency areas.

Acute biliary interventions.

Acute biliary conditions include cholangitis, obstruction, and biliary leakage. All these conditions may lead to severe biliary sepsis, which can be life threatening. Infected obstructed cholangitis is a medical emergency that requires active medical therapy and early biliary decompression is recommended. This article provides an overview of the clinical presentations and management of biliary sepsis. The technique, clinical applications, and outcomes of percutaneous transhepatic biliary drainage and those related to gall bladder drainage are highlighted. Future alternatives to conventional biliary drainage are discussed.

British Society of Interventional Radiology Iliac Angioplasty and Stent Registry: fourth report on an additional 8,294 procedures.

AIM: To provide an update of current practice in iliac artery intervention in the UK. MATERIALS AND METHODS: Ninety-nine interventional units across the UK completed online submission forms for iliac angioplasty and stent procedures between 2011 and 2014 (inclusive) for the British Iliac Angioplasty and Stenting (BIAS) IV registry. RESULTS: Data for 8,294 procedures were submitted during the study period. A total of 12,253 iliac segments were treated in 10,311 legs. The commonest indication was claudication (n=5219, 64.4%). Of the cases performed, 6,582 (80.8%) were performed electively with 3,548 (44.8%) of the procedures performed as a day-case and 6,586 (54%) of the lesions were treated with stents. Successful endovascular intervention (residual stenosis ≤49%) was achieved in 11,847 (97%) of treated segments, with residual stenosis in 1.5%. One point five percent of lesions could not be crossed with a wire. Limb complications were recorded in 366 (3.5%), resulting in 141 patients undergoing an unplanned intervention and 173 (2.2%) patients had a systemic complication. There were 84 deaths prior to discharge, of which 13 (15%) were procedure related. Both systemic and limb complication rates were higher in patients undergoing treatment for critical ischaemia. CONCLUSION: Iliac stenting and angioplasty are associated with high technical success with a low complication rate. These data provide up-to-date statistics for patient information and future audit and benchmarking purposes.

Outcomes of a pharmacist-led medication review programme for hospitalised elderly patients.

INTRODUCTION: Elderly patients are at risk of drug-related problems. This study aimed to determine whether a pharmacist-led medication review programme could reduce inappropriate medications and hospital readmissions among geriatric in-patients in Hong Kong. METHODS: This prospective controlled study was conducted in a geriatric unit of a regional hospital in Hong Kong. The study period was from December 2013 to September 2014. Two hundred and twelve patients were allocated to receive either routine care (104) or pharmacist intervention (108) that included medication reconciliation, medication review, and medication counselling. Medication appropriateness was assessed by a pharmacist using the Medication Appropriateness Index. Recommendations made by the pharmacist were communicated to physicians. RESULTS: At hospital admission, 51.9% of intervention and 58.7% of control patients had at least one inappropriate medication (P=0.319). Unintended discrepancy applied in 19.4% of intervention patients of which 90.7% were due to omissions. Following pharmacist recommendations, 60 of 93 medication reviews and 32 of 41 medication reconciliations (68.7%) were accepted by physicians and implemented. After the program and at discharge, the proportion of subjects with inappropriate medications in the intervention group was significantly lower than that in the control group (28.0% vs 56.4%; P<0.001). The unplanned hospital readmission rate 1 month after discharge was significantly lower in the intervention group than that in the control group (13.2% vs 29.1%; P=0.005). Overall, 98.0% of intervention subjects were satisfied with the programme. There were no differences in the length of hospital stay, number of emergency department visits, or mortality rate between the intervention and control groups. CONCLUSIONS: A pharmacist-led medication review programme that was supported by geriatricians significantly reduced the number of inappropriate medications and unplanned hospital readmissions among geriatric in-patients.

Evaluation of velocity-sensitized and acceleration-sensitized NCE-MRA for below-knee peripheral arterial disease.

