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Locoregional therapy with curative intent (CLRT) followed by salvage liver transplantation (SLT) in case of hepatocellular carcinoma (HCC) recurrence is an alternative to primary liver transplantation (LT) in selected patients with HCC.We performed a systematic review and meta-analysis of studies comparing the survival of patients treated with CLRT versus LT, stratified by the stage of liver disease, extent of cancer, and whether SLT was offered or not.We included 48 studies involving 9835 patients (5736 patients with CLRT and 4119 patients with primary LT). Five-year overall survival (OS) and disease-free survival (DFS) was worse for all categories of CLRT combined, than for primary LT (odds ratio [OR] for OS, 0.59; 95% confidence interval [CI], 0.48-0.71; P0.01). However, 5-year OS for CLRT and primary LT was not significantly different among patients with (i) Child-A cirrhosis and (ii) single HCC lesion, although DFS was worse. When SLT was offered after CLRT, intention-to-treat analysis showed no significant difference in 5-year OS (OR, 1.0; 95% CI, 0.6-1.7) between CLRT-SLT and primary LT, though noninferiority could not be shown. Only 32.5% patients with HCC recurrence after CLRT actually received SLT, as the rest were not medically eligible. Thus, the DFS was worse with CLRT-SLT (OR, 0.31; 95% CI, 0.2-0.6) compared with LT.CLRT-SLT may be offered as first-line therapy to patients with HCC and well-compensated cirrhosis instead of primary LT because it may lead to better utilization of donor liver. However, a large proportion of patients with HCC recurrence after CLRT may not be candidates for SLT.

Background: Community health workers (CHW) are specially trained lay-people often used as liaisons between underserved communities and the health care system. Prior studies suggest that use of CHWs can improve patient outcomes and reduce costs in a variety of illnesses. The role of CHW in managing patients with heart failure however has not been studied. This pilot study assesses the effect of CHW on hospital readmissions and Emergency Department (ED) visits for heart failure patients in an urban setting. Methods: Patients admitted to the hospital with a primary diagnosis of acute decompensated heart failure between April 2016 and March 2017 were screened for a pilot program to receive weekly home visits by a CHW. Visits included standardized assessment of overall well-being, vital signs, weight management, symptom control, medication compliance, diet education, and healthcare appointment reminders. Abnormal findings were reported to a cardiology nurse practitioner who triaged complaints and made appropriate changes. For this pilot study, enrolled patients were matched using 31 variables with retrospective control patients admitted with heart failure who did not receive a CHW. Hospital admissions and ED visits were compared for the 6 months following the index admission vs. the 6 months prior. Results: Sixteen patients received weekly visits from a CHW for 6 months after hospital admission. These were matched with 16 control patients who did not receive a CHW. Patients who received a CHW experienced a 36% decrease in Emergency Department (ED) visits in the 6 months after enrollment compared with the 6 months before. Control patients, however, experienced a 40% increase in ED visits over the same period. Similarly, patients with a CHW experienced a 42% decrease in hospital readmissions while control patients experienced a 28% increase. There was no significant difference in mortality between the groups. Conclusions: This pilot study suggests that CHW may reduce healthcare utilization for patients with heart failure without negatively impacting mortality. Based on these findings, a larger study is warranted to assess the efficacy and cost-efficiency of CHWs in helping to manage patients with heart failure.

Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P = 0.06) and more episodes of hypotension (22 versus 3%, P = 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P = 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.

Introduction: Right ventricular (RV) size and function are important predictors of outcomes. There are, however, no cut-off values for degrees of RV enlargement or dysfunction. Recent guidelines on the right heart classify measurements only as abnormal or normal. In a cohort of patients with closely-spaced 2DE and cardiovascular magnetic resonance (CMR) we sought to determine magnitudes of abnormality in 2DE values by using CMR normative values as determined by the Multi-Ethnic Study of Atherosclerosis (MESA) study. Methods: We studied 217 patients, who had CMR (1.5T), and 2DE within 2±2.5 d. CMR RV ejection fraction (EF) and end-diastolic volume (EDV) were measured using the method of disks. The RV-focused apical 4-chamber view was used to measure the functional parameters, TAPSE (M-mode) and S’ (pulsed-wave Doppler), and fractional area change (FAC) as well as the size parameters of end-diastolic basal (RVEDDb) and mid (RVEDDm) diameters. Using CMR normal values from the MESA study for males and females separately, magnitudes of abnormality in RV enlargement and dysfunction were determined using SDs from the population mean. Patients were categorized based on CMR results. Values for corresponding 2DE size and function parameters were then calculated for each category using the regression line and cut-offs proposed. Results: Mean CMR and 2DE values are reported (Table 1). At least moderate correlations (r>0.50) were seen between the functional parameters and CMR RV EF and size parameters and CMR RV EDV. The best correlation was seen between RV EDA and CMR RV EDV (r=0.79). Echocardiographic parameters at 0, 2, 4 and 6 SDs from MESA-derived normal values for males and females separately are shown (Tables 2&3). Conclusions: Studies combining information from echocardiography and CMR performed in close proximity could enhance the ability to qualify RV size and function other than as normal or abnormal potentially providing more value to the clinician.

