Intraoperative abdominal ultrasonography: initial experience with a dedicated high-resolution operative transducer

A dedicated 8-MHz intraoperative scanning probe was used in 42 patients who underwent exploratory abdominal surgery. A variety of pathologic processes involving the liver, pancreas, bowel, and biliary and genitourinary systems were evaluated. Sonographic studies were evaluated to determine if they added new information (20 patients, 47.6 per cent), confirmed known information (20 patients, 47.6 per cent), or provided false information (two patients, 4.8 per cent). Preliminary experience with a specially developed transducer suggests that its design avoids many of the difficulties encountered with other transducers employed for this technique. Intraoperative sonography has, in many instances, the potential to simplify surgery, shorten operating time, and modify the type of surgical procedure performed.     

Trauma pain protocol: an interdisciplinary approach to process improvement

The trauma pain protocol was developed in response to nursing staff concerns regarding pain management practices and hospital-wide goals. Data collected on pain management practices within the trauma patient population identified inconsistencies with the transition of patient-controlled analgesia (PCA) to oral (PO) and intravenous (IV) pain medications. Nursing staff cited concerns with the frequent need for calls to clinicians to obtain additional pain medication orders following discontinuation of PCA. An interdisciplinary team developed a protocol to address appropriate PCA to PO/IV conversion, adjuvant medications, opioid reversal, and management of adverse effects. Data collected from a 4-month pilot of the protocol demonstrated a reduction in changes made to PO/IV medications following discontinuation of PCA. Nursing response to the protocol included increased satisfaction with pain management practices and a perception of time saved through reduced need for calls to clinicians for additional pain medication modifications. We conclude that this protocol results in a more individualized, evidence-based transition from PCA to PO/IV.     

Homocysteine-lowering trials for prevention of vascular disease: protocol for a collaborative meta-analysis.

BACKGROUND: Elevated plasma total homocysteine is a risk factor for cardiovascular disease (CVD), but the randomized trials of dietary supplementation with B-vitamins to lower homocysteine have not yet provided clear evidence of benefit on vascular risk. METHODS: Cumulative meta-analysis of all randomized trials assessing the effects of lowering homocysteine levels with B-vitamins on risk of CVD. RESULTS: An individual patient data meta-analysis of all randomized trials of the effects on vascular risk of lowering homocysteine with B-vitamins will maximize the power to assess the epidemiologically predicted differences in risk. Among the 12 randomized homocysteine-lowering trials for prevention of CVD, involving more than 1000 participants, data should be available on approximately 52,000 participants (32,000 with prior CVD in unfortified populations; and 14,000 with prior CVD and 6000 with renal disease in fortified populations). To minimize bias, the design and primary analyses to be carried out have been pre-specified. The analyses will include assessment of effects on major vascular events (MVE), stroke, major coronary events (MCE), in addition to venous thrombosis, cancer and fractures. Additional analyses will assess effects on vascular outcomes in sub-groups defined by population, prior disease, per 3 micromol/L difference in homocysteine levels achieved by treatment, pre-treatment vitamin status, duration, age, sex and vascular events excluding revascularizations and, separately, excluding vascular events occurring during the first year of treatment. CONCLUSIONS: A cumulative meta-analysis of the homocysteine-lowering trials should ensure that reliable evidence emerges about the effects of lowering homocysteine on risk of vascular and non-vascular outcomes.     

A high-resolution melting protocol for rapid and accurate differential diagnosis of thyroid nodules

A large majority of thyroid nodules are benign, and only 5% have malignant features on cytological examination. Unfortunately, fine-needle aspiration is inconclusive in approximately 30% of all thyroid biopsies, because the cytological features are indeterminate (suspicious for malignancy but not completely diagnostic or nondiagnostic). Wide panels of somatic mutations have been identified in thyroid cancers, and detection of genetic alterations in fine-needle aspirate has been demonstrated to improve diagnostic accuracy. Nevertheless, the relatively high number of genetic targets to be investigated, in comparison with the low percentage of malignant samples, makes the usual diagnostic protocol both time-consuming and expensive. We developed a reliable and sensitive protocol based on high-resolution melting analysis for the rapid screening of mutations of KRAS, HRAS, NRAS, and BRAF oncogenes in thyroid fine-needle aspirations. The entire procedure can be completed in approximately 48 hours, with a dramatic reduction in costs. The proposed protocol was applied to the analysis of 260 consecutive fine-needle aspiration biopsy (FNAB) samples. In 35 of 252 samples, 36 sequence variants were detected for BRAF (17 samples), NRAS (6 samples), HRAS (3 samples), KRAS codon 12 (9 samples), and KRAS codon 61 (1 sample).     

