CALLA-positive myeloma: an aggressive subtype with poor survival

Detailed immunotyping was carried out on 21 direct myeloma bone marrow aspirates and eight human myeloma cell lines. Four previously untreated common acute lymphoblastic leukemia antigen (CALLA)-positive myeloma patients were identified and six of eight cell lines (75%) were also positive. CALLA positivity, as part of an immature B phenotype, was found to correlate with very aggressive clinical disease: median survival six months v 56 months for the CALLA-negative group.     

Stereotactic radiosurgery for locally recurrent nasopharyngeal carcinoma

BACKGROUND: Stereotactic radiosurgery has been used to treat intracranial tumors. Recently, it has also been used for the treatment of head and neck tumors involving the base of skull, including recurrent NPC. METHODS: From October 1994 to April 1999, 36 patients with recurrent NPC, were retreated by stereotactic radiosurgery. These patients received radiosurgery as a boost treatment after reirradiation for recurrence. The external RT dose ranged from 20 to 60 Gy. The tumor volume ranged from 3.58 to 24.6 cc. The target surface dose ranged from 8 to 20 Gy. The median follow-up was 22.1 months. RESULTS: The 3-year local control rate was 56%. The 5-year overall survival was 49%. Persistence after radiosurgery had a worse survival than those who had secondary recurrence. Age and gender were marginally significant. No patient had new severe complications after retreatment. Four patients (11%) had nasopharyngeal necrosis after radiosurgery, none had nasal bleeding or headache, but a foul odor was present in one patient. CONCLUSIONS: Conformal radiotherapy and stereotactic radiotherapy provide good local control and survival without severe complications for patients with recurrent NPC.     

Outcomes and poor prognostic factors in endovascular thrombectomy for octo- and nonagenarians with large vessel occlusion: A real-world experience

Endovascular thrombectomy (EVT) is the preferred treatment for eligible patients with acute large vessel occlusions (LVOs). However, its role in very elderly patients remains uncertain. This study retrospectively analysed EVT outcomes, including successful reperfusion, change in National Institutes of Health Stroke Scale (NIHSS) score at 24 h after EVT, inpatient haemorrhagic transformation and favourable functional outcomes and mortality at 90 days after EVT in patients aged over 80 years. The primary outcome of the study was risk factors significantly associated with poorer functional outcomes at 90 days after EVT. The secondary outcomes were risk factors associated with higher NIHSS scores at 24 h after EVT and higher mortality rates at 90 days after EVT. Among the 73 octo- and nonagenarians, successful reperfusion was achieved in 86.3%, and up to 35.6% maintained functional independence at 90 days. Poorer outcomes were associated with internal carotid artery occlusion; risk factors such as hypertension, diabetes mellitus and atrial fibrillation; higher admission NIHSS score; longer time between symptom onset and successful reperfusion and unsuccessful reperfusion. EVT is both safe and effective in our elderly population, with over one-third of very elderly patients achieving satisfactory functional outcomes after EVT. Therefore, age alone should not be the sole criterion for excluding very elderly LVO patients from EVT. Instead, each patient should undergo individual assessment based on their premorbid condition, clinical presentation and LVO characteristics before making a treatment decision.     

Preoperative imaging evaluation of potential living liver donors: reasons for exclusion from donation in adult living donor liver transplantation

