Clinical and imaging experience with yttrium-90 microspheres in the management of unresectable liver tumours.

INTRODUCTION: Selective internal radiation therapy (SIRT) is emerging as a new therapeutic modality in recent years for management of non-resectable hepatic malignancies. Our experience in clinical application of this treatment is reported here. MATERIAL AND METHODS: From June 2004, patients whose liver tumours were no longer amenable for any conventional treatment with either chemotherapy or surgery were considered for yttrium-90 microspheres treatment after discussion at our multidisciplinary meeting. A pre-treatment planning was carried out with visceral angiography and technetium-99m macroaggregated albumin (MAA) for assessment of both tumour volume and extrahepatic shunting in addition to a baseline PET and CT scans, respectively. Two weeks later, a second visceral angiogram was performed to deliver the calculated dosage of microspheres into the arterial system supplying the tumour. Patients were then followed up with tumour markers, repeat PET and CT scans of abdomen at 6 weeks and 3 monthly thereafter. RESULT: Twenty-one patients (F=11, M=10; age range 40-75 years, mean=58 years) received yttrium-90 microspheres consisting of liver metastases from colorectal primary (n=10) and non-colorectal primaries (n=8), and primary liver tumours (n=3). One patient received 2 treatments. The mean administered activity of microspheres delivered was 1.9 GBq (range 1.2-2.5 GBq). Injection of microspheres had no immediate effect on either clinical haematology or liver function tests. At follow-up, 86% of patients showed decreased activity on PET scan at 6 weeks (p=0.01). The mean pre-treatment SUV was 12.2+/-3.7 and the mean post-treatment SUV was 9.3+/-3.7, indicating a significant improvement measured with PET activity. Only 13% showed a reduction in the size of tumour on CT scan. For patients with colorectal liver metastases, there was no significant reduction in CEA level (127+/-115 vs 75+/-72 micro/l, p=0.39). Complications were seen in 4 patients (19%) including radiation hepatitis (n=2), cholecystitis (n=1) and duodenal ulceration (n=1). All resolved without surgical intervention. Seven patients died at follow-up from progressive extrahepatic disease (33%). CONCLUSION: SIRT should be considered for patients with advanced liver cancer. It has a significant effect on liver disease in the absence of extrahepatic disease. PET imaging has an integral role in the assessment of patients treated with yttrium-90 SIR-Spheres.     

A brain-actuated wheelchair: asynchronous and non-invasive Brain-computer interfaces for continuous control of robots

OBJECTIVE: To assess the feasibility and robustness of an asynchronous and non-invasive EEG-based Brain-Computer Interface (BCI) for continuous mental control of a wheelchair. METHODS: In experiment 1 two subjects were asked to mentally drive both a real and a simulated wheelchair from a starting point to a goal along a pre-specified path. Here we only report experiments with the simulated wheelchair for which we have extensive data in a complex environment that allows a sound analysis. Each subject participated in five experimental sessions, each consisting of 10 trials. The time elapsed between two consecutive experimental sessions was variable (from 1h to 2months) to assess the system robustness over time. The pre-specified path was divided into seven stretches to assess the system robustness in different contexts. To further assess the performance of the brain-actuated wheelchair, subject 1 participated in a second experiment consisting of 10 trials where he was asked to drive the simulated wheelchair following 10 different complex and random paths never tried before. RESULTS: In experiment 1 the two subjects were able to reach 100% (subject 1) and 80% (subject 2) of the final goals along the pre-specified trajectory in their best sessions. Different performances were obtained over time and path stretches, what indicates that performance is time and context dependent. In experiment 2, subject 1 was able to reach the final goal in 80% of the trials. CONCLUSIONS: The results show that subjects can rapidly master our asynchronous EEG-based BCI to control a wheelchair. Also, they can autonomously operate the BCI over long periods of time without the need for adaptive algorithms externally tuned by a human operator to minimize the impact of EEG non-stationarities. This is possible because of two key components: first, the inclusion of a shared control system between the BCI system and the intelligent simulated wheelchair; second, the selection of stable user-specific EEG features that maximize the separability between the mental tasks. SIGNIFICANCE: These results show the feasibility of continuously controlling complex robotics devices using an asynchronous and non-invasive BCI.     

A study of the Board Certification Examination in Child and Adolescent Psychiatry

In 1977, training directors of 55 child psychiatry training programs agreed to provide the Committee on Certification in Child Psychiatry of the American Board of Psychiatry and Neurology, Inc. with confidential data about the clinical performance of each of their graduates in 1978, 1979, and 1980. Information about 267 graduates from 37 programs was received. Almost all programs were university affiliated and located in medical centers. By 1986, 112 of these graduates had taken the child aboard examination. Training director ratings were found to be statistically correlated to a significant degree with actual pass or fail results on the written and on the overall examination.     

