90Y Radioembolization for Hepatic Malignancy in Patients with Previous Biliary Intervention: Multicenter Analysis of Hepatobiliary Infections.

Purpose To determine the frequency of hepatobiliary infections after transarterial radioembolization (TARE) with yttrium 90 (90Y) in patients with liver malignancy and a history of biliary intervention. Materials and Methods For this retrospective study, records of all consecutive patients with liver malignancy and history of biliary intervention treated with TARE at 14 centers between 2005 and 2015 were reviewed. Data regarding liver function, 90Y dosimetry, antibiotic prophylaxis, and bowel preparation prophylaxis were collected. Primary outcome was development of hepatobiliary infection. Results One hundred twenty-six patients (84 men, 42 women; mean age, 68.8 years) with primary (n = 39) or metastatic (n = 87) liver malignancy and history of biliary intervention underwent 180 procedures with glass (92 procedures) or resin (88 procedures) microspheres. Hepatobiliary infections (liver abscesses in nine patients, cholangitis in five patients) developed in 10 of the 126 patients (7.9%) after 11 of the 180 procedures (6.1%; nine of those procedures were performed with glass microspheres). All patients required hospitalization (median stay, 12 days; range, 2-113 days). Ten patients required percutaneous abscess drainage, three patients underwent endoscopic stent placement and stone removal, and one patient needed insertion of percutaneous biliary drains. Infections resolved in five patients, four patients died (two from infection and two from cancer progression while infection was being treated), and one patient continued to receive suppressive antibiotics. Use of glass microspheres (P = .02), previous liver resection or ablation (P = .02), and younger age (P = .003) were independently predictive of higher infection risk. Conclusion Infectious complications such as liver abscess and cholangitis are uncommon but serious complications of transarterial radioembolization with 90Y in patients with liver malignancy and a history of biliary intervention.

Ureteroarterial fistula embolization by transradial approach: A case report.

Ureteroarterial fistula is a rare condition wherein a communication develops between a ureter and the common, internal, or external iliac artery. Localizing the fistula can be difficult, as cystoscopy, CT angiography, and conventional angiography have low sensitivity in identifying the fistula. Provocative maneuvers within the ureter, however, can aid in the visualization of fistulae on angiography. Prior reports of endovascular repair have utilized transfemoral access, which makes performing concurrent provocative maneuvers in the ureter challenging. We present a case of successful endovascular ureteroarterial fistula localization and embolization in an 80-year-old woman with recurrent gross hematuria by the transradial approach, aided by concurrent provocative maneuvers performed via cystoscopy. The transradial endovascular approach facilitated a multi-disciplinary joint procedure that resulted in effective treatment of the patient.

MR distribution of active inflammatory and chronic structural sacroiliac joint changes in axial spondyloarthropathy: Challenging conventional wisdom.

OBJECTIVE: Evaluate the MR distribution of inflammatory sacroiliac joint changes in axial spondyloarthritis phenotypes, including Ankylosing Spondylitis (AS) and non-radiographic Axial Spondyloarthritis (nrAxSpA). METHODS: A retrospective review of 94 patients seen for treatment of axial spondyloarthritis (SpA) who underwent sacroiliac joint MRI between January 2011 and December 2015 was performed. MR images from 68 patients (20 with AS and 48 with nrAxSpA) were reviewed independently by two radiologists. Images were scored on presence of active inflammatory and chronic structural lesions. These lesions were further categorized as unilateral, bilateral and asymmetric, or bilateral and symmetric. RESULTS: No statistically significant difference was found in the distribution (laterality or symmetry) of bone marrow edema or sclerosis between the AS and nr-axSpA groups. Osseous erosions were more commonly bilateral symmetric in AS than nr-axSpA (11/20 vs. 8/48, p = 0.01). No statistically significant difference was noted between bone marrow edema scores in the AS and nr-axSpA subgroups (2.6 vs 3.3, p = 0.514). Patients with AS had a significantly higher fat metaplasia score compared to patients with nr-axSpA (7.3 vs 1.1, p = 0.001). Patients with nr-axSpA had a higher mean score for erosions (11.6 vs 4.2, p = 0.001). Only patients classified as AS were found to have bony ankylosis. Inter-observer reliability was strong to excellent. CONCLUSION: Ankylosing spondylitis findings at the sacroiliac joints are classically described as bilateral and symmetric on radiographs. Our study demonstrates that distribution on MRI at an individual time point is variable. The variable distribution should be considered when radiologists evaluate MRI exams of AS patients.

Temporal sequence of clinical manifestation in schizophrenia with co-morbid OCD: review and meta-analysis.

Obsessive-compulsive disorder (OCD) is often a comorbidity in schizophrenia (SCZ), but little is known about whether OCD emerges before or after a diagnosis of SCZ in the absence of atypical antipsychotic medications. The authors analyzed data from clinical studies reporting the temporal sequence of OCD and SCZ in comorbid patients to determine if there was a significant statistical difference between the mean ages of onset in both disorders and the percentage of patients diagnosed with OCD before SCZ. A MEDLINE search was conducted using the keywords "OCD" and "Schizophrenia." Studies were assessed for the presence of data regarding the ages of onset of patients comorbid with both disorders as well as the number of patients in each study diagnosed with OCD first, SCZ first, or both disorders concurrently. A meta-analysis was performed to test the a priori hypothesis that OCD is diagnosed before SCZ in patients who are comorbid with both disorders. There was no statistically significant difference in the unstandardized difference in the mean age of onset of OCD and SCZ. A strong trend in the data exists suggesting that the onset of OCD precedes SCZ. Future prospective studies with larger sample sizes are warranted.

