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INTRODUCTION Patients experience variable long-term improvement in chronic back pain despite successful spinal cord stimulation (SCS) trials. Iliopsoas (IP) size has been shown to differ between patients with low back pain and healthy controls. In this study, we examine whether IP muscle cross-sectional area (CSA) is associated with SCS outcomes. MATERIALS AND METHODS We examined patients for whom we had lumbar MRIs 6.3 years prior to SCS and had baseline and one-year outcome data. Percent change from baseline to one year was calculated for Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ). Correlations between IP muscle CSA, ratio of iliopsoas muscle size to the vertebral body area (P/VBA), and the ratio of iliopsoas muscle size to BMI (P/BMI) were examined. Sex differences were considered. RESULTS A total of 73 subjects were included in this study including 30 females and 43 males. Males had significantly larger IP (males 15.70 ± 0.58, females 9.72 ± 0.43; p

Primary hyperoxaluria type 1 is a rare inherited disorder caused by abnormal liver glyoxalate metabolism leading to overproduction of oxalate, progressive kidney disease, and systemic oxalosis. While the disorder typically presents with nephrocalcinosis, recurrent nephrolithiasis, and/or early chronic kidney disease, the diagnosis is occasionally missed until it recurs after kidney transplant. Allograft outcomes in these cases are typically very poor, often with early graft loss. Here we present the case of a child diagnosed with primary hyperoxaluria type 1 after kidney transplant who was able to maintain kidney function, thanks to aggressive renal replacement therapy as well as initiation of a new targeted therapy for this disease. This case highlights the importance of having a high index of suspicion for primary hyperoxaluria in patients with chronic kidney disease and nephrocalcinosis/nephrolithiasis or with end stage kidney disease of uncertain etiology, as initiating therapies early on may prevent poor outcomes.

Background Hepatoblastoma is the most common primary pediatric liver malignancy. Indocyanine green (ICG) has been described as an adjunct to resection in small series. Its utility remains undefined in larger cohorts. Methods Records for 29 patients diagnosed with hepatoblastoma who received ICG prior to surgical resection from 2017 to 2020 at a single institution were retrospectively reviewed. The primary outcome was correlation between intraoperative ICG‐avidity and histologic presence of hepatoblastoma. A secondary outcome included the histologic margin designation for resected liver specimens. Results ICG sensitivity was 91% for 120 resected thoracic specimens from 21 patients. Specificity was 57%. In 10% of operations, HB‐positive specimens were resected solely on ICG‐avidity. In an additional 40% of cases, ICG assisted in localizing a preoperatively diagnosed lesion. ICG sensitivity during thoracotomy and thoracoscopic surgery was 95 and 74%, respectively; primary and relapsed disease demonstrated sensitivity of 94 and 73%, respectively. Sensitivity was 92% for 25 resected liver specimens from nine patients with all parenchymal margins grossly negative for disease. Four multifocal lesions were identified with two resected solely by ICG‐avidity. Conclusions ICG is a sensitive adjunct for identifying local and metastatic hepatoblastoma, including lesions not visualized on preoperative imaging, and delineating margins during liver resection. False positives limit specificity; however, there were no adverse outcomes from additional resections. We noted that thoracoscopic surgery can be completed safely in patients with less significant disease burden, and conversion to thoracotomy, if necessary, is straightforward., ICG is a sensitive adjunct for identifying local and metastatic hepatoblastoma, including lesions not visualized on preoperative imaging, and delineating margins during liver resection. With its use, thoracoscopic surgery can be completed safely in patients with less significant disease burden with conversion to thoracotomy, if necessary.

The etiology of portal hypertension (pHTN) in children differs from that of adults and may require different management strategies. We set out to review the etiology, management, and natural history of pHTN at a pediatric liver center. From 2008 to 2018, 151 children and adolescents with pHTN were identified at a free‐standing children’s hospital. Patients were stratified by etiology of pHTN (intrahepatic disease [IH], defined as cholestatic disease and fibrotic or hepatocellular disease; extrahepatic disease [EH], defined as hepatic vein obstruction and prehepatic pHTN). Patients with EH were more likely to undergo an esophagoduodenscopy for a suspected gastrointestinal bleed (77% vs. 41%; P

In this study we aim to demonstrate the fundamental role of proprioceptive training as an integral part of the junior sports training in the 110 m hurdle test. For this we subjected the tests, before and after the training period, using proprioceptive techniques and exercises to influence the hurdle runner technique in the two subjects chosen for this experiment, and the results obtained revealed their progress in within the parameters we considered relevant to the study. The aim of this study is to reveal the importance of proprioceptive training in correcting the technique of hurdle running, but also parameters that change and their value.

Background Portal diversion by surgical shunt plays a major role in the treatment of medically refractory portal hypertension. We evaluate our center’s experience with surgical shunts for the treatment of pediatric portal hypertension. Methods All patients who underwent surgical shunt at a single institution from 2008 to 2017 were reviewed. The primary outcome was intervention-free shunt patency. Results In this study, 34 pediatric patients underwent portal shunt creation. The median age was 7.7 years (interquartile range 4.3–12.0). Twenty-nine patients (85%) had prehepatic portal hypertension and 5 patients (15%) had intrahepatic portal hypertension. The primary manifestations of portal hypertension were esophageal varices (97%) and gastrointestinal bleeding (77%). Eighteen patients (53%) underwent meso-Rex bypass, 10 patients (29%) underwent splenorenal shunt, and 6 patients (18%) underwent mesocaval shunt. Outcomes were notable for minimal wound complications (9%), rebleeding events (12%), and mortality (3%). In the postoperative setting, 10 patients (29%) experienced a shunt complication (occlusion or stenosis), 4 of which occurred in the early postoperative period and required urgent intervention. The 1-year and 5-year “primary patency” patency rates were 71% and 66%, respectively. Conclusion Children suffer significant morbidity from the sequelae of portal hypertension. Our experience reinforces the feasibility of surgical shunts as an effective treatment option associated with low rates of morbidity and mortality.

