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The frequency with which patients with high Model for End-Stage Liver Disease (MELD) scores undergo liver transplantation has been increasing. Canadian literature regarding the outcomes of liver transplantation in recipients with high MELD scores is limited. The primary objective of this study was to assess patient and graft survival among recipients with high (35) and low (≤ 35) MELD scores. Secondary objectives were to potentially identify independent predictors of graft failure and patient mortality.We conducted a retrospective chart review of patients undergoing liver transplantation at a single Canadian centre from 2012 to 2017.A total of 332 patients were included in the study: 280 patients had a MELD score of 35 or lower, and 52 had a MELD score above 35. Patients with high MELD scores had higher rates of pretransplant acute kidney injury and dialysis (No difference in patient mortality was found between MELD groups. Graft survival was significantly lower in recipients with MELD scores above 35. D-MELD may potentially be used as an adjunct in determining risk of graft failure in recipients with high MELD scores.

To evaluate the clinical efficacy of adding temozolomide (TMZ) to preoperative capecitabine (CAP)-based chemoradiotherapy in patients with locally advanced rectal cancer (LARC) and validate OLARC patients with clinical stage II (cT3-4N0) or III (cTBetween November 2017 and July 2020, 64 patients were randomised. Slow accrual caused early study termination. After excluding four ineligible patients, 60 were included in the full analysis set. The pCR rate was 15.0% (9/60), 0%, 14.3%, 18.8% and 26.7% for the entire cohort, arms A, B, C and D, respectively (P = 0.0498 between arms A and D). The pCR rate was 9.7% in the CAP group (arms A + C), 20.7% in the TMZ + CAP group (arms B + D), 6.9% in the uMGMT group (arms A + B) and 22.6% in the mMGMT group (arms C + D). Grade 1-2 nausea or vomiting was significantly more frequent in the TMZ + CAP treatment groups (arms B + D) than in the CAP treatment groups (arms A + C, P0.001) with no difference in grade 3 adverse events. There were no grade 4 or 5 adverse events.The addition of TMZ to CAP-based chemoradiotherapy tended to improve pCR rates, particularly in those with mMGMT LARC. MGMT status may warrant further investigation as a predictive biomarker for chemotherapeutic agents and radiotherapy.

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy with poor prognosis, particularly for patients with metastatic disease. Treatment for oligometastatic presentation has been reported in recent literature, but the role of intraperitoneal chemotherapy for patients with peritoneal metastases (PM) remains unclear. We performed a systematic literature search of the PubMed, Cochrane and Embase databases in order to identify clinical trials and case-series reporting on the safety and efficacy of intraperitoneal chemotherapy in patients with PDAC-derived PM. Eight publications reporting on 85 patients were identified, using three different therapeutic strategies. First, 37 patients received cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for PDAC with PM. Grade 3 and 4 complications occurred in 37.8% of patients, without perioperative mortality. Median disease-free survival and overall survival (OS) rates varied from 4 to 36 months and 4 to 62 months, respectively. Secondly, 40 patients with resectable PDAC without PM received prophylactic HIPEC following pancreatic resection, with postoperative morbidity and mortality rates of 30% and 5%, and 5-year OS rates of 23-24%. Finally, eight patients with PDAC-derived peritoneal disease were converted to resectable disease after receiving neoadjuvant intraperitoneal chemotherapy and operated on with curative intent, achieving a median OS of 27.8 months. In conclusion, CRS with HIPEC for PDAC-derived PM appears to be safe, conferring the same postoperative morbidity and mortality as reported on non-pancreatic malignancies. In highly selected patients, it could be considered for short-term disease control. However, long-term survival remains poor. The addition of prophylactic HIPEC for resectable PDAC cannot be recommended.

