Hepatic embolization through extrahepatic collateral pathways after hepatic arterial embolization for the hepatocellular carcinoma

Extrahepatic collateral pathways developing after repeated transcatheter arterial embolization (TAE) for hepatocellular carcinoma (HCC) make therapeutic arterial embolization for recurrent lesions extremely difficult. TAE was performed through the collateral pathways using a sophisticated micro-catheter with good trackability and pushability and a coaxial system. Twenty-three TAEs were undertaken through the collateral pathways in 13 patients with recurrent HCC who had extrahepatic collateral pathways after the previous hepatic arterial TAE. There were 69 extrahepatic collateral pathways, with partially obstructed hepatic arteries. On the average, three feeding arteries were seen in the liver. The main extrahepatic collateral pathways were the inferior phrenic artery and epicholedocal artery, 18 vessels and 29 vessels, respectively, accounting for about 80% of the total collateral pathways. TAEs were successful in all cases and the number of embolized vessels was 2.1 on average. The average time of the first collateral TAE after the initial conventional hepatic arterial TAE was 2.3 years. Excellent prognosis was observed with a one-year survival rate of 77% and 3-year survival rate of 38% after the collateral TAE. We consider that collateral TAE for recurrent HCC with obstruction of the hepatic artery is the procedure of choice, is technically feasible, and provides better prognosis for the patients.     

Palliation of recurrent endometriosis with radiotherapeutic ablation of ovarian remnants

OBJECTIVE: To review the use of radiotherapy for relieving the symptoms of recurrent endometriosis caused by functioning ovarian remnants. DESIGN: Retrospective study (case report). PATIENT(S): A woman with recurrent endometriosis of 14 years' duration. INTERVENTION(S): After hysterectomy and bilateral oophorectomy, hormonal management, and multiple explorations for recurrent endometriosis, cycling ovarian remnants were confirmed histologically. Pelvic irradiation was used to ablate this tissue. A dose of 15 Gy in 10 daily fractions was given through anterior and posterior opposed fields using 18-mV photons. RESULT(S): The patient had a prompt increase in FSH levels associated with castration levels of serum E2. A review of the literature on the use of radiotherapy in this clinical situation is presented. CONCLUSION(S): Radiotherapy should be considered in selected patients when ovarian castration is not a viable surgical option and hormonal therapies have failed.     

Acantholytic acanthoma

A child affected by giant recurrent aphthous ulcers was treated successfully over the long term with thalidomide, with no adverse reactions or reduction of therapeutic efficacy. The use of thalidomide in children for serious aphthosis is proposed.     

Inability of the activated partial thromboplastin time to predict heparin levels. Time to reassess guidelines for heparin assays

BACKGROUND: In treating venous thromboembolic disorders, patient outcomes appear to correlate with heparin levels. Due to pharmacokinetic and pharmacodynamic variations, a relationship between heparin dose and level cannot be reliably predicted in individual patients. Some patients have low heparin levels despite therapeutic activated partial thromboplastin times (aPTTs), which may increase their risk for recurrent thromboembolism. Patients with high heparin requirements appear to have fewer bleeding episodes with heparin level-guided therapy. The aPTT does not reliably correlate with heparin blood concentrations or antithrombotic effects. Consequently, heparin therapy monitored with heparin levels may be more effective and safer. OBJECTIVES: To prospectively determine whether (1) the aPTT therapeutic range adequately predicts heparin levels in 38 patients used to establish the therapeutic aPTT range as is currently recommended and (2) whether 3 paired sets of aPTT-antifactor Xa levels provide the basis for using aPTTs to predict subsequent heparin levels in individual patients (n = 27) receiving intravenous heparin for coronary artery disease or venous thromboembolic disease. RESULTS: In the therapeutic aPTT range established, the R2 value for the relationship was 0.4. Prediction intervals were wide. For an aPTT of 60 seconds, the 95% prediction interval estimates were heparin levels of 0.05 to 1.0 U/mL. In individual patients, the aPTT-antifactor Xa relationship had an average R2 value of 0.75. There was no consistent relationship between the aPTT and anti-factor Xa level in a significant number of patients. CONCLUSIONS: The aPTT does not appear to be a useful surrogate for heparin levels. These findings suggest that the current recommendations on the use of heparin levels should be expanded.     