腹部按摩改善早产儿喂养耐受性的临床研究

目的评估早期促进肠道蠕动对早产儿喂养耐受性的改善效果。方法选取2014年5月—2015年6月上海市儿童医院新生儿科早产儿病房患儿123例,入选104例。根据入院日期将入选病例方便分为对照组50例及观察组54例,两组在胎龄、出生体质量、1 min及5 min Apgar评分等方面基线一致。对照组采用静脉营养联合经肠道早产儿液体配方乳喂养,观察组在此基础上增加每日一次的腹部按摩。通过比较两组胎粪排尽时间、恢复至出生体质量时间、经肠道内喂养每日摄入热卡达到501.6 k J/kg(全肠道喂养)的时间,来评估早产儿喂养耐受情况。结果观察组患儿胎粪排尽时间明显短于对照组,差异有统计学意义(F=11.542,P0.001);恢复至出生体质量时间明显短于对照组,差异有统计学意义(F=7.76,P=0.006);经肠道内喂养达到每日摄入热卡501.6 k J/kg时间短于对照组,差异有统计学意义(F=6.547,P0.01)。结论对早产儿进行腹部按摩的干预方法能显著减少早产儿喂养不耐受情况的发生,对早产儿的生长发育具有促进意义。     

Alpha-galactosidase versus active charcoal for improving sonographic visualization of abdominal organs in patients with excessive intestinal gas

Background and aimsIntestinal gas is a frequent cause of poor visualization during gastrointestinal ultrasound (US). The enzyme alpha-galactosidase may reduce intestinal gas production, thereby improving abdominal US visualization. We compared the efficacies of alpha-galactosidase and active charcoal in improving US visualization in patients with previous unsatisfactory abdominal US scans caused by excessive intestinal gas.Materials and methods: 45 patients with poor visualization of at least one target organ: pancreas, hepatic lobes (score 0–2) or common bile duct (CBD) (score 0–1) were enrolled in a prospective randomized, crossover, observer-blinded study. The patients received alpha-galactosidase (Sinaire Forte, Promefarm, Milan, Italy) 600 GalU t.i.d. for 2 days before abdominal US plus 900 GalU the morning of exam or active charcoal 448 mg t.i.d., for 2 days before the exam plus 672 mg the morning of the exam. Visualization was graded as follows: 0 = none (complete gas interference); 1 = severe interference, 2 = moderate interference, 3 = mild interference; 4 = complete (no gas interference).Results: 42 patients completed the study. Both alpha-galactosidase and active charcoal improved the visualization of target organs. Visualization of the right hepatic lobe, CBD and pancreatic tail was significantly improved (vs. baseline) only by alpha-galactosidase (p < 0.01). Scores ≥3 for all parts of the pancreas and both hepatic lobes were achieved in only 12.5% of the patients after both treatments. Both products were well tolerated.Conclusion: Alpha-galactosidase and active charcoal can improve US visualization of abdominal organs in patients whose scans are frequently unsatisfactory due to excessive intestinal gas. Visualization of the pancreatic tail and right hepatic lobe was significantly improved only by alpha-galactosidase. However, both treatments allowed adequate visualization of all target organs during the same examination only in a few patients.     

Virtual high-resolution MR angiography from non-angiographic multi-contrast MRIs: synthetic vascular model populations for in-silico trials