PURPOSE: To evaluate the diagnostic performance of velocity- and acceleration-sensitized noncontrast-enhanced magnetic resonance angiography (NCE-MRA) of the infrageniculate arteries using contrast-enhanced MRA (CE-MRA) as a reference standard. MATERIALS AND METHODS: Twenty-four patients with symptoms of peripheral arterial disease were recruited. Each patient's infrageniculate arterial tree was examined using a velocity-dependent flow-sensitized dephasing (VEL-FSD) technique, an acceleration-dependent (ACC-FSD) technique, and our conventional CE-MRA technique performed at 1.5T. The images were independently reviewed by two experienced vascular radiologists, who evaluated each vessel segment to assess visibility, diagnostic confidence, venous contamination, and detection of pathology. RESULTS: In all, 432 segments were evaluated by each of the three techniques by each reader in total. Overall diagnostic confidence was rated as moderate or high in 98.5% of segments with CE-MRA, 92.1% with VEL-FSD, and 79.9% with ACC-FSD. No venous contamination was seen in 96% of segments with CE-MRA, 72.2% with VEL-FSD, and 85.8% with ACC-FSD. Per-segment, per-limb, and per-patient sensitivities for detecting significant stenotic disease were 63.4%, 73%, and 92%, respectively, for ACC-FSD, and 65.3%, 87.2%, and 96% for VEL-FSD, and as such no significant statistical change was detected using McNemar's chi-squared test with P-values of 1.00, 0.13, and 0.77 obtained, respectively. CONCLUSION: Flow-dependent NCE-MRA techniques may have a role to play in evaluation of patients with peripheral vascular disease. Increased sensitivity of a velocity-based technique compared to an acceleration-based technique comes at the expense of greater venous contamination. LEVEL OF EVIDENCE: 2J. Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;45:1846-1853.

Utilisation and outcomes following the introduction of an interventional radiology day unit.

AIM: To assess the utilisation of an interventional radiology day unit (RDU), the rates of on-time discharges, the financial performance of the unit, and finally, the patient satisfaction rates. MATERIALS AND METHODS: Data regarding the unit utilisation, discharge times, and complications were retrospectively collected for the first 2 years of operation of the unit (1 April 2013 to 1 January 2015). In addition, monitoring the activity going through the RDU and applying a contribution margin to the freed-up beds measured the financial performance. The data were provided by the finance department of the hospital. Satisfaction survey questionnaires were sent randomly by post to 100 patients who had been previously admitted to the RDU. RESULTS: During the study period, 3019 patients were admitted to the RDU, comprising 1426 during the first year and 1513 during the second. On average, 5.6 patients were discharged from the RDU on every working day during the first year and 7.1 patients during the second (21% increase in the discharge rate). Given the 8-hour working time configuration of the unit, a realistic 80% utilisation rate of the RDU's seven beds could free a total of 1400 inpatient bed days over a full year. The cost of delivering these episodes of care was reduced by approximately 50%. From the financial data, it was estimated that the RDU managed to achieve a total of £393,000 in savings for the Trust for the financial year 2013-2014. The return rate of the patient satisfaction survey was 40%. All patients were satisfied with their overall RDU experience. CONCLUSION: The RDU has brought significant benefits for patients and the Trust without compromises in safety or quality.

Evaluation of the Sherlock 3CG Tip Confirmation System on peripherally inserted central catheter malposition rates.

Peripherally inserted central catheters are often positioned blindly in the central circulation, and this may result in high malposition rates, especially in critically ill patients. Recently, a new technology has been introduced (Sherlock 3CG Tip Positioning System) that uses an electro-magnetic system to guide positioning in the superior vena cava, and then intra-cavity ECG to guide positioning at the cavo-atrial junction. In this observational study, we investigated how the Sherlock 3CG Tip Positioning System would affect peripherally inserted central catheter malposition rates, defined using a post-insertion chest radiograph, in critically ill patients. A total of 239 catheters positioned using the Sherlock 3CG Tip Positioning System were analysed. When an adequate position was defined as low superior vena cava or cavo-atrial junction, 134 catheters (56.1%; 95% CI 50-62%) were malpositioned. When an adequate position was defined as mid/low superior vena cava, cavo-atrial junction or high right atrium (≤ 2 cm from cavo-atrial junction), 49 (20.5%; 95% CI 16-26%) catheters were malpositioned. These malposition rates are significantly lower than our own historical data, which used a 'blind' anthropometric technique to guide peripherally inserted central catheter insertion.

