Current and future treatments for hepatocellular carcinoma

Hepatocellular carcinoma(HCC) represents a unique challenge for physicians and patients.There is no definitively curative treatment.Rather,many treatment and management modalities exist with differing advantages and disadvantages.Both current guidelines and individual patient concerns must be taken into account in order to properly manage HCC.In addition,quality of life issues are particularly complex in patients with HCC and these concerns must also be factored into treatment strategies.Thus,considering all the options and their various pros and cons can quickly become complex for both clinicians and patients.In this review,we systematically discuss the current treatment modalities available for HCC,detailing relevant clinical data,risks and rewards and overall outcomes for each approach.Surgical options discussed include resection,transplantation and ablation.We also discuss the radiation modalities:conformal radiotherapy,yttrium 90 microspheres and proton and heavy ion radiotherapy.The biologic agent Sorafenib is discussed as a promising new approach,and recent clinical trials are reviewed.We then detail currently described molecular pathways implicated in the initiation and progression of HCC,and we explore the potential of each pathway as an avenue for drug exploitation.We hope this comprehensive and forward-looking review enables both clinicians and patients to understand various options and thereby make more informed decisions regarding this disease.

Conf irmation of endotracheal tube placement using disposable f iberoptic bronchoscopy in the emergent setting

BACKGROUND:Patients intubated in the prehospital setting require quick and definitive confirmation of endotracheal (ET) tube placement upon arrival to the emergency department (ED).Direct and adjunct strategies exist,but each has limitations and there is no definitive gold standard.The utility of bronchoscopy in ED intubation has been studied,but scant literature exists on its use for ET tube confirmation.This study aims to assess effectiveness,ease and speed with which ET tube placement can be confirmed with disposable fiberoptic bronchoscopy.METHODS:Emergency medicine residents recruited from a 3-year urban residency program received 5 minutes of active learning on a simulation mannequin using a disposable,flexible Ambu aScope interfaced with a monitor.With residents blinded,the researcher randomly placed the ET tube in the trachea,esophagus or right mainstem.Residents identified ET tube position by threading the bronchoscope through the tube and viewing distal anatomy.Each resident underwent 4 trials.Accuracy,speed and perceptions of difficulty were measured.RESULTS:Residents accurately identified the location of the ET tube in 88 out of 92 trials (95.7%).The median time-to-guess was 7.0 seconds,IQR (5.0-10.0).Average perceived difficulty was 1.6 on a scale from 1-5 (1 being very easy and 5 being very difficult).No tubes were damaged or dislodged.CONCLUSION:While simulation cannot completely replicate the live experience,fiberoptic bronchoscopy appears to be a quick and accurate method for ET tube confirmation.Further studies directly comparing this novel approach to established practices on actual patients are warranted.