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PubMed2003

Trans-catheter arterial chemoembolisation for hepatocellular carcinoma in patients with viral cirrhosis: role of combined staging systems, Cancer Liver Italian Program (CLIP) and Model for End-stage Liver Disease (MELD), in predicting outcome after treatment.

BACKGROUND: Trans-catheter arterial chemoembolisation (TACE) is the most common palliative treatment for hepatocellular carcinoma (HCC). The therapeutic options depend both on the characteristics of the tumour and on functional staging of the cirrhosis. AIM: To evaluate the effects of TACE on the survival of cirrhotic patients with HCC according to different staging systems [Okuda score, Cancer Liver Italian Program (CLIP) score, Model for End-stage Liver Disease (MELD) score] and in relation to the side-effects of TACE. METHODS: Fifty cirrhotic patients, 36 CTP class A and 14 class B, underwent 106 TACE treatments with mitoxantrone. Survival at 12, 24, and 36 months was evaluated. RESULTS: MELD at 12 months and CLIP at 24 months were identified as significant variables associated with survival. Combined cut-offs of CLIP and of MELD identified four subgroups of patients with different survivals, at 12, 24 and 36 months, respectively: CLIP >or= 2 and MELD >or= 10 (63%, 20% and 0%), CLIP < 2 and MELD >or= 10 (73%, 40% and 22%), CLIP >or= 2 and MELD < 10 (73%, 40% and 22%) and CLIP < 2 and MELD < 10 (100%, 63% and 50%). Post-TACE side-effects proved to have no influence on survival. CONCLUSION: In patients with poor probability of survival (CLIP >or= 2 and MELD >or= 10), TACE must be planned with a great deal of caution, while in patients with possibly good outcomes (CLIP < 2 and MELD < 10), more 'aggressive' therapy should be taken into consideration.

Adult↗

PubMed1995

Binding of major histocompatibility complex class II to the invariant chain-derived peptide, CLIP, is regulated by allelic polymorphism in class II.

Major histocompatibility complex class II-associated invariant chain (Ii) provides several important functions that regulate class II expression and function. One of these is the ability to inhibit class II peptide loading early in biosynthesis. This allows for efficient class II folding and egress from the endoplasmic reticulum, and protects the class II peptide binding site from loading with peptides before entry into endosomal compartments. The ability of Ii to interact with class II and interfere with peptide loading has been mapped to Ii exon 3, which encodes amino acids 82-107. This same region of Ii has been described as a nested set of class II-associated Ii peptides (CLIPs) that are transiently associated with class II in normal cells and accumulate in human histocompatibility leukocyte antigen-DM-negative cell lines. Currently it is not clear how CLIP and the CLIP region of Ii blocks peptide binding. CLIP may bind directly to the class II peptide binding site, or may bind elsewhere on class II and modulate class II peptide binding allosterically. In this report, we show that CLIP can interact with many different murine and human class II molecules, but that the affinity of this interaction is controlled by polymorphic residues in the class II chains. Likewise, structural changes in CLIP also modulate class II binding in an allele-dependent manner. Finally, the specificity and kinetics of CLIP binding to class II molecule is similar to antigenic peptide binding to class II. These data indicate that CLIP binds to class II in an analogous fashion as conventional antigenic peptides, suggesting that the CLIP segment of Ii may actually occupy the class II peptide binding site.

Alleles↗

PubMed1997

A continuous central motif of invariant chain peptides, CLIP, is essential for binding to various I-A MHC class II molecules.

Invariant chain (li) associates with MHC class II molecules and performs a number of crucial functions in antigen presentation. A nested set of class II-associated li peptides (CLIP) has been isolated, comprising the li sequence between residues 82 and 107. Recently, X-ray crystallographic analysis has revealed that residues 87-101 occupy the HLA-DR3 peptide-binding groove. Based on our previous results, Lee and McConnell have also proposed a model for the binding of CLIP to various mouse I-A molecules in the binding groove. CLIP sequences are able to bind many MHC class II molecules but the molecular basis of this promiscuity has not yet been resolved. We have shown recently that CLIP binding to I-A class II molecules is generally tolerant to side chain substitutions, suggesting that the backbone structure of CLIP may provide the features critical for its interaction with class II. In pursuit of this, backbone stereochemical disruptions by serial D-alanine substitutions in CLIP86-104 have been used in competitive binding assays to I-A class II molecules. These studies have revealed that the phylogenetically conserved central continuous region, CLIP91-99, is intolerant to such configurational substitutions. Experiments with truncated and frame-shift analogues of CLIP showed that for effective binding to class II, the sequence element CLIP90-100 must be incorporated into a peptide of 13 or more residues including at least three residues N-terminal to this motif. Additionally, it appears that different I-A molecules accommodate CLIP in different binding frames. These investigations of the relationship between the structure and binding of CLIP analogues lead us to propose that there is a general backbone motif of a periodic nature within the CLIP sequence that minimizes deleterious contacts and allows promiscuous binding to class II molecules.

