ACR Appropriateness Criteria® Dialysis Fistula Malfunction.

The creation and maintenance of a dialysis access is vital for the reduction of morbidity, mortality, and cost of treatment for end stage renal disease patients. One's longevity on dialysis is directly dependent upon the quality of dialysis. This quality hinges on the integrity and reliability of the access to the patient's vascular system. All methods of dialysis access will eventually result in dialysis dysfunction and failure. Arteriovenous access dysfunction includes 3 distinct classes of events, namely thrombotic flow-related complications or dysfunction, nonthrombotic flow-related complications or dysfunction, and infectious complications. The restoration of any form of arteriovenous access dysfunction may be supported by diagnostic imaging, clinical consultation, percutaneous interventional procedures, surgical management, or a combination of these methods. This document provides a rigorous evaluation of how variants of each form of dysfunction may be appraised and approached systematically. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update.

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

A feasibility study of neoadjuvant talazoparib for operable breast cancer patients with a germline BRCA mutation demonstrates marked activity.

This study was undertaken to determine the feasibility of enrolling breast cancer patients on a single-agent-targeted therapy trial before neoadjuvant chemotherapy. Specifically, we evaluated talazoparib in patients harboring a deleterious BRCA mutation (BRCA+). Patients with a germline BRCA mutation and ≥1 cm, HER2-negative primary tumors were eligible. Study participants underwent a pretreatment biopsy, 2 months of talazoparib, off-study core biopsy, anthracycline, and taxane-based chemotherapy ± carboplatin, followed by surgery. Volumetric changes in tumor size were determined by ultrasound at 1 and 2 months of therapy. Success was defined as 20 patients accrued within 2 years and <33% experienced a grade 4 toxicity. The study was stopped early after 13 patients (BRCA1 + n = 10; BRCA2 + n = 3) were accrued within 8 months with no grade 4 toxicities and only one patient requiring dose reduction due to grade 3 neutropenia. The median age was 40 years (range 25-55) and clinical stage included I (n = 2), II (n = 9), and III (n = 2). Most tumors (n = 9) were hormone receptor-negative, and one of these was metaplastic. Decreases in tumor volume occurred in all patients following 2 months of talazoparib; the median was 88% (range 30-98%). Common toxicities were neutropenia, anemia, thrombocytopenia, nausea, dizziness, and fatigue. Single-agent-targeted therapy trials are feasible in BRCA+ patients. Given the rapid rate of accrual, profound response and favorable toxicity profile, the feasibility study was modified into a phase II study to determine pathologic complete response rates after 4-6 months of single-agent talazoparib.

Clinicopathological and surgical factors associated with long-term survival in patients with HER2-positive metastatic breast cancer.

Trastuzumab-based treatment has dramatically improved the outcomes of HER2-positive (HER2+) metastatic breast cancer (MBC) patients, with some patients achieving prolonged survival times. In this study, we aim to identify factors that are associated with long-term survival. Patients with HER2+ MBC treated with anti-HER2 target therapy were identified. Patients were grouped according to overall survival (OS) and categorized as long-term survivors (LTS, OS ≥ 5 years), or non-long-term survivors (non-LTS, OS < 5 years). Descriptive statistics and multivariable logistic regression modeling were used. A sensitivity analysis was carried out, including only patients diagnosed before 2007; therefore, 5 years of potential follow-up was possible. 1063 patients with HER2+ MBC diagnosed between 1994 and 2012 and treated with anti-HER2 therapy were identified. Among them, 154 (14.5 %) patients were categorized as LTS (median OS 92.2 months). Among LTS, 63.4 % were HR-positive and 32 % had de novo stage IV disease. Hormone receptor positivity (OR) 1.69; 95 % CI 1.17-2.44), resection of metastases (OR 2.38; 95 % CI 1.53-3.69), and primary breast surgery in patients with de novo stage IV (OR 2.88; 95 % CI 1.47-5.66) were associated with improved long-term survival. Greater number of metastatic sites (≥3 vs. 1, OR 0.41; 95 % CI 0.23-0.72) and visceral metastases (OR 0.61; 95 % CI 0.4-0.91) were associated with poor survival. Hormone receptor positivity, low burden of disease, metastasis to soft and bone tissues, and surgical management with resection of the metastatic site and the primary tumor were associated with long-term survival in patients with MBC who received anti-HER2 treatment.

Clinical applications of spectral domain optical coherence tomography in retinal diseases.