Objectives Megacystis–microcolon–hypoperistalsis syndrome (MMIHS) also called Berdon's Syndrome, is a smooth muscle myopathy that results in an enlarged bladder, microcolon, and small bowel hypoperistalsis. In our series of six patients with this disorder, all had disordered swallowing. Therefore, we prospectively characterized esophageal structure and function in all. Methods Diagnoses had been established by contrast radiography, small bowel manometry, and urodynamic studies. To investigate the esophagus, we endoscoped and biopsied the esophagus of each patient on multiple occasions. All patients also underwent water soluble contrast esophagography and esophageal manometry. Results Upon careful questioning, all patients had swallowing dysfunction, and the majority of their enteral intake was via gastrostomy or gastrojejunostomy. All took some oral alimentation, but eating was slow and none could aliment themselves completely by the oral route, receiving 50% or less of their calories by mouth. Four had megaesophagus whereas the esophagus of the two youngest was of normal caliber. All had eosinophilic esophagitis and/or esophageal Candidiasis from time to time, but successful treatment of these findings failed to improve their symptoms. Manometry revealed normal lower esophageal sphincter (LES) resting tone and normal LES relaxation, but for all, peristalsis was absent in the esophageal body. Conclusions This series expands the spectrum of findings in MMIHS, to include a primary motility disorder of the esophageal body. As patients age, the esophageal caliber appears to increase. Successful treatment of neither esophageal eosinophilia nor Candidiasis is effective in ameliorating the motility disorder. If our findings are confirmed in more patients with MMIHS, this disorder should be renamed, megacystis–microcolon–intestinal-and esophageal hypoperistalsis syndrome. Type of study Prognosis study, Level IV (case series).

Background Gamma Knife radiosurgery was introduced in the 1960s and is currently used worldwide. The internet has become a foremost source of information used by patients and their families. In this study, we aim to evaluate the accuracy and reliability of the Gamma Knife radiosurgery–related YouTube videos. Methods We searched YouTube and the first 3 pages sorted according to “Relevance-Based Ranking” were included for analysis. Four independent health care workers from different disciplines evaluated the videos using the validated DISCERN tool. Results Our search resulted in 65,774 videos, and 14 videos met inclusion criteria. Our study found that 50% (7 of 14) of the videos were uploaded by university-affiliated hospitals; 14% of videos scored 3. The search term “Radiosurgery for intraaxial brain lesions” had the highest percentage of moderate videos (DISCERN = 3) (50%). Conclusions Patients and caregivers turn to online sources to gather information about the disease. However, the available YouTube published videos are published without proper academic monitoring, as in such a free platform, published videos tend to catch a general audience for different purposes, which leads to diminishing quality control. Academic medical institutions should consider a proper monitoring process for videos to improve the accuracy of the published information for the patients.

The purpose of this qualitative phenomenological study was to explore the adaptation process of support group participants who are survivors of lower limb amputation (LLA) experiencing phantom limb pain (PLP). The study followed a qualitative, descriptive phenomenological design. Ten adult participants with LLA met inclusion criteria and through semi-structured interviews shared their lived experience. A qualitative descriptive methodology was used to analyze the data collected from interview transcriptions. Analysis involved coding and theme development. Three themes emerged: PLP interrupted but does not prevent participation, adapting to PLP allowed for continued participation in meaningful occupations, and education to promote self-management of PLP. Themes identified highlight the importance of social support and early education on PLP to facilitate the adaption process and promote occupational participation. The finding underscores the value of empowering survivors to self-manage pain through their own personal and unique ways.

Introduction: Spinal cord stimulation (SCS) is an efficacious chronic pain treatment most commonly used in middle-aged patients. Results from previous studies that investigated SCS′ effects in older patient populations have been equivocal. We examine whether SCS outcomes correlate with age. Methods: We retrospectively examined prospectively collected outcomes from 189 patients who underwent SCS at Albany Medical Center between 2012 and 2020. The patients completed the Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) preoperatively and 1 year postoperatively. The mean percent change in each outcome was determined and compared via a regression analysis to determine relationships between patient age and each respective outcome metrics. Demographics were compared between patients aged under 65 versus those aged 65 and older via χ2 tests. Results: All subjects demonstrated the expected improvement on NRS, BDI, PCS, and MPQ from baseline to 1-year follow-up, with several demonstrating statistically significant changes: NRS-worst pain (18.66%, p < 0.001), NRS-least pain (26.9%, p < 0.001), NRS-average pain (26.9%, p < 0.01), NRS-current pain (26.4%, p < 0.001), ODI (19.6%, p < 0.001), PCS (29.8%, p < 0.001), and MPQ (29.4%, p < 0.001). There was no significant difference between patients aged under 65 versus those aged 65 and older based on lead type (p = 0.454). Six patients (3.1%) had lead migration, one of whom was 65 or older. Regression analysis revealed improvements in MPQ-sensory and MPQ-affective scores as age increased (p < 0.001, R2 = 0.09; p = 0.046, R2 = 0.05, respectively). Age did not correlate with NRS, ODI, BDI, or PCS. Diagnosis, spinal level of SCS, and lead type were not found to influence any respective outcome measure based on covariate analysis. Conclusion: This study represents the largest study where age was correlated to specific pain, depression, and disability outcomes following SCS. We provide evidence that SCS outcomes are equivalent, or better, in older patients following SCS. Based on these findings, SCS is a viable option for treatment of chronic pain in elderly patient populations.

Faculty seek methods that efficiently use their time, facilitate deep learning, and acquire competencies through the curriculum. The flipped classroom, a pedagogical approach, is proposed to be one solution to these issues. This study is a scoping review of how health care professional courses apply the flipped classroom model. The specific aims of this scoping review are: (a) determine the health care disciplines using and researching flipped classrooms, (b) identify and categorize instructional/course design and teaching and learning strategies used in flipped classroom literature, and (c) classify the levels of evidence-based education and trustworthiness in the studies as defined by Kirkpatrick's hierarchy. Following the PRISMA guidelines for sectioning the study, twenty studies were included in this scoping review. This scoping review identified various health care professions that have implemented the flipped classroom model at multiple levels of courses and curriculum to enhance student learning experiences. The flipped classroom design model provides different ways of improving learning environments, which could benefit student learning outcomes in academic performance and satisfaction. Pre-class and in-class active learning is the most common teaching and learning strategies; although less common, there is value identified in the after-class learning activities. Research suggests that blended learning and flipped classrooms can be effective in health care professional education to learn, retain, apply, and think critically compared to traditional teaching. Occupational therapy educators can use various learning strategies discussed in this study as an alternative or supplement to enhance or replace the traditional lecture-based teaching style.

