Intralesional versus intracoronary administration of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention in patients with acute coronary syndromes: A meta-analysis of randomized controlled trials.

BACKGROUND: Glycoprotein IIb/IIIa inhibitors (GPIs) have been regarded as an adjuvant regimen to deal with no-reflow. However, whether intralesional (IL) administration of GPIs improves myocardial reperfusion without increasing bleeding in patients with acute coronary syndrome (ACS) compared with intracoronary (IC) administration has not been well addressed. Our meta-analysis aimed to evaluate the efficacy and safety of IL versus IC administration of GPIs for patients with ACS during percutaneous coronary intervention. METHODS: We systematically searched Medline, Embase, the Cochrane Central Register of Controlled Trials, and Cambridge Scientific Abstracts from January 2007 to May 2017. Thrombolysis in Myocardial Infarction (TIMI) 3 flow, corrected TIMI frame count (CTFC), and complete ST-segment resolution (>70%) were selected as the primary outcomes. Major adverse cardiac events (MACEs) were the secondary outcome, and major bleeding complications were the safety outcome. Data analysis was conducted using the Review Manager 5.3 software. RESULTS: Six randomized controlled trials were included in our meta-analysis. Compared with IC, IL obtained better results in terms of TIMI grade 3 flow [odds ratio (OR) 2.29; 95% confidence intervals (CIs) 1.31-4.01; P = .004], CTFC [weighted mean difference (WMD) -4.63; 95% CI -8.82 to -0.43; P = .03], and complete ST-segment resolution (OR 1.55; 95% CI 1.12-2.14; P = .008). There was a trend toward decreased MACE in the IL administration groups, which was not of statistical significance (OR 0.63; 95% CI 0.30-1.31; P = .22). No significant difference was found between the two groups in terms of in-hospital major bleeding events (OR 2.52; 95% CI .66 to 9.62; P = .18). CONCLUSION: IL administration yielded favorable outcomes in terms of myocardial tissue reperfusion as evidenced by the improved TIMI flow grade, CTFC, complete ST-segment resolution, and decreased MACE without increasing in-hospital major bleeding events. The IL administration of GPIs can be recommended as the preferred regimen to guard against no-reflow.

140 adult knee arthroscopies under intra-articular local anaesthetic

Aim: To analyse the use of intra-articular local anaesthetic (IALA) for therapeutic knee arthroscopy in the day care unit of a UK district general hospital. Methods: Investigation of 140 consecutive adult therapeutic knee arthroscopies. Visual analogue pain scores, patient satisfaction, operative details and difficulties were recorded. Costs were estimated. Results: Surgical pain scores varied between O and 6 with 87% experiencing no pain. Only 6 patients required intraoperative sedation. 95.5% of patients were satisfied with IALA and 93% would choose IALA during future knee arthroscopies. Employing IALA reduced costs from f59.33 to f17.06. Conclusion: IALA for ambulatory day case arthroscopic knee surgery is highly reliable, safe, and cost effective. It also provides an acceptable experience for patients (AU)

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Administración intrarterial de un magnetofluido termoterapéutico en un modelo experimental de metástasis hepáticas. Estudio de distribución con resonancia magnética y espectrometría / Magnetic resonance imaging and spectrometric study of the distribution of thermotherapeutic magnetofluid after intra-arterial administration in an experimental model of liver metastases

Objetivo. Valorar la distribución vascular de un magnetofluido por técnicas de imagen y laboratorio, en un modelo de metástasis hepáticas. Material y métodos. El hígado de 33 ratas WAG/RijCrl fue diseminado con células de carcinoma colorrectal CC-531. Tras comprobar desarrollo tumoral, diez ratas recibieron infusiones intrarteriales hepáticas de Lipiodol® con nanopartículas de Fe3O4 en suspensión, y cinco se reservaron como controles. Posteriormente, en RM de 1,5 T se practicaron secuencias axiales STIR (TR: 3.600ms/TE: 29ms/TI: 130ms) y eco de gradiente (EG) (120/4 y 120/14). Tras necropsia, según desarrollo tumoral, las ratas se clasificaron en dos estadios: precoz (< 10 metástasis, de < 3mm), avanzado (> 10 metástasis, de>3mm). De los 15 animales se tomaron muestras de hígado y metástasis, para cuantificar mediante espectrometría (ICP-MS) las concentraciones de hierro. En el análisis estadístico se emplearon pruebas no paramétricas. Se consideraron significativos valores de p < 0,05. Resultados. Cinco animales presentaron afectación precoz y cinco, avanzada. En secuencias EG, las metástasis en estadio precoz mostraron disminución homogénea de señal atribuible a presencia de magnetofluido. La espectrometría demostró diferencias significativas entre la concentración de hierro determinado en metástasis de ratas en estadio precoz y control (p=0,002), y entre animales en estadio precoz y avanzado (p=0,001). La razón entre hierro exógeno metastásico y hepático en ratas en estadio precoz fue 2,6:1. La concentración de hierro exógeno hepático y tumoral mostró diferencias significativas sólo en animales en estadio precoz (p=0,043). Conclusiones. RM y Espectrometría permitieron evaluar la distribución vascular hepática del magnetofluido, y revelaron su desigual afinidad por metástasis en diferentes estadios (AU)