Percutaneous image guided thermal ablation has become a cornerstone of therapy for patients with oligometastatic disease and primary liver malignancies. Evolving from percutaneous ethanol injection (PEI), thermal ablation utilizing radiofrequency ablation (RFA) and microwave ablation (MWA) have become the standard approach in the treatment of isolated lesions that fit within the size criteria for curative intent therapy (typically 3-4cm). With the evolution of more intense thermal ablation, such as MWA, the dramatic increase in both the size of ablation zone and intensity of heat generation have extended the limits of this technique. As a result of these innovations, intra-procedural and post-procedural pain have also significantly increased, requiring either higher levels of intravenous sedation or, in some institutions, general anesthesia. In addition to the increase in therapeutic intensity, the use of intravenous sedation during aggressive ablation procedures carries the risk of over-sedation when the noxious insult (i.e. the ablation) is removed, adding further difficulty to post-procedural recovery and management. Furthermore, high subdiaphragmatic lesions become challenging in this setting due to issues relating to sedation and compliance with breath hold/breathing instructions. Although general anesthesia may mitigate these complications, the added resources associated with providing general anesthesia during ablation is not cost effective and may result in substantial delays in treatment. The reduction of Aerosol Generating Medical Procedures (AGMP), such as intubation due to the COVID-19 Pandemic, must also be taken into consideration. Due to the potential increased risk of infection transmission, alternatives to general anesthesia should be considered when safe and possible. Upper abdominal regional nerve block techniques have been used to manage pain related to trauma, surgery, and cancer; however, blocks of this nature are not well described in the interventional radiology literature. The McGill University group has developed experience in using such blocks as splanchnic, celiac and hepatic hilar nerve blocks to provide peri-procedural pain control [1]. Since incorporating these techniques (along with hydrodissection with tumescent anesthesia), we have also observed in our high volume ablation center a dramatic decrease in the amount of sedatives administered during the procedure, a decrease in patient discomfort during localization and ablation, as well as decreased pain post-procedure. Faster time to discharge and overall reduction in room procedural time serve as added benefits. The purpose of this publication is to outline and illustrate the practical application and use of nerve block/regional anesthesia techniques with respect to percutaneous hepatic thermal ablation.

Recent rapid thinning of West Antarctic ice shelves are believed to be caused by intrusions of warm deep water that induce basal melting and seaward meltwater export. This study uses data from three bottom-mounted mooring arrays to show seasonal variability and local forcing for the currents moving into and out of the Dotson ice shelf cavity. A southward flow of warm, salty water had maximum current velocities along the eastern channel slope, while northward outflows of freshened ice shelf meltwater spread at intermediate depth above the western slope. The inflow correlated with the local ocean surface stress curl. At the western slope, meltwater outflows followed the warm influx along the eastern slope with a ~2–3 month delay. Ocean circulation near Dotson Ice Shelf, affected by sea ice distribution and wind, appears to significantly control the inflow of warm water and subsequent ice shelf melting on seasonal time-scales.

Olive oil milling, widely practiced in Mediterranean countries, including Palestine, yields the so-called olive mill waste water (OMWW) or Zebar (Zibar). The waste contains minerals and organic materials (including phenols and polyphenols) which undergo continuous oxidation and cause environmental hazards if not well managed. This work basically aims at purifying surface waters, intentionally pre-contaminated with OMWW organic contaminants. Fate of other mineral ions present in the contaminated water is also investigated. ZnO nanoparticles, deposited as films onto glass reactor bottom (165 cm2 area), are described as catalyst for photodegradation of the organic contaminants, in a continuous flow reaction mode (gravity fed, typically at flow rate 3.5 mL/min). Two types of ZnO materials, namely commercial ZnO onto glass (C–ZnO/Glass) and synthetic ZnO supported onto clay and deposited on glass (Syn–ZnO/Clay/Glass), have been examined. The Syn–ZnO/Clay/Glass catalyst is slightly more efficient in removing organic contaminants (~ 43%), compared to the C–ZnO/Glass (41%) in 30 h. Different reaction parameters have been investigated, such as waste dilution factor, exposure duration, pH and catalyst recovery and reuse.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. If diagnosed early, curative treatment options such as surgical resection, loco-regional therapies, and liver transplantation are available to patients, increasing their chances of survival and improving their quality of life. Unfortunately, most patients are diagnosed with late stage HCC where only palliative treatment is available. Therefore, biomarkers which could detect HCC early with a high degree of sensitivity and specificity, may play a crucial role in the diagnosis and management of the disease. This review will aim to provide an overview of the different biomarkers of HCC comprising those used in the diagnosis of HCC in at risk populations, as well as others with potential for prognosis, risk predisposition and prediction of response to therapeutic intervention.

