脾动脉瘤11例诊治分析

目的 总结11例脾动脉瘤的临床治疗经验。方法 2001-2014年本院共收治11例脾动脉瘤患者,对其治疗方法及预后等临床资料进行回顾性分析。结果11例中术前经彩超及彩色多普勒血流显像（CDFI）检查初诊9例。4例经螺旋CT血管造影、4例经数字减影血管造影（DSA）、1例经磁共振血管造影三维重建而确诊,剖腹探查确诊2例。本组3例行包括胰尾脾的脾动脉切除术,2例行动脉瘤远近端脾动脉结扎术,1例行脾切除术,1 例行脾动脉瘤切除+脾动脉重建术,4 例行介入栓塞术。11 例随访7 个月至3 年,均获治愈。无死亡及严重并发症。结论 脾动脉瘤发病率低,症状不典型,一旦破裂有致死的危险,手术及介入治疗预后均良好。     

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目的总结9例脾动脉瘤的临床治疗经验。方法1999年12月至2003年3月上海第二医科大学附属仁济医院经多普勒B超、CT、数字减影血管造影术(DSA)或磁共振成像(MRI)检查9例病人术前确诊为脾动脉瘤。手术方法包括动脉瘤体近远端动脉结扎术2例，动脉瘤切除脾动脉重建2例，动脉瘤切除、动脉瘤-门静脉内瘘关闭、脾切除1例，动脉瘤伴胰体尾部切除加脾切除4例。结果随访5个月至3年所有病人均手术治愈。无死亡及严重并发症。随访期间无动脉瘤复发或上消化道出血，腹水消失。结论脾动脉瘤一般起病隐匿．很少有临床症状。选择性内脏动脉造影最具有诊断价值。手术切除是脾动脉瘤最可靠的治疗方法，由于动脉瘤有破裂可能，有症状的脾动脉瘤是手术治疗的绝对指征。     

脾动脉瘤的诊断和治疗

目的：总结16例脾动脉瘤的外科诊治经验。方法：回顾性分析收治的16例脾动脉瘤患者的临床资料。其中男4例,女12例,经超声多普勒、CT血管造影（CTA）等检查发现脾动脉瘤15例,另1例术中探查发现。手术治疗11例,其中脾动脉瘤破裂行急诊手术4例,择期性手术7例,手术包括脾动脉瘤及脾切除9例,同时切除胰尾3例,脾动脉瘤切除、脾动脉重建1例,脾动脉瘤切除、近远端脾动脉结扎1例。另外行脾动脉瘤介入栓塞3例,非手术治疗2例。结果：手术及介入治疗的14例患者治疗后未发生严重的并发症,无死亡,均康复出院。术后随访0.5~19.0年,平均8.4年。11例手术及介入治疗者中,2例分别手术后3,7年死于其他疾病,另9例情况良好。2例非手术治疗者已分别随访3,5年,脾动脉瘤无变化。结论：脾动脉瘤女性多发;CT血管造影和多普勒超声等可明确诊断;早期切除动脉瘤或介入栓塞术是防止破裂出血导致死亡的有效方法。     

脾动脉瘤的诊治体会(附2例报告)

目的 探讨脾动脉瘤的诊治经验。方法 对我院1980－2000年收治的2例脾动脉瘤患者的临床资料进行回顾性分析。结果 例1为男性，因脾功能亢进入院，行C及血管造影检查发现脾动脉多发动脉瘤，行动脉瘤切除、脾切除术。例2为女性，因腹腔内出血而急诊行多普勒检查得以确诊，急诊手术行远端脾动脉结扎，脾切除术。结论 对临床症状明显且有增大趋势的脾动脉瘤应积极行手术治疗，特别是预期妊娠的女性患者及行肝移植患者。妊娠患者，推荐介入及腹腔镜微创治疗方法。     

脾动脉瘤7例诊治分析

目的：探讨脾动脉瘤的诊断和手术治疗方法。方法：回顾性分析7 例脾动脉瘤患者的临床资料。结果：6例经彩色多普勒超声（B超）初步诊断;4例经CT动脉造影（CTA）,2例经数字减影血管造影术（DSA）,1例经磁共振造影（MRA）确诊;无1例依靠临床症状而确诊。单纯脾动脉瘤切除术1例,脾动脉瘤加脾脏切除术1例,脾动脉瘤切除加动脉重建术1例,动脉瘤近远端脾动脉结扎术1例,脾动脉瘤栓塞术2例,脾动脉瘤栓塞术加脾切除术1例。随访2个月至3年。无死亡及严重并发症病例。结论：脾动脉瘤依赖临床表现难以诊断,B超有筛选价值,CTA,MRA,DSA均有诊断价值。一旦确诊应尽早选择腔内介入栓塞治疗或手术方法。     

经导管弹簧圈栓塞治疗脾动脉瘤

目的探讨经导管弹簧圈栓塞治疗脾动脉瘤的临床应用价值。方法回顾性分析接受经导管弹簧圈栓塞治疗的18例脾动脉瘤患者的资料,其中真性脾动脉瘤14例,假性脾动脉瘤4例;近端型6例,中间型4例,脾门型8例。根据患者脾动脉造影情况,选择普通弹簧圈、微弹簧圈或机械可脱式弹簧圈进行栓塞。术后1周及1、3、9个月行CT增强或CTA复查,随后每月行电话随访。结果对18例均顺利完成手术,11例采用隔绝旷置术,4例采用瘤腔填塞术,3例采用隔绝旷置术+瘤腔填塞术。术后12例出现栓塞后综合征,其中8例出现不同程度的脾梗死,梗死体积约10%~35%;余4例为轻微并发症。随访中无瘤体增大、破裂或复发及相关并发症。结论经导管弹簧圈栓塞治疗脾动脉瘤简单可行、安全有效。     