Relation between the time to achieve the lower limit of the APTT therapeutic range and recurrent venous thromboembolism during heparin treatment for deep vein thrombosis

BACKGROUND: Randomized trials have demonstrated the importance of achieving adequate heparinization early in the course of therapy. Recently, some authors reported a pooled analysis of selected studies in the literature that suggested that there is no convincing evidence that the risk of recurrent venous thromboembolism is critically dependent on achieving a therapeutic activated partial thromboplastin time result at 24 to 48 hours. METHODS: We provide the analyses of patient groups entered into our series of 3 consecutive double-blind randomized trials evaluating initial heparin therapy for proximal deep venous thrombosis. RESULTS: Logistic regression analysis of the patient groups receiving the less intense initial intravenous heparin dose of 30,000 U/24 h demonstrated that subtherapy for 24 hours predicted the onset of venous thromboembolic events. Failure to achieve a therapeutic activated partial thromboplastin time by 24 hours was associated with a 23.3% frequency of venous thromboembolism vs 4% to 6% for those whose activated partial thromboplastin time exceeded the therapeutic threshold by 24 hours (P=.02). Time-to-event analysis shows the increased frequency of recurrent venous thromboembolic events during the period of study in patients who were subtherapeutic for 24 hours compared with those who were therapeutic (P=.001). CONCLUSIONS: Our findings reaffirm the clinical importance of rapidly achieving therapeutic levels of heparin. Patients who failed to achieve the therapeutic threshold by 24 hours were at an increased risk of subsequent recurrent venous thromboembolism. These findings are independently supported by the results of a randomized trial comparing different intensities of initial heparin treatment by continuous infusion.     

Pitfalls and complications of antireflux surgery. Nissen and Collis-Nissen techniques

The outcome of total fundoplication surgery for GER disease is unsatisfactory in 15% of patients. The likelihood of an unsuccessful outcome can be reduced by careful patient selection, which includes making an accurate diagnosis, and by choosing an operation that is tailored to the patient's physiology. Intraoperative and acute postoperative complications fortunately are rare and can be avoided through the use of meticulous surgical techniques. Late complications, including dysphagia, recurrent reflux symptoms, and delayed gastric emptying, are common and have a rate of reoperation of up to 10%; a systematic evaluation usually discloses their underlying causes. A slipped fundoplication wrap, an excessively tight wrap, a paraesophageal hiatal hernia, and severe recurrent symptoms are common indications for reoperation.     

Oscillatory binocular system and temporal segmentation of stereoscopic depth surfaces

A dynamical neural network model of binocular stereopsis is proposed to solve the problem of segmentation which remains ambiguous even when the problem of binocular correspondence is solved. Being compatible with the recent neurophysiological findings (Engel et al. 1991), the model assumes that neural cells show oscillatory activities and that segmentation into a coherent depth surface is coded by synchronization of activities. Employing appropriate constraints for segmentation, the present model shows proper segmentation of depth surfaces and also solves segmentational ambiguity caused by a gap. It is newly shown that binocularly-unmatched monocular cells are discriminated in temporal segmentation of monocular cells caused by recurrent interactions between monocular and binocular cells. Integrative interactions with the other visual components through temporal segmentation are also discussed.     

A retrospective review of 61 patients with antiphospholipid syndrome. Analysis of factors influencing recurrent thrombosis

