Hepatic Hilar Nerve Block for Adjunctive Analgesia during Percutaneous Thermal Ablation of Hepatic Tumors: A Retrospective Analysis.

PURPOSE: To determine whether hepatic hilar nerve block techniques reduce analgesic and sedation requirements during percutaneous image-guided thermal ablation of hepatic tumors. MATERIALS AND METHODS: A single-center retrospective cohort analysis was performed of 177 patients (median age, 67 years; range, 33-86 years) who underwent percutaneous image-guided thermal ablation of liver tumors. All patients were treated utilizing local anesthetic and moderate sedation between November 2018 and November 2021 at a tertiary level hospital, with or without the administration of a hepatic hilar nerve block. Univariable and multivariable linear regression analyses were performed to determine the relationship between the administration of the hilar nerve block and fentanyl and midazolam dosages. RESULTS: A total of 114 (64%) patients received a hilar nerve block in addition to procedural sedation, and 63 (36%) patients received procedural sedation alone. There were no significant differences in the baseline demographic and tumor characteristics between the cohorts. The procedure duration was longer in the hilar block cohort than in the unblocked cohort (median, 95 vs 82 minutes; P = .0012). The technical success rate (98% in both the cohorts, P = .93) and adverse event rate (11% vs 3%, P = .14) were not significantly different between the cohorts. After adjusting for patient and tumor characteristics, ablation modality, and procedure and ablation durations, hilar nerve blocks were associated with lower fentanyl (-18.4%, P = .0045) and midazolam (-22.7%, P = .0007) dosages. CONCLUSIONS: Hepatic hilar nerve blocks significantly decrease the fentanyl and midazolam requirements during thermal ablation of hepatic tumors, without a significant change in the technical success or adverse event rates.

Hepatic Hilar Nerve Block for Hepatic Interventions: Anatomy, Technique, and Initial Clinical Experience in Thermal Ablation of Liver Tumors.

Background Image-guided procedures for treatment of liver diseases can be painful and require heavy sedation of the patient. Local-regional nerve blocks improve pain control and reduce oversedation risks, but there are no documented liver-specific nerve blocks. Purpose To develop a safe and technically simple liver-specific nerve block. Materials and Methods Between March 2017 and October 2019, three cadavers were dissected to evaluate the hepatic hilar anatomy. The hepatic hilar nerves were targeted with transhepatic placement of a needle adjacent to the main portal vein, under US guidance, and evaluated with use of an injection of methylene blue. A hepatic nerve block, using similar technique and 0.25% bupivacaine, was offered to patients undergoing liver tumoral ablation. In a prospective pilot study, 12 patients who received the nerve block were compared with a control group regarding complications, safety, pain scores, and intraoperative opioid requirement. Student t tests were used to compare the groups' characteristics, and Mann-Whitney U tests were used for the measured outcomes. Results Cadaver results confirmed that the hepatic nerves coursing in the hepatic hilum can be targeted with US for injection of anesthetic agents, with adequate spread of injected methylene blue around the nerves in the hepatic hilar perivascular space. The 12 participants (mean age ± standard deviation, 66 years ± 13; eight men) who received a hepatic hilar block before liver thermal ablations demonstrated reduced pain compared with a control group of 12 participants (mean age, 63 years ± 15; eight men) who received only intravenous sedation. Participants who received the nerve block had a lower mean visual analog scale score for pain than the control group (3.9 ± 2.4 vs 7.0 ± 2.8, respectively; P = .01) and decreased need for intraprocedural fentanyl (mean dose, 152 µg ± 78.0 vs 235.4 µg ± 58.2, respectively; P = .01). No major complications occurred in the hepatic hilar nerve block group. Conclusion A dedicated hepatic hilar nerve block with 0.25% bupivacaine can be safely performed to provide anesthesia during liver tumoral ablation. © RSNA, 2021.

International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres.

