Reappraisal of Percutaneous Transhepatic Biliary Drainage Tract Recurrence After Resection of Perihilar Bile Duct Cancer

Background

The high incidence of percutaneous transhepatic biliary drainage (PTBD) tract recurrence after resection of perihilar bile duct cancer (BDC) at a reference single center has suggested the need for endoscopic biliary drainage (EBD) to prevent PTBD-related tumor recurrence. To determine the general applicability of these findings, we validated the risk of PTBD tract recurrence in patients with resected BDC in our high-volume center.

Methods

The medical records of 306 patients with perihilar BDC who underwent hepatobiliary resection with curative intent over 10?years were reviewed retrospectively.

Results

Of the 306 patients, 293 (95.8%) underwent biliary decompression, 171 (56.1%) by preoperative PTBD, 62 (20.3%) by EBD alone, and 60 (19.7%) by both. Of the 231 patients who underwent PTBD, 160 (69.3%), 62 (26.8%), and 9 (3.9%) had one, two, or three catheters, respectively (mean of 1.3 catheters per patient for a median 23?days). No patient experienced synchronous PTBD tract metastasis, whereas 4 (1.7%) experienced PTBD tract recurrence a median 13.5?months after surgery, with 3 of these patients having an intraabdominal recurrence soon afterward. Only one patient had a solitary tract recurrence without intraabdominal metastasis. These patients survived for a median 25?months, which is comparable to survival outcomes after noncurative resection. No risk factor was significantly associated with PTBD tract recurrence.

Conclusions

We think that the risk of PTBD tract recurrence after resection of perihilar BDC is not negligible but is much lower than previously reported. There is no definitive reason to avoid PTBD when it is indicated.     

Combined tadalafil and α-blocker therapy for benign prostatic hyperplasia in patients with erectile dysfunction: a multicenter, prospective study

This prospective study evaluated the safety of tadalafil 5 mg taken once a day in terms of hypotensive side effects and whether it improves lower urinary tract symptoms (LUTS) and restores sexual function in patients with erectile dysfunction who are receiving concomitant α-blocker (AB) therapy for benign prostatic hyperplasia (BPH). A total of 158 LUTS/BPH patients receiving AB therapy for ≥3 months were given tadalafil 5 mg once a day. Before treatment with tadalafil (V1), and 4 weeks (V2) and 12 weeks (V3) after starting tadalafil, blood pressure, heart rate, International Prostate Symptom Score (IPSS), maximal urine flow rate (Qmax), postvoiding residual urine volume, and International Index of Erectile Function (IIEF-5) score were measured. Of the 158 LUTS/BPH patients, a total of 119 completed the trial. Blood pressure (systolic and diastolic) and heart rate did not change. IPSS and IIEF-5 scores improved significantly, but Qmax and postvoiding residual urine volume did not; however, in the 39 men with a low baseline Qmax (≤10 mL/s), Qmax rose significantly from 7.97 ± 1.44 mL/s (baseline) to 8.91 ± 1.60 mL/s (V3; P = .012). The remaining patients (baseline Qmax >10 mL/s) did not change. At V2 and V3, adverse side effects were observed in 10 men (7.30%) and 6 men (5.04%), respectively. Facial flushing was the most common adverse side effect (6 men at V2 and 4 men at V3), followed by headache (2 men each at V2 and V3) and dizziness (2 men at V2). Two patients dropped out of the study because of adverse side effects. In conclusion, tadalafil 5 mg once a day in combination with AB appeared to have few adverse effects on hypotensive events and can improve LUTS and restore sexual function.     