Fluorescence-guided surgery (FGS) is an increasingly available and popular method of visual field augmentation. The basic premise of FGS entails injection of fluorescent indocyanine green (ICG) and subsequent detection with a near-infrared (NIR) camera. For pediatric surgical oncologists, FGS remains experimental but is a promising modality for identifying tumor margins, locating metastases, performing sentinel lymph node biopsies, protecting peritumoral structures of interest, and facilitating reconstruction. Familiarity with basic ICG pharmacokinetics and NIR detection optics is critical for surgeons wishing to judiciously use FGS, as its success is firmly grounded in a thorough understanding of its capabilities and limitations. In this practical guide, we outline several well-described and innovative FGS applications by disease type, including their methods of administration, modes of detection, and typical ICG dosing paradigms. LEVEL OF EVIDENCE: V.

Background Hepatocellular carcinoma (HCC) is often a chemoresistant neoplasm with a poor prognosis. Pediatric HCC may reflect unique biological and clinical heterogeneity. Procedure An IRB-approved retrospective institutional review of patients with HCC treated between 2004 and 2015 was undertaken. Clinical, radiographic, and histologic data were collected from all patients. Results Thirty-two patients with HCC, median age 11.5 years (range 1-20) were identified. Seventeen patients had a genetic or anatomic predisposition. Histology was conventional HCC (25) and fibrolamellar HCC (7). Evans staging was 1 (12); 2 (1); 3 (10); 4 (9). Sixteen patients underwent resection at diagnosis and five patients after neoadjuvant chemotherapy. Surgical procedures included liver transplantation (LT, 11), hemihepatectomy (9), and segmentectomy (1). Eighteen patients had medical therapy (13 neoadjuvant, 5 adjuvant). Most common initial medical therapy included sorafenib alone (7) and cisplatin/doxorubicin-based therapy (8). Overall, 14 (43.8%) patients survived with a median follow-up of 58.8 months (range 26.5-157.6). Cause of death was most often linked to lack of primary tumor surgery (11). Of the survivors, Evans stage was 1 (11), 2 (1), and 3 (2, both treated with LT). Four of 18 patients (22%) who received medical therapy, 8 of 17 patients with a predisposition (47%), and 14 of 21 patients (66%) who underwent surgery remain alive. Conclusions Genetic and anatomic predisposing conditions were seen in over half of this cohort. Evans stage 1 or 2 disease was linked to improved survival. LT trended toward improved survival. Use of known chemotherapy agents may benefit a smaller group of pediatric HCC and warrants formal prospective study through cooperative group trials.

Background and aims Biliary atresia (BA) is a devastating neonatal cholangiopathy that progresses to fibrosis and end-stage liver disease by 2 years of age. Portoenterostomy may reestablish biliary drainage, but, despite drainage, virtually all afflicted patients develop fibrosis and progress to end-stage liver disease requiring liver transplantation for survival. Approach and results In the murine model of BA, rhesus rotavirus (RRV) infection of newborn pups results in a cholangiopathy paralleling human BA and has been used to study mechanistic aspects of the disease. Unfortunately, nearly all RRV-infected pups succumb by day of life 14. Thus, in this study we generated an RRV-TUCH rotavirus reassortant (designated as TR(VP2,VP4) ) that when injected into newborn mice causes an obstructive jaundice phenotype with lower mortality rates. Of the mice that survived, 63% developed Ishak stage 3-5 fibrosis with histopathological signs of inflammation/fibrosis and bile duct obstruction. Conclusions This model of rotavirus-induced neonatal fibrosis will provide an opportunity to study disease pathogenesis and has potential to be used in preclinical studies with an objective to identify therapeutic targets that may alter the course of BA.

Biliary atresia is a newborn cholangiopathy that may lead to portopulmonary hypertension and cirrhosis-induced cardiomyopathy while awaiting liver transplantation. Extracorporeal life support and hepatic toxin filtration are life-saving interventions that provide cardiopulmonary support and hepatic dialysis to allow resolution of a child's illness. We utilized a combination of these extreme measures to bridge an infant with biliary atresia to transplantation. We reviewed cases of extracorporeal life support utilization in transplantation recipients in the Extracorporeal Life Support Organization database and determined that ours was the only use of pretransplant extracorporeal life support in biliary atresia.

This descriptive study, consisting of a survey followed by semi-structured interviews, sought to describe the practice patterns and perceived competencies of occupational therapy practitioners in the provision of return to work (RTW) services for stroke survivors. Respondents (n = 119) were mostly occupational therapists (95%) working in outpatient settings (61%); 47% reported a caseload of mostly stroke survivors; and most addressing RTW (60%). Respondents focused predominantly on remediation of cognitive and physical skills and less on actual work performance and supports. Respondents assert occupational therapy's role in RTW for stroke survivors but generally reported limited competencies and low utilization of evidence-based approaches and theoretical models when addressing RTW. Systems, organizational support, and practitioner factors emerged as barriers and facilitators to RTW service provision. This study suggests there may be a critical gap in practitioners' RTW competencies with profound implications for entry-level education, professional development, advocacy, and research.

Biliary fibrosis is a complex process in which macrophages and myofibroblasts may play central roles. We investigated biliary fibrosis lesions induced in the Glisson's sheath in rats by alpha-naphthylisothiocyanate (ANIT) administration under macrophage depletion. Hepatic macrophages were depleted in F344 rats with liposome-encapsulated clodronate (CLD) (10mL/kg body weight, i.v) followed by bile duct injury with ANIT (75mg/kg body weight, i.p) (ANIT+CLD group). Rats received empty-liposomes (Lipo) followed by ANIT, and served as control (ANIT+Lipo group). In both ANIT+Lipo and ANIT+CLD groups, ANIT-induced bile duct injury with inflammatory cell infiltration was seen on days 1-3, and subsequently reparative fibrosis occurred on days 5 and 7. In comparisons between the two groups, macrophages reacting to CD68, CD163, MHC class II and CD204 were less in numbers in ANIT+CLD group; the most sensitive immunophenotype was of CD163-positive. Furthermore, in ANIT+CLD group interstitial mesenchymal cells/myofibroblasts reacting to vimentin, desmin and α-smooth muscle actin were also less in grades and tended to be delayed in appearance. Interestingly, MCP-1, IFN-γ, IL-10, and TGF-β1 mRNAs were significantly increased mainly on day 2 in ANIT+Lipo group, while the levels of these factors were prominently lower in ANIT+CLD group. Collectively, depletion of hepatic macrophages plays roles in attenuating biliary fibrogenesis by production of inflammatory factors. The present results indicated clearly importance of macrophage functions in the pathogenesis of biliary fibrosis.