PURPOSE: A multidisciplinary expert panel convened to formulate state-of-the-art recommendations for optimisation of selective internal radiation therapy (SIRT) with yttrium-90 (90Y)-resin microspheres. METHODS: A steering committee of 23 international experts representing all participating specialties formulated recommendations for SIRT with 90Y-resin microspheres activity prescription and post-treatment dosimetry, based on literature searches and the responses to a 61-question survey that was completed by 43 leading experts (including the steering committee members). The survey was validated by the steering committee and completed anonymously. In a face-to-face meeting, the results of the survey were presented and discussed. Recommendations were derived and level of agreement defined (strong agreement ≥ 80%, moderate agreement 50%-79%, no agreement ≤ 49%). RESULTS: Forty-seven recommendations were established, including guidance such as a multidisciplinary team should define treatment strategy and therapeutic intent (strong agreement); 3D imaging with CT and an angiography with cone-beam-CT, if available, and 99mTc-MAA SPECT/CT are recommended for extrahepatic/intrahepatic deposition assessment, treatment field definition and calculation of the 90Y-resin microspheres activity needed (moderate/strong agreement). A personalised approach, using dosimetry (partition model and/or voxel-based) is recommended for activity prescription, when either whole liver or selective, non-ablative or ablative SIRT is planned (strong agreement). A mean absorbed dose to non-tumoural liver of 40 Gy or less is considered safe (strong agreement). A minimum mean target-absorbed dose to tumour of 100-120 Gy is recommended for hepatocellular carcinoma, liver metastatic colorectal cancer and cholangiocarcinoma (moderate/strong agreement). Post-SIRT imaging for treatment verification with 90Y-PET/CT is recommended (strong agreement). Post-SIRT dosimetry is also recommended (strong agreement). CONCLUSION: Practitioners are encouraged to work towards adoption of these recommendations.

Early clinical experience with a touchless image navigation interface for the endovascular suite.

Introduction: The inability to having comprehensive access to all pertinent imaging data related to an endovascular procedure in the sterile field is an unmet need, and its absence may have deleterious effects on decision-making, outcomes and workflow. Current image navigation solutions rely on traditional personal computing interfaces which are difficult to use in the sterile field. Innovative technological solutions are needed to address this need.Material and methods: Utilizing novel hardware and software integration, a human computer interaction (HCI) based platform has been developed through an iterative design and development process, that allows intuitive real-time access to imaging data in the sterile field. Following validation and pre-clinical testing, the platform has been introduced to the endovascular suite for clinical use.Results: Three prospective case-based observational reviews are presented that demonstrate the utility of touchless image navigation in the sterile field in facilitating decision-making and resource utilization during endovascular procedures, while avoiding the cognitive and workflow disturbances inherent in leaving the sterile field or involving non-scrubbed third persons in the image navigation process.Conclusion: Physician engagement and 'needs-based' technological innovation is needed to improve human computer interaction in the endovascular suite, in hopes of positively affecting procedural decision-making, outcomes, and workflow.

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.

Intraprocedural Parenchymal Blood Volume Is a Predictor of Treatment Response for Chemoembolization in Hepatocellular Carcinoma: Results of a Prospective Study.

PURPOSE: To evaluate cone-beam parenchymal blood volume (PBV) before and after embolization as a predictor of radiographic response to transarterial chemoembolization in unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A phase IIa prospective clinical trial was conducted in patients with HCCs > 1.5 cm undergoing chemoembolization; 52 tumors in 40 patients with Barcelona Clinic Liver Criteria stage B disease met inclusion criteria. Pre- and postembolization PBV analysis was performed with a semiquantitative best-fit methodology for index tumors, with a predefined primary endpoint of radiographic response at 3 months. Analyses were conducted with Wilcoxon signed-rank tests and one-way analysis of variance on ranks. RESULTS: Mean tumoral PBV measurements before and after embolization were 170 mL/1,000 mL ± 120 and 0 mL/100 mL ± 130, respectively. Per modified Response Evaluation Criteria In Solid Tumors, 25 tumors (48%) exhibited complete response (CR), 13 (25%) partial response (PR), 3 (6%) stable disease (SD), and 11 (21%) progressive disease (PD). Statistically significant changes in median PBV (ΔPBV) were identified in the CR (P = .001) and PR (P = .003) groups, with no significant difference observed in SD (P = .30) and PD groups (P = .06). A statistically significant correlation between ΔPBV and tumor response was established by one-way analysis of variance on ranks (P = .036; CR, 200 mL/100 mL ± 99; PR, 240 mL/100 mL ± 370; SD, 64 mL/100 mL ± 99; PD, 88 mL/100 mL ± 129). CONCLUSIONS: Intraprocedural PBV can be used as a predictor of response in index HCC tumors of > 1.5 cm.

Use of blood pool agents with steady-state MRI to assess the vascular system.