BACKGROUND: Antiphospholipid syndrome (APS) is a disorder of recurrent venous or arterial thrombosis, pregnancy losses, and thrombocytopenia. Recurrent thrombosis has particularly adverse effects on patients prognosis. The factors that influence recurrence and management techniques that prevent these events remain controversial. To add further insight regarding predisposing factors and the prevention of thrombotic recurrence, 61 well-characterized patients with APS were followed up for a median time of 77 months. METHODS: A retrospective cohort study was conducted in which the following factors were examined to determine their influence on thrombotic recurrence: primary vs secondary syndrome; the presence of hypertension, hyperlipidemia, diabetes, or smoking; patient age, sex, and race; pregnancy and oral contraceptives use; and treatment with warfarin sodium, warfarin plus aspirin, aspirin alone, prednisone, or no treatment. RESULTS: There was no difference between patients with primary and secondary APS with respect to recurrent arterial (55% vs 38%, respectively) or recurrent venous (47% vs 50%, respectively) thrombotic events. In all patients with APS, white race (P = .02) was associated with recurrent arterial events. Venous thrombosis occurred during pregnancy or in the postpartum period in 16 (30%) of 53 women and in 8 women taking oral contraceptives. Recurrent arterial and venous thromboses were significantly decreased with prophylactic warfarin use when compared with prednisone use or no treatment. Recurrences were infrequent in patients with prothrombin ratios of 1.5 to 2.0. CONCLUSIONS: Treatment with warfarin was most effective in preventing recurrent arterial and venous thrombosis. Pregnancy and the use of oral contraceptives or prednisone may also influence recurrence.     

A condemnation of subcutaneous fasciotomy

Controversy exists regarding the indications and methods for lower-extremity fasciotomy. Two recent cases at our institution in which recurrent, acute limb-threatening ischemia occurred despite adequate fascial division have convinced us that in certain situations subcutaneous fasciotomy is clearly inadequate. In both patients, both of whom were young, intact healthy skin between the lower extent of the incision and the malleolus acted as a tourniquet, causing recurrent compartment syndrome as reperfusion edema occurred after initial repair. We believe that therapeutic fasciotomy in young patients with relatively noncompliant skin should include division of skin from the knee to the ankle on at least one side to prevent a tourniquet effect by intact skin at the ankle.     

Bullous erythema multiforme following topical diphenylcyclopropenone application

A 68 year-old woman underwent replacement of the descending thoracic aorta with a cryopreserved aortic homograft for the treatment of a Stanford B dissecting aneurysm. After surgery, the patient made an uneventful recovery without recurrent infection. In such cases, the use of aortic homografts to replace aortic segments is a promising and effective therapeutic option.     

Prognosis in chronic fatigue syndrome: a prospective study on the natural course

Twelve patients with recurrent abortion who had shown positive antiphospholipid antibodies were treated through the administration of a Japanese modified traditional Chinese herbal medicine Sairei-To (Chan ling-Tang) The patients had experienced a total of 27 spontaneous abortions in their previous pregnancies and had no other pregnancy history except for one patient. The patients were treated with 9.0 g of Sairei-To per day before their next pregnancy. The positive value of antiphospholipid antibodies returned to negative in 9 patients out of 12 patients through the treatment. Out of 12 patients, in 10 patients, their new pregnancy continued uneventfully and delivered an offspring (Success rate: 83.3%). Thus, the current treatment was considered to be an effective therapy for patients with recurrent abortion who were found to be positive for antiphospholipid antibodies.     

Itraconazole in the treatment of orbital aspergillosis

BACKGROUND: Sino-orbital aspergillosis is typically treated with surgical debridement and intravenous amphotericin B. Some authors have advocated intraorbital irrigation or injection of amphotericin B in specific cases. METHODS: An immunocompetent patient with recurrent sino-orbital aspergillosis is presented. After failing two attempts at traditional therapeutic modalities, treatment with oral itraconazole was initiated. RESULTS: The patient has had resolution of her sino-orbital disease without recurrence at 10 months of follow-up. CONCLUSION: In immunocompetent patients with orbital aspergillosis, itraconazole should be considered as a treatment option in patients who have recurrent or recalcitrant disease, or in those who cannot tolerate amphotericin B.     

