Indigo Aspiration System for Treatment of Pulmonary Embolism: Results of the EXTRACT-PE Trial.

OBJECTIVES: This study sought to prospectively evaluate the safety and efficacy of the Indigo aspiration system in submassive acute pulmonary embolism (PE). BACKGROUND: PE treatment with thrombolytics has bleeding risks. Aspiration thrombectomy can remove thrombus without thrombolytics, but data are lacking. METHODS: This study was a prospective, single-arm, multicenter study that enrolled patients with symptomatic acute PE ≤14 days, systolic blood pressure ≥90 mm Hg, and right ventricular-to-left ventricular (RV/LV) ratio >0.9. The primary efficacy endpoint was change in RV/LV ratio from baseline to 48 h post-procedure on core lab-adjudicated computed tomography angiography. The primary safety endpoint was a composite of 48-h major adverse events: device-related death, major bleeding, and device-related serious adverse events (clinical deterioration, pulmonary vascular, or cardiac injury). All sites received Institutional Review Board approval. RESULTS: A total of 119 patients (mean age 59.8 ± 15.0 years) were enrolled at 22 U.S. sites between November 2017 and March 2019. Median device insertion to removal time was 37.0 (interquartile range: 23.5 to 60.0) min. Two (1.7%) patients received intraprocedural thrombolytics. Mean RV/LV ratio reduction from baseline to 48 h post-procedure was 0.43 (95% confidence interval: 0.38 to 0.47; p < 0.0001). Two (1.7%) patients experienced 3 major adverse events. Rates of cardiac injury, pulmonary vascular injury, clinical deterioration, major bleeding, and device-related death at 48 h were 0%, 1.7%, 1.7%, 1.7%, and 0.8%, respectively. CONCLUSIONS: In this prospective, multicenter study the Indigo aspiration system was associated with a significant reduction in the RV/LV ratio and a low major adverse event rate in submassive PE patients. Intraprocedural thrombolytic drugs were avoided in 98.3% of patients. (Evaluating the Safety and Efficacy of the Indigo aspiration system in Acute Pulmonary Embolism [EXTRACT-PE]; NCT03218566).

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: main results of a cluster preference randomised controlled trial.

PURPOSE: The patient concerns inventory (PCI) is a prompt list allowing head and neck cancer (HNC) patients to discuss issues that otherwise might be overlooked. This trial evaluated the effectiveness of using the PCI at routine outpatient clinics for one year after treatment on health-related QOL (HRQOL). METHODS: A pragmatic cluster preference randomised control trial with 15 consultants, 8 'using' and 7 'not using' the PCI intervention. Patients treated with curative intent (all sites, disease stages, treatments) were eligible. RESULTS: Consultants saw a median (inter-quartile range) 16 (13-26) patients, with 140 PCI and 148 control patients. Of the pre-specified outcomes, the 12-month results for the mean University of Washington Quality of Life (UW-QOLv4) social-emotional subscale score suggested a small clinical effect of intervention of 4.6 units (95% CI 0.2, 9.0), p = 0.04 after full adjustment for pre-stated case-mix. Results for UW-QOLv4 overall quality of life being less than good at 12 months (primary outcome) also favoured the PCI with a risk ratio of 0.83 (95% CI 0.66, 1.06) and absolute risk 4.8% (- 2.9%, 12.9%) but without achieving statistical significance. Other non-a-priori analyses, including all 12 UWQOL domains and at consultant level also suggested better HRQOL with PCI. Consultation times were unaffected and the number of items selected decreased over time. CONCLUSION: This novel trial supports the integration of the PCI approach into routine consultations as a simple low-cost means of benefiting HNC patients. It adds to a growing body of evidence supporting the use of patient prompt lists more generally.

Multi-Family Therapy for First Episode Psychosis: Experiences of Families in Singapore.

