Percutaneous Ablative Therapies of Recurrent Hepatocellular Carcinoma after Hepatectomy: Proposal of a Prognostic Model

Background

Percutaneous ablative therapies (PAT) are valuable modalities for posthepatectomy recurrent hepatocellular carcinoma (RHCC), but its impact on long-term outcome and prognosis prediction have not been well documented. The present study aimed to analyze prognostic factors and to propose a prognosis-predicting model for RHCC treated with PAT.

Methods

A total of 288 patients with posthepatectomy RHCC treated with percutaneous ethanol ablation, radiofrequency ablation, microwave ablation, or ethanol ablation combined with radiofrequency ablation were included. Survival and prognostic factors were analyzed. A prognosis-predicting model was created by quantifying and integrating all prognostic factors.

Results

Three-, 5-, and 7-year postablation survival rates were 37.8, 20.7, and 14.2?%, respectively. Multivariate analysis revealed that interval between recurrence and initial hepatectomy, tumor number, largest diameter of tumor, and Barcelona Clinic Liver Cancer stage at hepatectomy were independent prognostic factors for survival. A scoring system for prognostic factors was proposed, and summation of 4 prognostic factors (prognostic score) was ranged from 4 to 10. Prognostic score was classified into three strata, designated as prognostic classes A (score 4 and 5), B (score 6 and 7), and C (??8). Three-, 5-, and 7-year postablation survival rates were 62.8, 39.4, and 26.9?% in class A, 36.9, 15.5, and 7.2?% in B, and 5.5, 0, and 0?% in class C, respectively (p?=?0.00). Three-, 5-, 7-, and 10-year survival rates after initial hepatectomy were 82.4, 66.3, 52.1, and 36.4?% in class A, 51.6, 34.8, 20.7, and 6.6?% in class B, and 11.9, 7.8, 0, and 0?% in class C, respectively (p?=?0.00).

Conclusions

The prognostic model developed in the study could clearly predict different long-term outcomes for patients with posthepatectomy RHCC and thus help decide appropriate therapeutic strategy.     

Impact of Impaired Coronary Flow Reserve and Insulin Resistance on Myocardial Energy Metabolism in Patients With Syndrome X

To evaluate the role of a decreased coronary flow reserve in the genesis of angina pectoris in patients with syndrome X, we studied myocardial hemodynamics and metabolism at rest, during pace stress, and in the recovery period after pacing in 18 consecutive patients with syndrome X and in 10 control subjects. By means of positron emission tomography or the intracoronary flow-wire method, patients were subclassified as having microvascular angina (MA, n = 8) when coronary flow reserve was reduced (<2.5) or no microvascular angina (non-MA, n = 10) when coronary flow reserve was preserved (≥2.5). At rest, coronary sinus blood flow was increased in MA patients. During pace stress, coronary sinus blood flow increased by 39 ± 6% in MA patients versus 67 ± 12% in non-MA patients and 69 ± 7% in controls (p <0.05). Patients with non-MA revealed fasting hyperinsulinemia, increased arterial concentration of free fatty acids, and a similar tendency for

Full-size image

-hydroxybutyrate. Oxygen extraction and carbon dioxide release did not differ between groups. Net myocardial lactate release was not observed in any patient during pace stress and myocardial energy metabolism was preserved in all patients with syndrome X. During pacing, myocardial uptake of free fatty acids and

Full-size image

-hydroxybutyrate was increased in non-MA patients. Myocardial uptake of free fatty acids correlated positively and myocardial glucose and lactate uptake correlated inversely with arterial concentrations of free fatty acids in all subjects. Metabolic evidence of myocardial ischemia is uncommon in patients with syndrome X, irrespective of a globally reduced coronary flow reserve. Although patients with syndrome X can be subclassified according to presence of a microvascular or a metabolic disorder, angina pectoris and ST-segment depressions coexist with a preserved global myocardial energy efficiency in all patients.We studied myocardial metabolism in patients with syndrome X subclassified depending on whether coronary flow reserve was reduced. None of the patients had metabolic evidence suggestive of myocardial ischemia, and myocardial energy metabolism remained preserved in all patients, including those with a reduced coronary glow reserve.     

Elderly care recipients in a Swedish municipality living in their own homes: their diseases, functional health status and care provided as reported by formal carers

The aim of this study was to investigate from the perspective of formal carers the care given to people aged 65 and over, who are cared for in their own homes by informal care. Thirty-three district nurses (DNs) and 20 home service assistants in a municipality with 13500 inhabitants (over 65 years old), were interviewed about the location of care recipients and 398 care recipients were located. Most of them were over 80 years old and had more than one disease (62%), mostly related to the circulatory system (27%). Dependence in three or more of the Katz ADL categories was seen in 30%, reduced mobility in 67%, reduced memory in 34% to a degree that restricted their everyday life and 34% of them could seldom or never be alone. Care had been given for three years or more for 57% of these people. The monitoring of the disabilities and reduced functional health status differed significantly between the diagnostic groups. Home help service was associated with the care recipients' ADL index but not with their need for continuous monitoring. The DNs' care did not relate to any of the variables. In conclusion, diagnoses, the care recipients ability to be alone and functional health status are important variables to include when assessing the demands for home care and when planning supplementary care for home care recipients and their informal caregivers.     

Clinical supervisors' views of their leadership role in the clinical supervision process within nursing care

The purpose of this study was to investigate nurse supervisors 'views of their supervisory styles, their personal qualities and their leadership role, and the development of these styles The sample consisted of 18 clinical nurse supervisors The data were collected by interviews using 15 open-ended questions, and a 10-item questionnaire, and the analysis was a combination of hermeneutical and factor analysis The analysis revealed two specific styles the emotional and the cognitive supervisory style The supervisors' personal qualities were willingness and preparedness to show understanding, bringing out genuine feelings and 'confirming', the latter being the most important in the nurse supervisors 'styles The supervisors' views of their leadership role showed that high values were given to the following three factors techniques in providing clinical supervision, responsibility for facilitating process, responsibility for creating a climate conducive to supervision and focusing on the main themes     

Transdermal nicotine patch enhances type I collagen synthesis in abstinent smokers

Cigarette smokers deposit less collagen, expressed as hydroxyproline, in granulation tissue than nonsmokers. We studied the effect of abstinence from smoking and transdermal nicotine patches on deposition of hydroxyproline, proline, type I procollagen, and total proteins. Fifty-four healthy smokers were studied during 10 days of smoking and again from days 10 to 20 following smoking cessation. After the first 10 days of abstinence they were randomized to double-blind treatment with transdermal nicotine patches of 25 mg/day or placebo for a period of 10 days. During this period and during smoking, an expanded polytetrafluoroethylene tube was implanted into the subcutis. Following removal of the implant, total amino acids and peptides were extracted. Hydroxyproline and proline were analyzed by high-pressure liquid chromatography, type I procollagen was analyzed by enzyme-linked immunoassay, and total proteins were determined colorimetrically. In the 39 subjects who complied with the study protocol, abstinence from smoking did not affect the deposition of hydroxyproline, proline, type I procollagen, or total protein in the implants. During abstinence, the type I procollagen level increased by 18% in the transdermal nicotine patches group and decreased by 10% in the placebo group (p<0.05). We conclude that 20 days of abstinence from smoking does not affect collagen deposition in granulation tissue. However, in abstinent smokers, transdermal nicotine patches appears to increase type I collagen synthesis.