Transarterial chemoembolisation for advanced hepatocellular carcinoma: results from a North American cancer centre.

AIMS: In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population. MATERIALS AND METHODS: This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response. RESULTS: The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE. CONCLUSIONS: The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Palliative care stress in a UK community hospital: evaluation of a stress-reduction programme.

In this study the Nurses Stress Scale and Nurses Coping With Stress Questionnaire were used to investigate work-related stress in 18 nurses providing palliative care in a UK NHS community hospital. These instruments were administered twice before and twice after a stress-reduction programme. In depth qualitative interviews were conducted before and after the programme and a 12-item questionnaire was used to assess whether the nurses found the programme useful. The findings indicated that most nurses did not find their work particularly stressful, and most felt well equipped to cope with palliative care stress. However, the interviews identified a small group of nurses who felt ill equipped to cope and routinely found their work stressful. The principal sources of support for both groups of nurses were family and friends at home rather than colleagues at work, and most felt there was little opportunity to share experiences and feelings with their colleagues. Likewise, few (only 33%) had found an opportunity to practice the relaxation skills they had learnt during the stress-reduction programme. This might explain why there was no evidence of any general improvement in stress and coping scores following the stress-reduction programme. Although the nurses enjoyed the programme and found it helpful, such programmes need to tackle contextual barriers to coping with stress as well as improving the individual coping skills of staff.

Carotid MRA--what advantages do the turbo field-echo and 3D phase-contrast sequences offer?

Our purpose was to investigate some of the newer MR angiography (MRA) techniques for studying the carotid arteries. Forty-two arteries in seven asymptomatic, healthy volunteers were studied using five MRA sequences: two conventional time-of-flight sequences, 2D time-of-flight (2DTOF) and 3D time-of-flight (3DTOF); 2D and 3D magnetisation-prepared, segmented time-of-flight sequences (2DTFE and 3DTFE); and a 3D phase contrast angiography (3DPCA) sequence. A protocol that could be realistically employed in a routine clinical situation was chosen. 2DTOF had significantly (P < 0.05) better signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) than 2DTFE. 3DTOF demonstrated better SNR than 3DTFE but 3DTFE demonstrated better CNR than 3DTOF. 3DPCA provided maximal anatomical coverage. No one sequence provided optimal anatomical coverage, accurate demonstration of the carotid bulb and maximal SNR and CNR. The combination of 3DPCA and a 3D inflow sequence was best. 2DTOF sequences are useful when only one brief sequence is practicably feasible.