Aim: This qualitative study examined the experiences of families with Multi-Family Therapy (MFT) provided by the Early Psychosis Intervention Programme (EPIP) in Singapore. The MFT was piloted over a period of 2 years and findings from this study were used to further refine the MFT to better meet the needs of Singaporean families in the service. Methods: Families who completed the MFT were invited to participate in the study. Nine clients and ten carers who consented to participate in the study were allocated to two client and two carer Focus Group Discussions (FGDs) respectively. A semi-structured interview schedule was used to facilitate the discussions. The FGDs were audio recorded, transcribed, and anonymised. The data was analysed using thematic analysis. Results: Four main themes emerged from the analysis: (1) therapeutic processes of MFT, (2) positive changes in family relationships, (3) improvements in coping with psychosis, and (4) suggestions for improvement in MFT. The families suggested some structural changes to the MFT, and more carers than clients would prefer therapists to offer more expert advice. Conclusions: Findings suggest that a Western-based MFT can be adapted to work with Singaporean families. This study sheds light on the therapeutic processes that may be related to the changes in family relationships and coping with psychosis. In addition, it suggests that therapists taking an expert and authoritative approach may not fit with the needs of younger generations in Singapore. It advocates for therapists to take a flexible and fluid stance to work with Singaporean families.

A Surgeon's Guide for Various Lung Nodule Localization Techniques and the Newest Technologies.

Preoperative image-guided localization of lung nodules is necessary for successful intraoperative localization and resection. However, current localization techniques carry significant intraoperative disadvantages for surgeons. Articles were selected through multiple search engines using key search terms and reviewed to compare results, outcomes, advantages, limitations, and complications of various localization methods. Current methods utilize microcoils, hookwires, contrast media, dyes, cyanoacrylate, radiotracers, or fluorescence tracers, which are associated with many intraoperative disadvantages even when paired with other imaging modalities including computed tomography and bronchoscopy techniques. Novel technologies including robotic bronchoscopy, 4-hook anchor, SPiN Thoracic Navigation System, superDimension, Ion Endoluminal System, and the SCOUT system are reviewed including their advantages, which may change the future direction of minimal thoracoscopic surgery with potential to improve intraoperative accuracy and efficiency.

Transoral laser microsurgery and radiotherapy for oropharyngeal squamous cell carcinoma: Equitable survival and enhanced function compared with contemporary standards of care.

INTRODUCTION: We describe the 5-year oncological and functional outcomes of transoral laser microsurgery, neck dissection (TLM + ND) and adjuvant radiotherapy (PORT) used to treat patients with oropharyngeal carcinoma. The effectiveness of external carotid artery (ECA) ligation in reducing post-operative bleeding, and fibrin glue following ND in reducing wound drainage and length of hospital stay is reported. MATERIALS AND METHODS: This retrospective case review of consecutive patients undergoing TLM between 2006 and 2017 used the Kaplan-Meier Estimator and Log-Rank Test for univariate, time-to-event analyses, and Cox-Proportionate Hazard modelling for multivariate analysis. RESULTS: 264 consecutive patients were included. Mean follow-up was 49.4 months. 219 (82.9%) patients received PORT. Five-year overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) rates were 74.9%, 73.7%, and 86.2%, respectively. Five-year locoregional control was 89.4%. 65.5% of cases were Human papillomavirus associated (HPV+), for whom OS, DFS and DSS was 85.6%, 84.7% and 92.7%, respectively, and demonstrated significantly higher OS (hazard ratio (HR) 0.28, CI 0.16-0.49, p < 0.0001), DFS (HR 0.28, CI 0.17-0.47, p < 0.0001) and DSS (HR 0.2, CI 0.09-0.44, <0.001). Post-operative oropharyngeal bleeding occurred in 23 patients (8.7%), of which 5 were major/severe, in patients without ECA ligation. Fibrin glue significantly reduced neck drain output (p < 0.001), and length of hospital stay (p < 0.001). One-year gastrostomy dependence rate was 2.3%. CONCLUSIONS: TLM + ND + PORT results in favourable 5-year survival and locoregional control rates, and low feeding tube dependency rates. ECA ligation and fibrin glue appear to reduce major post-operative haemorrhage, wound drainage and length of hospital stay.