A radiologist's guide to small bowel and multivisceral transplantation.

This review will describe the indications for the various small bowel containing transplants. The importance of early referral will be highlighted. Radiologists play a central role in assessing these complex patients prior to transplantation. Furthermore, in the postoperative period, radiologists play an important part in diagnosing and treating complications.

Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit.

Peripherally inserted central catheters are increasingly used to provide access to the central venous circulation. They are commonly positioned 'blind' using a variety of anthropometric techniques and operator experience to direct insertion length. Malposition rates are poorly defined because of differing insertion techniques, difficulties defining anatomical tip position on chest radiographs, controversy over what constitutes an adequate catheter position and possible differences between patient groups. We have developed a reproducible method to define catheter positions on chest radiograph and have applied this in a retrospective analysis of 256 ICU and 243 non-ICU catheter insertions over a 6-month period. Two different definitions were used for adequate position. 'Blind' positioning of peripherally inserted central catheters was associated with a definition-dependent malposition rate of 42-76%. Malposition rates were significantly higher in ICU patients. Emerging technologies may assist in reducing these high rates.

Acceptability of virtual unenhanced CT of the aorta as a replacement for the conventional unenhanced phase.

AIM: To evaluate whether virtual unenhanced (VU) computed tomography (CT) images generated of the aorta were of sufficient quality to replace the conventional unenhanced (CU) images. MATERIALS AND METHODS: Forty-nine patients undergoing examination of the thoracic or abdominal aorta were examined using a dual-energy protocol. VU images were generated from the arterial phase images and compared to the CU images. Objective analysis was performed by drawing paired regions of interest (ROIs) within the thoracic and abdominal aorta and measuring the radiodensity in Hounsfield units attenuation within the ROIs. Subjective analysis was performed by two experienced readers evaluating the VU images in terms of noise, quality, calcium loss, and overall acceptability. RESULTS: The attenuation was significantly higher in the VU images compared to the CU images within the thoracic aorta (p < 0.01) but not within the abdominal aorta (p = 0.15). Overall the VU images of the abdominal aorta were deemed acceptable as replacements for the CU images in 93% of cases. For the thoracic aorta, the VU images were deemed acceptable in only 12% of cases, primarily due to pulsation artefact. CONCLUSION: VU images of the abdominal aorta are acceptable as replacements for the CU images in the vast majority of cases; however, they are not suitable as replacements for the CU images of the thoracic aorta.

A meta-analysis of prevalence of diabetic retinopathy in Asia.

INTRODUCTION: Diabetic Retinopathy (DR) is a common microvascular complication of diabetes. This review reports the prevalence of DR in Asia and guides healthcare provision in screening and treatment. EVIDENCE ACQUISITION: Medline was searched for articles describing the prevalence of DR in Asia. Statistical analysis was performed using freeman turkey double arcsine transformation and the DerSimonian and Laird model. The prevalence of DR was estimated according to the following subgroups: Economic status (High Income, Middle Income, Low Income), Country, and Ethnicity. The risk of bias of the articles was also assessed. EVIDENCE SYNTHESIS: A total of 66 studies were included, and out of 2,599,857 patients with diabetes, 201,646 were diagnosed with DR. The overall prevalence of DR, nonproliferative DR (NPDR), proliferative DR (PDR) and maculopathy were recorded at 21.7% (CI:19.1% - 24.6%), 19.9% (CI:17.3% - 22.8%), 2.3% (CI:1.6% - 3.4%) and 4.8% (CI:3.5% - 6.7%) respectively. Low-income countries had the lowest prevalence of DR, NPDR, PDR and maculopathy compared to the middle- and high-income countries. Middle-income countries had the highest prevalence of DR (23.9%; CI:19.4% - 29.2%), NPDR (21.1%; CI:17.0% - 25.9%), moderate NPDR (7.9%; CI: 5.7% - 11.0%), PDR (3.0%; CI: 1.8% - 4.9%) and maculopathy (4.7%; CI:3.0% - 7.4%), while high-income countries had the highest prevalence of mild (10.3%; CI:4.2% - 23.2%) and severe NPDR (3.0%; CI:1.0% - 8.4%). CONCLUSIONS: One in five people with diabetes have diabetic retinopathy. It is imperative that public healthcare take heeds to heighten the screening program to provide all patients with diabetes equitable access to DR screening and ophthalmology services.

