Predictive Algorithm for Hepatic Steatosis Detection Using Elastography Data in the Veterans Affairs Electronic Health Records.

BACKGROUND AND AIMS: Nonalcoholic fatty liver disease (NAFLD) has reached pandemic proportions. Early detection can identify at-risk patients who can be linked to hepatology care. The vibration-controlled transient elastography (VCTE) controlled attenuation parameter (CAP) is biopsy validated to diagnose hepatic steatosis (HS). We aimed to develop a novel clinical predictive algorithm for HS using the CAP score at a Veterans' Affairs hospital. METHODS: We identified 403 patients in the Greater Los Angeles VA Healthcare System with valid VCTEs during 1/2018-6/2020. Patients with alcohol-associated liver disease, genotype 3 hepatitis C, any malignancies, or liver transplantation were excluded. Linear regression was used to identify predictors of NAFLD. To identify a CAP threshold for HS detection, receiver operating characteristic analysis was applied using liver biopsy, MRI, and ultrasound as the gold standards. RESULTS: The cohort was racially/ethnically diverse (26% Black/African American; 20% Hispanic). Significant positive predictors of elevated CAP score included diabetes, cholesterol, triglycerides, BMI, and self-identifying as Hispanic. Our predictions of CAP scores using this model strongly correlated (r = 0.61, p < 0.001) with actual CAP scores. The NAFLD model was validated in an independent Veteran cohort and yielded a sensitivity of 82% and specificity 83% (p < 0.001, 95% CI 0.46-0.81%). The estimated optimal CAP for our population cut-off was 273.5 dB/m, resulting in AUC = 75.5% (95% CI 70.7-80.3%). CONCLUSION: Our HS predictive algorithm can identify at-risk Veterans for NAFLD to further risk stratify them by non-invasive tests and link them to sub-specialty care. Given the biased referral pattern for VCTEs, future work will need to address its applicability in non-specialty clinics. Proposed clinical algorithm to identify patients at-risk for NAFLD prior to fibrosis staging in Veteran.

Combination transarterial chemoembolization and microwave ablation vs. microwave ablation monotherapy for hepatocellular carcinomas greater than 3 cm: a comparative study.

PURPOSE: To evaluate the efficacy of combination therapy using transarterial chemoembolization with microwave ablation (MWA) therapy vs. MWA monotherapy for hepatocellular carcinomas (HCCs) >3 cm in size. METHODS: This two-arm retrospective observational study included patients with HCCs >3 cm who underwent either combination therapy (29 patients) or MWA monotherapy (35 patients) between 2014 and 2020. The treatment outcomes related to primary treatment efficacy, local tumor progression (LTP), tumor control rate, and overall survival were compared between each cohort. RESULTS: The technical success and primary efficacy were 96.56% and 100.00% in the combination therapy cohort, and 91.42% and 100.00% in the MWA cohort, respectively, over a mean follow-up period of 27.6 months. The 1- and 3-year rates of LTP-free survival were 78.57% and 69.56% in the combination therapy cohort, vs. 72.45% and 35.44% in the MWA cohort, respectively (P = 0.001). The overall progression-free survival was longer in the combination therapy cohort compared with the MWA cohort (median: 56.0 vs. 13.0 months; P = 0.017). With the incorporation of additional locoregional therapy, the overall survival rates were not significantly different, with 1- and 3-year overall survival rates of 100.00% and 88.71% in the combination therapy cohort and rates of 90.15% and 82.76% in the MWA cohort, respectively (P = 0.235). CONCLUSION: The combination therapy provided significantly longer upfront LTP-free survival in HCCs >3 cm when compared with the MWA treatment alone, albeit with similar local tumor control and overall survival rates when accounting for additional locoregional therapies.

Hepatic Plexus Nerve Block for Microwave Ablation of Hepatic Tumors.

Seven patients underwent microwave ablation of hepatic tumors; during ablation, a hepatic nerve plexus block was used for pain control. The mean visual analog scale (VAS) score for pain (scale, 0-10) was 0.3 ± 0.5 (SD) at baseline and 2.5 ± 1.4, 2.6 ± 1.4, and 2.3 ± 0.9 at 1, 5, and 10 minutes during ablation. Two patients reported a VAS score of 4 or greater during ablation, which improved in both patients to a VAS score of 3 after one rescue sedation dose. The remaining patients required no additional sedation. No major complication occurred. No patient required conversion to general anesthesia.

Transarterial Chemoembolization of Hepatocellular Carcinoma with Oncozene Microspheres: An Initial, Short-Term Clinical Experience-A Retrospective, Matched, Comparison Study.

