Efficacy of Lusutrombopag for Thrombocytopenia in Patients with Chronic Liver Disease Scheduled to Undergo Invasive Procedures.

Objective Lusutrombopag is a thrombopoietin receptor agonist that improves thrombocytopenia in patients with chronic liver disease scheduled to undergo invasive procedures. However, information on the efficacy of repeated lusutrombopag treatment and factors associated with the treatment is scarce. We analyzed the efficacy of repeated lusutrombopag treatment and the factors associated with a response to lusutrombopag. Methods Thirty-nine patients with chronic liver disease who received lusutrombopag treatment before undergoing invasive procedures were enrolled in this retrospective study. Of the 39 patients, 10 received lusutrombopag treatment multiple times for a total of 53 regimens of lusutrombopag treatment. Changes in platelet counts, the effects of repeated lusutrombopag treatment, and factors associated with response to lusutrombopag were analyzed. Results The median platelet count increased significantly from 4.5×104/µL before lusutrombopag treatment to 7.2×104/µL before the invasive procedure (p<0.01), and patients undergoing 49 of the 53 (92%) treatment regimens succeeded in undergoing invasive procedures without needing platelet transfusions. In patients who received lusutrombopag treatment repeatedly, the median platelet count significantly increased following the second administration of lusutrombopag, and the effects of lusutrombopag were similar between the first and second administration. A multivariate analysis identified the absence of diabetes mellitus (odds ratio, 5.56 for presence; p=0.04) as a significant and independent predictor of a response to lusutrombopag. Conclusion Lusutrombopag treatment significantly increased platelet counts in patients with chronic liver disease, making it possible to receive invasive procedures. The treatment produced identical effects when it was repeated. The efficacy of lusutrombopag might be decreased in patients with diabetes mellitus.

[A case of primary epiploic appendagitis of the sigmoid colon diagnosed by abdominal CT and managed conservatively].

A 40-year-old man presented to our department with left lower abdominal pain. Laboratory test showed slight leukocytosis and moderately elevated C-reactive protein (CRP). Computed tomography (CT) of the abdomen showed a typical fat density lesion adjacent to the sigmoid colon. The diagnosis of primary epiploic appendagitis of the sigmoid colon was established, and the patient was managed conservatively. Primary epiploic appendagitis is a self-limiting illness, and diagnosed by characteristic radiographic findings. Inaccurate diagnosis can lead to unnecessary treatments including surgical intervention. When we encounter a case of acute abdomen, we should consider the possibility of this disease to make accurate diagnosis and give proper treatment.

[Case of hepatocellular carcinoma with abdominis muscle metastasis].

A 73-year-old man with liver cirrhosis type C, who was diagnosed as having hepatocellular carcinoma (HCC), underwent left lobectomy in March 2005. Two years later, intrahepatic recurrence was found, and he was treated with transcatheter arterial chemoembolization as well as hepatic arterial infusion. In July 2007, he complained of a painless mass over the right abdomen and demonstrated an elevated serum alpha-fetoprotein level. Computed tomography demonstrated a 3.0 cm lesion in the rectus muscle of the abdomen, which was histologically diagnosed as an intramuscular metastasis of HCC. Because there was no history of percutaneous abdominal procedures in this patient, it was suggested that this tumor had hematogeneously metastasized to the rectus muscle of the abdomen.

Transcatheter chemoembolization for unresectable hepatocellular carcinoma and comparison of five staging systems.