Amino Acid Sequence↗

PubMed2000

Scaled clips for aneurysm surgery: technical note.

OBJECTIVE: The tips of clip blades are often invisible during operations on large, deep, or posteriorly projecting aneurysms. To overcome this problem, we sought to develop a series of scaled clips. METHODS: We made scaled clips modified from Yaşargil titanium clips. The blades of the new clips are scaled every 5 mm from the tips with alternating colors. We have added six new types of straight scaled clips. RESULTS: To date, we have performed approximately 40 aneurysm clippings using the new scaled clips and have confirmed their usefulness. CONCLUSION: Scaling on the blades helps confirm accurate placement of a clip, even during operations for large, deep, or posteriorly projecting aneurysms, in which blade tips are often invisible.

Equipment Design↗

PubMed1986

Autoregulation of renal blood flow in two-kidney, one-clip hypertensive rats.

Renal blood flow (RBF) autoregulation was examined in the clipped and nonclipped kidneys in two groups of two-kidney, one-clip (2K-1C) hypertensive rats 10 wk after clipping. The arterial pressure distal to the clip and the renin secretion rate (RSR) were also examined. The blood pressure (BP) was 149 +/- 4 and 162 +/- 6 mmHg in the two hypertensive groups vs. 114 +/- 3 mmHg in the controls (P less than 0.02). The RBF (in ml X min-1 X kidney-1) was 4.27 +/- 0.41 in the nonclipped and 2.18 +/- 0.23 in the clipped kidneys (P less than 0.001). The pressure distal to the clip was 104 +/- 7 mmHg. The renal vascular resistance (RVR) (in mmHg X ml-1 X min-1 X g-1) was 25.0 +/- 1.4 in the control kidneys vs. 58.4 +/- 4.5 in the nonclipped (P less than 0.001) and 39.9 +/- 6.6 in the clipped kidneys (P less than 0.01). The RBF autoregulation was well preserved in the nonclipped kidneys but reset to a higher lower pressure limit of autoregulation of 106 +/- 4 mmHg, which was significantly higher than in the normotensive controls (84 +/- 6 mmHg) (P less than 0.01). In the clipped kidneys there was complete loss of RBF autoregulation. RSR decreased with reduction of the perfusion pressure in the clipped kidneys. The increased RVR might have been due to a combination of structural and functional changes in both kidneys.

Animals↗

PubMed2001

Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography.

BACKGROUND AND PURPOSE: With many patients living long after microsurgical aneurysm clipping for subarachnoid hemorrhage (SAH) and with the evolution of intravascular procedures as less invasive alternatives, knowledge of the long-term results of clipping is becoming important. METHODS: Of 412 patients who underwent clipping of ruptured or unruptured cerebral aneurysms at our institution between 1976 and 1994 and who survived >3 years after surgery, 225 patients who were in good general condition and younger than 80 years were offered follow-up angiography to detect newly formed aneurysms. Of the 225, 80 patients (35.6%) agreed to undergo angiography. In addition, 32 patients underwent angiography for new medical indications other than SAH. Therefore, 112 patients underwent angiography, representing a total of 140 clipped aneurysms. RESULTS: The mean interval from surgery was 9.3 years for all patients and 9.0 years for the clipped aneurysms (range 3 to 21 years). Four aneurysm regrowths were detected of the 140 (2.9%) clipped aneurysms, representing 3 of 125 completely clipped aneurysms, 1 of 14 incompletely clipped aneurysms, and 0 of 1 aneurysm not studied with postoperative angiography. De novo aneurysms were detected in 9 of 112 (8.0%) patients. The annual rate of de novo aneurysm formation was 0.89%. CONCLUSIONS: This study shows that the annual rate of de novo aneurysm formation is relatively high (0.89%) and that the cumulative risk becomes significant after 9 years. In consideration of the fatality rate of SAH, follow-up angiography may be indicated for patients with clipped aneurysms 9 to 10 years after surgery.

