Aetiological differences in demographical, clinical and pathological characteristics of hepatocellular carcinoma in The Gambia.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with a high burden in West Africa. Data evaluating aetiological differences in HCC presentation from this region are limited. AIMS: The aim of this study was to describe the demographical, clinical and pathological characteristics of HCC by aetiology (hepatitis B or C infection, aflatoxin associated). METHODS: One hundred and ninty-three cases of HCC diagnosed between 1997 and 2001 in The Gambia were analysed. Characteristics were compared by aetiology using χ(2)-tests, student t-test and Wilcoxon's rank sum tests as appropriate. RESULTS: The prevalence of hepatitis B surface antigen, hepatitis C antibody and aflatoxin-associated 249(ser) TP53 mutations among HCC patients was 60, 20 and 38% respectively. The typical HCC patient was a 49-year-old male positive for hepatitis B surface antigen presenting with hepatomegaly (93%), abdominal pain (94%) and weight loss (95%) 8 weeks after symptom onset. Most patients had multifocal lesions with background cirrhosis. The median largest tumour was 10.3 cm and the median α-fetoprotein level was 500 ng/ml. Eighty-four per cent of patients had advanced HCC (patients not meeting the Milan criteria) at presentation. CONCLUSIONS: Irrespective of aetiological agent, HCC among West Africans presents at very advanced stages. Few clinical or pathological differences exist by aetiology. More studies are needed to understand the mechanisms of hepatocarcinogenesis among these patients as well as identify high-risk populations in which early detection through screening will be beneficial.

Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury.

BACKGROUND: Barriers to evidence-based practice are not well understood. Within the intensive care unit (ICU) setting, low tidal volume ventilation (LTVV) in patients with acute lung injury (ALI) significantly decreases mortality. However, LTVV has not achieved widespread adoption. OBJECTIVES: To evaluate patient demographic and clinical factors, and ICU organizational factors associated with its use. DESIGN, SETTING AND PATIENTS: Prospective cohort study of 250 patients with ALI in 9 ICUs at 3 teaching hospitals in Baltimore, MD. MEASUREMENTS: Use of LTVV the day after ALI onset and association of patients' demographic and clinical factors and ICU organizational factors with LTVV using a multivariable logistic regression model adjusted for clustering of patients within ICUs. RESULTS: On the day after ALI onset, 46% and 81% of patients received a tidal volume < or = 6.5 and < or = 8.5 mL/kg predicted body weight (PBW), respectively, with no significant changes at 3 and 5 days after ALI. Using a strict definition of LTVV (< or = 6.5 mL/kg PBW), no patient demographic factors were independently associated with LTVV; however, two patient clinical and ICU organizational factors (odds ratio, 95% confidence interval) were independently associated: serum HCO3 level (< 22: .3, .1-.9, and > 26: .6, .1-3.5, versus 22-26) and use of a written protocol for LTVV (6.0, 1.3-27.2). In a sensitivity analysis using tidal volume < or = 8.5 mL/kg PBW, use of a written protocol remained significantly associated with LTVV. CONCLUSIONS: Patient demographic factors were not associated with LTVV. Given its strong association with LTVV, ICUs should use a written protocol for ventilation of ALI patients to help translate this evidence-based therapy into practice.

Small Bowel Volvulus in a Quadriplegic: A Rare Complication of the Simon Nitinol Inferior Vena Cava Filter.

The advent and use of inferior vena cava (IVC) filters have reduced the overall incidence of pulmonary embolism in hospitalized patients, but are not without potential complications. With the exponential increase in the utilization of IVC filters over the past two decades, it is important to consider the use of retrievable filters, where indicated, in order to potentially reduce long-term IVC filter-related complications. We report a rare case of small bowel volvulus due to IVC perforation by a Simon Nitinol filter strut in a quadriplegic patient 4 years after IVC filter insertion.