Nd:YAG laser therapy of recurrent epistaxis in hereditary hemorrhagic telangiectasia

BACKGROUND: Epistaxis is the leading symptom of hereditary hemorrhagic teleangiectasia (HHT). Over the last years several laser systems have been used for therapy. Only a few studies have published results of Nd:YAG laser therapy evaluating a larger number of patients. PATIENTS AND METHODS: From 1987 through 1996, forty-one patients with HHT were treated with a Nd:YAG laser due to recurrent epistaxis at the Department of Otorhinolaryngology of Kiel University. Thirty-two patients were followed-up over a period of at least 24 months. A centripetal technique was used for endonasal laser light application (15-25 Watts; 0.1-0.5 s), i.e., the laser light was applied from the periphery towards the center of the angiodysplasia. Intensive preoperative and postoperative nasal care with ointments was performed. RESULTS: Bleeding frequency and intensity decreased in 30 (94%) patients. Duration of the therapeutical success differed individually and varied from seven weeks to 14 months. Repeated laser therapy was necessary in 27 of 32 patients. CONCLUSION: The Nd:YAG laser is a suitable tool in the treatment of epistaxis in HHT. This procedure is less traumatic, less painful, and can be repeated multiple times. Nd:YAG laser therapy and other therapeutic options cannot obtain a lasting cure of Rendu-Osler-Weber syndrome. However, in the vast majority of cases recurrent nasal bleeding as the dominant symptom can be reduced in frequency as well as in intensity.     

Therapeutic control of plasma concentrations and long-term effect of nortriptyline in recurrent affective disorders

Based on the evidence that therapeutic plasma concentration range in fact exists for the tricyclic antidepressant drug, Nortriptyline (range 50-150 ng/ml), three different investigations were under taken in order to clarify some clinical pharmacological problems during long-term treatment with this drug. The possible prophlactic effect of the drug in recurrent affective disorders was specially examined in a group of patients with a high risk of episodes in their unipolar manic-depressive disease. The results highly demonstrate the value of monitoring plasma levels in achieving therapeutic control. Depressive relapses during treatment, for months and years, were only related to therapeutic insufficient plasma levels of the drug.     

Histopathological study of experimental recurrent pulmonary aspergillosis--the comparative study of steroid and cyclophosphamide induced models

A new animal model of recurrent pulmonary aspergillosis was established using cyclophosphamide (CPM) instead of cortisone acetate for reconstitution of immunosuppression, and histopathological findings were compared with those of the previous model. A recurrence of pulmonary aspergillosis, according to granulocytopenic conditions was much more rapid and uniform in this model than that of steroid induced model shown. In histopathologically, invasive and massive proliferation of Aspergillus hyphae was observed in lungs of rats 5-7 days after the CPM treatment and hyphal invasion into pulmonary vessels which suggested rapid systemic spreading of the infection was also found. This model considered to be good for the simulation of recurrent aspergillosis in patients with severe immunosuppression and also useful for studies of new diagnostic and therapeutic methods of recurrent pulmonary aspergillosis.     

Small group research and dynamical systems theory: Conceptual and methodological considerations, a reply to McGrath (1997).

This article responds to J. E. McGrath's (1997) integrative review of the small group literature and subsequent recommendations including the application of dynamical systems theory in group research. Parallels to the patterns and themes found in social psychology research are described from the therapeutic literature. Theoretical and methodological advantages of dynamical systems theory are noted. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emerging and re-emerging infectious diseases: a biological evolutionary drama

Cervical intraepithelial neoplasia grade 3 (CIN 3) is treated surgically. Follow-up of these patients is important to ensure successful treatment. The present study was undertaken to determine whether human papillomavirus (HPV) testing can be used to discriminate patients who will have recurrences from those who will not. It is composed of 26 patients who presented with recurrences of CIN and 22 patients who remained disease-free after treatment. DNA was extracted from paraffin-embedded cone biopsies of incident CIN 3, their corresponding follow-up Pap smears taken 3 months postoperatively, and their secondary cone biopsies of the recurrent lesions. The extracted DNA were then analyzed by PCR for the presence of HPV. The posttreatment cervical smears in the recurrent group had a (25/26) 96% HPV prevalence, while HPV DNA was not detectable in any of the 22 patients in the control group. The HPV types in both the initial and recurrent lesions correlated very well. This suggest that most recurrences are likely to be due to persisting lesions or subclinical HPV infections that had not been completely removed. Cytology alone was not sufficiently sensitive to discriminate the patients at risk for recurrences. It appears that HPV testing can be useful to monitor the therapeutic result.     