Outcomes and prognosticators in regionally recurrent cutaneous squamous cell carcinoma of the head and neck.

INTRODUCTION: Data regarding regionally metastatic cutaneous squamous cell carcinoma of the head and neck (cSCCHN) is limited and derived almost exclusively from Australian and United States (US) institutions. We report the first United Kingdom perspective, with the aims of benchmarking survival outcomes and identifying clinically relevant prognosticators. MATERIALS AND METHODS: Ninety-one patients with regionally recurrent cSCCHN treated with curative intent over a ten-year period (2009-2018) were studied retrospectively. Time-to-event analyses were used to estimate oncological outcomes, and log-rank statistics and Cox proportional hazards models used to examine potential prognosticators. Receiver operating characteristics were also used to analyse the influence of nodal disease burden. RESULTS: Parotid involvement (with or without neck involvement) was most common (79.2%), and time to recurrence in those with parotid disease alone significantly shorter than for any other disease distribution (p = 0.034). Respective five-year overall, disease-specific, and disease-free survival estimates were 43.8%, 63.8%, and 36.2%. Extracapsular spread (ECS) portended reduced DFS and DSS (p = 0.012 and p = 0.005 respectively). Increasing nodal burden (≥4 involved nodes) also reduced DSS (p = 0.020), while parotid disease alone predicted more favourable DSS (p = 0.008). ECS and isolated parotid involvement remained significant on multi-variate analysis (p = 0.014 and p = 0.028 respectively). CONCLUSIONS: Oncological outcomes were unfavourable but broadly consistent with previous reports, notionally lending support to a more proactive approach in managing the clinically node negative neck/parotid in selected high-risk cases. Our data also support distinct parotid classification and consideration of involved lymph node number in future staging systems.

Improving quality of life through the routine use of the patient concerns inventory for head and neck cancer patients: baseline results in a cluster preference randomised controlled trial.

PURPOSE: The main aim of this paper is to present baseline demographic and clinical characteristics and HRQOL in the two groups of the Patient Concerns Inventory (PCI) trial. The baseline PCI data will also be described. METHODS: This is a pragmatic cluster preference randomised control trial with 15 consultant clusters from two sites either 'using' (n = 8) or 'not using' (n = 7) the PCI at a clinic for all of their trial patients. The PCI is a 56-item prompt list that helps patients raise concerns that otherwise might be missed. Eligibility was head and neck cancer patients treated with curative intent (all sites, stage of disease, treatments). RESULTS: From 511 patients first identified as eligible when screening for the multi-disciplinary tumour board meetings, 288 attended a first routine outpatient baseline study clinic after completion of their treatment, median (IQR) of 103 (71-162) days. At baseline, the two trial groups were similar in demographic and clinical characteristics as well as in HRQOL measures apart from differences in tumour location, tumour staging and mode of treatment. These exceptions were cluster (consultant) related to Maxillofacial and ENT consultants seeing different types of cases. Consultation times were similar, with PCI group times taking about 1 min longer on average (95% CL for the difference between means was from - 0.7 to + 2.2 min). CONCLUSION: Using the PCI in routine post-treatment head and neck cancer clinics do not elongate consultations. Recruitment has finished but 12-month follow-up is still ongoing.

The role of multidisciplinary decision making in oropharyngeal cancer: do we follow guidelines and are treatment decisions being implemented?