Malignant Transformation of an Aneurysmal Bone Cyst to Fibroblastic Osteosarcoma.

Aneurysmal bone cysts are uncommon primary bone tumors typically regarded as histologically and clinically benign. Malignant transformation of these lesions occurs almost exclusively in the context of prior radiation exposure. However, 4 cases of an osteosarcoma developing without prior radiation exposure have been reported. In this article, we report a fifth case of degeneration of an aneurysmal bone cyst to a fibroblastic osteosarcoma. In addition to reviewing the earlier cases, we describe the radiologic, pathologic, and immunohistochemical basis of this diagnosis.

Endovascular treatment of fusiform intracranial aneurysms.

BACKGROUND AND PURPOSE: Endovascular treatment (EVT) has emerged as an alternative therapeutic strategy for the treatment of intracranial fusiform aneurysms (IFAs), but little is known about the safety and efficacy of deconstructive and reconstructive methods, especially in patients presenting with subarachnoid hemorrhage (SAH). The purpose of this study is to describe the radiological and clinical outcomes in patients with IFAs undergoing EVT. METHODS: A retrospective analysis was conducted of 18 patients undergoing EVT of IFAs, 13 of whom (72.2%) presented with SAH. Radiological outcomes were characterized by the presence of parent vessel opacification and aneurysmal remnants for patients undergoing deconstructive and reconstructive EVT, respectively. Clinical outcomes were characterized by the Glasgow Outcome Scale. Contingency analysis of factors associated with clinical outcomes in patients with ruptured aneurysms was conducted. RESULTS: Technical success was achieved in 17 of the 18 patients (94.4%), with 10 (55.6%) undergoing reconstructive EVT and eight (44.4%) undergoing deconstructive EVT. For patients with SAH, favorable clinical outcomes were achieved in 9/13 (69.2%), with 3/6 (50.0%) undergoing reconstructive EVT and 6/7 (85.7%) undergoing deconstructive EVT. Among patients with ruptured aneurysms, only Hunt-Hess grade ≥3 was associated with an unfavorable clinical outcome (p=0.007). Favorable clinical outcomes were seen in all five patients with unruptured aneurysms. CONCLUSION: Both deconstructive and reconstructive EVT were found to be safe and effective in patients with unruptured aneurysms. Reconstructive EVT may be associated with a higher incidence of poor clinical outcomes in patients presenting with high-grade SAH.

Why do persons with bipolar disorder stop their medication?

OBJECTIVE: Non-adherence to maintenance medication regimens is a major problem, limiting outcomes for many persons with bipolar disorder. The aim of this paper is to determine the most relevant aspects of adherence attitudes in a sample of bipolar patients selected for problems with adherence behavior. METHODS: Among a larger sample of bipolar disorder patients participating in a prospective follow-up study (N = 140), a subsample of patients were selected for non-adherent behavior defined as missing ≥ 30% of medication during the past month (n = 27; 19.3%). Adherence attitudes were assessed with the Rating of Medication Influences scale (ROMI), a self-reported attitudinal measure assessing reasons for and against adherence. Multiple logistic regression models for non-adherence vs. adherence were estimated with each of the 19 ROMI items in the model, while controlling for sex, age, ethnicity, education, duration of illness, and substance abuse. RESULTS: Mean score of ROMI items corresponding to reasons for treatment adherence was greater among adherent participants, whereas the mean score of ROMI items corresponding to reasons for treatment non-adherence was greater among nonadherent participants. The ROMI item identifying that the individual believes that medications are unnecessary had the strongest influence for non-adherence (p < 0.0001). This was followed by ROMI items corresponding to no perceived daily benefit (p = 0.0008), perceived change in appearance (p = 0.0057), and perceived interference with life goals (p = 0.0033). The ROMI item identifying fear of relapse was the strongest predictor for adherence (p = 0.0017). CONCLUSIONS: Non-adherent patients with bipolar disorder differ from adherent patients with bipolar disorder on reasons for adherence and non-adherence. Utilization of tools that evaluate medication treatment attitudes, such as the ROMI or similar measures, may assist clinicians in the selection of interventions that are most likely to modify future treatment adherence.

An analysis of the high psychotropic off-label use in psychiatric disorders The majority of psychiatric diagnoses have no approved drug.

OBJECTIVE: The authors' goals were to determine the extent of unapproved indications in the DSM-IV-TR, to highlight common off-label uses of psychotropic medications and offer insights into the rationale of the widespread off-label prescribing in psychiatry. METHOD: Indications for approved psychotropic agents, obtained from the Physicians Desk Reference and the Drug Information Handbook, Clinical Handbook of Psychotropic Drugs, 15th edition, and the Drugs@FDA online database were analyzed in the context of the DSM-IV-TR to determine the percent of DSM-IV-TR disorders that are indications for psychotropic agents. A literature search was performed to determine common off-label uses of major classes of psychotropic medications. RESULTS: 88.5% of all DSM-IV-TR categorized disorders lack an approved medication for their treatment. Atypical Antipsychotics had the most extensive off-label use for DSM-IV-TR categorized disorder, whereas Mood Stabilizers showed the greatest off-label use with regards to disorders and symptoms that are not DSM-IV classified. For each class of medications, more off-label uses exist than FDA-approved uses. CONCLUSIONS: The vast majority of DSM-IV-TR categorized disorders lack approved medications for their treatment. The large unmet need for approved psychiatric indications may explain the widespread off-label use of psychotropic medications in clinical practice.