Background/Aims: Nonalcoholic fatty liver disease (NAFLD) encompasses a range of diseases from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) and has been linked to cardiovascular disease and sub-clinical cardiac remodeling. This paper presents a retrospective study of biopsy-proven NAFL and NASH to examine the differences in subclinical cardiac remodeling. Methods: Patients were recruited from an institutional repository of patients with liver-biopsy-confirmed NAFLD. Patients with a transthoracic echocardiogram (TTE) within 12 months of the liver biopsy were included. The parameters of the diastolic dysfunction were reviewed for the differences between NAFL and NASH as well as between the stages and grades of NASH. Results: Thirty-three patients were included in the study, 17 with NAFL and 16 with NASH. The NASH patients were more likely to have lower platelets, higher AST, higher ALT, and higher rates of type 2 diabetes mellitus, coronary artery disease, and hypertension than the NAFL patients. The E/e’ ratio on transthoracic echocardiogram was significantly higher in NASH compared to NAFL, advanced-stage NASH compared to early stage, and high-grade NASH compared to low-grade. The E/e’ ratio was also significantly higher in NASH than NAFL in patients without diabetes mellitus. The presence of diastolic dysfunction trended toward significance. The other markers of diastolic dysfunction were similar. Logistic regression revealed a statistical association with E/e' and NASH. Conclusions NASH patients had evidence of a higher E/e’ ratio than NAFL, and there was a trend towards a significant diastolic dysfunction. Patients with NASH compared to NAFL should be closely monitored for signs and symptoms of cardiac dysfunction.

Background/Aims: Nonalcoholic fatty liver disease (NAFLD) encompasses a range of diseases from nonalcoholic fatty liver (NAFL) to nonalcoholic steatohepatitis (NASH) and has been linked to cardiovascular disease and sub-clinical cardiac remodeling. This paper presents a retrospective study of biopsy-proven NAFL and NASH to examine the differences in subclinical cardiac remodeling. Methods: Patients were recruited from an institutional repository of patients with liver-biopsy-confirmed NAFLD. Patients with a transthoracic echocardiogram (TTE) within 12 months of the liver biopsy were included. The parameters of the diastolic dysfunction were reviewed for the differences between NAFL and NASH as well as between the stages and grades of NASH. Results: Thirty-three patients were included in the study, 17 with NAFL and 16 with NASH. The NASH patients were more likely to have lower platelets, higher AST, higher ALT, and higher rates of type 2 diabetes mellitus, coronary artery disease, and hypertension than the NAFL patients. The E/e’ ratio on transthoracic echocardiogram was significantly higher in NASH compared to NAFL, advanced-stage NASH compared to early stage, and high-grade NASH compared to low-grade. The E/e’ ratio was also significantly higher in NASH than NAFL in patients without diabetes mellitus. The presence of diastolic dysfunction trended toward significance. The other markers of diastolic dysfunction were similar. Logistic regression revealed a statistical association with E/e' and NASH. Conclusions NASH patients had evidence of a higher E/e’ ratio than NAFL, and there was a trend towards a significant diastolic dysfunction. Patients with NASH compared to NAFL should be closely monitored for signs and symptoms of cardiac dysfunction.