PURPOSE: A multidisciplinary team (MDT) approach to cancer management is gold-standard. With an increasing disease incidence and growing research into human papillomavirus (HPV)-related oropharyngeal cancer (OPC), updated UK management guidelines were recently published. This study aimed to evaluate the MDT decision-making process among OPC patients at a tertiary centre. METHODS: MDT meetings over a 12-month period were analysed retrospectively. MDT decisions were compared with guidelines and patient records examined to identify decision implementation. Reasons behind any discordant decisions were explored. RESULTS: This study included 140 OPC patients. Thirty-three (23.6%) were not tested for HPV. Patients over 70 years with a smoking history treated palliatively were less likely to be tested (P = 0.017). Eighty-five percent of MDT decisions followed guidelines with the majority not complying (76.2%) related to patient comorbidity. Ten decisions (7.1%) were not implemented. Reasons included: Seven due to patient choice, of which four patients (57.1%) were only seen following the MDT meeting, and three due to clinician decisions as new clinical information emerged. CONCLUSION: The majority of MDT decisions followed guidelines and any discordant decisions were justifiable. Discussing management options with patients beforehand facilitates decision implementation as decisions can potentially change after seeing the patient. Progress is still needed with regards to HPV testing. Reasons for not testing could include subliminal decision-making among clinicians, and patients falling between centres. Crucially, the role of the MDT in head and neck cancer should be to ratify decisions rather than making them, hence the need to see patients prior to MDT discussion.

TNF-induced inflammatory genes escape repression in fibroblast-like synoviocytes: transcriptomic and epigenomic analysis.

OBJECTIVE: We investigated genome-wide changes in gene expression and chromatin remodelling induced by tumour necrosis factor (TNF) in fibroblast-like synoviocytes (FLS) and macrophages to better understand the contribution of FLS to the pathogenesis of rheumatoid arthritis (RA). METHODS: FLS were purified from patients with RA and CD14+ human monocyte-derived macrophages were obtained from healthy donors. RNA-sequencing, histone 3 lysine 27 acetylation (H3K27ac), chromatin immunoprecipitation-sequencing (ChIP-seq) and assay for transposable accessible chromatin by high throughput sequencing (ATAC-seq) were performed in control and TNF-stimulated cells. RESULTS: We discovered 280 TNF-inducible arthritogenic genes which are transiently expressed and subsequently repressed in macrophages, but in RA, FLS are expressed with prolonged kinetics that parallel the unremitting kinetics of RA synovitis. 80 out of these 280 fibroblast-sustained genes (FSGs) that escape repression in FLS relative to macrophages were desensitised (tolerised) in macrophages. Epigenomic analysis revealed persistent H3K27 acetylation and increased chromatin accessibility in regulatory elements associated with FSGs in TNF-stimulated FLS. The accessible regulatory elements of FSGs were enriched in binding motifs for nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), interferon-regulatory factors (IRFs) and activating protein-1 (AP-1). Inhibition of bromodomain and extra-terminal motif (BET) proteins, which interact with histone acetylation, suppressed sustained induction of FSGs by TNF. CONCLUSION: Our genome-wide analysis has identified the escape of genes from transcriptional repression in FLS as a novel mechanism potentially contributing to the chronic unremitting synovitis observed in RA. Our finding that TNF induces sustained chromatin activation in regulatory elements of the genes that escape repression in RA FLS suggests that altering or targeting chromatin states in FLS (eg, with inhibitors of BET proteins) is an attractive therapeutic strategy.

SAVI SCOUT as a Novel Localization and Surgical Navigation System for More Accurate Localization and Resection of Pulmonary Nodules.

Background. Current techniques for localization and resection of lung nodules carry many intraoperative challenges for surgeons. This article proposes a new localization method for diagnosis and treatment of pulmonary nodules, which provides a navigational system for more accurate lung resection. Methods. We report the case of a 77-year-old female with a pulmonary nodule of the right lower lobe. A nonradioactive localization technology, known as SAVI SCOUT (Cianna Medical Inc, Aliso Viejo, CA), was placed by interventional radiology under computed tomography guidance preoperatively. Using the SCOUT Wire-Free Radar Localization System, the pulmonary nodule was robotically localized and resected. SCOUT removal was confirmed using the Trident Specimen Radiology System. The efficacy of this procedure was evaluated in terms of ease of use and procedure time by interventional radiology, surgical resection accuracy, diagnostic accuracy, simplicity, and ease to implement this technology in an existing hospital. Results. The SCOUT system allowed for the first reported case of successful SCOUT placement in lung tissue, targeted the pulmonary nodule intraoperatively, and facilitated accurate lung resection. Conclusions. The SCOUT system shows promising advancements in the ability to eliminate many challenges currently seen with lung nodule localization and resection.