Accurate pretransplant evaluation of a potential donor in living donor liver transplantation (LDLT) is essential in preventing postoperative liver failure and optimizing safety. The aim of this study was to investigate the reasons for exclusion from donation of potential donors in adult LDLT. From September 2003 to June 2006, 266 potential donors were evaluated for 215 recipients: 220 potential donors for 176 adult recipients; 46 for 39 pediatric recipients. Imaging modalities including Doppler ultrasound, computerized tomography (CT), and magnetic resonance (MR) angiography provided vascular evaluation and MR cholangiopancreatography to evaluate biliary anatomy. Calculation of liver volume and assessment of steatosis were performed by enhanced and nonenhanced CT, respectively. In the adult group, only 83 (37.7%) potential donors were considered suitable for LDLT. Of the 137 unsuitable potential donors, 36 (26.2%) candidates were canceled because of recipient issues that included death of 15 recipients (10.9%), main portal vein thrombosis (8%), recipient condition beyond surgery (5%), and no indication for liver transplantation due to disease improvement (2%). The remaining 101 (73.8%) candidates who were excluded included steatosis (27.7%), an inadequate remnant volume (57.4%), small-for-size graft (8.9%), HLA-homozygous donor leading to one-way donor-recipient HLA match (3%), psychosocial problems (4%), as well as variations of hepatic artery (4%), portal vein (1%), and biliary system anatomy (5%). Anatomic considerations were not the main reason for exclusion of potential donors. An inadequate remnant liver volume (<30%) is the crucial point for the adult LDLT decision.     

Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma

PURPOSE

Intrahepatic portal vein injuries secondary to blunt abdominal trauma are difficult to diagnose and can result in insidious bleeding. We aimed to compare computed tomography arterial portography (CTAP), reperfusion CTAP (rCTAP), and conventional computed tomography (CT) for diagnosing portal vein injuries after blunt hepatic trauma.

METHODS

Patients with blunt hepatic trauma, who were eligible for nonoperative management, underwent CTAP, rCTAP, and CT. The number and size of perfusion defects observed using the three methods were compared.

RESULTS

A total of 13 patients (seven males/six females) with a mean age of 34.5±14.1 years were included in the study. A total of 36 hepatic segments had perfusion defects on rCTAP and CT, while there were 47 hepatic segments with perfusion defects on CTAP. The size of perfusion defects on CT (239 cm³; interquartile range [IQR]: 129.5, 309.5) and rCTAP (238 cm³; IQR: 129.5, 310.5) were significantly smaller compared with CTAP (291 cm³; IQR: 136, 371) (both, P = 0.002).

CONCLUSION

Perfusion defects measured by CTAP were significantly greater than those determined by either rCTAP or CT in cases of blunt hepatic trauma. This finding suggests that CTAP is superior to rCTAP and CT in evaluating portal vein injuries after blunt liver trauma.The liver is one of the most frequently injured solid abdominal organs in the setting of blunt abdominal trauma (1). Fortunately, most patients with blunt hepatic trauma have relatively stable vital signs and need only supportive treatment or transarterial embolization (TAE) (1–9). Only 15% of patients, who present with hemodynamic instability or fail with nonoperative management, require operative intervention to manage their liver injury.Embolic therapy has been shown to have a high success rate in hemodynamically stable patients with blunt hepatic injury. TAE is associated with decreased abdominal infections, decreased transfusions, and decreased length of hospital stay compared with operative management (2, 3, 7). However, angiography can only detect bleeding from the hepatic artery; it cannot locate bleeding from the hepatic or portal vein. In the literature, portal vein injuries are not commonly described and most are the result of penetrating injuries to the extrahepatic portal veins. Mortality after a portal vein injury due to trauma is primarily due to hypovolemic shock and can be as high as 50% or greater (10, 11).Since the intrahepatic portions of the hepatic and portal veins are low pressure systems, they can bleed insidiously. Nevertheless, this subtle bleeding may require multiple transfusions and result in a prolonged hospital stay. Relative to an extrahepatic portal vein injury, patients with an intrahepatic portal vein injury may have relatively stable vital signs and slowly decreasing hemoglobin levels (10, 11). In addition, traumatic occlusion and/or thrombosis of the portal vein may cause large hepatic parenchymal infarction.Computed tomography arterial portography (CTAP) is a useful method based on portal enhancement of the liver by infusion of contrast material through the superior mesenteric artery for evaluating the portal venous system (12–15) and is widely used in patients with hepatic tumors with portal venous invasion (13, 16, 17). CTAP has a high sensitivity and specificity in the evaluation of portal vein thrombosis due to tumor (90% sensitivity, 99% specificity, 95% positive predictive value, 97% negative predictive value) (14). However, few studies have focused specifically on the utility of CTAP in the evaluation of portal vein injury as a result of trauma.The liver has a dual blood supply and receives between 66% and 75% of its blood supply from the hepatic portal vein with the remainder supplied by the hepatic artery (18). CTAP reflects only portal venous perfusion while reperfusion CTAP (rCTAP) reflects hepatic arterial reperfusion. Both rCTAP and conventional computed tomography (CT) are useful for determining certain liver injuries. However, they do not specifically evaluate the portal vein.The purpose of this study was to compare CTAP, rCTAP, and CT for diagnosing portal vein injuries after blunt hepatic trauma. We hypothesized that CTAP would be superior to rCTAP and CT in assessing portal vein injury after blunt hepatic trauma.     