Despite success on multi-contrast MR image synthesis, generating specific modalities remains challenging. Those include Magnetic Resonance Angiography (MRA) that highlights details of vascular anatomy using specialised imaging sequences for emphasising inflow effect. This work proposes an end-to-end generative adversarial network that can synthesise anatomically plausible, high-resolution 3D MRA images using commonly acquired multi-contrast MR images (e.g. T1/T2/PD-weighted MR images) for the same subject whilst preserving the continuity of vascular anatomy. A reliable technique for MRA synthesis would unleash the research potential of very few population databases with imaging modalities (such as MRA) that enable quantitative characterisation of whole-brain vasculature. Our work is motivated by the need to generate digital twins and virtual patients of cerebrovascular anatomy for in-silico studies and/or in-silico trials. We propose a dedicated generator and discriminator that leverage the shared and complementary features of multi-source images. We design a composite loss function for emphasising vascular properties by minimising the statistical difference between the feature representations of the target images and the synthesised outputs in both 3D volumetric and 2D projection domains. Experimental results show that the proposed method can synthesise high-quality MRA images and outperform the state-of-the-art generative models both qualitatively and quantitatively. The importance assessment reveals that T2 and PD-weighted images are better predictors of MRA images than T1; and PD-weighted images contribute to better visibility of small vessel branches towards the peripheral regions. In addition, the proposed approach can generalise to unseen data acquired at different imaging centres with different scanners, whilst synthesising MRAs and vascular geometries that maintain vessel continuity. The results show the potential for use of the proposed approach to generating digital twin cohorts of cerebrovascular anatomy at scale from structural MR images typically acquired in population imaging initiatives.     

Needle tip visualization during ultrasound-guided vascular access: short-axis vs long-axis approach

Objectives

Ultrasound guidance for central venous catheterization improves success rates and decreases complications when compared to the landmark technique. Prior research has demonstrated that arterial and/or posterior vein wall puncture still occurs despite real-time ultrasound guidance. The inability to maintain visualization of the needle tip may contribute to these complications. This study aims to identify whether long-axis or short-axis approaches to ultrasound-guided vascular access afford improved visibility of the needle tip.

Methods

A prospective trial was conducted at a level I trauma center with an emergency medicine residency. Medical students and residents placed needles into vascular access tissue phantoms using long-axis and short-axis approaches. Ultrasound images obtained at the time of vessel puncture were then reviewed. Primary outcome measures were visibility of the needle tip at the time of puncture and total time to successful puncture of the vessel.

Results

All subjects were able to successfully obtain simulated blood from the tissue phantom. Mean time to puncture was 14.8 seconds in the long-axis group and 12.4 seconds in the short-axis group (P = .48). Needle tip visibility at the time of vessel puncture was higher in the long-axis group (24/39, 62%) as opposed to the short-axis group (9/39, 23%) (P = .01).

Conclusions

In a simulated vascular access model, the long-axis approach to ultrasound-guided vascular access was associated with improved visibility of the needle tip during vessel puncture. This approach may help decrease complications associated with ultrasound-guided central venous catheterization and should be prospectively evaluated in future studies.     

Novel therapy for atherosclerosis and inflammatory vascular disease

How to manage residual atherosclerosis risk after the statin therapy is a major concern in cardiovascular medicine. In addition to life-style modifications, new drugs against atherosclerotic and inflammatory vascular diseases are expected. In current clinical trials, phospholipase A2 inhibitors(darapladib, varespladib), RVX-208, D-4F, CETP inhibitors (anacetrapib, dalcetrapib), succinobucol are investigated. Some has been failed, but others are still promising. On molecular target basis of PAF-AH, CETP, PON, ABC transporters of A1 and G1, SR-BI, HO-1, potential benefits and side effects are discussed.     

Optimal CT protocol for the diagnosis of active bleeding in abdominal trauma patients

ObjectivesThe aim of this study is to compare the radiologic diagnostic performance of arterial phase, portal phase and combined phase computed tomography (CT) for traumatic abdominal injury. In addition, this study is attempted to decrease lifetime attributable risks (LARs) of cancer due to radiation exposure by using optimal CT protocol.Materials and methodsA total of 114 consecutive patients with a traumatic abdominal injury and an abdominal hematoma on CT were enrolled at a single tertiary regional trauma center between January 2016 and March 2017. Each CT protocol set was independently reviewed by three radiologists, and the diagnostic performance of all three CT phases were compared with regard to the capability to detect active bleeding, contained vascular injuries, and organ injuries. Additionally, LARs for cancer incidence and mortality were calculated using dose-length product values, for each phase of CT.ResultsThe pooled area under the receiver operating characteristic curves for the diagnosis of active bleeding, contained vascular injuries, and organ injuries ranged from 0.910 to 0.922, 0.643 to 0.723, and 0.948 to 0.915 for arterial, portal, and combined phase CT, respectively. There was no statistically significant difference in the diagnosis of active bleeding and organ injuries for any combination of two phase sets. The mean LARs for cancer incidence was 0.059%, 0.062% and 0.121% during arterial, portal and combined phase CT, respectively.ConclusionSingle phase CT could be a potential protocol for abdominal trauma patients. Use of single phase CT could significantly decrease the incidence of radiation-associated cancer in the future.     