Over the past two decades there have been significant advances in the use of magnetic resonance imaging (MRI) to assess the vascular system. New imaging sequences and improvements in magnet design have enabled the creation of higher spatial resolution images. MRI is now a viable alternative imaging modality when compared to both invasive angiography and computed tomographic angiography. The use of blood pool agents has further facilitated the use of MR angiography (MRA); their high molecular weight allows for lower doses of contrast medium administration while their prolonged presence in the blood stream allows for repeated high-quality volumetric imaging of both the arterial and venous circulation. As such, MRA is now no longer constrained by the tight windows for first-pass arterial and venous enhancement, which has resulted in the ability to assess and diagnose a large range of vascular pathologies in both arterial and venous systems. The intent of this review is to highlight MRI findings in common vascular pathologies including peripheral arterial disease (PAD), abnormalities of the abdominal aortic branches, postendovascular aortic aneurysm repair (EVAR) endoleak assessment, popliteal artery entrapment syndrome (PAES), deep venous thrombosis (DVT), vascular thoracic outlet syndrome (TOS), and vascular malformations. In addition, the latest MRI techniques currently used to optimally assess each of these pathologies will be discussed. LEVEL OF EVIDENCE: 5 Technical Efficacy: Stage 3 J. MAGN. RESON. IMAGING 2017;45:1559-1572.

State of the ablation nation: a review of ablative therapies for cure in the treatment of hepatocellular carcinoma.

Primary liver cancer, mainly hepatocellular carcinoma, is one of the most common malignancies worldwide. Surgical management, either resection or transplantation, is considered definitive treatment, however, less than 20% of patients are ultimately candidates. Thermal ablation modalities such as radiofrequency ablation and microwave ablation have evolved such that these modalities have been applied with curative intent. Moreover, thermal ablation has demonstrated efficacy in treating early-stage tumors and can be offered as first-line treatment in patients with uncomplicated disease. Attributing to refinements in technology and techniques, recent studies evaluating stereotactic ablative body radiotherapy have shown promising results, while irreversible electroporation, an emerging modality, may further expand the role of ablative therapy in treating potentially resectable hepatocellular carcinoma.

Transradial Access for Interventional Radiology: Single-Centre Procedural and Clinical Outcome Analysis.

PURPOSE: The study sought to describe a single centre's technical approach to transradial intervention and report on clinical outcomes and safety. METHODS: A total of 749 transradial access (TRA) procedures were performed at a single hospital in 562 patients (174 women and 388 men). Procedures included 445 bland embolizations or chemoembolizations of the liver, 88 uterine artery embolizations, and 148 procedures for Selective Internal Radiation Therapy (Y90), which included mapping and administration. The mean age of the patients was 62 years (range 27-96 years). RESULTS: Four cases (0.5%) required crossover to transfemoral (tortuous anatomy, inability to secure a stable position for embolization, vessel spasm and base catheter not being of a sufficient length). A single asymptomatic, short-segment radial artery occlusion occurred (0.3%), 3 patients (0.4%) developed small hematomas postprocedurally, and 2 patients (0.7%) had transient neurological pain, which was resolved within a week without treatment. It was found that 98% of patients who had a previous femoral access procedure would choose radial access for subsequent procedures. CONCLUSIONS: Transradial access is a safe, effective technique, with a learning curve; however, this procedure has the potential to significantly improve departmental workflow and cost savings for the department and patient experience.

A review of conventional and drug-eluting chemoembolization in the treatment of colorectal liver metastases: principles and proof.

The management of colorectal liver metastasis has undergone a significant change since the development of novel ablation and embolization. Drug-eluting microsphere platforms, designed to deliver targeted concentrations of systemic therapy directly into the tumor via its arterial vasculature, have garnered interest and gained in popularity in recent years. Based on in vitro and in vivo data, multiple factors contribute to locoregional exposure including carrier base, smaller particle size (larger surface area), chemotherapeutic and chemotherapeutic intensity. Based on the current published clinical data, therapy appears well tolerated but the questions remain as to the ideal technique, patient population and overall efficacy. The purpose of this article is to provide a perspective on the scientific basis, and clinical review of the current data supporting the use of this platform in the setting of metastatic colorectal carcinoma.

The Role of Contrast-enhanced Ultrasound in Guiding Radiofrequency Ablation of Hepatocellular Carcinoma: A Retrospective Study.