AIM: We compared the ability of five staging system to predict survival in patients with hepatocellular carcinoma (HCC) treated with chemoembolization. METHODS: The study subjects were 214 patients with HCC treated with repeated chemoembolization alone using cisplatin and lipiodol. Predictors of survival were assessed by multivariate analysis. Before chemoembolization was carried out, the modified Japan Integrated Staging (m-JIS), Japan Integrated Staging (JIS score), Barcelona (BCLC) stage, Liver Cancer Study Group of Japan/Tumor-Node-Metastasis (LCSGJ/TNM) and Italian score (CLIP score) were checked. To validate the prognostic value of these staging systems, the survival curve was obtained and analyzed by the Kaplan-Meier method. Discriminatory ability and predictive power were compared using Akaike's information criterion (AIC) score and the likelihood ratio (LR) χ(2) . RESULTS: Overall survival was 1 year in 82.9%, 3 years in 39.9% and 5 years in 15.1%. Multivariate analysis identified more than 90% lipiodol accumulation (grade I) after the first chemoembolization (P = 0.001), absence of portal vein tumor thrombosis (PVTT) (P < 0.001) and liver damage A (P = 0.012) as independent determinants of survival. AIC score and the LR χ(2) showed superior predictive power of the m-JIS system in 95 patients with grade I accumulation of lipiodol after first chemoembolization. CONCLUSION: The discriminate ability of the m-JIS score is substantially better than those of other staging systems and has better prognostic predictive power in patients with grade I accumulation of lipiodol after first chemoembolization.

Partial loss of hippocampal striation in medial temporal lobe epilepsy: pilot evaluation with high-spatial-resolution T2-weighted MR imaging at 3.0 T.

PURPOSE: To determine whether partial loss of the hippocampal striation (PLHS) at 3.0 T is more accurate than the currently accepted methods of using conventional magnetic resonance (MR) imaging to detect hippocampal sclerosis in medial temporal lobe epilepsy (MTLE). MATERIALS AND METHODS: This retrospective study had institutional review board approval, and informed consent was waived. Fluid-attenuated inversion-recovery (FLAIR) MR images and T2-weighted MR images in the oblique coronal plane in 22 consecutive patients (10 men, 12 female patients; mean age, 41.0 years; range, 14-76 years) (25 hemispheres) with a clinical diagnosis of MTLE were retrospectively evaluated. Twenty-five hippocampi in 15 subjects without epilepsy were evaluated as age-matched controls. The volumes and thicknesses of the four anatomic sections of the hippocampi were quantitatively measured on the T2-weighted images. Two radiologists independently reviewed the MR imaging findings of the hippocampus regarding atrophy, abnormal signal intensity, and PLHS on each side separately, without comparing both sides. Sensitivity and specificity were calculated among the MR imaging findings. RESULTS: Signal intensity abnormality on FLAIR images had a sensitivity of 36%, a specificity of 96%, and an accuracy of 66% for the diagnosis of hippocampal sclerosis. PLHS on T2-weighted MR images had a sensitivity of 76% and a specificity of 80% for the diagnosis of hippocampal sclerosis. The sensitivity for PLHS was higher than that for atrophy (44%) and abnormal signal intensity (48%) of the hippocampus on T2-weighted MR images. Although the mean volume of the hippocampus and the thickness of the hippocampal body were significantly smaller for patients with MTLE than for control subjects (P < .001 for both), there was no clear distinguishing threshold value between abnormal and normal hippocampi. CONCLUSION: PLHS showed the highest sensitivity for MTLE. This MR imaging feature might improve the accuracy of the diagnosis of bilateral hippocampal sclerosis, although further research is required.

Signal intensity of motor and sensory cortices on T2-weighted and FLAIR images: intraindividual comparison of 1.5T and 3T MRI.

We compared the signal intensity of motor and sensory cortices on T2-weighted and FLAIR images obtained at 3T and 1.5T. MR images of 101 consecutive neurologically normal patients who underwent both 1.5T and 3T MRI were retrospectively evaluated. The signal intensities of motor and sensory cortices were analyzed both visually and quantitatively in comparison with superior frontal cortex. On T2-weighted images, decreased signal intensity of the motor cortex was seen in 6 (32%) of 19 patients aged 61-70 years and 14 (48%) of 29 at 71 years and older at 3T, compared with only 1 (5%) and 2 (7%) at 1.5T, respectively. On FLAIR images, the decreased signal intensity in the motor cortex was also more frequently seen at 3T than at 1.5T. The mean CNRs of motor and sensory cortices were significantly higher at 3T than at 1.5T on both T2-weighted and FLAIR images. The decreased signal intensity in the motor cortex was frequently seen at 3T compared with 1.5T. Knowledge of the finding at 3T can help the recognition of abnormalities of the motor cortex caused by various pathologic conditions.