The aim of this study was to compare demographic characteristics, disease activity, functional status, and quality of life between ankylosing spondylitis (AS) with neuropatic pain (NP) and AS without NP (Non-NP). The MEDLINE via PubMed, Cochrane, Scopus, and Embase database, from the earliest available date of indexing through December 20, 2018, were searched for comparative studies evaluating NP in AS patients. Two authors performed the data extraction independently. Any discrepancies were resolved by consensus. Four comparative studies were identified. There was no statistically significant difference in terms of age, body mass index, symptom duration, and inflammatory markers, such as erythrocyte sedimentation rate and C‑reactive protein between NP and Non-NP. The sex ratios (F/M) were approximately 1/1 in NP and 1/2 in Non-NP and the proportion of human leukocyte antigen (HLA) B27-positive patients in NP and Non-NP was 65.7% and 83.0%, respectively. NP patients had significantly higher visual analogue scale pain scores, higher Bath Ankylosing Spondylitis Disease Activity Index, higher Bath Ankylosing Spondylitis Functional Index, and lower SF-Item Short Form physical component scores compare to Non-NP patients. The current meta-analysis showed that NP patients had significantly higher pain severity, higher disease activity and lower quality of life than Non-NP patients. The sex ratio (F/M) and proportion of HLA-B27 positive patients were different between the two groups. Further well-designed studies are needed to substantiate our results.

Summary Aims In the present study, we aimed to determine the muscles that mostly respond to the push-start of the sled. Methods Seven male Korea Winter Olympics elite athletes form the two-man bobsleigh team. Performance was assessed using push-start time. Electromyogram (EMG) activity of the rectus femoris (RF), tibialis anterior (TA), gastrocnemius medialis (GM), and biceps femoris (BF) muscles was recorded during the push-start phases. Results The paired t-test showed that right and left GM activity (P Conclusion This study provides preliminary evidence to suggest that BF muscle activity may represent an effective push-start time to reduce race time in bobsleigh athletes.

This article conducts an exact analysis of a thermal dielectric crack moving in piezoelectric materials. Self-generating thermal and electric loadings by the crack interior are exerted on the crack surfaces as well as various external loadings including a shearing force. Fundamental solutions of the thermal and electro-elastic coupling fields are given by determining a temperature function and a harmonic function with eigenvalues properties due to material properties considered. Analytical expressions are obtained benefiting evaluation of key parameters. Numerical analysis is done and some interesting observations are found. There is a critical crack velocity within and beyond which the electric loading exerts different influences on the thermal flux of crack interior and the thermal stress intensity factor.

Recent rapid thinning of West Antarctic ice shelves are believed to be caused by intrusions of warm deep water that induce basal melting and seaward meltwater export. This study uses data from three bottom-mounted mooring arrays to show seasonal variability and local forcing for the currents moving into and out of the Dotson ice shelf cavity. A southward flow of warm, salty water had maximum current velocities along the eastern channel slope, while northward outflows of freshened ice shelf meltwater spread at intermediate depth above the western slope. The inflow correlated with the local ocean surface stress curl. At the western slope, meltwater outflows followed the warm influx along the eastern slope with a ~2-3 month delay. Ocean circulation near Dotson Ice Shelf, affected by sea ice distribution and wind, appears to significantly control the inflow of warm water and subsequent ice shelf melting on seasonal time-scales.

Patient: Female, 67-year-old Final Diagnosis: Gastrinoma • neurofibromatosis type 1 • pheochromocytoma • thyroid cancer Symptoms: Abdominal pain • pneumoperitoneum Medication: — Clinical Procedure: — Specialty: Oncology • Surgery Objective: Rare co-existance of disease or pathology Background: Neurofibromatosis type 1 (NF1) is a multi-tumor syndrome in which affected patients develop malignancies that are rare in the overall population, such as tumors of neural or endocrine origin. Case Report: A 67-year-old woman with a clinical diagnosis of NF1 presented with abdominal pain and pneumoperitoneum. She underwent small-bowel resections for a perforated jejunal lesion and a second lesion in the ileum; pathology showed a neurofibroma at the site of the perforation and a 1-cm low-grade GIST, respectively. Additional staging with cross-sectional imaging identified a 3.7-cm pancreatic head mass and a 1.7-cm left adrenal mass; biochemical studies revealed elevated serum gastrin and urinary free metanephrines and catecholamines consistent with pheochromocytoma. Initial surgical management was a left posterior retroperitoneoscopic adrenalectomy. Postoperatively, gallium-68-DOTATOC PET/CT showed uptake in the pancreatic head and a 28-mm left thyroid nodule. Months later, she had an open pancreaticoduodenectomy. Pathology showed pheochromocytoma and a low-grade (G1) gastrinoma involving 2/8 peripancreatic lymph nodes (pT3pN1M0), respectively. Fine-needle aspiration biopsy of the thyroid nodule showed features consistent with a Hürthle cell neoplasm. Genetic testing identified a pathogenic mutation in NF1 and no mutations in BRCA1/2, CDC72, MEN1, or PALB2. The patient continues surveillance, with no evidence of recurrent disease. Conclusions: We report the fifth case of gastrinoma associated with NF1 and the first to arise from the pancreas. This case of a pancreatic neuroendocrine tumor was associated with multiple additional neoplasms. Neuroendocrine tumors found in NF1 should raise suspicion of other malignancies.