The optimal dose of esmolol and nicardipine for maintaining cardiovascular stability during rapid-sequence induction

Study ObjectiveTo determine the optimal dose of esmolol in combination with nicardipine in effectively blocking undesirable cardiovascular responses during rapid-sequence induction.DesignProspective, randomized clinical comparison study.SettingOperating room of a university hospital.Patients200 ASA physical status 1 and 2 patients requiring general anesthesia with endotracheal tube placement.InterventionsPatients were randomly allocated into one of 4 groups: Group E0 (no esmolol; control), Group E0.25 (esmolol 0.25 mg/kg), Group E0.5 (esmolol 0.5 mg/kg), and Group E1.0 (esmolol 1.0 mg/kg). All patients received 20 μg/kg of nicardipine, and esmolol was then given according to group allocation. Ninety seconds later, thiopental sodium 5 mg/kg and succinylcholine 1.0 mg/kg were injected. Endotracheal intubation was performed 60 seconds after injection of the anesthetic agents.MeasurementsSystolic (SBP), diastolic (DBP), and mean arterial (MAP) pressures; heart rate (HR), and rate-pressure product (RPP) were measured 30 seconds before and after intubation, and at 1, 3, 5, and 10 minutes after intubation. Rate changes using baseline values as the standard [rate changes = measured value/baseline value × 100 (%)] were calculated.Main ResultsSignificant attenuations in SBP, MAP, HR, and RPP after intubation were noted in the experimental groups as compared with the control group (P < 0.05). Rate changes in HR in Groups E0.5 and E1.0 were significantly lower than those in Group E0.25 immediately and one minute after intubation (P < 0.05). No difference in rate changes in HR were noted between the E0.5 and E1.0 groups.ConclusionsThe combination of nicardipine 20 μg/kg and esmolol 0.5 mg/kg most effectively attenuates the cardiovascular responses during rapid-sequence induction.     

Pitfalls and Important Issues in Testing Reliability Using Intraclass Correlation Coefficients in Orthopaedic Research

Background

Intra-class correlation coefficients (ICCs) provide a statistical means of testing the reliability. However, their interpretation is not well documented in the orthopedic field. The purpose of this study was to investigate the use of ICCs in the orthopedic literature and to demonstrate pitfalls regarding their use.

Methods

First, orthopedic articles that used ICCs were retrieved from the Pubmed database, and journal demography, ICC models and concurrent statistics used were evaluated. Second, reliability test was performed on three common physical examinations in cerebral palsy, namely, the Thomas test, the Staheli test, and popliteal angle measurement. Thirty patients were assessed by three orthopedic surgeons to explore the statistical methods testing reliability. Third, the factors affecting the ICC values were examined by simulating the data sets based on the physical examination data where the ranges, slopes, and interobserver variability were modified.

Results

Of the 92 orthopedic articles identified, 58 articles (63%) did not clarify the ICC model used, and only 5 articles (5%) described all models, types, and measures. In reliability testing, although the popliteal angle showed a larger mean absolute difference than the Thomas test and the Staheli test, the ICC of popliteal angle was higher, which was believed to be contrary to the context of measurement. In addition, the ICC values were affected by the model, type, and measures used. In simulated data sets, the ICC showed higher values when the range of data sets were larger, the slopes of the data sets were parallel, and the interobserver variability was smaller.

Conclusions

Care should be taken when interpreting the absolute ICC values, i.e., a higher ICC does not necessarily mean less variability because the ICC values can also be affected by various factors. The authors recommend that researchers clarify ICC models used and ICC values are interpreted in the context of measurement.     