Background Helicobacter pylori infection has become increasingly resistant to traditional first-line treatment regimens because of emerging antibiotic resistance coupled with poor patient compliance with completing the treatment course. There is limited data regarding the incidence of H. pylori treatment resistance in the Philippines. This study aims to guide physicians in deciding the choice of the treatment regimen for both treatment-naive and treatment-resistant organisms. Methods This is a prospective, cohort study in St. Luke’s Medical Center. We currently enrolled 73 patients positive for H. pylori infection based on rapid urease test, and gastroscopy, biopsy of the antrum, incisura and corpus and subsequent H. pylori culture and sensitivity against amoxicillin, clarithromycin, metronidazole, tetracycline, and levofloxacin were done. Results Thirty-eight percent (38%) or 28 out of 73 patients enrolled are H. pylori culture positive and we were able to isolate and do sensitivity analysis in 42 samples. The incidence rate of Helicobacter treatment-resistant infection is high at 66.7% or 28 out of 42 isolates. Among the medications used, no resistance was noted for amoxicillin and tetracycline, while the resistance rates are as follows for other antibiotics: clarithromycin 28.6% (12/42), metronidazole 40.5% (17/42) and levofloxacin 61.9% (26/42). Conclusions The rates of resistance to clarithromycin, metronidazole and levofloxacin are high in Filipino H. pylori strains. This is in contrast to the earlier antibiotic susceptibility study by Destura et. al in 2004 in which all isolated strains were sensitive to tested antibiotics. This new pattern of resistance indicates the decreased usefulness of the first line therapy in the Philippines and the need for other treatment regimens is emerging.

There is a need for speech-language pathology (SLP) research in the Philippines, in order to fill in knowledge gaps relevant to the local context. Information about the local SLP research status remains inadequate. This study describes local SLP research done over the almost past four decades.Using a descriptive retrospective design, a search was made for all empirical research articles completed by Filipino SLPs from 1978 to 2015.A total of 250 research articles were identified and described along several parameters. A predominant number were authored by the SLPs in the academe (97.20%). There was a focus on language (27.60%) and the nature of communication/swallowing disorders (20.80%). More than half utilised quantitative exploratory research designs (69.20%). Several used survey forms to generate data (38.41%). Nearly all were unpublished (93.60%) and were unfunded (94.80%).The current study revealed a dearth of research studies, limited diversity of research articles, limited research dissemination and funding concerns. It is suggested that the results of the current study can serve as a reference point to restructure research systems in the Philippines and in other developing countries, and offer data that can be used to develop a research agenda for the profession.

Diffuse intrinsic pontine glioma (DIPG) is surgically unresectable and one of the most devasting tumours in children. To date, there have been no effective chemotherapeutics against DIPG, despite a myriad of clinical trials. The intact blood-brain barrier (BBB) is partly responsible for the limited clinical response to chemotherapy. MRI-guided focused ultrasound (MRgFUS) is a promising non-invasive tissue ablation method for treating CNS tumours. Moreover, MRgFUS allows for temporary and repeatable BBB disruption. Our first objective was to determine the feasibility and safety of temporary BBB disruption within the brainstem using MRgFUS following intravenous administration of microbubbles in vivo. Our second objective was to select effective chemotherapeutics against DIPG cell lines, and to examine their therapeutic effects with MRgFUS in a murine model of DIPG which exhibits an intact BBB. Non-invasive opening of the BBB was determined in the brainstem of normal rodents using physiological monitoring and histological analysis. Doxorubicin was selected from a drug screen consisting of conventional chemotherapeutics tested against DIPG cell lines. We established SU-DIPG17 orthotopic xenografts which demonstrated diffusely infiltrative tumour growth. By LC-MS/MS analysis, MRgFUS led to a 4-fold increase in doxorubicin concentrations within the brainstem tumours as compared to controls. Moreover, the volumetric tumour growth rate was significantly suppressed in MRgFUS-treated animals, which also exhibited decreased Ki-67 expression. We demonstrated the feasibility and safety of MRgFUS in the rodent brainstem and have shown that MRgFUS increases doxorubicin uptake in the brainstem of a rodent model of DIPG. This preclinical data provides critical support for clinical trials investigating MRgFUS-mediated BBB opening, which may greatly improve chemotherapeutic efficacy against DIPG in children.

Background:Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit.Methods:Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed.Results:This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft.Conclusions:We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.

The most common primary malignant liver tumor of childhood, hepatoblastoma has increased in incidence over the last 30 years, but little is still known about its pathogenesis. Discoveries in molecular biology provide clues but have yet to define targeted therapies. Disease-free survival varies according to stage, but is greater than 90% in favorable risk populations, in part due to improvements in chemotherapeutic regimens, surgical resection, and earlier referral to liver transplant centers. This article aims to highlight the principles of disease that guide current treatment algorithms. Surgical treatment, especially orthotopic liver transplantation, will also be emphasized in the context of the current Children’s Oncology Group international study of pediatric liver cancer (AHEP-1531).

Liposomes have been used as a vehicle for encapsulating chemicals or toxins in toxicological studies. We investigated the transient effects of empty liposomes on hepatic macrophages by applying a single intravenous injection at a dose of 10 ml/kg body weight in 6-week-old male F344 rats. One day after injection, the numbers of hepatic macrophages reacting to CD163, CD68, Iba-1, MHC class II, Gal-3 and CD204 were significantly increased in liposome-treated rats. CD163(+) Kupffer cells and CD68(+) macrophages with increased phagocytic activity in hepatic lobules were most sensitive. The histological architecture of the liver was not changed following liposome injection; however, hepatocytes showed increased proliferating activity, demonstrable with proliferation marker immunostaining and by an increase in gene profiles related to the cell cycle. In the liposome-treated rats, interestingly, AST and ALT values were significantly decreased, and MCP-1, IL-1β and TGF-β1 mRNAs were significantly increased. Collectively, the present study found that hepatic macrophages activated by liposomes can influence liver homeostasis. This information would be useful for background studies on liposomes.