PURPOSE: The objective of the study was to determine the efficacy of contrast-enhanced ultrasound (CEUS) using ultrasound (US)-specific microbubbles in guiding radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC). METHODS: A retrospective analysis of 50 patients with HCC treated with CEUS guided RFA using perflutren at our institution was performed. CEUS images were first compared to B-mode US images performed at the same RFA session to determine the ability of CEUS to increase the conspicuity of lesions. A qualitative score (1 = poor, 2 = fair, 3 = excellent) was used to grade the ability to visualize the lesions. The preprocedure CEUS images were then evaluated using the most recent prior contrast enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The efficacy of the treatment was evaluated with short-term follow-up imaging (median 1 month) for presence of residual or recurrent disease. RESULTS: CEUS allows at least fair visualization (score ≥2) in 78% (reader 1) and 80% (reader 2) of the lesions not visualized by B-mode US, and 50% (reader 1) and 42% (reader 2) of the lesions poorly visualized by B-mode US. Lesion appearances on CEUS are largely concordant with those on CT or MRI: 88% for reader 1, 96% for reader 2. With CEUS-guided RFA, complete response was achieved in the vast majority of the lesions at short-term follow-up: 82% for reader 1, 94% for reader 2. CONCLUSIONS: CEUS increases the conspicuity and provides better characterization of hypervascular HCC that are either not seen or poorly seen on B-mode US, and CEUS provides real-time guidance of RFA with good short-term treatment responses.

A practical guide to magnetic resonance vascular imaging: techniques and applications.

Magnetic resonance angiography is a technique used to image both central and peripheral arteries using contrast and noncontrast techniques. These techniques are similar in that a bright signal, which appears white within blood vessels, is generated and the background tissues, veins, and stationary tissues are dark. This allows for assessment of anatomy and vascular disease. Extracellular gadolinium-based contrast agents allow for excellent visualization of both central and peripheral arteries. Acquiring images during first pass is required for high-contrast images within arteries, thereby limiting contamination with contrast enhancement of veins and soft tissue. Contrast-enhanced techniques using time-resolved angiography and blood pool contrast agents minimize this temporal limitation. Noncontrast techniques eliminate the uncommon but potentially fatal complications associated with gadolinium contrast agents, such as nephrogenic systemic fibrosis. These techniques including phase contrast and time-of-flight sequences have inferior contrast resolution compared with contrast-enhanced techniques and are susceptible to artifacts, which can limit interpretation. The advantage, however, is the ability to assess vascular disease in patients with severe renal failure without the added risks of gadolinium contrast media. The aim of this review is to outline the different techniques available for imaging both the arterial and venous systems, their advantages and disadvantages, and the indications in vascular disease.

Diagnosis and therapy of acute hemorrhage in patients with pelvic fractures.

Within the past 15 years, significant advances in the imaging of multiorgan and complex trauma primarily due to the improvement of cross-sectional imaging have resulted in the optimization of the expedient diagnosis and management of the polytrauma patient. At the forefront, multidetector computed tomography (MDCT) has become the cornerstone of modern emergency departments and trauma centers. In many institutions, MDCT is the de facto diagnostic tool upon trauma activation. In the setting of pelvic imaging, MDCT (with its high spatial resolution and sensitivity as well as short acquisition times) allows for rapid identification and assessment of pelvic hemorrhage leading to faster triage and definitive management. In trauma centers throughout the world, angiography and minimally invasive catheter-based embolization techniques performed by interventional radiologists have become the standard of care for patients with acute pelvic trauma and related multiorgan hemorrhage. In an interdisciplinary setting, embolization may be performed either alone or as an adjunct procedure with open or closed reduction and stabilization techniques. A team-based approach involving multiple disciplines (e.g., radiology, traumatology, orthopedic surgery, intensive care medicine) is crucial to monitor and treat the actively bleeding patient appropriately.

The evolution of immune checkpoint inhibitor combinations in advanced hepatocellular carcinoma - A systematic review.

