Indian College of Radiology and Imaging Guidelines on Interventions in Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is one of the most common malignancies and a significant cause of cancer-related death. Treatment of HCC depends on the stage of the tumor. As many patients with HCC are not deemed fit for surgical resection or liver transplantation, locoregional therapies play an essential role in the management. Image-guided locoregional treatments include percutaneous ablative therapies and endovascular therapies. The choice of an individual or a combination of therapies is guided by the tumor and patient characteristics. As the outcomes of image-guided locoregional treatments depend on the ability to achieve necrosis of the entire tumor along with a safety margin around it, it is mandatory to follow standard guidelines. In this manuscript, we discuss in detail the various aspects of image-guided locoregional therapies to guide interventional radiologists involved in the care of patients with HCC.

MRI-Targeted Prostate Biopsy: What Radiologists Should Know

Transrectal ultrasound (TRUS)-guided systematic biopsy, the current gold standard for the detection of prostate cancer, suffersfrom low sensitivity for clinically significant cancer. The use of diagnostic multiparametric MRI has increased the relevanceof targeted biopsy techniques such as MRI-TRUS fusion biopsy and direct (in-bore) MRI-guided biopsy, which have higherdetection rate for clinically significant cancer. Although primarily used in patients who remain at high clinical suspicion forprostate cancer despite a negative systematic biopsy, with the increasing use of upfront diagnostic MRI, these biopsies areexpected to replace routine systematic biopsies. This pictorial essay aims to enhance our understanding of the concepts ofthese biopsy techniques so that they can be performed safely and provide maximum diagnostic yield.

Intratunnel versus extratunnel autologous hamstring double-bundle graft for anterior cruciate ligament reconstruction: a comparison of 2 femoral fixation procedures.

BACKGROUND: Anatomic double-bundle anterior cruciate ligament (ACL) reconstruction provides excellent results for restoring normal kinematics to the knee. Nevertheless, strong evidence supporting an ideal method for fixation of the ACL graft is lacking. HYPOTHESIS: Intratunnel femoral fixation of the ACL graft via a cross-pin fixation technique would provide better clinical and objective results than the extratunnel femoral fixation with cortical buttons. STUDY DESIGN: Randomized clinical trial; Level of evidence, 2. METHODS: Seventy patients with a unilateral ACL-deficient knee were randomly assigned to 1 of 2 femoral fixation groups. Group A (35 patients) was fixed with 2 bioabsorbable Rigidfix pins, 1 cross-pin per bundle, while group B (35 patients) was secured with 1 EndoButton cortical button per bundle. All femoral tunnels were created via an anteromedial portal, and a bioabsorbable Biointrafix interference screw was used for tibial fixation for both groups. The evaluation of the patients was performed by history details, clinical examination findings, measurement of the joint laxity by KT-1000 arthrometer, and use of validated patient outcome questionnaires. Statistical analysis was carried out with Fisher exact and Mann-Whitney U tests, with P<.05 considered the cutoff level of significance. RESULTS: At a mean follow-up of 30 months, 34 and 32 patients of group A and B, respectively, were available for evaluation. There were no statistically significant differences between the treatment groups regarding the subjective and objective outcomes, except for KT-1000 arthrometer values. The median KT-1000 value of patients in the cross-pin fixation group was 1.30 mm, while the median value in the cortical button fixation group was 1.95 mm (P<.001). Four patients with ACL grafts that were fixed with cortical buttons demonstrated failure of stability via the instrumented knee laxity testing, while patients from the other group had no failures. CONCLUSION: Intratunnel femoral fixation of the double-bundle ACL graft from the cross-pin fixation technique provided better instrumented knee laxity results than did the extratunnel femoral fixation with cortical buttons. Future larger studies comparing these 2 techniques should be conducted to ensure the availability of stronger evidence supporting the findings of this study.

Surgical management of traumatic knee dislocation with posterolateral corner injury.