Objective: To compare the epidemiology, management, and outcomes of patients suffering FFs from high-energy and low-energy mechanisms. Methods: We conducted a 6-year retrospective local trauma registry analysis of adults aged 18–55 years old that suffered a FF treated at the Santa Barbara Cottage Hospital. Fracture patterns, concomitant injuries, procedures, and outcomes were compared between patients that suffered a high-energy mechanism (HEM: motor vehicle crash, bicycle crash, auto versus pedestrian, falls from height > 20 feet) and those that suffered a low-energy mechanism (LEM: assault, ground-level falls) of injury. Results: FFs occurred in 123 patients, 25 from an HEM and 98 from an LEM. Rates of Le Fort (HEM 12% vs. LEM 3%, P = 0.10), mandible (HEM 20% vs. LEM 38%, P = 0.11), midface (HEM 84% vs. LEM 67%, P = 0.14), and upper face (HEM 24% vs. LEM 13%, P = 0.217) fractures did not significantly differ between the HEM and LEM groups, nor did facial operative rates (HEM 28% vs. LEM 40%, P = 0.36). FFs after an HEM event were associated with increased Injury Severity Scores (HEM 16.8 vs. LEM 7.5, P <0.001), ICU admittance (HEM 60% vs. LEM 13.3%, P <0.001), intracranial hemorrhage (ICH) (HEM 52% vs. LEM 15%, P <0.001), cervical spine fractures (HEM 12% vs. LEM 0%, P = 0.008), truncal/lower extremity injuries (HEM 60% vs. LEM 6%, P <0.001), neurosurgical procedures for the management of ICH (HEM 54% vs. LEM 36%, P = 0.003), and decreased Glasgow Coma Score on arrival (HEM 11.7 vs. LEM 14.2, P <0.001). Conclusion FFs after HEM events were associated with severe and multifocal injuries. FFs after LEM events were associated with ICH, concussions, and cervical spine fractures. Mechanism-based screening strategies will allow for the appropriate detection and management of injuries that occur concomitant to FFs.

Purpose: With advancing endovascular technology and increasing interest in minimally invasive intra-arterial therapies such as stem cell and chemotherapy for cerebral disease, the establishment of a translational model with cerebral circulation accessible to microcatheters is needed. We report our experience catheterizing canine cerebral circulation with microcatheters, present high-resolution angiographic images of the canine vascular anatomy, describe arterial branch flow patterns and provide measurements of canine arterial conduits. Materials and Methods: Angiograms were performed on 10 intact purpose-bred hounds. Angiography, measurements of arterial conduits and catheterization information for intracranial arterial branches were obtained. Results: Selective and superselective cerebral angiography was successful in all subjects. Relevant arterial mean diameters include the femoral (4.64 mm), aorta (9.38 mm), external carotid (3.65 mm), internal carotid arteries (1.6 mm), vertebrobasilar system and Circle of Willis branches. Catheterization of the Circle of Willis was achieved via the posterior circulation in all subjects tested (n=3) and the use of flow directed microcatheters resulted in reduced arterial tree deformation and improved superselection of intracranial vessels. Catheterization of the intracranial circulation was attempted but not achieved via the internal carotid artery (n=7) due to its tortuosity and subsequent catheter related vasospasm. Conclusion The canine cerebral vasculature is posterior circulation dominant. Anterior circulation angiography is achievable via the internal carotid artery, but direct cerebral arterial access is best achieved via the posterior circulation using flow-directed microcatheters. It is feasible to deliver intra-arterial therapies to selective vascular territories within the canine cerebral circulation, thus making it a viable animal model for testing novel intra-arterial cerebral treatments.

Objective: To compare the epidemiology, management, and outcomes of patients suffering FFs from high-energy and low-energy mechanisms. Methods: We conducted a 6-year retrospective local trauma registry analysis of adults aged 18–55 years old that suffered a FF treated at the Santa Barbara Cottage Hospital. Fracture patterns, concomitant injuries, procedures, and outcomes were compared between patients that suffered a high-energy mechanism (HEM: motor vehicle crash, bicycle crash, auto versus pedestrian, falls from height > 20 feet) and those that suffered a low-energy mechanism (LEM: assault, ground-level falls) of injury. Results: FFs occurred in 123 patients, 25 from an HEM and 98 from an LEM. Rates of Le Fort (HEM 12% vs. LEM 3%, P = 0.10), mandible (HEM 20% vs. LEM 38%, P = 0.11), midface (HEM 84% vs. LEM 67%, P = 0.14), and upper face (HEM 24% vs. LEM 13%, P = 0.217) fractures did not significantly differ between the HEM and LEM groups, nor did facial operative rates (HEM 28% vs. LEM 40%, P = 0.36). FFs after an HEM event were associated with increased Injury Severity Scores (HEM 16.8 vs. LEM 7.5, P <0.001), ICU admittance (HEM 60% vs. LEM 13.3%, P <0.001), intracranial hemorrhage (ICH) (HEM 52% vs. LEM 15%, P <0.001), cervical spine fractures (HEM 12% vs. LEM 0%, P = 0.008), truncal/lower extremity injuries (HEM 60% vs. LEM 6%, P <0.001), neurosurgical procedures for the management of ICH (HEM 54% vs. LEM 36%, P = 0.003), and decreased Glasgow Coma Score on arrival (HEM 11.7 vs. LEM 14.2, P <0.001). Conclusion FFs after HEM events were associated with severe and multifocal injuries. FFs after LEM events were associated with ICH, concussions, and cervical spine fractures. Mechanism-based screening strategies will allow for the appropriate detection and management of injuries that occur concomitant to FFs.