Hepatic macrophages play crucial roles in hepatotoxicity. We investigated immunophenotypes of macrophages in liver injury induced in rats by thioacetamide (TAA; 300 mg/kg, intraperitoneal) after hepatic macrophage depletion; hepatic macrophages were depleted by liposomal clodronate (CLD; 10 ml/kg, i.v.) one day before TAA injection. Samples were obtained on post-TAA injection days 0, 1, 2, 3, 5, and 7. TAA injection induced coagulation necrosis of hepatocytes on days 1 through 3 and subsequent reparative fibrosis on days 5 and 7 in the centrilobular area, accompanied by increased numbers of M1 macrophages (expressing cluster of differentiation [CD]68 and major histocompatibility complex class II) and M2 macrophages (expressing CD163 and CD204) mainly on days 1 through 3. TAA + CLD treatment markedly decreased the numbers of M1 and M2 macrophages mainly on days 1 through 3; CD163+ Kupffer cells were most sensitive to CLD depletion. In TAA + CLD–treated rats, interestingly, coagulation necrosis of hepatocytes was prolonged with more increased levels of hepatic enzymes (aspartate transaminase, alanine transaminase, and alkaline phosphatase) to TAA-treated rats; reparative fibrosis was incomplete and replaced by dystrophic calcification in the injured area, indicating the aggravated damage. Furthermore, in TAA + CLD–treated rats, inflammatory factors (monocyte chemoattractant protein [MCP]-1, interferon-γ, tumor necrosis factor-α, and interleukin-10) and fibrosis-related factors (transforming growth factor-β1, matrix metalloproteinase-2, tissue inhibitor of metalloproteinase-1) were decreased at messenger RNA levels, indicating abnormal macrophage functions. It was clearly demonstrated that hepatic macrophages have important roles in tissue damage and remodeling in hepatotoxicity.

Hepatic macrophages (including Kupffer cells) play a crucial role in the homeostasis and act as mediators of inflammatory response in the liver. Hepatic macrophages were depleted in male F344 rats by a single intravenous injection of liposomal clodronate (CLD; 50mg/kg body weight), and immunophenotypical characteristics of depleting and repopulating macrophages were analyzed by different antibodies specific for macrophages. CD163(+) Kupffer cells were almost completely depleted on post-injection (PI) days 1-12. Macrophages reacting to CD68, Iba-1, and Gal-3 were drastically reduced in number on PI day 1 and then recovered gradually until PI day 12. MHC class II(+) and CD204(+) macrophages were moderately decreased during the observation period. Although hepatic macrophages detectable by different antibodies were reduced in varying degrees, Kupffer cells were the most susceptible to CLD. Liver situation influenced by depleted hepatic macrophages was also investigated. No marked histological changes were seen in the liver, but the proliferating activity of hepatocytes was significantly increased, supported by changes of gene profiles relating to cell proliferation on microarray analysis on PI day 1; the values of AST and ALT were significantly elevated; macrophage induction/activation factors (such as MCP-1, CSF-1, IL-6 and IL-4) were increased exclusively on PI day 1, whereas anti-inflammatory factors such as IL-10 and TGF-β1 remained significantly decreased after macrophage depletion. The present study confirmed importance of hepatic macrophages in liver homeostasis. The condition of hepatic macrophages should be taken into consideration when chemicals capable of inhibiting macrophage functions are evaluated.

Occupational and physical therapy professionals are natural partners in neurorehabilitation especially in the acute stages of recovery. To enhance student-learning experiences from both disciplines, we have developed an interprofessional (IP) learning unit that was embedded in neurorehabilitation tracks of each respective program. The primary goal of this project was to examine interprofessional attitudes and perception toward interprofessional learning and practice. A total of 117 occupational therapy (53) and physical therapy (64) students completed an IP case-based learning module with the goal of developing an IP care plan typically seen in neurorehabilitation. Using a sequential explanatory mixed methods design, we collected data pre- and postintervention using the Readiness for Interprofessional Learning Survey (RIPLS). We also utilized a postintervention questionnaire and focus groups intended to solicit information regarding IP competencies. At pretest, students had high ratings on the RIPLS that led to minimal changes at posttest (p = .157). However, common threads from the questionnaire and focus groups showed positive effects on student learning and attitudes toward interprofessionalism. Students reported positive experiences with the IP module. An IP case-based educational module has the potential to facilitate professional development and readiness for future IP practice. Students from different disciplines appreciate the value of IP education (IPE) in reinforcing their professional identity and understanding the professional contributions of others. Our findings are consistent with literature on best practices for IPE.

BACKGROUND Hepatocellular carcinoma (HCC) is an aggressive malignant neoplasm that is often chemoresistant. Complete surgical resection remains the mainstay of therapy. The role of liver transplantation (LT) in pediatric HCC is in evolution, as is the role of adjuvant chemotherapy for stage I disease. METHODS A retrospective review of patients < 18 years of age with completely resected HCC treated with surgical intervention alone at our institution from 2004 to 2015 was conducted. RESULTS Twelve patients with a median age of 12 years (range = 1-17; number of females = 7) with upfront resected HCC (Evans stage I) were identified. Four patients had HCC without identifiable risk factors (fibrolamellar-HCC = 2; early HCC arising in focal nodular hyperplasia = 1, well-differentiated [wd] HCC = 1). Four patients had early or wd-HCC in the context of portosystemic shunts (Abernethy = 2; mesocaval shunt and portal vein thrombosis = 2). Four patients had moderate to wd-HCC in the context of pre-existing liver disease with cirrhosis (progressive familial intrahepatic cholestasis type-2 = 2, alpha-1 antitrypsin deficiency = 1, Alagille syndrome = 1). Seven patients underwent LT (multifocal = 5; solitary = 2); five exceeded Milan criteria (MC) by imaging. Five patients underwent complete resection (segmentectomy = 2; hemihepatectomy = 3). Ten patients received no adjuvant chemotherapy. All patients are alive without evidence of disease with a median follow-up of 54.1 months (range = 28.1-157.7 months). CONCLUSIONS Pediatric and adolescent patients with upfront, completely resected HCC can be effectively treated without chemotherapy. LT should be considered for nonmetastatic HCC, especially in the context of pre-existing chronic liver disease, even when the tumor exceeds MC. Distinct pediatric selection criteria are needed to identify patients most suitable for LT.