Novel single-source high-pitch protocol for CT angiography of the aorta: comparison to high-pitch dual-source protocol in the context of TAVI planning

Purpose Computed tomography (CT) is increasingly being used for planning purposes prior to trans-arterial valve implantation (TAVI). High-pitch protocols using a 2nd generation dual-source CT (DSCT) allow for a comprehensive assessment of the aortic valve anulus, its distance to the coronary artery ostia, the aortic bulbus and the iliofemoral arteries with very low radiation exposure and low amount of contrast agent. The aim of this study was to evaluate the image quality of a comparable high-pitch scan mode in a modern single-source CT (SSCT) system. Methods 40 patients with severe symptomatic aortic valve stenosis have been examined for planning purposes prior to TAVI. The first 20 consecutive patients were examined with a 2nd generation DSCT system using a high-pitch scan mode (pitch value 3.4) and 60 ml of contrast agent. The second group of 20 consecutive patients were examined with a 128-slice SSCT system, using a high-pitch scan mode (pitch value of 1.7) and 60 ml of contrast agent. Image quality of the aortic valve, the ascending aorta, the coronary artery ostia, the iliofemoral arteries and overall image quality were graded in a blinded fashion using a 4-point-grading-scale. Furthermore, signal intensity and image noise were derived in the ascending aorta and in the ilio-femoral arteries. Results There was a minor but significant difference in the overall image quality score with lower image quality in SSCT (3.5 ± 0.6) when compared to DSCT (3.85 ± 0.4; p = 0.037). The mean image quality score was significantly higher in patients examined in DSCT when compared to SSCT regarding the evaluability of the coronary ostia (4.0 vs. 3.5; p < 0.01) and the image quality of the ascending aorta (4.0 vs. 3.5; p < 0.01). There was no significant difference in evaluation of the aortic valve and its anulus (3.85 for DSCT and 3.65 for SSCT; p = 0.149) and image quality of the iliofemoral arteries (3.65 for DSCT and 3.85 for SSCT; p = 0.140). Signal intensity and image noise did not differ significantly between both groups. Conclusions This study presents a novel high-pitch protocol for modern SSCT scanners, which allows CT angiography for TAVI planning with a similar radiation dose and contrast agent exposition and only small compromises in image quality compared to a high-pitch protocol on a DSCT scanner.     

首灵健脑胶囊改善血管性痴呆患者脑功能的效果分析

目的:观察首灵健脑胶囊治疗血管性痴呆(vasculardementia,VD)的疗效。方法:采用国际诊断标准选择60例VD患者,按随机数字量表分为治疗组32例(采用首灵健脑胶囊),对照治疗组28例犤采用甲磺酸双氢麦角毒碱片(商品名喜得镇)犦观察两组的疗效及中医症候改善疗效,同时,测定两组患者治疗前后简明精神状态量表(MMSE)、长谷川痴呆量表(HDS)及中医症状各项积分和微量元素的含量,并比较它们的变化。结果:治疗组MMSE,HDS及中医症状总积分的增加值分别为(4.9±2.1),(2.5±0.3)及(5.8±4.3)分,均较对照组明显犤(3.4±1.9),(2.3±0.3)及(3.0±4.2)分犦,差异有显著性意义(P<0.05或0.01);而且治疗组MMSE量表的部分分项能力积分值的变化也比对照组明显,差异亦有显著性意义(P<0.05或0.01)。另外,治疗组微量元素锌的增加、镉等微量元素的减少也较对照组明显,差异有显著性意义(t=4.236～15.362,P<0.05或0.01);治疗组总有效率(56%,18/32)虽然比对照组(50%,14/24)高,但无统计学意义(χ2=0.23,P>0.05)。结论:首灵健脑胶囊治疗轻中度VD疗效肯定,能使患者微量元素的缺乏及代谢异常恢复平衡,改善脑功能、提高VD患者的学习记忆。     

Quality improvement in an anticoagulation clinic: development of a new treatment protocol

We sought to improve patient outcomes and efficiency in our anticoagulation clinic through development of a new protocol for managing heart valve patients with subtherapeutic international normalized ratio (INR) tests. The new protocol standardized use of 1 anticoagulation agent while warfarin was retitrated, timelines for INR retesting, and target INR levels depending on the type of valve implanted. The new protocol provided significant improvements in patient care; however, outcomes for clinic operating efficiency were mixed.     