A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures

Objective

To compare minimally invasive dynamic hip screw (MIDHS) fixation with conventional dynamic hip screw (CDHS) fixation for treatment of intertrochanteric femoral fracture.

Methods

Of the 66 participants in this double-blind study, 35 were randomised to MIDHS and 31 to CDHS fixation. Main outcome measurements were wound size, haemoglobin decrease, blood transfusion rate, pain score, analgesic consumption, Elderly Mobility Scale score, hip screw position, tip-apex distance, union rate, time to healing and complication rate.

Results

The groups had similar preoperative clinical data. Postoperatively the MIDHS group had significantly smaller wound size, less blood loss, lower blood transfusion rates, pain scores and rates of analgesic consumption, and higher early Elderly Mobility Scale scores. There were no significant differences in fracture alignment, hip screw position, tip-apex distance, union rate, time to healing or complication rate.

Conclusion

MIDHS fixation of intertrochanteric fractures is effective and safe and significantly reduces blood loss, pain and rehabilitation period, without sacrificing reduction alignment, screw position, fixation stability or bone healing.     

Emergency splenic arterial embolization for massive variceal bleeding in liver recipient with left-sided portal hypertension.

Splenic vein thrombosis with gastric variceal bleeding is difficult to manage, and splenectomy may be necessary to stop variceal bleeding. The authors report the case of a post-orthotopic liver transplant patient with bleeding gastric varices secondary to splenic vein thrombosis treated by partial splenic artery embolization. Successful embolization was performed via transcatheter approach depositing Gianturco coils into the intrasplenic artery resulting in immediate cessation of variceal bleeding. No recurrence of bleeding was noted postembolization. In conclusion, splenic artery embolization can be used as treatment for postliver transplant variceal bleeding with hypersplenism.     

Survey of hospital doctors' attitudes and knowledge of oral conditions in older patients

The study was designed to assess the views and knowledge of hospital doctors in general and geriatric medicine on oral health in older people. Eighty two doctors in general and geriatric medicine at two hospitals were shown 12 colour slides of oral mucosal conditions and asked to give a diagnosis for each slide and complete a questionnaire. Completed questionnaires with the answers to the coloured slides were returned completed by 70 doctors. The majority of doctors (84%) felt it was important to examine older patients' mouths, however only 19% (chi(2) p=0.0001) routinely do so. If asked to prescribe nystatin by the nursing staff, 30% said they would do so without examining the mouth itself. Only 9% of doctors knew that wearing dentures was a specific risk factor for oral candidiasis (chi(2) p=0.001). Altogether 56% of doctors did not feel confident in examining the oral cavity and most (77%) did not think they had had sufficient training in this examination. Only two doctors correctly diagnosed all of the slides. An early squamous carcinoma was misdiagnosed by 80% of the doctors (chi(2) p=0.0001). Hospital doctors do not routinely inspect older patients' mouths. Even if shown slides of typical oral mucosal lesions many hospital doctors are unable to diagnose them. Issues on training need to be addressed. From the patients' point of view a public health campaign is required to educate older people on the need for a regular dental review and be aware that doctors may not be able to diagnose serious oral conditions.