Angiography, Digital Subtraction↗

PubMed1986

Effect of ketanserin on pressor response to vasoactive substances in early phase of one-kidney, one clip renal artery stenosis in rats and rabbits.

The effect of ketanserin (KET), a specific 5-hydroxytryptamine2 (5-HT2) receptor blockade, on pressor response to vasoactive substances was examined in rats with one-kidney, one clip renal artery stenosis of 2 days' duration (2-day clipped rat) and in rabbits with renal artery stenosis of 3 days' duration (3-day clipped rabbits). The 2-day clipped rats showed hyperresponsiveness to norepinephrine (NE), arginine vasopressin (AVP) and 5-HT. All hyperresponsiveness were attenuated by a subdepressor dose of KET. The infusion of KET, 10 micrograms/kg/min for 30 minutes, decreased mean arterial pressure of the 3-day clipped rabbits; the dose did not alter blood pressure of the normal controls. Exaggerated pressor response to NE was observed in the 3-day clipped rabbits and was abolished by a subdepressor dose of KET, 2.5 micrograms/kg/min. These results suggest that 5-HT may be involved in the enhanced pressor response to vasoconstrictor substances in the 2-day clipped rats and 3-day clipped rabbits, and that it may also play an important role in maintaining blood pressure in the 3-day clipped rabbits.

Animals↗

PubMed1985

Clip with enclosed spring for aneurysm surgery. Technical note.

A clip for aneurysm surgery has been designed with several unique features. The coil spring is fully hidden and protected within two hub sections so that it cannot be handled or become entrapped in tissue. The clip is milled from a piece of solid stock of nonmagnetic stainless steel to the desired size and shape by a computer milling process, thus avoiding the stresses and structural weaknesses caused by the bending, curling, and milling needed to prepare clips made from wire or sheet metal. The only means of opening the clip is by applying pressure to the solid milled surfaces, thus the spring cannot be weakened or bent by squeezing it or by trauma applied to the clip. The clip may be grasped in either a clip applier that holds the clip in one fixed position or in an applier that allows the clip to be rotated through an arc of 180 degrees.

Aneurysm↗

PubMed2003

Aneurysm clips: evaluation of magnetic field interactions and translational attraction by use of "long-bore" and "short-bore" 3.0-T MR imaging systems.

BACKGROUND AND PURPOSE: The use of 3.0-T MR systems is increasing worldwide. We evaluated magnetic field interactions and translational attraction for 32 aneurysm clips in association with exposure to "long-bore" and "short-bore" 3.0-T MR imaging systems. METHODS: Thirty-two different aneurysm clips were evaluated in this investigation. Each aneurysm clip was qualitatively evaluated for magnetic field interactions and quantitatively assessed for translational attraction by using the deflection angle test. The deflection angle tests were performed at the points of the highest spatial gradients for long-bore and short-bore 3.0-T MR imaging systems. RESULTS: Seventeen of the 32 aneurysm clips showed positive magnetic field interactions. Deflection angles for the aneurysm clips were significantly (P <.001) higher on the short-bore (range, 0-18 degrees) compared with those recorded on the long-bore (range, 0-16 degrees) 3.0-T MR imaging system. Aneurysm clips made from commercially pure titanium and titanium alloy displayed no translational attraction (n = 15), whereas those made from stainless steel alloy, Phynox, and Elgiloy displayed positive deflection angles (n = 17). CONCLUSION: The 32 different aneurysm clips passed (angle <45 degrees) the deflection angle test by using the long- and short-bore 3.0-T MR imaging systems, indicating that they are safe for patients and other persons in these MR environments (ie, immediate area of MR imaging systems). However, only clips made from the titanium and titanium alloy are entirely safe for patients undergoing MR imaging procedures because of the total lack of magnetic field interactions. The remaining clips require characterization of magnetic field-induced torque. Because of possible differences in the points of the highest spatial gradients for different 3.0-T MR imaging systems, the results are specific to the imaging units and bore designs used in this investigation.