迷走脾动脉瘤12例报道并文献复习

目的 探讨迷走脾动脉瘤的治疗方法及疗效评价.方法 回顾性分析新疆维吾尔自治区人民医院血管外科2012年1月-2014年5月收治的12例迷走脾动脉瘤患者,其中男性4例,女性8例,对其治疗方法进行临床分析.迷走脾动脉瘤均起源于肠系膜上动脉,瘤体均为单发,直径1.5 ～2.8 cm,平均2.1 cm.12例均行手术治疗,4例行开放手术切除瘤体,5例行脾动脉介入栓塞治疗,3例行瘤体内栓塞+肠系膜上动脉内覆膜支架植入.结果 12例治疗均获成功,2例出现腹痛、发热等不适反应.未出现脾动脉瘤复发、增大或破裂.12例均获随访,每隔3个月复查彩色多普勒超声或CT血管成像,随访时间6～24个月,1例术后1年死于腹腔大出血;11例情况良好,无复发.结论 对于具有适合解剖条件的迷走脾动脉瘤,腔内治疗安全有效,对于累及肝动脉的迷走脾动脉瘤,需开放手术进行血管重建.     

脾动脉瘤27例诊治分析

目的 探讨脾动脉瘤的早期诊断和治疗方法。方法 对1957年9月－2000年6月诊治的27例脾动脉瘤作一回顾性分析。结果 27例脾动脉瘤中伴动脉粥样硬化12例,门静脉高压症9例,胰腺炎2例,外伤2例,肌纤维发育不良及细菌性心内膜炎所致各1例。发生自发性破裂大出血4例（14．8％）。术前20例经彩超及彩色多普勒血流显像（CDFI）检查初步确诊16例;5例经螺旋CT血管造影（SCTA）、5例经选择性内脏动脉造影、5例数字减影血管造影（DSA）、例经磁共振血管造影三维重建（3D MRA）而确诊;术前依靠临床表现获诊断仅1例;11例经手术探查确诊。本组行包括胰尾脾的脾动脉瘤切除术11例,脾动脉瘤切除加脾动脉重建术6例,脾动脉瘤切除术未重建脾动脉3例,动脉瘤近远端脾动脉结扎术3例,介入栓塞术4例。无死亡病例。结论 重视和警惕脾动脉瘤的可能并通过CDFI、SCTA、3D MRA及DSA等影象技术对脾动脉瘤作出早期诊断;一旦确诊应根据病情微创、安全、有效的腔内介入栓塞治疗或尽早手术。     

真性脾动脉瘤结肠瘘行腹腔镜治疗1例报告并文献复习

背景与目的 真性脾动脉瘤结肠瘘是一类罕见且凶险的疾病,笔者报告1例特殊的真性脾动脉瘤结肠瘘患者的诊治过程,以期提高对该病的认识和诊治水平。方法 对1例真性脾动脉瘤结肠瘘患者的临床表现、影像学特点、介入治疗及腹腔镜手术治疗过程及预后进行回顾性分析,并结合国内外文献,总结真性脾动脉瘤结肠瘘的临床和影像学特点、诊断及治疗方法。结果 2020年10月31日北京大学第一医院急诊科收治了1例首发症状为暗红色血便的40岁女性患者,通过腹盆部增强CT、肠镜和脾动脉造影检查发现患者真性脾动脉瘤破裂至结肠脾曲导致下消化道出血,经介入下弹簧圈栓塞治疗后康复出院,出院后无再发便血等不适。2023年8月7日患者排便时从肛门排出金属丝,自行剪断后出现左上腹痛,再次就诊于我院急诊科,通过腹盆部平扫CT发现患者脾动脉瘤栓塞所用的一部分弹簧圈钢丝经脾动脉瘤结肠瘘进入结肠并从肛门脱出,于2023年8月14日行全麻腹腔镜探查+脾切除+脾动脉瘤切除+结肠部分切除+结肠异物取出术,手术过程顺利,术后病理符合真性脾动脉瘤诊断。出院后随访3个月,患者无腹痛便血等不适。真性脾动脉瘤结肠瘘经介入栓塞,腹腔镜手术切除后痊愈,检索国内外近30年文献未见报道。结论 真性脾动脉瘤结肠瘘尽早行增强CT或数字减影血管造影可明确诊断,对于血流动力学稳定患者首选腹腔镜手术切除,血流动力学不稳定患者可先介入弹簧圈栓塞动脉瘤,待血流动力学稳定后再评估腹腔镜手术,能获得较好的预后。     

脾动脉起始部动脉瘤的切除及血管重建的手术探讨

目的探讨脾动脉起始部动脉瘤的切除及脾动脉重建的手术方法。方法回顾性分析1996年1月~2007年3月收治的8例脾动脉起始部动脉瘤患者的临床资料,经彩色超声、CT和血管造影检查证实脾动脉起始部真性动脉瘤;均在全身麻醉下首先阻断腹腔干起始部,远端脾动脉阻断后切除动脉瘤,1例行腹腔干-脾动脉自体静脉移植,4例行肾下主动脉-脾动脉人工血管转流,3例同时切除动脉瘤和脾脏。结果均于手术后10~14 d治愈出院。随访0.5~10年;其中1例人工血管转流术后2年死于急性心肌梗塞,余7例均健康生活,无动脉瘤复发。结论动脉瘤切除、脾动脉重建是一种较好的脾动脉起始部真性动脉瘤的治疗方案。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.