Magnetic Resonance Image-guided Focused Ultrasound (MRgFUS) has been used to achieve transient blood brain barrier (BBB) opening without tissue injury. Delivery of a targeted ultrasonic wave causes an interaction between administered microbubbles and the capillary bed resulting in enhanced vessel permeability. The use of MRgFUS in the brainstem has not previously been shown but could provide value in the treatment of tumours such as Diffuse Intrinsic Pontine Glioma (DIPG) where the intact BBB has contributed to the limited success of chemotherapy. Our primary objective was to determine whether the use of MRgFUS in this eloquent brain region could be performed without histological injury and functional deficits. Our secondary objective was to select an effective chemotherapeutic against patient derived DIPG cell lines and demonstrate enhanced brainstem delivery when combined with MRgFUS in vivo. \ud \ud \ud \ud Female Sprague Dawley rats were randomised to one of four groups: 1) Microbubble administration but no MRgFUS treatment; 2) MRgFUS only; 3) MRgFUS + microbubbles; and 4) MRgFUS + microbubbles + cisplatin. Physiological assessment was performed by monitoring of heart and respiratory rates. Motor function and co-ordination were evaluated by Rotarod and grip strength testing. Histological analysis for haemorrhage (H & E), neuronal nuclei (NeuN) and apoptosis (cleaved Caspase-3) was also performed. A drug screen of eight chemotherapy agents was conducted in three patient-derived DIPG cell lines (SU-DIPG IV, SU-DIPG XIII and SU-DIPG XVII). Doxorubicin was identified as an effective agent. NOD/SCID/GAMMA (NSG) mice were subsequently administered with 5 mg/kg of intravenous doxorubicin at the time of one of the following: 1) Microbubbles but no MRgFUS; 2) MRgFUS only; 3) MRgFUS + microbubbles and 4) no intervention. Brain specimens were extracted at 2 h and doxorubicin quantification was conducted using liquid chromatography mass spectrometry (LC/MS). \ud \ud \ud \ud BBB opening was confirmed by contrast enhancement on T1-weighted MR imaging and positive Evans blue staining of the brainstem. Normal cardiorespiratory parameters were preserved. Grip strength and Rotarod testing demonstrating no decline in performance across all groups. Histological analysis showed no evidence of haemorrhage, neuronal loss or increased apoptosis. \ud \ud \ud \ud Doxorubicin demonstrated cytotoxicity against all three cell lines and is known to have poor BBB permeability. Quantities measured in the brainstem of NSG mice were highest in the group receiving MRgFUS and microbubbles (431.5 ng/g). This was significantly higher than in mice who received no intervention (7.6 ng/g). \ud \ud \ud \ud Our data demonstrates both the preservation of histological and functional integrity of the brainstem following MRgFUS for BBB opening and the ability to significantly enhance drug delivery to the region, giving promise to the treatment of brainstem-specific conditions.

Patient-derived xenografts (PDXs) retain the genotype of the parental tumors more readily than tumor cells maintained in culture. In order to study the genetics of clival chordoma in the absence of prior radiation we sought to establish a PDX following the primary resection of a clival chordoma. Epicranial grafting of a primary clival chordoma was performed in NOD/SCID mice. Tumors have been passaged serially in mice for 7 generations. Physaliferous cell architecture was demonstrated in the regenerated tumors, which stained positive for Brachyury, Cytokeratin, and S100. The tumors demonstrated bone invasion. Single-nucleotide polymorphism analysis of the tumor xenograft was compared to the parental tumor. We identified homozygous amplification of the T-gene (brachury) and heterozygous loss of CDKN2A. We also identified heterozygous loss of the tumor suppressor FHIT gene, although protein expression was preserved. Accumulation of copy number losses and gains over three generations showed for the first time that there is inherent genomic instability in chordoma. In conclusion, this PDX reproduces the phenotype of clival chordoma. This study is the first to show chromosomal genomic instability in a chordoma that is serially propagated through multiple generations. The genomic instability observed in chordoma may serve as the biological basis for resistance to chemotherapy as is observed for other forms of cancer.

Unlike other solid-organ transplants, whole pancreas transplantation in children is relatively rare, and it occurs more frequently in the context of multivisceral or composite organ transplantation. Because children only infrequently suffer severe sequelae of type 1 diabetes mellitus, pancreas transplantation is rarely indicated in the pediatric population. More commonly, pediatric pancreas transplant occurs in the setting of incapacitating acute recurrent or chronic pancreatitis, specifically islet autotransplantation after total pancreatectomy. In this clinical scenario, total pancreatectomy removes the nidus of chronic pain and debilitation, while autologous islet transplantation aims to preserve endocrine function. The published experiences with pediatric total pancreatectomy with islet autotransplantation (TPIAT) in children has demonstrated excellent outcomes including liberation from chronic opioid use, as well as improved mental and physical quality of life with good glycemic control. Given the complexity of the operation, risk of postoperative complication, and long-term physiologic changes, appropriate patient selection and comprehensive multidisciplinary care teams are critical to ensuring optimal outcomes.