Objective. To use imaging and laboratory techniques to evaluate the vascular distribution of magnetofluid in a rat model of liver metastases. Material and methods. The livers of 33 WAG/Rij Crl rats were seeded with CC-531 colorectal cancer cells. After we checked tumor development, 10 rats received hepatic intra-arterial infusions of Lipiodol® with nanoparticles of Fe3O4 in suspension, and 5 were reserved as controls. Axial STIR (TR: 3,600ms/TE: 29ms/TI: 130ms) and gradient-echo (GE) (120/4 and 120/14) MRI sequences were acquired on a 1.5 T scanner. After necropsy, rats were classified into one of two stages according to tumor development: early (< 10 metastases, each < 3mm) or advanced (> 10 metastases, each > 3mm). Samples of liver and of metastases were taken from the 15 animals for quantification of iron concentrations by inductively coupled plasma mass spectrometry (ICP-MS). The data were analyzed using nonparametric tests; values of p < 0.05 were considered significant. Results. Five animals had early tumor development and five had advanced tumor development. In the GE sequences, early stage metastases showed homogeneous signal reduction attributable to the presence of magnetofluid. Spectrometry found significant differences between the iron concentration in rats with early stage metastases and controls (p=0.002) as well as between rats with early stage metastases and those with late stage metastases (p=0.001). The ratio of exogenous iron in metastases and in liver in early stage rats was 2.6:1. The concentration of exogenous iron in the liver was significantly different from that in tumors only in early stage animals (p=0.043). Conclusions. MRI and spectrometry made it possible to evaluate the vascular distribution of magnetofluid in the liver and revealed the differences in its affinity for metastases in different stages of disease (AU)

A prospective randomized controlled trial of preoperative whole-liver chemolipiodolization for hepatocellular carcinoma.

BACKGROUND: We previously reported that preoperative chemolipiodolization of the whole liver is effective for reducing the incidence of postoperative recurrence and prolonging survival in patients with resectable hepatocellular carcinoma (HCC). The present randomized controlled trial was performed to evaluate the influence of preoperative transcatheter arterial chemoembolization (TACE) on survival after the resection of HCC. METHODS: Operative results and long-term outcome were prospectively compared among 42 patients who received only selective TACE targeting the tumor (selective group), 39 patients who received TACE targeting the tumor plus chemolipiodolization of the whole liver (whole-liver group), and 43 patients without preoperative TACE or chemolipiodolization (control group). RESULTS: There were no serious side effects of TACE or chemolipiodolization and the operative outcomes did not differ among the three groups. Even though preoperative TACE induced complete tumor necrosis, there were no significant differences in the pattern of intrahepatic recurrence or the time until recurrence among the three groups. There were also no significant differences in disease-free survival or overall survival among the three groups, even among patients with larger tumor size. CONCLUSION: These results indicate that preoperative selective TACE and whole-liver chemolipiodolization plus TACE do not reduce the incidence of postoperative recurrence or prolong survival in patients with resectable HCC.

Previous chemoembolization response after transcatheter arterial chemoembolization (TACE) can predict the anti-tumor effect of subsequent TACE with miriplatin in patients with recurrent hepatocellular carcinoma.

AIM: The purpose of this retrospective study was to evaluate the efficacy and safety of transcatheter arterial chemoembolization (TACE) with miriplatin in patients with unresectable hepatocellular carcinoma (HCC). METHODS: From 2007 to 2010, 122 consecutive patients with unresectable HCC were treated by TACE with miriplatin-lipiodol suspension in our institute. Twenty-two patients (18%) had a solitary nodule and 100 patients (82%) had multiple nodules. Ninety-eight patients (80%) had a history of TACE. RESULTS: Thirty-five of the 122 treated patients (29%) showed complete response (CR). And no serious complications were observed. Patients who had shown CR after previous TACE (pre-CR) were significantly more likely to show CR in the current study compared with patients who had shown less successful responses after previous TACE (56 vs. 20%, p = 0.003). Multivariate analysis revealed that response after previous TACE (pre-CR, risk ratio: 4.76; p = 0.035), tumor multiplicity (solitary, risk ratio: 9.69; p = 0.003), and injection artery (peripheral to segmental hepatic artery, risk ratio: 5.28;p = 0.040) were significant independent predictors associated with CR after TACE using miriplatin. CONCLUSION: In repetition of TACE treatment, switching the TACE agent from epirubicin or cisplatin to miriplatin offered a favorable treatment effect, especially in patients who had shown a CR after previous TACE.