Use of the suture anchor in open Bankart reconstruction. A follow-up report

We previously reported early results of a new technique using a suture anchor to perform a modified Bankart reconstruction. That study included patients from two medical centers and had an average followup of only 1 year. This report includes patients from a single center with followup extended to a mean of 42 months (range, 33 to 61). Between April 1988 and August 1991, 53 patients with recurrent anterior glenohumeral instability underwent modified Bankart reconstruction with the use of a suture anchor. Thirty-two patients met inclusion criteria (identifiable Bankart lesion, open repair with suture anchors, and minimum followup of 2 years); 4 patients were lost to followup. There have been no complications as a result of this technique. Ninety-three percent of the patients in the study had objectively excellent or good results. There were 2 failures with recurrent anterior dislocation. The use of a suture anchor can simplify the Bankart reconstruction. At average followup of 3 years, 26 patients have returned to presurgery activity levels without recurrent dislocation or subluxation. However, careful attention to anchor placement at the junction of articular cartilage and the glenoid neck is necessary to avoid technical failure.     

Reduced adipose tissue lipoprotein lipase responses, postprandial lipemia, and low high-density lipoprotein-2 subspecies levels in older athletes with silent myocardial ischemia

BACKGROUND: Radioimmunoguided surgery (RIGS) by means of radiolabeled monoclonal antibodies and a probe has been reported to be useful in recognizing subclinical tumor deposits during operation. Aim of this study was to understand the limits of this technique and to assess the potential diagnostic use of RIGS in colorectal cancer surgery. METHODS: Monoclonal antibody B72.3 reacting with TAG 72 antigen, labeled with iodine 125, was injected in 32 patients with primary tumors and in 22 patients with recurrent colorectal cancer. One hundred thirty-three suspected tumor sites were evaluated during operation by means of probe and resected with immunohistochemistry as control. RESULTS: Primary tumor sites were localized by RIGS in 60% of cases, and recurrent sites were localized in 82% of cases. There was a significant correlation both for primary (p < 0.001) and recurrent (p < 0.001) tumor sites between intraoperative RIGS findings and TAG 72 tumor antigen expression. Results obtained with the probe were instrumental in modifying the surgical approach in six (27%) of 22 patients with recurrences, allowing the removal of tumor masses that would otherwise have been overlooked. CONCLUSIONS: The results of RIGS seems to be encouraging in terms of clinical use. The potential high diagnostic resolution appears to improve surgical ablation of colorectal cancer, especially in patients with recurrent cancer or suspected recurrent tumors who have negative results for intraabdominal disease by all other roentgenographic criteria with rising carcinoembryonic antigen or TAG 72 antigen levels.     

Epidemiology of recurrent cerebral infarction: a medicare claims-based comparison of first and recurrent strokes on 2-year survival and cost

BACKGROUND AND PURPOSE: Because recurrent strokes will tend to leave patients with greater disability than first strokes, patients with recurrent strokes should have poorer outcomes on average than those with first strokes. The extent of this difference has, however, not yet been estimated with precision. METHODS: Using a random 20% sample of Medicare patients aged 65 years and older admitted with a primary diagnosis of cerebral infarction during calendar year 1991, we used historical data from the previous 4 years to classify patients as having either first or recurrent stroke and followed survival and direct medical costs for 24 months after stroke. First and recurrent stroke groups were compared with the log-rank test (survival) and t test (cost) and also multivariate modeling. RESULTS: Survival from first stroke is consistently better than that for recurrent stroke: 24-month survival was 56.7% versus 48.3%, respectively. Costs were similar for the initial hospital stay and in months 1 to 3 after stroke. During months 4 to 24 after stroke, total costs were higher among those with recurrent stroke by approximately $375/mo across all patients, with this difference being greatest for younger patients and least for patients aged 80 years or older. Most of the difference in total monthly cost was attributable to nursing home utilization (averaging approximately $150/mo) and acute hospitalization (averaging approximately $120/mo). CONCLUSIONS: Patients with recurrent stroke have, on average, poorer outcomes than those with first stroke. To be as accurate as possible, clinical policy analyses should use different estimates of health and cost outcomes for first and recurrent stroke.