Optical coherence tomography (OCT) was introduced about two decades ago and has revolutionized ophthalmic practice in recent years. It is a noninvasive noncontact imaging modality that provides a high-resolution cross-sectional image of the cornea, retina, choroid and optic nerve head, analogous to that of the histological section. Advances in OCT technology in signal detection technique from time-domain (TD) to spectral-domain (SD) detection have given us the potential to study various retinal layers more precisely and in less time. SD-OCT better delineates structural changes and fine lesions in the individual retinal layers. Thus, we have gained substantial information about the pathologic and structural changes in ocular conditions with primary or secondary retinal involvement. This review we discuss the clinical application of currently available SD-OCT in various retinal pathologies. Furthermore, highlights the benefits of SD-OCT over TD. With the introduction of enhanced depth imaging and swept - source OCT visualization of the choroid and choriocapillaris has become possible. Therefore, OCT has become an indispensable ancillary test in the diagnosis and management of diseases involving the retina and/or the choroid. As OCT technology continues to develop further it will provide new insights into the retinal and choroidal structure and the pathogenesis of posterior segment of the eye.

Sequential spectral domain OCT documentation of retinal changes after branch retinal artery occlusion.

Branch retinal artery occlusions (BRAO) are characterized histopathologically by inner retinal edema initially and atrophy in the presence of persistent ischemia. The duration of ischemia leading to irreversible atrophic retinal changes is not clear. Spectral-domain optical coherence tomography (SD-OCT) provides non-invasive detailed in-vivo histological changes in the retina. In this case report, we show sequential in vivo pathological changes seen in the inner retinal layers, in spite of clinical improvement, following the migration of an intraretinal embolus on the optic nerve head, which had previously resulted in symptomatic BRAO.

Strengthening accountability to citizens on gender and health.

Accountability refers to the processes by which those with power in the health sector engage with, and are answerable to, those who make demands on it, and enforce disciplinary action on those in the health sector who do not perform effectively. This paper reviews the practice of accountability to citizens on gender and health, assesses gaps, and recommends strategies. Four kinds of accountability mechanisms have been used by citizens to press for accountability on gender and health. These include international human rights instruments, legislation, governance structures, and other tools, some of which are relevant to all public sector services, some to the health sector alone, some to gender issues alone, and some to gender-specific health concerns of women. However, there are few instances wherein private health sector and donors have been held accountable. Rarely have accountability processes reduced gender inequalities in health, or addressed 'low priority' gender-specific health needs of women. Accountability with respect to implementation and to marginalized groups has remained weak. This paper recommends that: (1) the four kinds of accountability mechanisms be extended to the private health sector and donors; (2) health accountability mechanisms be engendered, and gender accountability mechanisms be made health-specific; (3) resources be earmarked to enable government to respond to gender-specific health demands; (4) mechanisms for enforcement of such policies be improved; and (5) democratic spaces and participation of marginalized groups be strengthened.

Efficacy of species specific anti-scorpion venom serum (AScVS) against severe, serious scorpion stings (Mesobuthus tamulus concanesis Pocock)--an experience from rural hospital in western Maharashtra.

BACKGROUND: Death caused by scorpion envenoming is a common event in the tropical and subtropical countries including many regions in India. Severe scorpion envenoming causes an autonomic storm producing multi-system organ-failure (MSOF) and death. OBJECTIVES: To determine the efficacy of Anti-scorpion venom serum (AScVS) in patients stung by scorpions (Mesobuthus tamulus concanesis Pocock--earlier called Buthus tamulus); to compare it with other modalities of therapy and to detect complications, if any, arising out of AScVS treatment. METHODS: Total 48 patients of severe, serious scorpion envenoming syndrome were studied during the period from 1992 to 2002. In 17 patients AScVS was the only mode of treatment. Others had received adjunctive therapy along with AScVS. RESULTS: 47 patients out of 48 scorpion sting victims recovered completely. Recovery period in patients given AScVS (10 hours) was faster than those who received alpha blockers (16-42 hours). No anaphylactic reaction with AScVS was observed. CONCLUSIONS: AScVS is effective and safe method of therapy in severe scorpion envenoming syndrome.

Mechanism of extracellular release of human neutrophil calprotectin complex.