Transarterial chemoembolization for inoperable, early stage hepatocellular carcinoma in patients with Child-Pugh grade A and B: results of a comparative study in 96 Chinese patients.

OBJECTIVE: The efficacy of transarterial chemoembolization (TACE) in prolongation of survival is controversial. We conducted a comparative study to determine whether TACE treatment had any survival benefit for patients with unresectable hepatocellular carcinoma (HCC) and with relatively preserved liver function. METHODS: In all, 96 patients with unresectable HCC of Okuda stage I or II and Child-Pugh grade A or B were recruited. A total of 80 patients (group 1) who received TACE were compared to 16 patients (group 2) who were treated conservatively. RESULTS: The median survival time of group 1 patients was significantly longer than that of group 2 patients (31.2 vs 14.1 months respectively, p = 0.0126). The cumulative survival rates at 6 months, 1 yr, 2 yr, 3 yr, and 4 yr of group 1 compared to group 2 were as follows: 93.8% versus 62.5% (p = 0.002); 86.3% versus 62.5% (p = 0.023); 78.8% versus 50% (p = 0.017); 57.5% versus 50% (p = ns); and 51.3% versus 43.8% (p = ns), respectively. Tumor response was observed in 28% of patients receiving TACE. Patients with higher pretreatment albumin levels, lower pretreatment alpha-fetoprotein levels, and Okuda stage I disease were associated with a favorable response to TACE. CONCLUSION: TACE treatment improved survival in patients with unresectable HCC in the early stages and with relatively preserved liver function.

Safe radiation exposure of medical personnel by using simple methods of radioprotection while administering 131I-lipiodol therapy for hepatocellular carcinoma.

The intra-arterial administration of 131I-lipiodol is a therapeutic approach increasingly used for the treatment of inoperable hepatocellular carcinomas. This technique has even become the reference treatment for hepatocellular carcinomas with portal thrombosis and is the only effective treatment to reduce the risk of recurrence among patients who could benefit from surgical operation. Currently, few data have been published concerning the levels of exposure for personnel carrying out this type of treatment. We undertook a dosimetric study targeted mainly on the exposure of the person performing the injection of 131I-lipiodol to show that this treatment can be carried out with an exposure at the extremities distinctly lower than the regulatory annual threshold by using simple means of radioprotection. The point of puncture was carried out at the level of left femoral artery, the preparation and injection of the therapeutic dose was carried out extemporaneously by the nuclear medicine specialist using a 10 ml syringe (for an injected volume of 4 ml) fitted with an adapted syringe protector. The injection was carried out as rapidly as possible under scopic control while avoiding reflux, with compression carried out by the radiologist. This study comprises 52 intra-arterial injections of 131I-lipiodol (2016+/-92 MBq). For the nuclear medicine specialists, 52 measurements were carried out at the level of the thorax and 41 on the fingers. For the radiologists, 22 measurements were carried out at the level of the thorax and six on their index fingers; nine measurements were carried out at the level of the thorax for the technologist and four at the level of the thorax for the stretcher bearer. For the nuclear medicine specialists, the average dose received at the level of the fingers varies between 140 and 443 microSv (according to the fingers) and the average dose at the thorax is 17 microSv. For the radiologists, the average dose received is 215 microSv at the level of the fingers and 15 microSv at the thorax. These results show that the administration of high therapeutic activities of 131I-lipiodol can be carried out for the exposed personnel with a dose at the level of the fingers much lower than the European regulatory limit of 500 mSv.

Intra-arterial radionuclide therapy for liver tumours: effect of selectivity of catheterization and 131I-Lipiodol delivery on tumour uptake and response.