BACKGROUND AND OBJECTIVE: Since approval of sorafenib in 2008, systemic therapy has been established as the main treatment option for advanced hepatocellular carcinoma (HCC). Recently, immune checkpoints inhibitors (ICIs) have been extensively tested in this setting. Multiple ICI combination regimens have recently received regulatory approval and new data continues to emerge. The purpose of this review is to provide a comprehensive summary of the most up-to-date evidence on ICI combinations in advanced HCC. METHODS: A search of published and presented literature was conducted to identify phase III trials of ICI combinations in advanced HCC patients. Supplemental bibliographic search of review articles and meta-analyses was also conducted. Efficacy and safety data was summarized in text, tables, and plots. FINDINGS AND DISCUSSION: The literature search identified a total of six phase III trials assessing ICI combinations in advanced HCC. Two trials compared ICI plus anti-VEGF monoclonal antibody combinations to sorafenib, three trials compared ICI plus tyrosine kinase inhibitor (TKI) combinations to TKIs alone, and one trial compared a dual ICI regimen to sorafenib. Statistically significant survival benefits were seen with atezolizumab-bevacizumab and sintilimab-bevacizumab biosimilar as well as durvalumab-tremelimumab and camrelizumab-rivoceranib combinations. ICI combination regimens have also shown improvements in response rates and progression-free survival relative to the previous standard of care, sorafenib, and generally presented predictable and manageable safety profiles. CONCLUSION: ICI combinations represent the new standard of care for advanced HCC. Ongoing randomized trials and real-world evidence will further clarify the role of these combinations in this rapidly evolving field.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada.

BACKGROUND: Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context. METHODS: A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement. RESULTS & CONCLUSION: The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

The road less traveled: importance of the lesser branches of the celiac axis in liver embolotherapy.

Effective treatment of unresectable hepatic neoplasms depends on the appropriate identification of tumor arterial supply. Because hepatic tumors derive more than 90% of their blood supply from the hepatic arteries, awareness of common hepatic arterial anatomic variants (e.g., replaced or accessory left or right hepatic artery), as well as parasitized collateral vessels originating from the celiac axis (e.g., right inferior phrenic, omental, and cystic arteries) that can supply hepatic neoplasms-particularly those with a surface location-is important for safe and effective interventional therapy for these tumors. Moreover, recognition of certain nonhepatic branches arising from the hepatic arterial circulation is important for optimizing transarterial therapy and blocking the passage of treatment particles into sensitive structures, thereby preventing unwanted clinical sequelae such as gastrointestinal ulceration, skin ulceration or pain, and, rarely, ischemic cholecystitis.

Clinical consensus statement: Selective internal radiation therapy with yttrium 90 resin microspheres for hepatocellular carcinoma in Asia.

BACKGROUND: Hepatocellular carcinoma (HCC) is subject to different management approaches and guidelines according to Eastern and Western therapeutic algorithms. Use of selective internal radiation therapy (SIRT) with resin yttrium 90 microspheres for HCC has increased in Asia in recent years, without clearly defined indications for its optimal application. The objective of this systematic review and expert consensus statement is to provide guidance and perspectives on the use of SIRT among patients with HCC in Asia. MATERIALS AND METHODS: A systematic literature review identified current publications on HCC management and SIRT recommendations. A group of 10 experts, representing stakeholder specialties and countries, convened between August 2020 and March 2021 and implemented a modified Delphi consensus approach to develop guidelines and indications for use of SIRT for HCC in Asia. Final recommendations were organized and adjudicated based on the level of evidence and strength of recommendation, per approaches outlined by the American College of Cardiology/American Heart Association and Oxford Centre for Evidence-Based Medicine. RESULTS: The experts acknowledged a general lack of evidence relating to use of SIRT in Asia and identified as an unmet need the lack of phase 3 randomized trials comparing clinical outcomes and survival following SIRT versus other therapies for HCC. Through an iterative process, the expert group explored areas of clinical relevance and generated 31 guidance statements and a patient management algorithm that achieved consensus. CONCLUSION: These recommendations aim to support clinicians in their decision-making and to help them identify and treat patients with HCC using SIRT in Asia. The recommendations also highlight areas in which further clinical trials are needed to define the role of SIRT in management of HCC among Asian populations.

Elution characteristics of doxorubicin-loaded microspheres differ by drug-loading method and microsphere size.