No abstract available.
Carcinosarcoma*

The outcome of hepatocellular carcinoma (HCC) patients significantly differs between western and eastern population centers. Our group previously developed and validated the Chinese University Prognostic Index (CUPI) for the prognostication of HCC among the Asian HCC patient population. In the current study, we aimed to validate the CUPI using an international cohort of patients with HCC and to compare the CUPI to two widely used staging systems, the Barcelona Clinic Liver Cancer (BCLC) classification and the Cancer of the Liver Italian Program (CLIP). To accomplish this goal, two cohorts of patients were enrolled in the United Kingdom (UK; n = 567; 2006-2011) and Hong Kong (HK; n = 517; 2007-2012). The baseline clinical data were recorded. The performances of the CUPI, BCLC, and CLIP were compared in terms of a concordance index (C-index) and were evaluated in subgroups of patients according to treatment intent. The results revealed that the median follow-up durations of the UK and HK cohorts were 27.9 and 29.8 months, respectively. The median overall survival of the UK and HK cohorts were 22.9 and 8.6 months, respectively. The CUPI stratified the patients in both cohorts into three risk subgroups corresponding to distinct outcomes. The median overall survival of the CUPI low-, intermediate-, and high-risk subgroups were 3.15, 1.24, and 0.29 years, respectively, in the UK cohort and were 2.07, 0.32, and 0.10 years, respectively, in the HK cohort. For the patients who underwent curative treatment, the prognostic performance did not differ between the three staging systems, and all were suboptimal. For those who underwent palliative treatment, the CUPI displayed the highest C-index, indicating that this staging system was the most informative for both cohorts. In conclusion, the CUPI is applicable to both western and eastern HCC patient populations. The performances of the three staging systems differed according to treatment intent, and the CUPI was demonstrated to be optimal for those undergoing palliative treatment. A more precise staging system for early-stage disease patients is required.
Carcinoma, Hepatocellular ; Hong Kong ; Humans ; Liver Neoplasms ; Neoplasm Staging ; Prognosis ; United Kingdom

A clinical role for pharmacists has developed in response to the societal need to improve the use of medicines. Clinical role development has been led by initiatives in the hospital sector which have enabled Schools of Pharmacy to make shifts in the pre-graduate education of pharmacists. The increasing complexity in the management of drug therapy has given pharmacists clear roles that integrate within the healthcare team. The history is one in which the development of changing roles of pharmacists is an example of progress in healthcare delivery creating the need for revision of the curriculum for a whole profession. Milestones in the changing roles and in the preparation of pharmacists for those roles have been; Establishment of clinical pharmacy in the US hospitals and the doctorate (PharmD) as the professional entry qualification; postgraduate clinical pharmacy education in UK and elsewhere, notably Asia and Australasia; hospital pharmacist specialisation across the wide range of medical specialties; the clinical teaching of pharmacists; the concept of ‘pharmaceutical care’ as a factor in public health; changes in Schools of Pharmacy – with professors of pharmacy practice and a shift to patient-centred teaching. Future evolution of pharmacist roles will follow the wider use of quality systems to address errors in prescribing and drug administration; the automation of systems of drug prescribing and administration and improved documentation of care; widening of prescribing roles; increased patient education and higher patient expectations; patient-centred research in Schools of pharmacy; development of primary care and improved accessibility to pharmaceutical advice; integration of pharmacists’ public health roles in strategies to address prevention and management of disease.