MRA of intracranial aneurysms embolized with platinum coils: a vascular phantom study at 1.5T and 3T.

PURPOSE: To analyze the influence of matrix and echo time (TE) of three-dimensional time-of-flight (3D TOF) magnetic resonance angiography (MRA) on the depiction of residual flow in aneurysms embolized with platinum coils at 1.5T and 3T. MATERIALS AND METHODS: A simulated intracranial aneurysm of the vascular phantom was loosely packed to maintain the patency of some residual aneurysmal lumen with platinum coils and connected to an electromagnetic flow pump with pulsatile flow. MRAs were obtained altering the matrix and TE of 3D TOF sequences at 1.5T and 3T. RESULTS: The increased spatial resolution and the shorter TE offered better image quality at 3T. For the depiction of an aneurysm remnant, the high-spatial-resolution 3T MRA (matrix size of 384 x 224 and 512 x 256) with a short TE of < or =3.3 msec were superior to the 1.5T MRA obtained with any sequences. CONCLUSION: 3T MRA is superior to 1.5T MRA for the assessment of aneurysms embolized with platinum coils; the combination of the 512 x 256 matrix and short TE (3.3 msec or less) seems feasible at 3T.

Detection of brain metastasis at 3T: comparison among SE, IR-FSE and 3D-GRE sequences.

The objective of this study is to compare the detectability of brain metastases at 3T among three contrast-enhanced sequences, spin-echo (SE) sequence, inversion recovery fast SE (IR-FSE) sequence (both with section thickness of 6 mm), and three-dimensional fast spoiled gradient-echo (3D fast SPGR) sequence with 1.4 mm isotropic voxel. First, phantom studies were performed to quantify the contrast-enhancement ratio (CER) with three sequences. In 21 consecutive patients with brain metastases, axial images of three sequences at 3T were obtained after administration of gadoteridol. Two neuroradiologists assessed the detectability of brain metastases for the three sequences. In the phantom study, no evident difference in the CER was demonstrated among three sequences. Significantly more brain metastases were detected with 3D fast SPGR than with SE and IR-FSE (a total of 97 lesions with 3D fast SPGR vs. 64 with SE and 63 with IR-FSE). In particular, 3D fast SPGR was superior to the other two sequences in detection of the small lesions (<3 mm). At 3T, the contrast-enhanced 3D fast SPGR with 1.4 mm isotropic voxel is clinically more valuable for detecting small brain metastases than the SE and IR-FSE with section thickness of 6 mm.

Effect of temporal subtraction technique on interpretation time and diagnostic accuracy of chest radiography.

OBJECTIVE: Our purpose was to compare reviewing time and diagnostic accuracy in the interpretation of radiographs without and with subtraction images and to examine whether this temporal subtraction technique can contribute to improving radiologists' performance. MATERIALS AND METHODS: Thirty cases with newly developed chest abnormalities on chest radiographs and 90 negative cases were selected. All chest radiographs were obtained with a computed radiography system. For the 90 negative cases, subtraction images were classified into two groups: 33 clean images without misregistration artifacts and 57 images with some misregistration artifacts. Eight radiologists (four board-certified radiologists and four radiology residents) participated in observer tests and interpreted the original radiographs without and with subtraction images using an independent test method. The reviewing time for each radiologist was recorded in each case. The observers' performance was evaluated by use of receiver operating characteristic (ROC) analysis. RESULTS: When subtraction images were available, the mean reviewing time per case was reduced significantly from 13.6 to 10.8 seconds for the cases with newly developed abnormalities (p < 0.001) and from 29.8 to 14.1 seconds for negative cases (p < 0.001). The reduction in the mean reviewing time with subtraction images was greater for clean images than for images with artifacts (17.7 vs 14.5 seconds, p < 0.001). The average mean area under the ROC curve value increased significantly from 0.942 without subtraction images to 0.988 with subtraction images (p = 0.025). There were significant differences in the sensitivity (0.963 with and 0.888 without the subtraction images) and the specificity (0.976 with and 0.899 without the subtraction images) (p < 0.001). CONCLUSION: The temporal subtraction technique can reduce reviewing time and also improve diagnostic accuracy in the interpretation of chest radiographs.