PURPOSE: To evaluate the results of our method of surgical treatment of traumatic knee dislocation with injury to the posterolateral corner by use of a standardized protocol. METHODS: Twenty-five consecutive patients presented with a grossly dislocated or reduced knee. Five of these patients were not included in this series. The remaining 20 patients were treated by primary arthroscopic reconstruction. The anterior cruciate ligament (ACL) was reconstructed using gracilis tendon reinforced with artificial ligament (Ligament Augmentation and Reconstruction System [LARS] ligament); the posterior cruciate ligament (PCL) was reconstructed with semitendinosus tendon and reinforced with LARS ligament; and the posterolateral corner was treated using the gracilis and semitendinosus tendons from the uninjured knee. Twenty patients returned for subjective and objective evaluation at a minimum of 24 months after surgery. Early mobilization through continuous and active exercise was started on the fourth day postoperatively. RESULTS: At a mean follow-up of 44 months, the mean Lysholm score was 90 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the knee outcome survey averaged 80 points. By the rating of Meyers et al. the results were excellent in 6 patients, good in 10 patients, fair in 3 patients, and poor in one patient. The final International Knee Documentation Committee (IKDC) rating was not normal in any knee. The mean loss of extension was 2° (range, 0° to 3°) and loss of flexion was 12° (range, 10° to 15°). CONCLUSIONS: By using the described method of arthroscopically assisted reconstruction of the cruciate ligaments and the posterolateral corner, 80% of the patients had good subjective results and functional stability, and according to the IKDC scale, 45% of knees were nearly normal, 45% were abnormal, and 10% were severely abnormal. No patient's rating returned to normal. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Surgical treatment of chronic Achilles tendon rupture.

UNLABELLED: Chronic Achilles tendon ruptures are often challenging to repair because of muscle and tendon atrophy, retraction, and short distal stumps. We undertook a retrospective investigation of 14 patients who were treated with the Ligament Advanced Reinforcement System (LARS) ligament for the treatment of chronic, neglected rupture of the Achilles tendon. The patients pursued a course of early functional rehabilitation, and postoperative outcome scores were obtained at 3, 6, and 12 months, based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scoring system, and the Tegner Activity score. The minimum duration of follow-up was 36 months. After a minimum of 28 months postoperative, and up to 41 months postoperative, there was no observed incidence of rerupture or recurrent pain. The mean time to return to full activity was 18.3 +/- 2.7 weeks, and >90% of the patients scored > or =80 points on the AOFAS scoring scale. Specifically, the mean AOFAS score increased from 48.64 +/- 12.67 to 85.86 +/- 6.6 after the operation, and this difference was statistically significant (P = .001). Furthermore, the Tegner activity scale score improved from 2.58 +/- 0.31 to 1.73 +/- 0.29 after the operation, and this difference was also statistically significant (P = .001). The results of this retrospective clinical study suggest that augmentation with the LARS ligament offers a satisfactory reconstructive option for the neglected Achilles tendon rupture. LEVEL OF CLINICAL EVIDENCE: 4.

Surgical management of traumatic knee dislocation.

PURPOSE: The purpose of this study was to evaluate our method of surgical treatment of traumatic knee dislocation, by use of a standardized protocol, and to report our clinical results. METHODS: Thirty-six consecutive patients presented with a grossly dislocated or reduced knee. Ten of these patients were not included in this series. Five had vascular or neurovascular injury. Three had open fracture dislocation, and two had associated severe injury. The remaining 26 patients were treated by primary arthroscopic reconstruction with autologous grafting of the anterior cruciate ligament, posterior cruciate ligament, and collateral ligaments. The anterior cruciate ligament and posterior cruciate ligament were reconstructed via the gracilis and semitendinosus tendons of the uninjured and injured limbs. The collateral ligaments were reconstructed via artificial ligaments (LARS Ligament; J. K. Orthomedic, Dollard-des-Ormeaux, Quebec, Canada). Of the 26 patients, 20 returned for subjective and objective evaluation at a minimum of 24 months after the operation. Early mobilization via a continuous passive motion machine and active exercise were started on the fourth day postoperatively. RESULTS: At a mean follow-up of 43 months, the mean Lysholm score was 91 points, the mean score on the survey of daily activities was 90 points, and the sports activities score on the Knee Outcome Survey averaged 86 points. On the basis of the rating of Meyers et al., the results were excellent in 5 patients, good in 12, fair in 2, and poor in 1. The final International Knee Documentation Committee rating was not normal in any knee, nearly normal in 9, abnormal in 9, and severely abnormal in 2. The mean loss of extension was 0 degrees to 2 degrees , and the mean loss of flexion was 10 degrees to 15 degrees . CONCLUSIONS: By use of the described method of arthroscopic-assisted reconstruction of the cruciate ligaments and repair or reconstruction of the collateral ligament and other injured structures, 45% of the patients had good subjective results and functional stability and 45% had satisfactory subjective and functional stability within 2 to 3 weeks after surgery. According to the International Knee Documentation Committee scale, 45% of knees were nearly normal, 45% were abnormal, and 10% were severely abnormal. No patient's rating returned to normal. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Clinical evaluation of arthroscopically assisted anterior cruciate ligament reconstruction: patellar tendon versus gracilis and semitendinosus autograft.