Case management in early psychosis intervention programme: Perspectives of clients and caregivers.

AIM: This qualitative study explored the perspectives of clients and caregivers on case management provided by the Singapore Early Psychosis Intervention Programme (EPIP), with the intent to understand the salient aspects of case management from their perspective. METHODS: Clients and their caregivers were recruited from the EPIP outpatient clinics. Focus group discussions (FGDs) were conducted at a community centre outside the hospital with 47 clients and 19 caregivers. Facilitators were experienced researchers who were not involved in the care of the clients and trained in qualitative research methodologies. All FGDs were audio recorded and transcribed verbatim with all participants' identifiers omitted to protect confidentiality. Qualitative data analysis was conducted using thematic analysis. RESULTS: There were 11 themes that emerged from the FGDs: therapeutic alliance, holistic monitoring, collaborative role with other care providers, counselling and guidance, crisis management, bridging role, client-centred care, client empowerment and strength building, psychoeducation/education on illness, support and problem solving. "Problem solving" surfaced only from the client FGDs; the remaining themes were common to both groups. CONCLUSIONS: The voices of clients and caregivers are important to EPIP case management service. This study has provided insights into their perspectives, understandings and lived experiences of case management and its impact on clients and caregivers.

Genomic Adequacy from Solid Tumor Core Needle Biopsies of ex Vivo Tissue and in Vivo Lung Masses: Prospective Study.

Purpose To identify the variables and factors that affect the quantity and quality of nucleic acid yields from imaging-guided core needle biopsy. Materials and Methods This study was approved by the institutional review board and compliant with HIPAA. The authors prospectively obtained 232 biopsy specimens from 74 patients (177 ex vivo biopsy samples from surgically resected masses were obtained from 49 patients and 55 in vivo lung biopsy samples from computed tomographic [CT]-guided lung biopsies were obtained from 25 patients) and quantitatively measured DNA and RNA yields with respect to needle gauge, number of needle passes, and percentage of the needle core. RNA quality was also assessed. Significance of correlations among variables was assessed with analysis of variance followed by linear regression. Conditional probabilities were calculated for projected sample yields. Results The total nucleic acid yield increased with an increase in the number of needle passes or a decrease in needle gauge (two-way analysis of variance, P < .0001 for both). However, contrary to calculated differences in volume yields, the effect of needle gauge was markedly greater than the number of passes. For example, the use of an 18-gauge versus a 20-gauge biopsy needle resulted in a 4.8-5.7 times greater yield, whereas a double versus a single pass resulted in a 2.4-2.8 times greater yield for 18- versus 20-gauge needles, respectively. Ninety-eight of 184 samples (53%) had an RNA integrity number of at least 7 (out of a possible score of 10). Conclusion With regard to optimizing nucleic acid yields in CT-guided lung core needle biopsies used for genomic analysis, there should be a preference for using lower gauge needles over higher gauge needles with more passes. ©RSNA, 2016 Online supplemental material is available for this article. An earlier incorrect version of this article appeared online. This article was corrected on October 21, 2016.

Usefulness of intra-procedural cone-beam computed tomography in modified balloon-occluded retrograde transvenous obliteration of gastric varices.