Retentive strength of metal copings on prefabricated abutments with five different cements.

BACKGROUND: Despite their wide use in implant dentistry, there is insufficient information concerning the retentive strength of cement-retained superstructures. PURPOSE: This study compared the retentive strength of metal copings on prefabricated abutments with five different luting cements. MATERIALS AND METHODS: Eight prefabricated abutments were placed on titanium screw implants torqued to 35 Ncm. Metal copings were cast with Au-Pt-Pd alloy (DeguDent Universal, Degussa, Hanau, Germany) using burnt-out plastic copings. Cements used were zinc oxide-eugenol-free temporary (ZO), zinc phosphate (ZP), glass ionomer (GI), resin-reinforced glass ionomer (RG), and composite resin (CR) cements. Retentive strength was measured with a universal testing machine. The means of each group were compared by one-way analysis of variance and Tukey-Kramer multiple-comparison intervals at a significance level of p < .05. RESULTS: The mean +/- SD retentive strength of the cements in Newtons was ZO 56 +/- 12 (Tukey group C), ZP 158 +/- 79 (Tukey group B), GI 132 +/- 29 (Tukey group B), RG 477 +/- 52 (Tukey group A), and CR 478 +/- 50 (Tukey group A). CONCLUSION: The retentive strength of metal copings on implant abutments is somewhat different from those of conventional cemented restorations on natural teeth. These differences may be influenced by differences in surface roughness and the height of the abutment.

Postsurgical change in the tracheal bifurcation angle after upper lobectomy: radiographic evaluation.

RATIONALE AND OBJECTIVES: The purpose of this study was to evaluate postsurgical changes in the tracheal bifurcation angle on chest radiographs after upper lobectomy and to determine whether bronchial repositioning after upper lobectomy mimics that in upper lobe collapse. MATERIALS AND METHODS: The authors selected 81 patients who had undergone upper lobectomy with complete mediastinal and subcarinal lymph node dissection and in whom chest radiographs had been obtained before operation and at four postoperative intervals. The interbronchial angle and the subcarinal angle were measured on the preoperative and postoperative radiographs and compared statistically. RESULTS: The average interbronchial angle and subcarinal angle during any postoperative period were significantly smaller than those before lobectomy (P < .001). These average angles decreased gradually during the postoperative periods. CONCLUSION: The tracheal bifurcation angle was decreased on follow-up chest radiographs in most patients who underwent upper lobectomy with mediastinal lymph node dissection. This finding may be useful for establishing a history of this surgical procedure on the basis of chest radiographs.

Combination of transcatheter arterial chemoembolization using cisplatin-lipiodol suspension and percutaneous ethanol injection for treatment of advanced small hepatocellular carcinoma.