数字化微笑设计在前牙瓷贴面美学修复中的应用及其修复效果分析

目的：分析结合数字化微笑设计（DSD）进行前牙瓷贴面修复患者的术后满意度及修复体的修复效果,探讨其在前牙美学修复中的应用。方法：选择因四环素牙、氟斑牙、牙体着色、轻度釉质缺损和前牙散在间隙等原因要求进行美学修复,且临床诊断符合贴面修复适应证的患者32例共91颗前牙。术前采用DSD软件对患者进行牙齿形态的美学分析及虚拟修复效果的预览,并在设计结果指导下进行牙体预备,常规印模制取后制作IPS e-max瓷贴面,最后完成永久修复体的戴入。在治疗完成后采用调查问卷的形式让患者对修复体的外形、与邻牙协调程度、颜色、发音、微笑效果和医患交流等6项内容作出满意度评价,并在治疗后1、3、6和12个月参照改良版美国公共卫生署（USPHS）标准对瓷贴面的临床修复效果进行评估。结果：患者对于各项调查内容的满意率均可达90%以上,其中对于微笑效果和医患交流2项满意率高达100%。将DSD应用于瓷贴面修复后,患者对于最终修复体的功能、美学效果和医患交流体验等各方面满意度较高。各时期修复体临床表现,修复后1个月,4颗牙齿出现轻度牙龈炎,3颗牙齿出现术后敏感;修复后3个月,1颗修复体出现不影响美观及功能的微小缺损,3颗牙齿出现牙龈轻度红肿,1颗修复体轻微变色;修复后6个月,1颗修复体出现切缘缺损,4颗牙齿出现轻度牙龈炎;修复后12个月,2颗牙齿出现修复体缺损,3颗牙齿修复体边缘欠密合,1颗牙齿出现牙龈炎。修复后出现牙龈炎症反应的患者在经过正确的口腔卫生指导后牙周状况均有明显好转,且上述缺损均不影响修复体的美观和功能,调磨后可正常使用,医患双方对修复体的修复效果均满意。结论：将DSD与瓷贴面修复联合应用是一种可获得较高患者满意度和理想修复效果的前牙美学修复方案。     

The Role of Donor Bone Marrow Infusions in Withdrawal of Immunosuppression in Adult Liver Allotransplantation

We investigated the role of donor bone marrow cell (DBMC) infusions in immunosuppression withdrawal in adult liver transplantation. Patients enrolled were at least 3 years post-transplantation, with stable graft function. Forty-five (study group: G1) received DBMC, and 59 (control group: G2) did not. Immunosuppression was reduced by one third upon enrollment, by another third the second year of the study and was completely withdrawn the third year. Patient and graft survival were similar between the two groups. Although rejection episodes were significantly less in G1 the first 2 years of the study (35% vs. 57%, p = 0.016), there was no significant difference overall (74% vs. 81%, p = 0.14). Until February 2004, 20 patients, 10 in each group, were immunosuppression free for 1-3 years. Approximately 20% of long-term survivors of liver transplantation can successfully discontinue their immunosuppression. DBMC infusions, do not increase this likelihood.     

Repeatability of hypoxia PET imaging using [<Superscript>18</Superscript>F]HX4 in lung and head and neck cancer patients: a prospective multicenter trial

Purpose

Hypoxia is an important factor influencing tumor progression and treatment efficacy. The aim of this study was to investigate the repeatability of hypoxia PET imaging with [¹⁸F]HX4 in patients with head and neck and lung cancer.

Methods

Nine patients with lung cancer and ten with head and neck cancer were included in the analysis (NCT01075399). Two sequential pretreatment [¹⁸F]HX4 PET/CT scans were acquired within 1 week. The maximal and mean standardized uptake values (SUV_max and SUV_mean) were defined and the tumor-to-background ratios (TBR) were calculated. In addition, hypoxic volumes were determined as the volume of the tumor with a TBR >1.2 (HV_1.2). Bland Altman analysis of the uptake parameters was performed and coefficients of repeatability were calculated. To evaluate the spatial repeatability of the uptake, the PET/CT images were registered and a voxel-wise comparison of the uptake was performed, providing a correlation coefficient.

Results

All parameters of [¹⁸F]HX4 uptake were significantly correlated between scans: SUV_max (r?=?0.958, p?<?0.001), SUV_mean (r?=?0.946, p?<?0.001), TBR_max (r?=?0.962, p?<?0.001) and HV_1.2 (r?=?0.995, p?<?0.001). The relative coefficients of repeatability were 15 % (SUV_mean), 17 % (SUV_max) and 17 % (TBR_max). Voxel-wise analysis of the spatial uptake pattern within the tumors provided an average correlation of 0.65?±?0.14.

Conclusion

Repeated hypoxia PET scans with [¹⁸F]HX4 provide reproducible and spatially stable results in patients with head and neck cancer and patients with lung cancer. [¹⁸F]HX4 PET imaging can be used to assess the hypoxic status of tumors and has the potential to aid hypoxia-targeted treatments.

     

Tumour volume doubling time of molecular breast cancer subtypes assessed by serial breast ultrasound

Objectives

The aim of our study was to evaluate the tumour volume doubling time (TVDT) of molecular breast cancer subtypes by serial ultrasound (US).