Several authors have demonstrated the good tolerance of hepatic intra-arterial 131I-Lipiodol therapy and report survival rates of 21-25% after 1 year in inoperable patients. This study explored the possibility that more selective hepatic arterial instillation could be a strategy for increasing tumoural uptake and response of 131I-Lipiodol. Between June 1999 and September 2001 we selected 24 patients: 14 received a selective instillation of 131I-Lipiodol to the proper hepatic artery (SEL group); and 10 received a hyperselective instillation in the right or left hepatic artery (HYP-SEL group). The individual 131I-Lipiodol activity as a per cent of the injected activity per millilitre of tumour (%IA/ml tumour) was correlated with the selectivity of instillation in 28 tumours and with tumour response in 24 tumours. Differences in tumour response or tumour uptake between the SEL and HYP-SEL groups were not significant. In general, we observed a %IA/ml tumour of 0.05-2.6% for the uptake of 131I-Lipiodol. The uptake was significantly higher in responsive disease than in stable or progressive disease (P=0.002). A large tumour volume was invariably related to low uptake of 131I-Lipiodol and progressive disease (P=0.008). In conclusion, our study does not support the general use of hyper-selective or super-selective intra-arterial administration of 131I-Lipiodol. This result may be extrapolated to similar types of intra-arterial, loco-regional hepatic radionuclide therapy.

Radiation exposure and radiation protection of the physician in iodine-131 Lipiodol therapy of liver tumours.

Intra-arterial iodine-131 labelled Lipiodol therapy for liver cancer has been investigated for safety and efficacy over a number of years, but data on radiation exposure of personnel have remained unavailable to date. The aim of this study was to assess the radiation exposure of the physician during intra-arterial 131I-Lipiodol therapy for liver malignancies and to develop appropriate radiation protection measures and equipment. During 20 intra-arterial administrations of 131I-Lipiodol (1110-1924 MBq), radiation dose equivalents (RDE) to the whole body, fingers and eyes of the physician were determined for (a) conventional manual administration through a shielded syringe, (b) administration with an automatic injector and (c) administration with a lead container developed in-house. Administration by syringe resulted in a finger RDE of 19.5 mSv, an eye RDE of 130-140 microSv, and a whole-body RDE of 108-119 microSv. The injector reduced the finger RDE to 5 mSv. With both technique (a) and technique (b), contamination of angiography materials was observed. The container allowed safe transport and administration of the radiopharmaceutical from 4 m distance and reduced the finger RDE to <3 microSv and the eye RDE to <1 microSv during injection. During femoral artery compression, radiation exposure to the fingers reached 170 microSv, but the whole-body dose could be reduced from a mean RDE of 114 microSv to 14 microSv. No more contamination occurred. In conclusion, radiation exposure was high when 131I-Lipiodol was administered by syringe or injector, but was significantly reduced with the lead container.

[Treatment of hemorrhoid of III, IV stage by four steps injection of xiaozhiling].

OBJECTIVE: To find a new method of non-operation treatment of hemorrhoid in III, IV stage. METHODS: Based on the principle "sore herbs can astringent and the puckery can control prolapse" and precious experience in treating hemorrhoid, four step injections of Xiaozhiling (XZL, preparation made from gallnut and alum chiefly) were injected into the branches of rectal superior artery, the submucosa, the mucous lamina propria and the sinusoid veins, to cause sclerosis and atrophy of hemorrhoid by obliterating branches of rectal superior artery. RESULTS: 21,361 cases were treated from 1987 to 1996. Among them 21,148 (99.00%) were cured, 203 (0.95%) improved and 10 (0.05%) ineffective and for whom surgical operation was used. Of the 620 cases who were followed up for 3 years, only 6 cases (0.97%) relapsed. CONCLUSION: This method is a relative ideal non-operative approach in the treatment of hemorrhoid of stage III and IV.

[Carbon dioxide as an intra-arterial contrast agent in echography: a technic for its preparation and the preliminary results in assessing hepatocarcinoma vascularization]. / Anidride carbonica come mezzo di contrasto intraarterioso in ecografia: tecnica di preparazione e risultati preliminari nella valutazione della vascolarizzazione dell'epatocarcinoma.

This paper reports on an original method to prepare a contrast agent consisting of CO2 microbubbles to be injected i.a. during ultrasound examinations (ultrasound angiography-USA), whose value was investigated in the study of tumor neovascularity in HCC patients. Thirty-five HCC patients underwent USA. CO2 was drawn out from a gas container under pressure and, through a sublimation process, made available in predetermined quantities in test tubes. USA was performed during angiography in 9 cases and immediately before arterial chemoembolization in the other 26 cases. In 51 lesions vascularity was evaluated with conventional angiography, USA and lipiodol CT. USA demonstrated lesion hypervascularity in 91% of cases, as confirmed by lipiodol CT (88%), versus 72.4% of angiography. In 3 of 35 patients USA demonstrated 6 more lesions undetected by other modalities: two of them were proved to be HCC and adenomatous hyperplasia at percutaneous biopsy. USA is a cost-effective procedure, which is easy to perform during conventional angiography: it is more sensitive than conventional angiography in the study of lesion neovascularity and can help plan lesion management, anticipating the results of chemoembolization. The role of USA in the diagnosis and treatment of HCC is, however, still to be defined.