Current liver transplantation societies recommend recipients with active coronavirus disease 2019 (COVID-19) be deferred from transplantation for at least 2 wks, have symptom resolution and at least 1 negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test.1 This approach does not address patients who require urgent transplantation and will otherwise die from liver failure. We report a successful orthotopic liver transplant (OLT) in a patient with active COVID-19 infection. This is only the second to be reported worldwide and the first in Canada.

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient&rsquo, s symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Antarctica's Getz Ice Shelf has been rapidly thinning in recent years, producing more meltwater than any other ice shelf in the world. The influx of fresh water is known to substantially influence ocean circulation and biological productivity, but relatively little is known about the factors controlling basal melt rate or how basal melt is spatially distributed beneath the ice shelf. Also unknown is the relative importance of subglacial discharge from the grounded ice sheet in contributing to the export of fresh water from the ice shelf cavity. Here we compare the observed spatial distribution of basal melt rate to a new sub-ice-shelf bathymetry map inferred from airborne gravity surveys and to locations of subglacial discharge from the grounded ice sheet. We find that melt rates are high where bathymetric troughs provide a pathway for warm Circumpolar Deep Water to enter the ice shelf cavity and that melting is enhanced where subglacial discharge fresh water flows across the grounding line. This is the first study to address the relative importance of meltwater production of the Getz Ice Shelf from both ocean and subglacial sources.

Over the last decade, liver transplantation of sicker, older non-hepatitis C cirrhotics with multiple co-morbidities has increased in the United States. We sought to identify an easily applicable set of recipient factors among HCV negative adult transplant recipients associated with significant morbidity and mortality within five years after liver transplantation.We collected national (n = 31,829, 2002-2015) and center-specific data. Coefficients of relevant recipient factors were converted to weighted points and scaled from 0-5. Recipient factors associated with graft failure included: ventilator support (five patients; hazard ratio [HR] 1.59; 95% CI 1.48-1.72); recipient age60 years (three patients; HR 1.29; 95% CI 1.23-1.36); hemodialysis (three patients; HR 1.26; 95% CI 1.16-1.37); diabetes (two patients; HR 1.20; 95% CI 1.14-1.27); or serum creatinine ≥1.5 mg/dl without hemodialysis (two patients; HR 1.15; 95% CI 1.09-1.22).Graft survival within five years based on points (any combination) was 77.2% (0-4), 69.1% (5-8) and 57.9% (8). In recipients with8 points, graft survival was 42% (model for end-stage liver disease [MELD] score25) and 50% (MELD score 25-35) in recipients receiving grafts from donors with a donor risk index1.7. In center-specific data within the first year, subjects with ≥5 points (vs. 0-4) had longer hospitalization (11 vs. 8 days, p 0.01), higher admissions for rehabilitation (12.3% vs. 2.7%, p 0.01), and higher incidence of cardiac disease (14.2% vs. 5.3%, p 0.01) and stage 3 chronic kidney disease (78.6% vs. 39.5%, p = 0.03) within five years.The impact of co-morbidities in an MELD-based organ allocation system need to be reassessed. The proposed clinical tool may be helpful for center-specific assessment of risk of graft failure in non-HCV patients and for discussion regarding relevant morbidity in selected subsets.Over the last decade, liver transplantation of sicker, older patient with multiple co-morbidities has increased. In this study, we show that a set of recipient factors (recipient age60 years, ventilator status, diabetes, hemodialysis and creatinine1.5 mg/dl) can help identify patients that may not do well after transplant. Transplanting sicker organs in patients with certain combinations of these characteristics leads to lower survival.