PURPOSE: To examine the loading and elution behavior of doxorubicin and superabsorbent polymer microspheres (SAP-MS) as they relate to particle size and loading techniques. MATERIALS AND METHODS: SAP-MS, 30-60 µm and 50-100 µm, were subject to loading 50 mg of doxorubicin from a dry lyophilized state. Doxorubicin loading was performed after prehydration of SAP-MS (one-step method) or serially in two divided administrations (two-step method). Loading rate and elution characteristics were determined after doxorubicin analysis using a high-pressure liquid chromatography (HPLC) assay. All experiments were performed in triplicate. RESULTS: All systems showed the ability to load and elute doxorubicin effectively in the specified time frame (loading 15 minutes to 2 hours and elution 1 hour to 14 days). For the two loading methods, 30-60 µm SAP-MS showed no statistically significant difference in loading rate but a statistically significant difference in cumulative elution at 14 days (19.13 mg vs 17.83 mg, one-step vs two-step; P = .02). For the two loading methods, 50-100 µm SAP-MS showed no statistically significant difference in loading rate and no statistically significant difference in cumulative elution at 14 days (14.87 mg vs 12.77 mg, one-step vs two-step; P = .20). CONCLUSIONS: SAP-MS exhibit the ability to load and release doxorubicin. In comparing particle size and loading methods, higher cumulative elution rates were associated with smaller (30-60 µm) particle size and one-step loading. Higher elution from the one-step loading method may be due to release of unbound doxorubicin. Differences in the loading and elution of doxorubicin may depend on the increased surface area of smaller SAP-MS resulting in alterations of behavior of doxorubicin and its interactions with the polymer microspheres.

Fire and ice: percutaneous ablative therapies and cement injection in management of metastatic disease of the spine.

Oncology intervention is actively moving beyond simple bone cement injection. Archimedes taught us that a volume displaces its volume. Where does the tumor we displace with our cement injection go? It is no longer acceptable that we displace tumor into the venous system with our cement injections. We must kill the tumor first. Different image-guided percutaneous techniques can be used for treatment in patients with primary or secondary bone tumors. Curative ablation can be applied for the treatment of specific benign or in selected cases of malignant localized spinal tumors. Pain palliation therapy of primary and secondary bone tumors can be achieved with safe, fast, effective, and tolerable percutaneous methods. Ablation (chemical, thermal, mechanical), cavitation (radiofrequency ionization), and consolidation (cementoplasty) techniques can be used separately or in combination. Each technique has its indications, with both advantages and drawbacks. To prevent pathological fractures, a consolidation is necessary. In spinal or acetabular tumors, a percutaneous cementoplasty should be associated with cryoablation to avoid a compression fracture. The cement is injected after complete thawing of the ice ball or the day after the cryotherapy. A syndrome of multiorgan failure, severe coagulopathy, and disseminated intravascular coagulation following hepatic cryoablation has been described and is referred to as the cryoshock phenomenon.

Social determinants of health for Native Hawaiian children and adolescents.

INTRODUCTION: Traditional Hawaiian thought places children in a position of prominence in the family. Yet in Hawai'i, Native Hawaiian children and adolescents face significant inequity in health outcomes. From prenatal alcohol and tobacco use, late or no prenatal care, macrosomia as well as low birth rates, to exclusive breastfeeding rates at 6 months, and high rates of infant mortality, Native Hawaiians face inequities in pre and early childhood indicators. During childhood and adolescence, Native Hawaiians experience high rates of obesity, and physical, mental and sexual abuse. This review examines the determinants behind the health inequities encountered by Native Hawaiian children and adolescents, and contextualizes those inequities s in a human rights-based approach to health. METHODS: A literature review was conducted for relevant research on Native Hawaiian and other indigenous children and adolescents. Existing data sources were also reviewed for relevant Native Hawaiian data. RESULTS: There is a significant dearth of data on the determinants of health for Native Hawaiian children and adolescents. Some prenatal data is available from the Prenatal Risk Assessment Monitoring System, while selected youth data is available from the Youth Behavioral Risk Factor system. Available data show significant inequities for Native Hawaiian children and adolescents, compared to other groups in Hawai'i. Based on comparisons with other indigenous and marginalized peoples, the etiology of these disparities may be a lack of health equity, deriving from multigenerational trauma and discrimination as well as poverty and inequities of housing, education, environment, healthcare access, and social capital. CONCLUSIONS: The significant barriers facing Native Hawaiian children and adolescents achieving their full potential constitute a challenge to the fulfillment of the human right to health. Future research needs to more fully articulate the linkage between the health status of Native Hawaiian children and adolescents, the determinants of that status, and the requirements of the human right to health. Needed particularly are longitudinal studies which provide data that may link multigenerational trauma and discrimination to poverty and other factors, ultimately producing healthy inequity for Native Hawaiian children and adolescents.