Methods

Sixty-six patients (mean age, 50 years; range, 29–78 years) with invasive breast cancer underwent initial and follow-up breast US examinations (at least three months apart) with no intervention. TVDT was determined using the tumours’ greatest dimensions in two orthogonal planes. The results were compared with clinical, imaging, and tumour variables and molecular subtypes (oestrogen receptor [ER]-positive, human epidermal growth factor receptor 2 [HER2]-positive, and triple negative) using a multiple linear regression analysis.

Results

TVDT exhibited a wide range (46–825 days; median, 141 days) with an overall mean of 193?±?141 days and mean values of 241?±?166 days for ER-positive tumours (n?=?37), 162?±?60 days for HER2-positive tumours (n?=?12), and 103?±?43 days for triple-negative tumours (n?=?17) (P?P?Conclusions TVDT differed significantly among the three molecular breast cancer subtypes, with the triple-negative tumours showing the fastest growth.

Key Points

? Knowledge of tumour volume doubling time provides clues for improving screening. ? TVDT assessed by serial US differed significantly between breast cancer subtypes. ? Triple-negative tumours had 2.4-fold shorter TVDT compared to ER-positive tumours. ? Tumours classified as BI-RADS 3 had shorter TVDT than BI-RADS 4.     

Sagittal and coronal plane location of the popliteal artery in the open-wedge high tibial osteotomy

Purpose

The objectives of this study were (1) to evaluate the sagittal and coronal plane location of the popliteal artery during the advancement of open-wedge high tibial osteotomy and (2) to confirm the effect of osteoarthritis if it changes the relationship between the popliteal artery and posterior cortex.

Methods

Two hundred consecutive patients were enrolled, and we divided patients into two subgroups according to age and cartilage status in the radiologic report of magnetic resonance imaging (group I: 100 non-arthritic knees; group II: 100 arthritic knees). For prediction of the location of the popliteal artery during the operation, sagittal and coronal plane location along the osteotomy plane was evaluated.

Results

The distance between the posterior cortex of the osteotomy and popliteal artery was 13–14 mm on the sagittal plane, and the popliteal artery was located at an approximately 35 ± 5.5 mm portion from the starting point of the osteotomy on the coronal plane. The distance at the starting point of osteotomy was larger than at the end portion and prominent area. In comparison between groups I and II, group II showed a larger distance on the sagittal planes [osteotomy–vascular: 13.6 vs 14.4 (p = 0.01), fibula–vascular: 4.88 vs 6.5 (p < 0.01), and prominence–vascular: 4.3 vs 5.3 (p < 0.01)] compared to the group I.

Conclusions

Special caution and some protection should be given until the approximately 35 mm portion from the starting point of the posteromedial cortex with consideration for the approximity on the sagittal plane. In comparison between the non-arthritic and arthritic knee, differences were observed on the sagittal plane. However, the value was minimal, and the clinical relevance was questionable.

Level of evidence

Case series, Level IV.     

The impact of Campath 1H induction in adult liver allotransplantation

BACKGROUND: We report our experience with Campath 1H in adult liver allotransplantation. METHODS: Between December 2001 and February 2004, 77 patients underwent liver transplantation using Campath 1H induction and low-dose maintenance tacrolimus immunosuppression. The control group consisted of 50 patients with similar baseline characteristics and the same eligibility criteria, transplanted under our standard Tacrolimus/steroids regimen. Hepatitis C patients were excluded from the study. RESULTS: Patient and graft survival were similar for both groups. The incidence of rejection was significantly lower in the Campath vs the control group (51% vs 65% at 12 months, P = .009). Tacrolimus trough levels and conversion from Tacrolimus or the addition of other immunosuppressive drugs due to nephrotoxicity were also significantly lower in the Campath 1H group. CONCLUSION: Campath 1H induction with low-dose Tacrolimus maintenance immunosuppression is an effective regimen in reducing acute rejection in adult liver transplantation, while maintaining lower tacrolimus levels and less nephrotoxicity than our conventional immunosuppressive regimen.