Analysis of a National Programme for Selective Internal Radiation Therapy for Colorectal Cancer Liver Metastases.

AIMS: Patients with chemotherapy-refractory colorectal cancer liver metastases have limited therapeutic options. Selective internal radiation therapy (SIRT) delivers yttrium 90 microspheres as a minimally invasive procedure. This prospective, single-arm, observational, service-evaluation study was part of National Health Service England Commissioning through Evaluation. METHODS: Patients eligible for treatment had histologically confirmed carcinoma with liver-only/liver-dominant metastases with clinical progression during or following oxaliplatin-based and irinotecan-based chemotherapy. All patients received SIRT plus standard of care. The primary outcome was overall survival; secondary outcomes included safety, progression-free survival (PFS) and liver-specific PFS (LPFS). RESULTS: Between December 2013 and March 2017, 399 patients were treated in 10 centres with a median follow-up of 14.3 months (95% confidence interval 9.2-19.4). The median overall survival was 7.6 months (95% confidence interval 6.9-8.3). The median PFS and LPFS were 3.0 months (95% confidence interval 2.8-3.1) and 3.7 months (95% confidence interval 3.2-4.3), respectively. During the follow-up period, 143 patients experienced an adverse event and 8% of the events were grade 3. CONCLUSION: Survival estimates from this pragmatic study show clinical outcomes attainable in the National Health Service comparable with previously published data. This study shows the value of a registry-based commissioning model to aid national commissioning decisions for highly specialist cancer treatments.

Internal iliac artery branch graft for common iliac artery aneurysm following previous open abdominal aortic aneurysm repair.

To demonstrate the use of a commercially available branch stent graft system, designed to preserve the internal iliac artery (IIA) in common iliac artery (CIA) aneurysms (CIAA) in two patients, who had undergone previous abdominal aortic aneurysm (AAA) surgery.

Imaging appearances and endovascular management of uncommon pseudoaneurysms.

Pseudoaneurysms are uncommon and their aetiology is varied. They occur in numerous anatomical locations and present with a multitude of clinical presentations sometimes life-threatening. This review describes the causes, sites, and presentations of uncommon pseudoaneurysms, as well as illustrating their diagnostic appearances and endovascular management.

Peripheral arterial ischemia by a primary lung tumour invading left atrium.

Peripheral arterial embolism from a malignant tumour is an uncommon manifestation of a neoplasm. Here, we present a case of acute upper limb ischemia due to an embolus originating from primary lung malignancy invading the left atrium.

Appendicitis: spectrum of appearances on helical CT.

Acute appendicitis has extremely varied clinical presentations. A delayed or missed diagnosis may result in severe adverse consequences. Helical CT is evolving as an important diagnostic aid, but the CT signs can be varied and can easily be overlooked by the unwary. This pictorial review illustrates the spectrum of radiological signs and appearances of appendicitis on helical CT.

Transpleural ultrasound diagnosis of a pulmonary arteriovenous malformation.

Pulmonary arteriovenous malformations (PAVMs) are rare. We discuss a case of an 81-year-old female who attended hospital with a haemothorax. Ultrasound not only demonstrated an echogenic effusion in the right pleural space, but also identified an associated tubular structure. Doppler was applied to this structure, which exhibited pulsatile flow. This raised the possibility of a PAVM, which was subsequently confirmed on CT and angiography. Although, PAVM is a rare cause of haemothorax, the diagnosis should still be considered and transpleural ultrasound can detect these malformations non-invasively by the bedside.

Cutaneous leukocytoclastic vasculitis in relation to streptokinase.

The case history is presented of a patient who developed a cutaneous leukocytoclastic vasculitis after he had been treated with intravenous streptokinase because of an acute myocardial infarction. Leukocytoclastic vasculitis is a seldom reported side effect of streptokinase and may be caused by a type III-hypersensitivity reaction.