Contraindications↗

PubMed1991

Laparoscopic clips. Evaluation of absorbable and titanium with regard to hemostasis and tissue reactivity.

Advanced laparoscopic techniques require laparoscopic means of providing hemostasis. We tested the hemostatic ability of laparoscopic surgical clips and their tissue reactivity as assessed by adhesion formation in an animal model. Twenty-six New Zealand white rabbits were randomized at laparotomy to one of three treatment groups: titanium surgical clips, absorbable surgical clips (both applied with a laparoscopic clip applicator) and chromic sutures of equal mass. Either the right fallopian tube was transected, with clips or sutures applied proximally and distally to control bleeding, or the clips or sutures were applied 5 mm apart and the tube transected. A clip or suture of the same material was placed on the midportion of the left fallopian tube. Necropsy was performed at 42 days, and each clip/suture site was scored for adhesions. All the materials were easily applied and effective in achieving hemostasis. The adhesion scores tended to be lower with the absorbable clips; however, there were no statistically significant differences between the groups. Laparoscopic clips are effective in providing hemostasis, are easily applied and cause no more adhesion formation than do conventional suture materials.

Animals↗

PubMed1998

Surgical clips: a cause of late recurrent gallstones.

The formation of gallstones around surgical clips after cholecystectomy is a rare complication, with only seven reported cases in the English literature since its initial description in 1979. Three other cases report clip migration into the common bile duct and obstruction. We report a recent experience with "clip cholelithiasis." A 78-year-old female, 16 years following cholecystectomy, presented with a several-month history of colicky abdominal pain worsened by meals, and a 1 week history of jaundice, anorexia, nausea, and vomiting. An abdominal ultrasound demonstrated dilatation of the biliary tree without visible choledocholithiasis. Endoscopic retrograde cholangiopancreatography demonstrated a 1.5-cm radiolucent stone in the common bile duct containing a central surgical clip. She was successfully treated with endoscopic sphincterotomy and stone retrieval. The first report of clip cholelithiasis occurred in 1979. Six additional cases have been reported as well as three cases of clip migration without stone formation into the common bile duct. The incidence of clip cholelithiasis may increase in frequency with the increased use of metallic clips during laparoscopic cholecystectomy. The occurrence of cholelithiasis around inert metals is rare and may be prevented using absorbable clips; however, stone formation is also reported around absorbable materials.

Absorption↗

PubMed1983

[Is tubal sterilization with the Tupla-clip a reversible method?].

Between 1976 and 1981 402 tubal sterilizations were performed with Tupla-clip most of them by laparoscopic application. 11 tubes were removed between 15 and 47 months following the sterilization with the Tupla-clip. The local changes both macroscopically and microscopically to the tupla-clip were evaluated. The possibility of tubal patency following removal of the clips was tested by carbon dioxide pertubation. The tubal-occlusion with the tupla-clip is definitive since all tubes had a fibrous tissue strand where the clip had been applied which still carried blood vessels. No tube was patent with the carbon dioxide pertubation. The intra-operative testing of correct application of the clip and the documentation of this correct application is again mentioned. This is especially important in view of the recent judgements of the federal supreme court regarding liability in failed tubal sterilizations. The excellent chance of reversal by tubal anastomosis and the 100% success rate of this method of sterilization within the 6 years under observation will increase the acceptance of the tupla-clip as a method for tubal sterilizations.

Female↗

PubMed2000

[Endoscopic pretherapeutic clipping for gastrointestinal tumors. A method for exact definition of the target volume].