The liver is the primary organ participating in the metabolism of xenobiotics and is therefore an important target in the safety assessment of drugs, chemicals and environmental toxins. Drug-induced liver injury (DILI) has recently become widely recognized in human medicine as an adverse event. The progression of DILI often involves "damage-associated molecular patterns" (DAMPs) of gene and protein expression such as high-mobility group boxes (HMGBs), S100 proteins and heat shock proteins (Hsp). DAMPs are released from injured or necrotic cells and are bound to Toll-like receptors (TLRs) and modulate inflammatory reactions. Previously, in thioacetamide (TAA; 300mg/kg body weight, single injection)-induced rat liver, we demonstrated that the expressions of DAMPs, TLR4 and major histocompatibility complex (MHC) class II were simultaneously increased, accompanied with progression of hepatocellular injury and inflammation. Here we investigated the association of DILI and DAMPs, TLRs and MHC class II by using rat livers repeated injections with TAA (100mg/kg body weight, once, three times). Two days after TAA single injection, centrilobular hepatocellular necrosis with infiltration of mononuclear cells was observed, being paralleled with increase in serum levels of aspartate transaminase (AST), alanine transaminase (ALT) and alkaline phosphatase (ALP). However, two days after duplicate and triplicate injections, only mild degenerative change of hepatocytes and slight infiltration of mononuclear cells were seen in the affected centrilobular area. Serum levels of AST, ALT and ALP were also decreased to the same levels of control. mRNA expressions of DAMPs (HMGBs, S100A4 and Hsp 70-2), TLR4 and MHC class II tended to be increased only on single injection, although the number of MHC class II-positive cells in the centrilobular area was still increased on each examination point. The analysis of enzymes (CYP2E1 and Flavin monooxygenase (FMO) 3), which metabolize TAA in hepatocytes, showed a significant decrease in FMO3 on the duplicate and triplicate injections. Autophagy and regulatory T cells were not significantly changed for the attenuation of hepatocyte injury. Collectively, these results suggest that hepatocytes may adapt accumulation of the toxicant by changing their enzyme functions; furthermore, MHC class II cells, which still showed increased number in the duplicate and triplicate injections, may be related with protection from the toxicant.

There are few surgeons in the United States, within private practice and academic centers, currently performing transvaginal cholecystectomies (TVC). The lack of exposure to TVC during residency or fellowship training, coupled with a poorly defined learning curve, further limits interested surgeons who want to apply this technique to their practice. This study describes the learning curve encountered during the introduction of TVC to our academic facility.This study is an analysis of consecutive TVCs performed between August 14, 2009 and August 3, 2012 at an academic center. The TVC patients were divided into sequential quartiles (n = 15/16). The learning curve outcome was measured as the operative time of TVC patients and compared to the operative time of female laparoscopic cholecystectomy (LC) patients performed during the same time period.Sixty-one patients underwent a TVC with a mean age of 38 ± 12 years and mean BMI was 29 ± 6 kg/m(2). Sixty-seven female patients who underwent a LC with average age 41 ± 15 years and average BMI 33 ± 12 kg/m(2). The average operative time of LC patients and TVC patients was 48 ± 20 and 60 ± 17 min, respectively. Significant improvement in TVC operative times was seen between the first (n = 15 TVCs) and second quartiles (p = 0.04) and stayed relatively constant for third quartile, during which there was no statistically significant difference between the mean LC operative time for the second and third TVC quartilesThe learning curve of a fellowship-trained surgeon introducing TVC to their surgical repertoire, as measured by improved operative times, can be achieved with approximately 15 cases.

Advanced stage hepatoblastoma, including both locally advanced primary tumors as well as metastatic disease, poses unique clinical challenges. Despite substantial advances in chemotherapeutics, surgical extirpation remains the mainstay of cure for this tumor. Locally advanced tumors that involve multiple hepatic lobes and/or invade significant vascular structures can be managed either by complex hepatic resections or liver transplantation. We review the indications, roles, and outcomes of these surgical approaches as well as those for the resection of pulmonary metastases.

Transvaginal cholecystectomy (TVC) is the most common natural orifice transluminal surgery (NOTES) performed in women, yet there is a paucity of data on intraoperative and immediate postoperative pain management. Previous studies have demonstrated that NOTES procedures are associated with less postoperative pain and faster recovery times. This study analyzes intraoperative and postoperative opioid use for TVC compared with traditional four-port laparoscopic cholecystectomies (LCs).This is a retrospective analysis of consecutive TVC and LC female patients between August 2009 and August 2012 in an academic institution. We compared demographics, intraoperative and postoperative opioid use and times in the operating room (OR) and in the post anesthesia care unit (PACU).A total of 68 TVC and 67 LC patients were included in this study. The TVC and LC groups were similar in terms of age (both 41 years) and body mass index (29 and 31 kg/m2, respectively). The intraoperative preparation, surgical, and emergence times were significantly longer for the TVC than for the LC (p ≤ 0.01). Compared with the LC group, the intraoperative opioid requirement was significantly greater (TVC 27 mg vs. LC 25 mg; p = 0.003), but after adjusting for anesthesia time, the difference in OR opioid consumption became non-significant (p = 0.08). The PACU opioid requirement (TVC 2.5 vs. LC 5 mg; p = 0.04) was significantly lower for the TVC group, and a greater proportion of patients did not need any pain medications (TVC 38 % vs. LC 21 %; p = 0.04), compared with the LC group. The average PACU pain scores were not significantly different between the groups (p = 0.45).TVC patients did not experience more pain than LC patients. Although the average pain scores of TVC patients did not differ from those of the LC patients, TVC patients did require less pain medication in the PACU.

Background This study was conducted to provide preliminary data regarding current Internet use practices for information about anaesthesia in patients undergoing elective surgical procedures at a major academic institution. Methods With IRB approval, 2936 patients coming for preanaesthetic evaluation at a tertiary academic hospital's preadmission testing (PAT) centre were invited to voluntarily participate in a 20-item questionnaire designed to obtain participants' characteristics and Internet use for information pertaining to their upcoming surgery. Data were analysed using statistical software SAS (Cary, NC, USA). Descriptive statistics were calculated for continuous variables using mean ( sd ), and for categorical data using n (%). Association analysis was performed using the Fisher's exact test. Results Eight hundred and seventy-seven patients (30%) responded. Of these, 356 (41%) looked for information about their medical condition, 321 (37%) for their surgery, 279 (32%) for surgeon, 163 (19%) for the hospital, and only 36 (4%) for information regarding anaesthesia. Of these 36 patients, 14 (39%) said the sites they used helped answer their questions regarding anaesthesia. Of the 831 patients who did not use the Internet for anaesthesia, 503 (57%) indicated that they would be receptive to being directed to specific websites for anaesthesia. Conclusions Of the patients coming for elective surgery who responded (30%), the majority did not use the Internet to seek information regarding anaesthesia. Respondents indicated a high degree of interest in being directed to appropriate websites for further information. These results suggest that it may be beneficial to include information regarding reliable web-based resources to interested patients at preoperative visits.