Background Little published data exist examining causes of hospital readmission following total pancreatectomy with islet autotransplantation (TPIAT). Methods A retrospective analysis was performed of a prospectively collected institutional TPIAT database. Primary outcome was unplanned readmission to the hospital within 30 days from discharge. Reasons and risk factors for readmission as well as islet function were evaluated and compared by univariate and multivariate analysis. Results 83 patients underwent TPIAT from 2006 to 2014. 21 patients (25.3%) were readmitted within 30 days. Gastrointestinal problems (52.4%) and surgical site infection (42.8%) were the most common reasons for readmission. Initial LOS and reoperation were risk factors for early readmission. Patients with delayed gastric emptying (DGE) were three times more likely to get readmitted. In multivariate analysis, patients undergoing pylorus preservation surgery were nine times more likely to be readmitted than the antrectomy group. Conclusion Early readmission after TPIAT is common (one in four patients), underscoring the complexity of this procedure. Early readmission is not detrimental to islet graft function. Patients undergoing pylorus preservation are more likely to get readmitted, perhaps due to increased incidence of delayed gastric emptying. Decision for antrectomy vs. pylorus preservation needs to be individualized.

Summary An open-label, first-in-human phase 1/2 study is being conducted to evaluate the safety and efficacy of pancreatic endoderm cells (PECs) implanted in non-immunoprotective macroencapsulation devices for the treatment of type 1 diabetes. We report an analysis on 1 year of data from the first cohort of 15 patients from a single trial site that received subcutaneous implantation of cell products combined with an immunosuppressive regimen. Implants were well tolerated with no teratoma formation or severe graft-related adverse events. After implantation, patients had increased fasting C-peptide levels and increased glucose-responsive C-peptide levels and developed mixed meal-stimulated C-peptide secretion. There were immunosuppression-related transient increases in circulating regulatory T cells, PD1high T cells, and IL17A+CD4+ T cells. Explanted grafts contained cells with a mature β cell phenotype that were immunoreactive for insulin, islet amyloid polypeptide, and MAFA. These data, and associated findings ( Shapiro et al., 2021 ), are the first reported evidence of meal-regulated insulin secretion by differentiated stem cells in patients.

Liver disease etiology and transplantation outcomes may vary by ethnicity. We aimed to determine if disparities exist in our province.We reviewed the provincial database for liver transplant referrals. We stratified cohorts by ethnicity and analyzed disease etiology and outcomes.Four thousand nine hundred sixteen referrals included 220 South Asians, 413 Asians, 235 First Nations (Indigenous), and 2725 Caucasians. Predominant etiologies by ethnicity included alcohol (27.4%) and primary sclerosing cholangitis (PSC) (8.8%) in South Asians, hepatitis B (45.5%) and malignancy (13.9%) in Asians, primary biliary cholangitis (PBC) (33.2%) and autoimmune hepatitis (AIH) (10.8%) in First Nations, and hepatitis C (35.9%) in Caucasians. First Nations had lowest rate of transplantation (30.6%, P = .01) and highest rate of waitlist death (10.6%, P = .03). Median time from referral to transplantation (268 days) did not differ between ethnicities (P = .47). Likelihood of transplantation increased with lower body mass index (BMI) (hazard ratio [HR] 0.99, P = .03), higher model for end stage liver disease (MELD) (HR 1.02, P < .01), or fulminant liver failure (HR 9.47, P < .01). Median time from referral to ineligibility status was 170 days, and shorter time was associated with increased MELD (HR 1.01, P < .01), increased age (HR 1.01, P < .01), fulminant liver failure (HR 2.56, P < .01) or South Asian ethnicity (HR 2.54, P < .01). Competing risks analysis revealed no differences in time to transplant (P = .66) or time to ineligibility (P = .91) but confirmed increased waitlist death for First Nations (P = .04).We have noted emerging trends such as alcohol related liver disease and PSC in South Asians. First Nations have increased autoimmune liver disease, lower transplantation rates and higher waitlist deaths. These data have significance for designing ethnicity specific interventions.

Liver disease is a major cause of mortality worldwide. Liver transplantation (LT) is the most effective treatment for end stage liver disease. Available resources and social circumstances have led to different ways of implementing LT around the world. The experience with pediatric LT corroborates the hypothesis that a combination of surgical strategies can be beneficial. The goal of this manuscript is to describe the strategies used by LT centers in North America, Europe and Asia and how these strategies can be applied to reduce waitlist mortality and increase access to LT.