BACKGROUND: In many cases it is not possible to exactly define the extension of carcinoma of the gastrointestinal tract with the help of computertomography scans made for 3-D-radiation treatment planning. Consequently, the planning of external beam radiotherapy is made more difficult for the gross tumor volume as well as, in some cases, also for the clinical target volume. PATIENTS AND METHODS: Eleven patients with macroscopic tumors (rectal cancer n = 5, cardiac cancer n = 6) were included. Just before 3-D planning, the oral and aboral border of the tumor was marked endoscopically with hemoclips. Subsequently, CT scans for radiotherapy planning were made and the clinical target volume was defined. Five to 6 weeks thereafter, new CT scans were done to define the gross tumor volume for boost planning. Two investigators independently assessed the influence of the hemoclips on the different planning volumes, and whether the number of clips was sufficient to define the gross tumor volume. RESULTS: In all patients, the implantation of the clips was done without complications. Start of radiotherapy was not delayed. With the help of the clips it was possible to exactly define the position and the extension of the primary tumor. The clinical target volume was modified according to the position of the clips in 5/11 patients; the gross tumor volume was modified in 7/11 patients. The use of the clips made the documentation and verification of the treatment portals by the simulator easier. Moreover, the clips helped the surgeon to define the primary tumor region following marked regression after neoadjuvant therapy in 3 patients. CONCLUSIONS: Endoscopic clipping of gastrointestinal tumors helps to define the tumor volumes more precisely in radiation therapy. The clips are easily recognized on the portal films and, thus, contribute to quality control.

Endoscopy, Gastrointestinal↗

PubMed2001

Endoscopic thoracic sympathetic block by clipping for palmar and axillary hyperhidrosis in children and adolescents.

Endoscopic thoracic sympathectomy or sympathicotomy is a safe and effective method of treating primary hyperhidrosis (PH), but postoperative compensatory sweating may be a problem. There are few reports of sympathetic blockade by clipping for PH. We present our experience of endoscopic thoracic sympathetic block (ETSB) by clipping in treating palmar (PAH) and axillary hyperhidrosis (AH) in children and adolescents. Between May 1997 and June 1998, a total of 78 patients with PAH or AH underwent ETSB by clipping using an 8-mm, 0 degrees thoracoscope. There were 33 males and 45 females with a mean age of 14.1 years (range 9-16 y). All patients were placed in a semi-sitting position under single-lumen intubation anesthesia; 52 patients with PAH underwent T2 sympathetic block by clipping at the 2nd and 3rd rib beds, and T3 and T4 sympathetic block was performed at the 3rd, 4th and 5th rib beds in 26 patients with AH. A total of 156 sympathetic blocks by clipping were achieved. The operation was usually accomplished within 20 min (range 16-30 min). Most patients were discharged within 4 h after the operation. There were neither surgical complications nor mortality. The mean postoperative follow-up period was 32.7 months (range 26-40). Improvement of PAH or AH could be obtained in all cases; 70 patients (85.4%) developed compensatory sweating of the trunk and lower limbs. One patient with PAH underwent a reverse operation with improvement of the sweating 14 days after removal of the endo-clips. ETSB by clipping is thus a safe and effective method for treating PH in children and adolescents; compensatory sweating may be improved after a reverse operation with removal of the endo-clip.

Adolescent↗

PubMedDate not supplied

The MHC class II-associated invariant chain-derived peptide clip binds to the peptide-binding groove of class II molecules.

Major Histocompatibility Complex (MHC) class II proteins bind to peptides derived from processed foreign antigens, and display them on the cell surface of antigen presenting cells for recognition by CD4+ regulatory T lymphocytes. Prior to their binding to antigenic peptides in endosomal compartments, class II molecules are associated with a nested set of peptides CLIP derived from amino acids 80 to 107 of the invariant chain (Ii). Currently the interaction between the CLIP peptide and class II molecules is not clear. Using an FITC-labeled CLIP peptide and soluble empty class II molecules synthesized in insect cells, we have investigated the direct binding of the CLIP peptide to class II molecules, and the influence of localized polymorphic residues in the peptide-binding groove on the binding. We found that the human class II HLA-DR1 molecule contains a single-binding site for the CLIP peptide as well as the antigenic peptide MP19-31, as analysed by Scatchard analysis. Further studies also showed that occupancy of the peptide-binding groove by antigenic peptides inhibited the binding of CLIP to DR1 molecules and vice versa. Most importantly, the polymorphic residues beta 85 and 86, which define the major peptide-binding pocket, strikingly influence the CLIP-DR1 interaction, as assayed by the SDS-stability of class II-peptide complexes and the affinity of class II-peptide interactions. These data indicate that the peptide-binding pocket and thus the peptide-binding groove of the class II molecule are directly involved in the association with the CLIP peptide.