AIM: To evaluate whether intra-procedural cone-beam computed tomography (CBCT) performed during modified balloon-occluded retrograde transvenous obliteration (mBRTO) can accurately determine technical success of complete variceal obliteration. METHODS: From June 2012 to December 2014, 15 patients who received CBCT during mBRTO for treatment of portal hypertensive gastric variceal bleeding were retrospectively evaluated. Three-dimensional (3D) CBCT images were performed and evaluated prior to the end of the procedure, and these were further analyzed and compared to the pre-procedure contrast-enhanced computed tomography to determine the technical success of mBRTO including: Complete occlusion/obliteration of: (1) gastrorenal shunt (GRS); (2) gastric varices; and (3) afferent feeding veins. Post-mBRTO contrast-enhanced CT was used to confirm the accuracy and diagnostic value of CBCT within 2-3 d. RESULTS: Intra-procedural 3D-CBCT images were 100% accurate in determining the technical success of mBRTO in all 15 cases. CBCT demonstrated complete occlusion/obliteration of GRS, gastric varices, collaterals and afferent feeding veins during mBRTO, which was confirmed with post-mBRTO CT. Two patients showed incomplete obliteration of gastric varices and feeding veins on CBCT, which therefore required additional gelfoam injections to complete the procedure. No patient required additional procedures or other interventions during their follow-up period (684 ± 279 d). CONCLUSION: CBCT during mBRTO appears to accurately and immediately determine the technical success of mBRTO. This may improve the technical and clinical success/outcome of mBRTO and reduce additional procedure time in the future.

Dosimetric comparison of brachyablation and stereotactic ablative body radiotherapy in the treatment of liver metastasis.

PURPOSE: We compared the dosimetry of brachyablation (BA) and stereotactic ablative radiotherapy (SABR) in the treatment of liver metastases. METHODS AND MATERIALS: Treatment plans for 10 consecutive liver metastasis patients, treated with SABR, were replanned for BA. BA treatment was planned using five 12 Gy fractions to the same planning target volume (PTV) used for SABR. Dosimetric parameters were compared using a Student's paired t test. RESULTS AND CONCLUSIONS: BA and SABR plans had similar mean volume receiving 100% of the prescribed dose (94.1% vs. 93.9% of PTV, p = 0.8). Mean volume receiving 150% of the prescribed dose for BA was 63.6%, whereas for SABR it was 0. The minimum dose to the PTV was 65.8% for BA, whereas for SABR it was 87.4% (p = 0.0002). Liver volume receiving ≥15 Gy was similar for BA and SABR (278 vs. 256 cc, p = 0.3). Small bowel mean dose, as percent prescription dose, was higher for BA (10.8% vs. 7.1%, p = 0.006). Stomach mean dose was similar (4.9% vs. 4.8% of prescription dose, p = 0.98). Right kidney mean dose was greater for BA (6.7% vs. 4.2%, p = 0.07). BA leads to a higher target dose, similar dose to organs at risk, but potentially with lower target coverage compared with SABR. Further work is needed to determine ideal suitability for mono vs. combination therapy with this approach.

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results.

OBJECTIVES: To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage. METHODS: From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up. RESULTS: A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days. CONCLUSIONS: CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding.

Immune responses to pneumococcal pilus RrgA and RrgB antigens and their relationship with pneumococcal carriage in humans.

OBJECTIVES: Pneumococcal pilus antigens are shown to be important in pneumococcal pathogenesis and induce protective immunity in animal studies, but data in humans are limited. We aimed to investigate serum and mucosal immune responses to pilus-1 proteins (RrgA and RrgB) and their relationship with pneumococcal carriage in humans. METHODS: Serum and salivary antibodies to RrgA and RrgB in children and adults were analysed by ELISA and immunoblotting. Induction of B cell antibody responses to RrgA and RrgB in nasopharynx-associated lymphoid tissue was studied by ELISpot assay following stimulation with pneumococcal culture supernatants containing pilus proteins. RESULTS: Significant levels of serum anti-RrgA and -RrgB antibodies were observed, and anti-RrgA antibody appeared to develop earlier in childhood. Importantly, anti-RrgA IgG titres in both serum and saliva were shown to be higher in culture-negative children than in those who were culture-positive for Streptococcus pneumoniae. Stimulation of adenotonsillar cells with pneumococcal culture supernatant induced significant RrgA- and RrgB-specific antibody secreting cells and antibody production. CONCLUSIONS: Pneumococcal pilus antigens, particularly RrgA, seem to induce significant serum and mucosal antibody responses that may contribute to natural immunity against pneumococcal carriage in children.