This study was conducted to determine effect of lower measured hepatic arterial (HA) flow (400 mL/min) on biliary complications and graft survival after deceased donor liver transplantation. Hepatic artery is the main blood supply to bile duct and lack of adequate HA flow is thought to be a risk factor for biliary complications.A retrospective review of 1300 patients who underwent deceased donor liver transplantation was performed. Patients with arterial complications were excluded to eliminate potential contribution to biliary complications from HA thrombosis. Patients were divided into low (400 mL/min; N = 201) and high (≥400 mL/min; N = 1099) HA flow groups. Incidence of biliary complications and graft survival were analyzed.HA flows less than 400 mL/min were associated with increased rate of biliary strictures in younger donors (50 years old), and in patients with duct-to-duct anastomoses (P = 0.028). Lower HA flows were associated with decreased graft survival (P = 0.013). Donor older than 50 years was associated with increased rate of biliary strictures (hazard ratio [HR], 1.67; 95% confidence interval [CI], 1.14-2.45; P = 0.0085) and graft failure (HR, 1.68; 95% CI, 1.35-2.1; P0.0001) on multivariate analyses. HA flow less than 400 mL/min was associated with biliary strictures (HR, 1.53; 95% CI, 1.04-2.24; P = 0.0297) on univariate analysis only.HA flow less than 400 mL/min was associated with higher rate of biliary strictures in younger donors with duct-to-duct reconstruction and lower graft survival. A consideration should be given to increase the intraoperative HA flow to prevent biliary strictures in such patients.

Pancreatic fistula (PF) is common after pancreaticoduodenectomy (PD). Its effect on recurrence and survival is not known. Retrospective study of patients undergoing PD for periampullary adenocarcinomas (2000–2012). Standard statistical analyses were performed to determine the impact of PF on disease-free survival (DFS) and overall survival (OS). There were 634 PDs (pancreatic adenocarcinoma: 347, other periampullary adenocarcinomas: 287). Any-grade PF developed in 81/634 (13%). Perioperative mortality rate was 1.7 per cent (11/634), higher in patients with PF (10 vs 0.5%, P < 0.001). In multivariable analysis, PF significantly reduced DFS in pancreatic [hazard ratio (HR) = 1.6, 95% confidence-interval (CI): 1.1–2.6, P = 0.043] but not in other periampullary adenocarcinomas [HR = 1.3 (95% CI: 0.8–2.2), P = 0.45]. Positive lymph nodes, margins, and high-grade histology were associated with decreased DFS and OS. Adjuvant therapy was associated with improved OS in pancreatic [HR = 0.7 (95% CI: 0.5–0.9), P = 0.02] but not in other periampullary adenocarcinomas [HR = 1.14 (95% CI: 0.8–1.7), P = 0.49]. PF did not alter OS in either group. After PD, PF is associated with decreased DFS in pancreatic but not in other periampullary adenocarcinomas. This decrease DFS did not alter OS. Tumor grade, lymph nodes, and resection margin status are associated with DFS and OS.

Patients with hepatocellular carcinoma and portal vein tumor thrombus have a poor prognosis and limited therapeutic options. We sought to compare survival, tolerability, and safety in such patients treated with conventional yttrium-90 transarterial radioembolization dosimetric techniques or ablative transarterial radioembolization. This retrospective, single-center cohort study included patients with hepatocellular carcinoma and right, left, and/or main portal vein tumor thrombus, preserved liver function (Child–Pugh class ≤ B7), and good performance status (Eastern Cooperative Oncology Group score ≤ 1) treated with yttrium-90 microspheres from 2011 to 2018 with ablative intent transarterial radioembolization (A-TARE), or conventional technique (cTARE). Statistical models were used to compare overall survival, post-treatment survival, toxicities, and prognosticators of response. Fifty-seven patients were included (21 [36.8%] ablative and 36 [63.2%] conventional intent). Median overall survival was 15.7 months. Compared to conventional treatment, ablative radioembolization was associated with longer median overall survival (45.3 vs 18.2 months; P = 0.003), longer post-treatment survival (19.1 vs 4.9 months; P = 0.005), a 70% lower risk of death (hazard ratio 0.30; 95% confidence interval, 0.13–0.70; P = 0.005), and improved 4-year survival (53.9% vs 11.2%). Overall survival did not differ significantly between treatment with resin and glass microspheres (27.5 vs 22.2 months; P = 0.62). Acceptable hepatic toxicities were observed after yttrium-90 administration, without statistical differences between the groups. In patients with advanced hepatocellular carcinoma and portal vein tumor thrombus, A-TARE is associated with longer survival than cTARE. Neither modality is associated with deleterious effects on liver function.