BACKGROUND: We evaluated the long-term efficacy of the combination of transcatheter arterial chemoembolization (TACE) using cisplatin-lipiodol suspension and percutaneous ethanol injection (PEI) for treatment of advanced small hepatocellular carcinoma (HCC). PATIENTS AND METHODS: Sixty-nine patients with HCC less than 3 cm in diameter and at most three lesions were enrolled in this study. HCC nodules were confirmed to be hypervascular by angiography. Thirty-two patients were treated with a combination of TACE and PEI (TACE/PEI group) and 37 patients with TACE alone (TACE group). RESULTS: The 5-year survival rates were 50% for the TACE/PEI group and 22% for the TACE group. The TACE/PEI group had a slightly but not significantly better survival than the TACE group. The 5-year survival rates of patients with solitary HCC were 61% for the TACE/PEI group and 24% for the TACE group. Although the two therapeutic groups both had high rates of recurrence, the rates in the TACE/PEI group were significantly lower than those in the TACE group (P <0.05). Severe complications such as intraperitoneal bleeding and segmental hepatic infarction were observed at low incidence, and recovered with supportive treatment. CONCLUSIONS: The combination of TACE and PEI appears to prolong survival, compared with TACE alone. This combination therapy can thus be a valuable form of treatment for unresectable advanced small HCC.

Improved detection of lung nodules by using a temporal subtraction technique.

PURPOSE: To evaluate the effect of a temporal subtraction technique for digital chest radiography with regard to the accuracy of detection of lung nodules. MATERIALS AND METHODS: Twenty solitary lung nodules smaller than 30 mm in diameter, including 10 lung cancers and 10 benign nodules, were used. The nodules were grouped subjectively according to their subtlety. For non-nodular cases, 20 nodules without perceptible interval changes were selected. All chest radiographs were obtained by using a computed radiographic system, and temporal subtraction images were produced by using a program developed at the University of Chicago. The effect of the temporal subtraction image was evaluated by using an observer performance study, with use of receiver operating characteristic analysis. RESULTS: Observer performance with temporal subtraction images was substantially improved (A(z) = 0.980 and 0.958), as compared with that without temporal subtraction images (A(z) = 0.920 and 0.825) for the certified radiologists and radiology residents, respectively. The temporal subtraction technique clearly improved diagnostic accuracy for detecting lung nodules, especially subtle cases. CONCLUSION: The temporal subtraction technique is useful for improving detection accuracy for peripheral lung nodules on digital chest radiographs.

Balloon-occluded retrograde transvenous obliteration of gastric fundal varices with hemorrhage.

OBJECTIVE: This study was performed to evaluate the clinical efficacy, feasibility, and complications of balloon-occluded retrograde transvenous obliteration for patients with hemorrhage from gastric fundal varices. SUBJECTS AND METHODS: Between December 1994 and February 2001, 24 consecutive patients with hemorrhage from gastric fundal varices were enrolled in this study. Balloon-occluded retrograde transvenous obliteration consisted of injecting 5% ethanolamine oleate iopamidol through the outflow vessels during balloon occlusion. The treatment was performed during acute bleeding in 11 patients and electively in 13 patients. Among those patients with acute bleeding, six were treated for temporary hemostasis with balloon tamponade, and five were treated endoscopically. RESULTS: Cannulation into the outflow vessels was performed in 23 patients, but the balloon catheter could not be inserted in one patient who had inferior phrenic vein outflow. Complete success was obtained in 88% (21/24) of patients, and partial success was obtained in two patients. In nine of 11 patients with acute bleeding, complete success was achieved. Rebleeding from gastric varices was not observed in patients treated with complete success, whereas two patients treated partially rebled within 1 week of the treatment (rate of rebleeding, 9%). Eradication of gastric varices was obtained in all patients (n = 19) who were examined by endoscopy 3 months after the treatment. Eight patients experienced worsening of esophageal varices. These patients were treated endoscopically because of findings that suggested a risk of hemorrhage. The overall mortality rate was 4% (1/24). No damage to the kidney was observed, although 11 patients had macrohematuria. CONCLUSION: Balloon-occluded retrograde transvenous obliteration followed by any hemostatic procedure might be effective for both prophylaxis of rebleeding and eradication of gastric fundal varices, even in urgent cases.