PURPOSE: To evaluate the clinical results of anterior cruciate ligament (ACL) reconstruction in patients with ACL-deficient knee in 2 similar groups of patients. TYPE OF STUDY: A prospective randomized comparison of patellar tendon (PT) versus semitendinosus and gracilis tendon (STG) autografts for ACL reconstruction. METHODS: Between 1994 and 1996, 85 consecutive male patients with chronic ACL-deficient knees underwent arthroscopically assisted reconstruction with either autologous PT or double-loop STG (4-strand) graft. PT grafts were used in patients with even-numbered birth dates and STG grafts for those with odd-numbered birth dates. Preoperatively, no significant differences between the 2 groups were noted with respect to age, level of activity, and degree of laxity (chi-square analysis). A standardized rehabilitation program was used for both groups postoperatively that included immediate active extension and early weight bearing and gradual flexion. Return to sports was permitted 8 months postoperatively. Assessment of the patients was carried out using a questionnaire, clinical assessment, Lysholm knee scores, the International Knee Documentation Committee scale, and radiological examination. RESULTS: At a mean follow-up of 81 months, there was no significant difference between the 2 groups with respect to subjective complaints (recurrent giving way, functional level) or objective laxity evaluation, including KT-1000 measurement or return to sports. Loss of extension of < or =5 degrees was greater in the PT group (12 patients, 30 %) than in the STG group (8 patients, 17 %). There was loss of flexion of < or =15 degrees in 5 patients (12 %) in the PT group and 1 patient (2.2 %) in the STG group. Anterior knee pain was recorded in 10 patients (24 %) in the PT group and 3 patients (5 %) in the STG group. The Lysholm knee score was 91.6 and 92.7 for the PT and STG groups, respectively, and the Tegner activity score decreased from 8.9 preoperatively for both groups to 7.9 for the PT group and 7.8 for the STG group. CONCLUSION: In this study, the 2 groups had comparable results in terms of patient satisfaction, activity level, and knee function. Our study showed that patellofemoral problems and loss of knee motion are more frequent in patients with PT grafts than in those with STG grafts. LEVEL OF EVIDENCE: Level I, Randomized Controlled Trial.

Psychiatric morbidity among housemaids in Kuwait. III: Vulnerability factors.

BACKGROUND: Housemaids are a relatively homogenous immigrant subgroup in terms of their gender; ethnic origin; and socio-cultural, educational and occupational background. Psychiatric morbidity among housemaids is two to five times higher than the native female population. AIMS: To determine the possible pre-immigration risk factors for prospective psychiatric breakdown among the housemaids. METHODS: The sample consisted of all the housemaids (N = 197) hospitalised during the two-year study period. The controls comprised all the newly arrived housemaids (N = 502). The measures obtained included demographic characteristics and previous history of physical illness, psychiatric illness, hospitalisation and family history of psychiatric disorder. RESULTS: More than a quarter of the hospitalised group broke down within one month of their arrival. The hospitalised group had a significant excess of Sri Lankan housemaids; non-Muslims; those with less than four years of education and those with a previous history of physical illness, psychiatric illness or hospitalisation. CONCLUSIONS: A number of potential risk factors results in premature repatriation of housemaids on mental health grounds. Preventive measures involving recruitment procedures and pre-departure orientation courses are needed to minimise the expatriate failure among the housemaids.