For over a quarter of a century, echocardiography has made an unparalleled contribution to clinical cardiology as a major tool for real-time imaging of cardiac dynamics. Echocardiography is widely used to assess cardiac function and provides noninvasive information, which is invaluable for the diagnosis of various disease states. However, despite its numerous advantages echocardiography has remained mostly qualitative and subjective. The continued progress in our understanding of the interaction between ultrasound and tissue has brought about several new developments, which allow quantitative analysis of ultrasound data. Among these new developments are endocardial boundary detection (frequently referred to as acoustic quantification) and color kinesis, which provide a more objective, robust, and convenient evaluation of cardiac and vascular dynamics that embraces multiple clinical applications. This review describes these two techniques, focusing on their current status and the evolving clinical applications.

The laryngeal mask airway (LMA) was introduced more than two decades ago cl), and a comprehensive review article on the LMA has been published (2). The LMA has many advantages over the endotracheal tube (3), including increased speed in establishing an airway, reduced anesthetic requirements for airway tolerance, and lower frequency of coughing during emergence. Insertion of the LMA is performed blindly so that the LMA cuff is placed to cover the laryngeal inlet. The technique of LMA insertion described by Brain (4,5) has been widely accepted and used. Fukuhara (6) had designed and developed the J-shaped LMA holding forceps, named the Fukuhara (F) forceps, for easy and accurate placement of the LMA. The current study was undertaken to evaluate the effectiveness of the F forceps, which have been approved by the Food and Drug Administration.

To determine the effects of intravenous dexmedetomidine (DMED) on the sympathetic nervous system and to elucidate the mechanism of hypotension, we administered 3 micrograms/kg of DMED to nerve-intact and baroreceptor-denervated rabbits and compared the changes in renal sympathetic nerve activity (RSNA) and hemodynamic variables. In nerve-intact animals, mean arterial pressure (MAP) was increased briefly and then decreased significantly. Changes in RSNA were reciprocal to those of MAP. Heart rate decreased throughout the period of observation. In baroreceptor-denervated rabbits, both MAP and RSNA decreased significantly (-39.4% +/- 3.8% and -21.3% +/- 4.7%, respectively) after the initial increase of MAP. Twenty minutes after administration, hypotension had still continued (-21.1% +/- 3.2%) although RSNA returned to the baseline value. These results indicate that suppression of sympathetic nerve discharge is indeed one of the mechanisms of DMED-induced hypotension, although it may not be the principal one.

BACKGROUND The Poiseuillian model of the arterial system currently applied in clinical physiology does not explain how arterial pressure is maintained during diastole after cessation of pulsatile aortic inflow. Arterial pressure-flow relations can be more accurately described by models that incorporate arterial viscoelastic properties such as arterial compliance. Continuous pressure and flow measurements are needed to evaluate these properties. Since the techniques used to date to acquire such data have been invasive, physiological models of the circulation that incorporate these properties have not been widely applied in the clinical setting. The purpose of this study was (1) to validate noninvasive methods for continuous measurement of central arterial pressure and flow and (2) to determine normal reference values for arterial compliance using physiological models of the circulation applied to the noninvasively acquired pressure and flow data. METHODS AND RESULTS Simultaneously acquired invasive and noninvasive aortic pressures (30 patients), flows (8 patients), and arterial mechanical properties (8 patients) were compared. Pressure was measured by high-fidelity catheter aortic micromanometer (invasive) and calibrated subclavian pulse tracing (noninvasive). Aortic inflow was determined from thermodilution-calibrated electromagnetic flow velocity data (invasive) and echo-Doppler data (noninvasive). Arterial compliance was determined for two- and three-element windkessel models of the circulation using the area method and an iterative procedure, respectively. Once validated, the noninvasive methodology was used to determine normal compliance values for a reference population of 70 subjects (age range, 20 to 81 years) with normal 24-hour ambulatory blood pressures and without Doppler-echocardiographic evidence for structural heart disease. The limits of agreement between invasive and noninvasive pressure data, compared at 10% intervals during ejection and nonejection, were narrow over a wide range of pressures, with no significant differences between methods. Invasive and noninvasive instantaneous aortic inflow values differed slightly but significantly at the start of ejection (P < .05), but during the latter 90% of ejection, values for the two methods were similar, with narrow limits of agreement. Total vascular resistance and arterial compliance values derived from invasive and noninvasive data were similar. Arterial compliance values for the normal population using the two-element model (C2E) ranged from 0.74 to 2.44 cm3/mm Hg (mean, 1.57 +/- 0.38 cm3/mm Hg), with a beat-to-beat variability of 5.2 +/- 3.9%. C2E decreased with increasing age (r = -.73, P < .001) and tended to be higher in men (1.67 +/- 0.41 cm3/mm Hg) than in women (1.51 +/- 0.35 cm3/mm Hg, P = .07). Compliance values for the three-element model (C3E) were predictably smaller than for the two-element model (mean, 1.23 +/- 0.30; range, 0.59 to 2.16 cm3/mm Hg, P < .001 versus C2E) but correlated with C2E values (r = .81, P < .001) and were also inversely related to age (r = -.56, P < .001). Ridge regression and principal component analyses both showed the compliance value to be a composite function whose variation could be best predicted by consideration of simultaneous values for five major hemodynamic determinants: heart rate, mean flow, mean aortic pressure, minimal diastolic pressure, and end-systolic pressure. Multivariate analysis revealed age and sex to be independent predictors of compliance (P < .01 for both). There were no differences in compliance between black and white subjects. CONCLUSIONS Noninvasive methods can be used to acquire the hemodynamic data necessary for clinical application of physiological models of the circulation that incorporate arterial viscoelastic properties such as arterial compliance. The strong inverse linear relation between model-based compliance estimates and age mandates incorporation of this demographic parameter in