Clinching the diagnosis: fine needle aspiration cytology

Fine needle aspiration cytology is now a recognised and well established technique. The procedure is simple and relatively non-invasive. It is cost-effective, and may significantly reduce diagnostic delay. It is particularly indicated in the diagnosis of malignant neoplasia, both primary and metastatic. It is also suitable for identification and culture of infective agents. In addition, certain other benign lesions and non-neoplastic conditions may be recognised. The contraindications and complications are few. The limitations of the procedure are related to the nature, site and size of the lesion. The accuracy of the procedure is also influenced by the adequacy of the aspirator's technique as well as the experience and skill of the pathologist.     

Fathers' Participation in Childcare Within Navajo Indian Families

Fathers' and mothers' reports of their participation in early caregiving tasks and the amount of social support they received regarding their involvement with their infants were examined for 28 two-parent Navajo Indian families. Mothers were significantly more involved in basic caregiving activities than fathers. Fathers invested about sixty percent as much time as mothers did in direct caregiving tasks. Mothers and fathers did not differ on the degree to which they reported receiving social supports for childcare tasks. Navajo parents received significantly more extrafamilial and/or institutional sources of support than family support for early caregiving activities. Navajo fathers were highly involved with their young children. The results are discussed in relation to role differences in early caregiving within Navajo families.     

Thromboxane synthesis inhibition reverses group B Streptococcus-induced pulmonary hypertension

Group B Streptococcus (GBS) sepsis in humans may cause the persistent pulmonary hypertension syndrome. Infusions of GBS in animals elevate pulmonary artery pressure (PAP) and resistance and are associated with elevated thromboxane levels. We investigated the hemodynamic effects of the specific thromboxane synthesis inhibitor, dazmegrel, in a piglet model of GBS-induced pulmonary hypertension. PAP rose from 22 +/- 6 to 42 +/- 11 (SD) mm Hg during infusion of heat-killed GBS; pulmonary vascular resistance increased from 1440 +/- 400 to 4000 +/- 1040 dyne X sec/cm5. No significant changes in cardiac output, mean arterial pressure, or left atrial pressure were noted. Treatment with 1 mg/kg of dazmegrel resulted in a rapid return of PAP and resistance to control values. No other hemodynamic effects of either bacteria or drug were observed despite continued infusion of GBS.     

Geranylgeranyltransferase I as a target for anti-cancer drugs

Posttranslational modification is critical for the function of the gene products of ras oncogenes, which are frequently mutated in cancer. Ras proteins are modified by farnesyltransferase (FTase), but many related small GTPases that also end in a CAAX motif (where C is cysteine, A is often an aliphatic amino acid, and X is any amino acid) are modified by a closely related enzyme known as geranylgeranyltransferase type I (GGTase-I). Accordingly, inhibitors for both of these enzymes have been developed, and those active against FTase are in clinical trials. In this issue of the JCI, Sjogren et al. report the development of a mouse strain homozygous for a conditional allele of the gene that encodes GGTase-I (see the related article beginning on page 1294). They found that ablation of the GGTase-I-encoding gene in cells destined to produce lung tumors driven by oncogenic K-Ras resulted in delayed onset and decreased severity of disease, validating in a genetic model the theory that GGTase-I is a good target for anti-cancer drug development.     

Perspectives on perinatal asphyxia: pathophysiology, presentation, and prognosis

Perinatal asphyxia is a common and potentially serious problem in the management of labor and delivery. Severe perinatal asphyxia can cause significant short- and long-term sequelae. While the pathophysiology and sequelae of perinatal asphyxia in animals is understood fairly well, asphyxiation cannot be reliably prevented or effectively treated once it occurs in the newborn human. However, with a better understanding of what perinatal asphyxia is and its expected clinical symptoms and outcomes, perinatal nurses can better care for asphyxiated infants.     

Client and therapist agreement about the client's problems—Associations with treatment alliance and outcome

Objective: A shared understanding of the patient's symptoms and problems is seen by most theories as a crucial aspect of the collaboration in therapy, presumably influencing alliance and outcome. The empirical ground for this argument is not solid, however. Several studies have found weak associations between a common view of the patient's problems and outcome. The purpose of the present study was to analyze whether agreement in the understanding of the patient's depression and anxiety problems was important for alliance and outcome. Method: The study used data from a practice-based study using the CORE system with 846 patients who received psychological treatment in primary care. Results: The analyses indicated that although patients who were assessed by their therapists as having depression and anxiety problems scored higher on these subscales than other patients, about half of the patients reported such problems when the therapists did not, and vice versa. Agreement was not associated with better alliance or outcome. Conclusions: Productive collaboration in psychotherapy may be based on other factors than agreement about symptoms.