Calprotectin is an abundant cytosolic protein complex of human neutrophils with in vitro extracellular antimicrobial activity. Studies suggest that calprotectin may be actively secreted from intact HL-60 cells and that it can be translocated to polymorphonuclear neutrophil (PMN) cell membranes. To examine whether calprotectin is secreted extracellularly, we incubated soluble and particulate stimuli, including live and heat-inactivated Candida albicans, with whole blood and measured calprotectin levels in the plasma. We compared the release of calprotectin to that of lactoferrin, a protein known to be secreted by PMNs. Extracellular lactoferrin was detected after incubation with any of the particulate stimuli. In contrast, a significant increase in extracellular calprotectin was found only after incubation with live C. albicans. Specifically, the increase in extracellular calprotectin correlated directly with a proportional decrease in PMN viability. Our results indicate that human PMN calprotectin is not secreted extracellularly except as a result of cell disruption or death.

Fighting female infanticide by working with midwives: an Indian case study.

PIP: In many cultures throughout history, parents have preferred to conceive and bear sons rather than daughters. In May 1995, Adithi, a nongovernmental organization (NGO) working in parts of Bihar with resource-poor women, and Bal Mahila Kalyan (BMK), an NGO working with poor people in general, organized a workshop with traditional midwives on the issue of female infanticide. A prior study found that traditional midwives are often called upon to kill female infants. These women mainly belong to the dalit community, are mostly illiterate, typically live in poverty, and have little power in the community. The workshop goals were to explore gender discrimination in different caste and religious groups; to understand the history and extent of female infanticide in the area, and to examine whether the incidence varies with caste, class, religion, and birth order; and to identify strategies to combat female infanticide. 28 traditional midwives participated. This paper describes the proceedings of the workshop and examines strategies for combatting female infanticide.^ieng

Effects of chronic exposure to ammonia on glutamate and glutamine interconversion and compartmentation in homogeneous primary cultures of mouse astrocytes.

Accumulation of radioactivity was studied in primary cultures of mouse astrocytes as a function of time of exposure (4-60 min) to 50 microM glutamate and 200 microM glutamine (initial concentrations), of which either glutamate or glutamine was 14C-labeled. Both the glutamate pool and the glutamine pool were compartmentalized. Initially, by far the major intracellular glutamate pool (> or = 90%) was derived from extracellular glutamate and could be converted to glutamine. This allowed a rather accurate determination of metabolic flux from glutamate to glutamine, which under control conditions amounted to 2.0-2.2 nmol/min per mg protein. After chronic exposure to 3 mM ammonia for 3 days this flux was significantly increased to 3.1-3.6 nmol/min per mg protein. Acute exposure to ammonia caused a smaller, apparent increase, which was not statistically significant. The glutamine content was compartmentalized at all stages of the incubation. It consisted of at least two different pools. One of these was accessible to extracellular glutamine and could be converted to intracellular glutamate (constituting a sizeable fraction of the total glutamate pool after longer incubation), whereas the other constituted endogenously derived glutamine, formed from accumulated glutamate. The specific activity of the precursor pool for glutamate synthesis could not be accurately determined and relatively exact fluxes therefore not be calculated. There was, however, no evidence that chronic exposure to ammonia decreases the rate of glutamine hydrolysis.

Combined myopia and astigmatism surgery. Review of 350 cases.

Between February 1985 and December 1987, 350 eyes had combined radial keratotomy and transverse keratotomy surgery. All procedures were performed by the same surgeon. The number and length of the radial and transverse incisions were varied according to the surgeon's clinical judgment based on his personal experience and the nomograms developed by Thornton. Our results showed that 93% of the eyes had 20/40 or better uncorrected visual acuity at the last follow-up visit. The data indicate that quantifiably predictable results can be achieved with this procedure and that results appear stable up to five years after surgery in 80% of the documented cases. There was a tendency toward increasing effect of the transverse incisions in 20% of cases studied. This seems to correlate well with previous studies measuring long-term results with radial incisions for myopia.

Secretion of myeloperoxidase isoforms by human neutrophils.

The human neutrophil lysosomal enzyme, myeloperoxidase (MPO), exists in three major and chromatographically distinct forms, MPO I, MPO II, and MPO III. We used cation-exchange medium-pressure liquid chromatography and kinetic microenzyme assay (or spectrophotometric monitoring) to analyze the secretion of MPO isoforms by neutrophils exposed to N-formylmethionylleucylphenylalanine (FMLP), digitonin, the ionophore A23187, and serum-opsonized zymosan A (SOZ). All three MPO isomers were released into the fluid phase after neutrophils were exposed to these secretagogues. A significant proportional increase in MPO I was released when neutrophils were stimulated with SOZ. MPO I was released in higher proportions than found in the whole cell constituency when neutrophils were stimulated with FMLP + cytochalasin B, A23187, and digitonin, but this was not statistically significant.