Assessment of the pulsatile mechanical behavior of the coupled left ventricle and the peripheral arterial circulation requires accurate estimation of instantaneous aortic flow. Before the availability of Doppler technologies, this could only be achieved by invasive techniques. The purpose of this study was to assess the accuracy of Doppler-based measurement of instantaneous aortic blood flow and waveform morphology throughout ventricular ejection when compared with an established invasive method. Accordingly, data from electromagnetic flow and continuous-wave aortic Doppler recordings were simultaneously acquired and compared in five monkeys over a wide range of flows generated by intravenous infusions of the beta-adrenoceptor agonist dobutamine and the alpha-receptor agonist methoxamine. Instantaneous aortic pressure was measured using a high-fidelity micromanometer-tipped catheter placed in the ascending aorta. Excellent correlations were noted for stroke volume, cardiac output, left ventricular ejection time, maximal flow velocity, and maximal rate of change of flow velocity (dQ/dtmax). When compared with electromagnetic flows, continuous-wave aortic Doppler had significantly lower times to maximal flow velocity and dQ/dtmax. Frequency domain analysis indicated that both the magnitude and phase were within +/- 6% up to the third harmonic. Instantaneous comparison disclosed that during early systole (up to 10% of ejection) Doppler was higher than electromagnetic flow rate by 11 +/- 19% (p less than 0.05). At 20-30% of systolic ejection, electromagnetic flow rates were slightly higher than Doppler (5 +/- 4% at 20% of ejection, p less than 0.001 and 2 +/- 3% at 30% of ejection, p less than 0.05). From 40% of ejection to the end of systole, flow rates using both techniques were virtually identical.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of the arterial baroreflex response is important to restore cardiac output and blood pressure by reflex sympathetic nerve activation in the event of sudden hypotension caused by acute blood loss during surgery. However, the arterial baroreflex may be significantly attenuated by both anesthetics and hypotensive agents. In isoflurane-anesthetized dogs, the authors investigated the arterial baroreflex response 1) to bolus injections of sodium nitroprusside (SNP), prostaglandin E1 (PGE1) and trimethaphan (TM); and 2) to rapid blood loss (5 ml/kg) before and during induced hypotension with SNP, PGE1, and TM by measuring mean arterial pressure (MAP), heart rate (HR), and renal sympathetic nerve activity (RSNA). Hypotension produced by both SNP and PGE1 was accompanied by an increase in RSNA and HR. The increase in RSNA and HR following the SNP bolus injection was significantly greater than that following injection of PGE1 (P less than 0.05). Trimethaphan was associated with a decrease in RSNA and HR. Rapid blood loss resulted in the same degree of MAP reduction (20 +/- 2 mmHg) before and during induced hypotension. Sensitivities of baroreflex, as evaluated by ratios of maximum changes in RSNA or HR to MAP (delta RSNA/delta MAP, delta HR/delta MAP), in response to rapid blood loss, were significantly suppressed during continuously induced hypotension, as compared with responses before induced hypotension. Despite the same degree of induced hypotension (70 +/- 5 mmHg of MAP), delta RSNA/delta MAP and delta HR/delta MAP in response to rapid blood loss were significantly greater with PGE1 than those with SNP (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute pulmonary embolism may occur rapidly and unpredictably and may be difficult to diagnose. Treatment can reduce mortality, and appropriate primary prophylaxis is usually effective. This review focuses on the pathogenesis, diagnosis, and treatment of acute pulmonary embolism of thrombotic origin.

A54-year-old woman, status post–mitral valve repair for severe mitral regurgitation secondary to mitral valve prolapse, was admitted 7 weeks after surgery with shortness of breath and fatigue. Hematological studies revealed a Coomb’s-negative hemolytic anemia with a hematocrit of 17.1%, haptoglobin of

A68-year-old man presented with epigastric burning associated with exercise. A stress echocardiogram was ordered. Baseline ECG (top panel, Rest) and echocardiographic images (bottom panel, Rest) were within normal limits. During stage I of the Bruce protocol, the patient’s blood pressure became unattainable. The test was terminated. …