Use of Yttrium-90 TheraSphere for the treatment of unresectable hepatocellular carcinoma

This is a retrospective analysis of a new treatment modality, intra-arterial administration of Yttrium-90 TheraSphere, for unresectable hepatocellular carcinoma (HCC). Patients with HCC not amenable to surgical treatment who had satisfactory physiological function without comorbid disease or significant pulmonary shunting were eligible for treatment. Patients were categorized into complete, partial, or no response based on serum alpha-fetoprotein (AFP) levels and CT or MRI imaging. Fourteen patients were considered candidates for treatment. Three patients were excluded due to significant hepatopulmonary shunting. Eleven patients were treated with TheraSphere. One patient (9%) had a complete response, eight patients (78%) had a partial response, and two patients (18%) showed no response. Partial and complete responders with AFP-associated HCC demonstrated a median decrease in AFP levels of 79 per cent at 73 days. No patients developed liver toxicity nor died due to treatment. Five patients (45%) died of progressive disease at a median of 7 months post-treatment. Six patients (54%) were alive at a median of 11 months (range, 9 to 20 months). Okuda stage 2 and 3 patients showed a median survival of 11 months and 7 months, respectively. Yttrium-90 TheraSphere treatment for unresectable hepatocellular carcinoma is well tolerated and appears to extend survival.     

Ultrasound guidance in caudal epidural needle placement

BACKGROUND: This study was conducted to investigate the feasibility of using ultrasound as an image tool to locate the sacral hiatus accurately for caudal epidural injections. METHODS: Between August 2002 and July 2003, 70 patients (39 male and 31 female patients) with low back pain and sciatica were studied. Soft tissue ultrasonography was performed to locate the sacral hiatus. A 21-gauge caudal epidural needle was inserted and guided by ultrasound to the sacral hiatus and into the caudal epidural space. Proper needle placement was confirmed by fluoroscopy. RESULTS: In all the recruited patients, the sacral hiatus was located accurately by ultrasound, and the caudal epidural needle was guided successfully to the sacral hiatus and into the caudal epidural space. There was 100% accuracy in caudal epidural needle placement into the caudal epidural space under ultrasound guidance as confirmed by contrast dye fluoroscopy. CONCLUSIONS: Ultrasound is radiation free, is easy to use, and can provide real-time images in guiding the caudal epidural needle into the caudal epidural space. Ultrasound may therefore be used as an adjuvant tool in caudal needle placement.     

Dexamethasone has a central antiemetic mechanism in decerebrated cats

Dexamethasone is an effective antiemetic drug, but its mechanism of action is unclear. We designed this study to investigate the direct antiemetic action of dexamethasone in the medulla of cats. By using an oscillographic vomiting model, decerebrated cats received microinjections of dexamethasone 100 nL (1 microg, n = 7; 0.1 microg, n = 7) into the bilateral nuclei tractus solitarii, which led to a significant prolongation of the latency (1 microg, 6.4 +/- 1.1 min versus 28.2 +/- 4.9 min, P < 0.05; 0.1 microg, 6.7 +/- 1.1 min versus 27.1 +/- 5.0 min, P < 0.05) of the first emetic episode and significantly decreased the frequency of emetic episodes (1 microg, 2.7 +/- 0.8 versus 0.1 +/- 0.4, P < 0.05; 0.1 microg, 2.9 +/- 0.9 versus 0.3 +/- 0.5, P < 0.05) induced by xylazine. Pretreatment with mifepristone, a glucocorticoid receptor antagonist, blocked the antiemetic effect of dexamethasone in the bilateral nuclei tractus solitarii. However, microinjection of dexamethasone into the unilateral nucleus tractus solitarius alone did not alter the latency of the first emetic episode or the frequency of emetic episodes induced by xylazine. Local application of dexamethasone into the area postrema had no effect on the latency of the first emetic episode or the frequency of emetic episodes induced by xylazine. These results suggest that dexamethasone exerts its central antiemetic action through an activation of the glucocorticoid receptors in the bilateral nuclei tractus solitarii in the medulla.     

Epidural analgesia associated with a fatal outcome in a patient with an unrecognized brain tumour

A fatality associated with epidural analgesia in a patient with an unsuspected brain tumour has not been reported in the literature. We describe a case of postoperative lumbar epidural analgesia in a 54-year-old female patient who had an undiagnosed brain tumour and a fatal outcome postoperatively. The factors that potentially contributed to this mishap and the possible alternative management of this patient are discussed.     

Effect of Surgecel coverage with topical electrocauterization for preventing and sealing pulmonary air leakage

Pleural tears usually occur after pneumolysis for dense adhesion or after cone biopsy of lung parenchyma. Repair of the tears is sometimes very difficult. Herein we compared different methods on a pig lung air leak model. Twenty pigs with pleural tears by surgical manipulation through sternotomy were not treated (n = 5) or treated by simple electroablation (n = 5), pleural coverage (n = 5), or Surgecel coverage with surface electroablation (n = 5). We evaluated their immediate and delayed treatment effect by measuring the critical leak pressure, degree of air leakage, and air leakage period and histological examination. It was found that Surgecel coverage with surface electrocauterization had similar early and delayed effects in sealing air leakage to pleural coverage and was much better than the other two groups (P < 0.05). We conclude that coverage with Surgicel with local electroablation can significantly decrease immediate and late air leakage from pleural tears.     

Systemic Vibrio infection presenting as necrotizing fasciitis and sepsis. A series of thirteen cases

BACKGROUND: Vibrio species are an uncommon cause of necrotizing fasciitis and primary septicemia, which are likely to occur in patients with hepatic disease, diabetes mellitus, adrenal insufficiency, and immunocompromised conditions. These organisms are found in warm sea waters and are often present in raw oysters, shellfish, and other seafood. The purposes of the present report were to describe a series of patients who had this potentially lethal infection and to identify clinical features associated with a poor prognosis. METHODS: We retrospectively reviewed the records of thirteen patients (ten men and three women) who had necrotizing fasciitis and sepsis caused by Vibrio species. All patients had a history of contact with seawater or raw seafood. Eight patients had a hepatic disease such as hepatitis or cirrhosis of the liver, three had diabetes mellitus (without hepatic disease), and two had chronic renal or adrenal insufficiency (without hepatic disease). RESULTS: Twelve patients underwent fasciotomy or limb amputation. Five patients (38%) died within two to six days after admission, and eight patients survived. Patients with a systolic blood pressure of < or =90 mm Hg and leukopenia in the emergency room had a significantly higher mortality rate (p < 0.05). CONCLUSIONS: The diagnosis of Vibrio necrotizing fasciitis should be suspected when a patient has the appropriate clinical findings and a history of contact with seawater or raw seafood. The treatment should begin as early as possible, essentially when the patient has symptoms of sepsis. Although emergency fasciotomy or limb amputation did not reduce the mortality rate in this series, we consider such operations to be an important aspect of treatment.