Subcutaneous T-fastener gastropexy: a new technique.

OBJECTIVE: T-fastener gastropexy is a step in percutaneous radiologic gastrostomy in which the stomach is fastened to the abdominal wall. Minor complications of gastropexy are often related to the prolonged presence of T-fastener sutures. We describe a new technique for gastropexy using absorbable sutures placed subcutaneously, as opposed to the standard percutaneous approach. CONCLUSION: Subcutaneous gastropexy is safe, obviates follow-up suture removal, and eliminates complications associated with cutaneous sutures.

Non-super-selective venous sampling for persistent hyperparathyroidism using a systemic hypocalcemic challenge.

PURPOSE: To describe a new protocol employing an acute systemic hypocalcemic challenge (SHC) aimed at augmenting the parathyroid hormone (PTH) gradient to enable non-super-selective venous sampling (VS) in patients with persistent primary hyperparathyroidism (PHPT). MATERIALS AND METHODS: In a retrospective study, 37 patients (39 studies-20 SHC, 19 super-selective VS) who underwent VS for persistent or recurrent PHPT were examined. Study patients were pretreated with intravenous hydration, diuretics, and bicarbonate to induce temporary relative hypocalcemia and then underwent non-super-selective VS targeted at large vessels within the neck and chest with rapid PTH testing. The traditional VS protocol involved super-selective VS with arteriography. RESULTS: SHC decreased ionized calcium by 0.098 mmol/L ± 0.18 (P = .07) and increased peripheral PTH by 10.2 pg/mL (P = .58). Positive VS gradients, defined as a ≥ 1.4-fold difference from baseline to after SHC, were detected in 95% of patients. VS findings guided successful surgery in 77% of SHC cases and 90% of super-selective VS cases; the peak gradient site was concordant with operative findings in 46% of SHC cases and 80% of super-selective VS cases. Avoidance of super-selective sampling decreased mean fluoroscopy time from 91 minutes to 33 minutes and decreased contrast material administered from 204 mL to 63 mL (both P < .0001). CONCLUSIONS: The SHC protocol to enable non-super-selective VS in patients with persistent PHPT had the same ability as super-selective VS to detect a positive (≥ 1.4-fold) PTH gradient, was associated with decreased accuracy in identifying the site of the adenoma compared with super-selective VS, and significantly decreased contrast material used and fluoroscopy time.

Particle embolization to control life-threatening hemorrhage from a fungating locally advanced breast carcinoma: a case report.

INTRODUCTION: Sudden severe hemorrhage from locally advanced fungating breast carcinoma and its associated cutaneous lesions is rarely reported. Transcatheter arterial embolization has been used widely in the setting of intractable neoplastic hemorrhage arising from primary and metastatic tumors of the lung, liver, kidney, and gastrointestinal tract. Here, we detail the use of transcatheter arterial embolization in controlling torrential hemorrhage in a patient with advanced invasive breast cancer and multiple comorbidities. CASE PRESENTATION: We report the case of a 28-year-old African-American woman who presented with acute torrential hemorrhage from a high-grade invasive ductal breast carcinoma. A computed tomography scan demonstrated a 14cm mass with extensive muscle, fascial, and cutaneous invasion. Owing to the extent of invasion and multiple comorbidities, she was deemed to be unsuitable for surgical management. Selective angiography of the left internal mammary artery revealed no tumoral blush, extravasation, or pseudoaneurysm. Transcatheter arterial embolization was undertaken, and complete occlusion of the vessel was demonstrated. No further episodes of hemorrhage occurred. CONCLUSIONS: Though rare, sudden severe hemorrhage from advanced breast cancer may be definitively managed by embolization alone and thus surgery may be avoided.