Mass loss from the Antarctic Ice Sheet to the ocean has increased in recent decades, largely because the thinning of its floating ice shelves has allowed the outflow of grounded ice to accelerate

Marine biota is an important source of atmospheric aerosol particles in the remote marine atmosphere. However, the relationship between new particle formation and marine biota is poorly quantified. Long-term observations (from 2009 to 2016) of the physical properties of atmospheric aerosol particles measured at the Antarctic Peninsula (King Sejong Station; 62.2∘ S, 58.8∘ W) and satellite-derived estimates of the biological characteristics were analyzed to identify the link between new particle formation and marine biota. New particle formation events in the Antarctic atmosphere showed distinct seasonal variations, with the highest values occurring when the air mass originated from the ocean domain during the productive austral summer (December, January and February). Interestingly, new particle formation events were more frequent in the air masses that originated from the Bellingshausen Sea than in those that originated from the Weddell Sea. The monthly mean number concentration of nanoparticles (2.5–10 nm in diameter) was >2-fold higher when the air masses passed over the Bellingshausen Sea than the Weddell Sea, whereas the biomass of phytoplankton in the Weddell Sea was more than ∼70 % higher than that of the Bellingshausen Sea during the austral summer period. Dimethyl sulfide (DMS) is of marine origin and its oxidative products are known to be one of the major components in the formation of new particles. Both satellite-derived estimates of the biological characteristics (dimethylsulfoniopropionate, DMSP; precursor of DMS) and phytoplankton taxonomic composition and in situ methanesulfonic acid (84 daily measurements during the summer period in 2013 and 2014) analysis revealed that DMS(P)-rich phytoplankton were more dominant in the Bellingshausen Sea than in the Weddell Sea. Furthermore, the number concentration of nanoparticles was positively correlated with the biomass of phytoplankton during the period when DMS(P)-rich phytoplankton predominate. These results indicate that oceanic DMS emissions could play a key role in the formation of new particles; moreover, the taxonomic composition of phytoplankton could affect the formation of new particles in the Antarctic Ocean.

This article proposes a thermal facture model of sandwich structures occupying a functionally graded interlayer with thermal resistance inside the crack region introduced. The crack surfaces are partially thermally insulated with thermally insulated crack and thermally conductive crack as limiting cases. A system of singular integral equations in thermo-elastic field is reduced and solved numerically by using the collocation methods with higher asymptotic terms in order to improve the convergence and accuracy. For a special case, exact solution is derived to validate the theoretical analysis and numerical computation. Numerical analyses are conducted to reveal the influences of the graded interlayer size, graded parameter and dimensionless thermal resistance on the temperatures along the crack plane and the stress intensity factors.

This paper quantifies the transformed effectiveness of alternatives for watershed management caused by climate change and urbanization and prioritizes five options using multi-criteria decision making techniques. The climate change scenarios (A1B and A2) were obtained by using a statistical downscaling model (SDSM), and the urbanization scenario by surveying the existing urban planning. The flow and biochemical oxygen demand (BOD) concentration duration curves were derived, and the numbers of days required to satisfy the environmental flow requirement and the target BOD concentration were counted using the Hydrological Simulation Program-Fortran (HSPF) model. In addition, five feasible alternatives were prioritized by using multi-criteria decision making techniques, based on the driving force-pressure-state-impact-response (DPSIR) framework and cost component. Finally, a sensitivity analysis approach for MCDM methods was conducted to reduce the uncertainty of weights. The result indicates that the most sensitive decision criterion is cost, followed by criteria response, driving force, impact, state and pressure in that order. As it is certain that the importance of cost component is over 0.127, construction of a small wastewater treatment plant will be the most preferred alternative in this application.