Date Presented 4/20/2018 Occupational therapy can play an integral role in improving the quality of life (QOL) of stroke survivors. This study shows how the use of interviews can best capture perceptions of QOL and how client-centered practice can lead to a positive perception of the occupational therapy profession and optimize functional outcomes. Primary Author and Speaker: Claribell Bayona Additional Authors and Speakers: Salvador Bondoc Contributing Authors: Steve Van Lew

e22505Background: Hepatocellular carcinoma (HCC) is an often chemoresistant neoplasm with a poor prognosis. Pediatric HCC may reflect unique biological and clinical heterogeneity. Methods: An IRB a...

Background Metabolic syndrome is increasing among patients undergoing liver transplantation. Nonalcoholic steatohepatitis is a manifestation of metabolic syndrome and is an increasingly common cause of end-stage liver disease necessitating orthotopic liver transplantation. We sought to determine the effect of preoperative risk factors on the development of post-transplant metabolic syndrome, complications, readmissions, and mortality. Methods We conducted a review of 114 orthotopic liver transplantations at our institution from May 2012 to April 2014. Results Patients with (n = 19) and without (n = 95) metabolic syndrome were similar with regard to age, race, and model for end-stage liver disease at time of transplant. Donor and operative factors also were similar between the groups. Preoperative diabetes was found to be associated with an increased rate of readmission (odds ratio 3.45, P = .03). While preoperative metabolic syndrome itself was not a significant predictor of worse outcomes, postoperative metabolic syndrome was associated with significantly greater readmissions in the first year. Major predictors of new onset metabolic syndrome after orthotopic liver transplantation included preoperative diabetes and obesity (odds ratio 8.54 and odds ratio 5.49, P Conclusion Efforts to decrease the incidence of postoperative metabolic syndrome after orthotopic liver transplantation may decrease readmissions and improve outcomes, along with decreasing resource utilization.

C-terminal Agrin Fragment (CAF) has been proposed as a potential circulating biomarker for predicting changes in physical function among older adults. To determine the effect of a one-year PA intervention on changes in CAF concentrations and to evaluate baseline and longitudinal associations between CAF concentrations and indices of physical function.Ancillary study to the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P), a multi-site randomized clinical trial designed to evaluate the effects of chronic exercise on the physical function of older adults at risk for mobility disability.Four academic research centers within the U.S.Three hundred thirty three older adults aged 70 to 89 with mild to moderate impairments in physical function.A 12-month intervention of either structured physical activity (PA) or health education promoting successful aging (SA).Serum CAF concentrations and objectives measures of physical function - i.e. gait speed and performance on the Short Physical Performance Battery (SPPB).The group*time interaction was not significant for serum CAF concentrations (p=0.265), indicating that the PA intervention did not significantly reduce serum CAF levels compared to SA. Baseline gait speed was significantly correlated with baseline CAF level (r = -0.151, p= 0.006), however the association between CAF and SPPB was not significant. Additionally, neither baseline nor the change in CAF concentrations strongly predicted the change in either performance measure following the PA intervention.In summary, the present study shows that a one-year structured PA program did not reduce serum CAF levels among mobility-limited older adults. However, further study is needed to definitively determine the utility of CAF as a biomarker of physical function.

PURPOSE OF REVIEW This review of the most recent publications is aimed to look at the current developments regarding the effects of regional anesthesia on perioperative outcome. RECENT FINDINGS The debate continues on whether regional anesthesia and analgesia improve outcome or not. Researchers are still divided in their views. While previous meta-analyses are more favorable, more recent trials are rather on the con side. In an attempt to lessen heterogeneity, meta-analyses have now incorporated data from more recent trials to perform subgroup analyses. Such analyses persistently show the same positive results. The established outcome effects of regional anesthesia are mostly due its ability to provide superior analgesia, its ability to reduce the perioperative stress response and subsequent physiologic perturbations, and its ability to reduce pulmonary complications. Its potential to prevent cardiac morbidity in patients undergoing coronary artery bypass grafting is investigated further by looking at valuable specific biological markers like troponin I and natriuretic peptides. Intrathecal opioids do not seem to improve outcome, unlike the intrathecal local anesthetics. The latter improve outcome presumably by blocking the surgical stress response. In contrast, opioids, non-steroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors have been shown not to impact outcome presumably by not being able to interfere with the stress response. The safety and efficacy of epidural or spinal anesthesia for spinal surgery continue to be demonstrated by current studies. SUMMARY Despite the controversies, the numerous potential benefits and advantages of regional anesthesia are keys to its continued popularity. With constant search for new scientific clues by improving experimental designs, valuable evidence slowly unfolds. Regional anesthesia certainly takes a leading role in the current trends for a multimodal approach of perioperative pain management.

The objectives were to define the incidence, risk factors, clinical features and outcome of arterial desaturation syndrome following talc pleurodesis in patients with malignant pleural effusions. This retrospective, observational study took place at a tertiary care cancer center in New York. All patients were those with malignancy who underwent pleurodesis with talc in 1998 at Memorial Sloan Kettering Cancer Center. Characteristics of patients are described by using summary statistics. Differences between groups were assessed with the Fisher's exact statistic for categorical variables and Student's t-test for continuous variables. Among patients who were considered to have arterial desaturation syndrome, we evaluated the relation of SaO2/FIO2 pre- and post-talc installation using a paired Student's t-test. During 1998, 120 patients underwent pleurodesis with talc, and 8 (7%) developed arterial desaturation following the procedure. Symptoms included chest pain, dyspnea, fever, and increased need for oxygen supplementation developed typically within 1 day. Three of the eight patients in this series required mechanical ventilation, but all recovered uneventfully after treatment, which included high-dose corticosteroids. Patients with breast and ovarian cancer appeared to be at increased risk for this complication compared to those patients with other types of cancer (p = 0.01). Approximately 7% of patients who have undergone sclerosis with talc for a malignant pleural effusion will develop arterial desaturation with clinically significant hypoxia requiring supplemental oxygen following the procedure. It appears that most patients recover from this complication and that those with breast and ovarian cancer may be at higher risk.