Antigens, Differentiation, B-Lymphocyte↗

PubMed1996

Surgical clips in planning the electron boost in breast cancer: a qualitative and quantitative evaluation.

PURPOSE: To evaluate, qualitatively and quantitatively, the role of surgical clips in planning the tumor bed electron boost in patients undergoing breast conserving surgery and radiotherapy. METHODS AND MATERIALS: In 50 patients, the excision cavity boundaries were marked by clips at surgery. The electron boost field was first planned using clinical information, aiming to achieve a margin of 2 cm, and its accuracy evaluated by screening the surgical clips and, if necessary, adjusting the field to encompass all clips with 2 cm margins. Orthogonal radiographs were take with solder wire delineating the clinical and screened fields and the scar. Hypothetical clinical and radiological fields, with 1 and 3 cm margins, were reconstructed on the radiographs. RESULTS: The clinical field was inadequate in 34 patients (68%). The precision of each clinical setup was quantified by two indices. The Normal Tissue Index defined the percentage of the clinical field comprised of tissue, beyond the tumor bed, not at high risk of local recurrence, and gave an estimate of potential spring of normal tissue: median 14.6% (range 0-83.0), 17 out of 50 > 25%; median 13% (range 0-70.7), 12 out of 50 > 25%; median 9.7% (range 0-59.8), 10 out of 50 > 25%, for 1, 2, and 3 cm margins, respectively. The Geographical Miss Index defined the percentage of the radiologically defined field, at high risk of local recurrence, not predicted by the clinical field, and gave an estimate of the extent of geographical miss: median 32.9% (range 0-83.5), 28 out of 50 > 25%; median 26.1% (range 0-69.8%), 26 out of 50 > 25%; median 18.6% (range 0-60.3), 20 out of 50 > 25%, for 1, 2, and 3 cm margins, respectively. The median distance from the scar midpoint to the furthest clip was 3.8 (range 1.2-8.1) cm. The median maximal clip depth was 3.1 (range 1.4-5.2) cm. CONCLUSION: (a) Electron boost field planning by clinical landmarks alone was inaccurate in 68% of cases. (b) Quantitative measures, based on margins of 1, 2, and 3 cm, revealed that in 20-34% of patients more than one-quarter of the clinical field covered tissue at low risk of local recurrence, and in 40-56% of patients less than three-quarters of the final radiological field was predicted clinically. (c) The relative positions of the scar and clips may be widely disparate. (d) Clip depth measurements reveal a significant risk of underdosing at depth.

Breast Neoplasms↗

PubMed1995

In vitro changes in clips and bars used to retain implant overdentures.

Although implant-retained overdentures are a less expensive alternative to fixed implant-supported prostheses in certain situations, problems with retentive clips fracturing and needing frequent replacement have been reported. This study compared baseline and posttest retention of metal and plastic clip-retained overdenture analogs and monitored surface changes in bars and clips throughout the testing process. A laboratory model was made with two implant analogs processed into an acrylic resin platform to which three bars were fitted. Two overdenture analogs were made and retained on the model with metal or plastic clips. Each bar-clip assembly was subjected to 5500 insertion and removal cycles to simulate 3 years of in vivo insertion and removal. Although the differences in retention between metal and plastic clips and between clips before and after testing were statistically significant, it is questionable whether they are clinically significant. Neither clip fracture nor loss occurred during this study, which suggests that it may be functional or parafunctional loading and not repeated insertion and removal of an implant overdenture that may cause the stated problems.

Acrylic Resins↗

PubMed1996

The effect of simulated function on the retention of bar-clip retained removable prostheses.

Patients wearing bar-clip retained removable prostheses may have loss of retention because of changes within the bar-clip assembly. This in vitro study recorded and compared the retention of one- and two-clip retained simulated mandibular complete denture prostheses before and after simulated function. Cast metal Hader bars and clip holders were used to make 10 one-clip and 10 two-clip specimen pairs. Tensile removal values before and after simulated function were recorded and compared by repeated-measures analysis of variance and Student tau tests (significance level 0.05). The results revealed that the use of two clips instead of one significantly increased retention of the simulated prosthesis. It was also found that there was a significant loss of retention after the specimens were placed on the bars and then removed once for both the one- and two-clip groups. Simulated function did not cause a significant change in retention for either group.

Analysis of Variance↗