Background Forefoot deformity has been a common problem in rheumatoid patients, often demanding surgery. Typical deformities include hallux valgus and deformity of lesser metatarsophalangeal joints (MTPJ) and toes. Patient’s satisfaction has not been well dealt in the literature as most studies have focused on radiological and clinical parameters following surgical treatment. Objectives to assess preoperative patient‘s expectations and postoperative satisfaction, and also factors (e.g. fulfilment of expectations, radiological parameters, and clinical outcomes) that could affect on postoperative satisfaction following first MTPJ arthrodesis and lesser toe resection arthroplasty in patients with rheumatoid forefoot deformity Methods 40 patients who underwent first MTPJ arthrodesis on great toe and resection arthroplasty for all less toes were enrolled. Clinical and radiological outcomes were investigated retrospectively. Preoperative primary expectations for surgery were questioned and fulfilment of expectation was assessed by 5-point ordinal scale. Overall subjective satisfaction, radiological improvements, AOFAS forefoot score, and subjective Foot function index were also assessed. Correlation between overall satisfaction after surgery and above other factors was performed. Statistical analysis was done using SPSS and Spearman’s rho rank correlation test was performed to analyse the correlation between factors. Results Mean follow-up was 38 months (range; 24~54). For preoperative expectations, 30 (75%) patients considered improvement in pain as the most important parameter and improvements in shoe wearable and gross appearance were expected in 7 (17.5%) and 3 (7.5%) patients, respectively. Fulfilment of expectations assessed showed very satisfied in 14 (35%), satisfied in 20 (50%), average in 5 (12.5%) and disappointed in 1 (2.5%) for great toe, and those regarding lesser toe showed very satisfied in 15 (37.5%), satisfied in 18 (45%), average in 6 (15%) and disappointed in 1 (2.5%), respectively. For overall postoperative satisfaction assessment, 16 patients (40%) were excellent while 16 (40%) were good, 6 (15%) fair, and 2 (5%) poor. AOFAS hallux and lesser toe score were 69.7±11.71 and 70.7±12.26, respectively. Foot function index was 20.5±12.07 at final follow-up. Preoperative and postoperative hallux valgus angle were 45.6°±10.55 and 17.4°±5.13, respectively. Those of 1–2 intermetatarsal angle were 14.2°±3.84 and 8.4°±3.72, respectively. Correlation analysis showed that significant factors that affected on overall satisfaction were fulfilment of expectation on the great toe (Spearman’s rho=0.842, p Conclusions Expectations from surgery on rheumatoid forefoot deformity were improvement in pain as the most common parameter, improvements in shoe wearable and gross appearance. Fulfilment of patients’ expectations on the great toe as well as on the lesser toe significantly affected on postoperative satisfaction. Careful counselling for patients’ expectations and corresponding fulfilment should be performed before performing reconstructive surgery for rheumatoid forefoot deformity. Reference [1] Nash WJ, Al-Nammari S, Khan WS, Pengas IP. Surgical Management of the Forefoot in Patients with Rheumatoid Arthritis: A Review Article. Open Orthop J. 2015;9:78–83. Disclosure of Interest None declared

Bile duct size discrepancy in liver transplantation may increase the risk of biliary complications (BCs). The aim of this study was to evaluate the safety and outcomes of the eversion bile duct anastomosis technique in deceased donor liver transplantation (DDLT) with duct-to-duct anastomosis. A total of 210 patients who received a DDLT with duct-to-duct anastomosis from 2012 to 2017 were divided into 2 groups: those who had eversion bile duct anastomosis (n = 70) and those who had standard bile duct anastomosis (n = 140). BC rates were compared between the 2 groups. There was no difference in the cumulative incidence of biliary strictures (P = 0.20) and leaks (P = 0.17) between the 2 groups. The BC rate in the eversion group was 14.3% and 11.4% in the standard anastomosis group. All the BCs in the eversion group were managed with endoscopic stenting. A severe size mismatch (≥3:1 ratio) was associated with a significantly higher incidence of biliary strictures (44.4%) compared with a 2:1 ratio (8.2%; P = 0.002). In conclusion, the use of the eversion technique is a safe alternative for bile duct discrepancy in DDLT. However, severe bile duct size mismatch may be a risk factor for biliary strictures with such a technique.

The inferior vena cava (IVC) is the most common site of leiomyosarcomas arising from a vascular origin. Leiomyosarcomas of the IVC are categorized by anatomical location. Zone I refers to the infrarenal portion of the IVC, Zone II from the hepatic veins to the renal veins, and Zone III from the right atrium to the hepatic veins. This is a rare presentation of a Zone I-III leiomyosarcoma. Fifty-two-years-old female with a medical history significant only for HTN was admitted to the hospital with bilateral lower extremity edema and dyspnea. Two-dimensional echo demonstrated a right atrial thrombus, extending into the IVC. On subsequent CT and MRI, a 15 cm mass was noted that began in the right atrium and extended into the IVC, with continuation below the renal veins to above the level of the confluence of the common iliac veins. The patient underwent a complete resection of the mass, replacement of the IVC with Dacron graft, total hepatectomy and bilateral nephrectomy, with liver and kidney autotransplantation. Pathology was consistent with a high grade spindle cell sarcoma of vena cava origin. Patient was readmitted approximately 4 weeks postoperatively to begin adjuvant chemotherapy. This case represents a zone I-III IVC leiomyosarcoma treated with surgical R0 resection. This included a hepatectomy, bilateral nephrectomy, and hepatic and left renal autotransplantation. These complex tumors should be treated with surgical resection, and require a multidisciplinary approach.