紧急气管插管护理配合流程改进的方法与效果

目的探讨紧急气管插管护理配合流程在临床应用与效果。方法对2010年7月至2011年2月需紧急气管插管的32例危重患者实施紧急气管插管的护理配合流程。在实施前对护士进行规范化培训,并与实施前27例患者进行比较。结果实施组患者的插管时间缩短（P〈0．01）,一次插管成功率提高（P〈0．05）。结论应用紧急气管插管护理配合流程能缩短紧急气管插管时间,提高急性呼吸衰竭患者抢救的有效性。     

A rapid two-stage screening protocol for palliative care in the emergency department: a quality improvement initiative

BackgroundA rapid two-stage screening protocol was developed to improve referral for palliative care needs among frail elderly in the emergency department (ED).MeasuresA new triage tool was administered, with assessment tools for activities of daily living, performance, functional staging, symptom burden, and caregiver distress.InterventionStage One identified elderly patients meeting criteria for life-limiting conditions. Stage Two referred patients with crescendo losses in activities of daily living, high symptom burden, and caregiver distress to palliative care or hospice.OutcomesOver eight months, 1587 patients were screened, representing 22% of ED visits made by patients older than 65 years during this time period. Of these, 140 met functional decline criteria, and 51 of these needed palliative care consultation. Five patients were referred to hospice, 20 received palliative care, and 26 received no further service.Conclusions/Lessons LearnedThe project shows unmet needs among elderly ED patients, and the feasibility of rapid screening and referral using a quality improvement approach. At its peak, the project accounted for half the referrals to the palliative care consultation service.     

Complete mesocolic excision and central vascular ligation for right colon cancer: an introduction for abdominal radiologists

Abdominal Radiology - To provide an overview of complete mesocolic excision, along with a review of the relevant vascular anatomy and locoregional staging concepts, for abdominal radiologists....     

Outcomes of a nurse-initiated intravenous analgesic protocol for abdominal pain in an emergency department: A quasi-experimental study

Background

Abdominal pain is one of the most frequent reasons for seeking care in an emergency department. Surveys have shown that patients are not satisfied with the pain management they receive. Reasons for giving inadequate pain management may include poor knowledge about pain assessment, myths concerning pain, lack of communication between the patient and healthcare professional, and organizational limitations.

Objectives

The aim of the study was to investigate the outcome of nursing assessment, pain assessment and nurse-initiated intravenous opioid analgesic compared to standard procedure for patients seeking emergency care for abdominal pain. Outcome measures were: (a) pain intensity, (b) frequency of received analgesic, (c) time to analgesic, (d) transit time, and (e) patients’ perceptions of the quality of care in pain management.

Design

A quasi-experimental design with ABA phases was used.

Setting

The study was conducted in an emergency department at a Swedish university hospital.

Participants

Patients with abdominal pain seeking care in the emergency department were invited to participate. A total of 50, 100 and 50 patients, respectively, were included for the three phases of the study. The inclusion criteria were: ongoing abdominal pain not lasting for more than 2 days, ≥18 years of age and oriented to person, place and time. Exclusion criteria were: abdominal pain due to trauma, in need of immediate care and pain intensity scored as 9-10.

Methods

The patients’ perceptions of the quality of care in pain management in the emergency department were evaluated by means of a patient questionnaire carried out in the three study phases. The intervention phase included education, nursing assessment protocol and a range order for analgesic.

Results

The nursing assessment and the nurse-initiated intravenous opioid analgesic resulted in significant improvement in frequency of receiving analgesic and a reduction in time to analgesic. Patients perceived lower pain intensity and improved quality of care in pain management.

Conclusions

The intervention improved the pain management in the emergency department. A structured nursing assessment could also affect the patients’ perceptions of the quality of care in pain management in the emergency department.