Background: The purpose of this study is to describe a single institution's experience using Oncozene (OZ) microspheres for transarterial chemoembolization (OZ-TACE) of hepatocellular carcinoma (HCC), and to compare tolerability, safety, short-term radiographic tumor response, progression-free survival (PFS), and overall survival (OS) of these procedures to TACE (LC-TACE) performed with LC beads (LC). Methods: A retrospective, matched cohort study of patients undergoing DEB-TACE (drug-eluting bead transarterial chemoembolization) with OZ or LC was performed. The cohort comprised 23 patients undergoing 29 TACE with 75 or 100 µm OZ and 24 patients undergoing 29 TACE with 100-300 µm LC. Outcome measures were changes in liver function tests, complications, treatment tolerability, short-term radiographic tumor response according to modified RECIST criteria for HCC, PFS, and 1-year OS. The Mann-Whitney U test, Fisher exact test, and log rank test were used to compare the groups. Results: The BCLC or Child-Pugh scores were similar between the OZ and LC group. However, the two groups differed with respect to the etiology of background cirrhosis (p = 0.02). All other initial demographic and tumor characteristics were similar between the two groups. OZ-TACE used less doxorubicin per treatment compared to LC-TACE (median 50 vs. 75 mg; p = 0.0005). Rates of pain, nausea, and postembolization syndrome were similar, irrespective of the embolic agent used. OZ-TACE resulted in an overall complication rate comparable to LC-TACE (20.7% vs. 10.3%; p = 0.47). LC-TACE resulted in a higher percent increase in total bilirubin on post-procedure day 1 (median 18.8 vs. 0%; p = 0.05), but this difference resolved at 1 month. Both OZ-TACE and LC-TACE resulted in similar complete (31% vs. 24%) and objective (66% vs. 79%) target lesion response rates on 1-month post-TACE imaging. Both OZ-TACE and LC-TACE had similar median progression-free survival (283 vs. 209 days; p = 0.14) and 1-year overall survival rates (85% vs. 76%; p = 0.30). Conclusion: With a significantly reduced dose of doxorubicin, TACE performed with Oncozene microspheres in a heterogeneous patient population is well-tolerated, safe, and produces a similar radiological response and survival rate when compared to LC Bead TACE.

Anisotropic Pinning-Effect of Inclusions in Mg-Based Low-Carbon Steel.

In this study, the effect of austenite grain size on acicular ferrite (AF) nucleation in low-carbon steel containing 13 ppm Mg is determined. The average austenite grain size was calculated using OM Leica software. Results show that the predicted and experimental values of austenite grain size are extremely close, with a deviation of less than 20 µm. AF formation is difficult to induce by either excessively small and large austenite grain sizes; that is, an optimal austenite grain size is required to promote AF nucleation probability. The austenite grain size of 164 µm revealed the highest capacity to induce AF formation. The effects of the maximum distance of carbon diffusion and austenite grain size on the microstructure of Mg-containing low carbon steel are also discussed. Next, the pinning ability of different inclusion types in low-carbon steel containing 22 Mg is determined. The in situ observation shows that not every inclusion could inhibit austenite grain migration; the inclusion type influences pinning ability. The grain mobility of each inclusion was calculated using in situ micrographs of confocal scanning laser microscopy (CSLM) for micro-analysis. Results show that the austenite grain boundary can strongly be pinned by Mg-based inclusions. MnS inclusions are the least effective in pinning austenite grain boundary migration.

Caval Thrombus Management: The Data, Where We Are, and How It Is Done.

Thromboses of the superior and inferior vena cava, either isolated or associated with distal deep venous thrombosis, are uncommon, but confer potentially serious morbidity and mortality. Incidence is increasing, especially with the prominence of intravascular devices. The range of treatment options is also expanding to include medical management, surgery, and endovascular techniques which are now frequently considered first line therapy due to lower reintervention rates and decreased periprocedural morbidity. Currently, there are no official guidelines for screening or treatment. This article reviews the etiology, diagnosis, and management of caval thromboses, including equipment, procedural steps, outcomes, and complications, particularly with regard to endovascular techniques, such as catheter-directed thrombolysis, pharmacomechanical catheter-directed thrombolysis, angioplasty, and stenting.

Percutaneous Transthoracic Treatment of Ascending Aortic and Root Pseudoaneurysms: Procedural Aspects and Guidance with the Use of Multimodality Imaging.

Open repair of ascending aortic pseudoaneurysms (AAPs) is currently the standard of care, but it is associated with high morbidity and mortality. A single-center retrospective experience of 4 patients after cardiac surgery undergoing 5 percutaneous transthoracic embolization procedures is presented. In 3 of the 4 patients, the primary outcome of complete thrombosis was achieved after the first procedure, with a mean follow-up time of 11.5 months. In all 5 procedures, the patients tolerated the procedure well without associated acute complications. Percutaneous transthoracic embolization of AAPs offers an alternate minimally invasive treatment pathway for prohibitive-risk candidates.

Radiographic appearance of pulmonary tuberculosis: dogma disproved.

OBJECTIVE: The purpose of this article is to review the origins of the classic teaching on pulmonary tuberculosis, its evolution in the modern literature, and the evidence that led to its demise. CONCLUSION: Use of molecular epidemiologic techniques that entail DNA finger-printing has led to the discovery that the radiographic appearance of pulmonary tuberculosis does not depend on the time since infection. It has been confirmed that the upper lobe cavitary disease typical in adults is the disease of the immunocompetent host, whereas lower lung zone disease, adenopathy, and effusions, which are uncommon in adults, are the hallmarks of tuberculosis in an immunocompromised host.