Methods for siting emergency stomas in the absence of a stoma therapist

Introduction

Stomas often have to be sited in emergencies by trainees who may have had little training in this. Emergency stomas and stomas where the site has not been marked preoperatively by a stoma therapist are more prone to complications. These complications may severely affect a patient’s quality of life. Advice in the literature on how to best site stomas is conflicting. We compared two easy anatomical methods of siting stomas to sites chosen by a stoma therapist and looked at how this site was affected by the patients’ body mass index (BMI).

Methods

Patients undergoing elective colorectal surgery were seen either pre or postoperatively. Each patient’s BMI was recorded and the positions of three different potential stoma positions (site G: the gold standard, marked by a stoma therapist; site S: marked using a pair of scissors against the umbilicus; site H: halfway between the umbilicus and anterior superior iliac spine) were compared.

Results

The two fixed anatomical methods described (method S and method H) both gave poor results. The most common reason for poor siting was the proximity of a skin crease. There was a statistically significant correlation between the patient’s BMI and the laterality of the gold standard site.

Conclusions

The two simple anatomical methods described here do not provide a shortcut to effective siting. A more effective method may be calculating the laterality of the site using the patient’s BMI, and then moving up/down to avoid a skin crease and improve the patient’s view for changing the bag. This deserves further study.     

Monitoring human tumor response to therapy by means of P-31 MR spectroscopy

Tumors in 23 patients were studied by means of in vivo phosphorus-31 magnetic resonance (MR) spectroscopy. In five patients, the response to chemotherapy and radiation therapy was monitored in a long-term follow-up study. In one patient, the P-31 MR spectra were recorded during the infusion of chemotherapeutic drugs. In comparison with healthy muscle tissue of patients, the tumors showed elevated inorganic phosphate, phosphomonoester, and phosphodiester peaks and reduced creatine phosphate peaks, whereas the nucleoside 5'-triphosphate levels remained nearly unchanged. Tumor treatment resulted in changes in the ratio of the signal intensity value of creatine phosphate to that of inorganic phosphate and in the sum of these values. In an osteosarcoma, an initial response followed by renewed tumor growth was clearly indicated by changes in these parameters. In the short-term follow-up examination, slight spectral changes were observed during the infusion of chemotherapeutic drugs. Changes in the concentrations of phosphorus metabolites during therapy can therefore be monitored in human tumors by means of P-31 MR spectroscopy.     

Thrombolytic efficacy of tissue plasminogen activator-loaded echogenic liposomes in a rabbit thrombus model

Introduction

Ultrasound (US)-enhanced thrombolytic treatment protocols currently in clinical trials for stroke applications involve systemic administration of tissue plasminogen activator (tPA; Alteplase), which carries a risk of adverse bleeding events. The present study aimed to compare the thrombolytic efficacy of a tPA-loaded echogenic liposome (ELIP) formulation with insonification protocols causing rapid fragmentation or acoustically-driven diffusion.

Materials and Methods

Thrombi were induced in the abdominal aortas of male New Zealand white rabbits (2-3 kg) using thrombin and a sclerosing agent (sodium ricinoleate) after aortic denudation with a balloon catheter. Thrombolytic and cavitation nucleation agents (200 μg of tPA alone, tPA mixed with 50 μg of a microbubble contrast agent, or tPA-loaded ELIP) were bolus- injected proximal to the clot through a catheter introduced into the abdominal aorta from the carotid artery. Clots were exposed to transabdominal color Doppler US (6 MHz) for 30 minutes at a low mechanical index (MI = 0.2) to induce sustained bubble activity (acoustically-driven diffusion), or for 2 minutes at an MI of 0.4 to cause ELIP fragmentation. Degree of recanalization was determined by Doppler flow measurements distal to the clots.

Results

All treatments showed thrombolysis, but tPA-loaded ELIP was the most efficacious regimen. Both US treatment strategies enhanced thrombolytic activity over control conditions.

Conclusions

The thrombolytic efficacy of tPA-loaded ELIP is comparable to other clinically described effective treatment protocols, while offering the advantages of US monitoring and enhanced thrombolysis from a site-specific delivery agent.     

Malignant fibrous histiocytoma complicating nephrogenic systemic fibrosis post liver transplantation

A 46-year-old man with cirrhosis secondary to hepatitis C virus infection and alcohol underwent orthotopic liver transplantation, which required urgent re-grafting because of biliary sepsis from necrosis of the left liver lobe. Recovery was complicated by renal failure and nephrogenic systemic fibrosis (probably related to intravenous gadolinium exposure). He subsequently developed a malignant fibrous histiocytoma. We present this case highlighting the occurrence of two rare conditions in the same patient following liver transplantation. We believe this is the first case of its kind to be reported.     

Dyspnea assessment and management in hospice patients with pulmonary disorders

Accurate assessments and appropriate management of dyspnea are essential to provide improved quality of life for hospice patients. This study describes methods of assessing dyspnea and interventions used to manage dyspnea in 72 hospice patients with end-stage lung disease or lung cancer. The mean age of the sample was 72.46 years old and the majority was white (80 percent) and male (62 percent). Paired t-tests were used to compare mean scores on admission and near death for dyspnea severity, Karnofsky functional status, pain, and Mini-Mental Status scores. Results showed significant decline in functional and cognitive status, but no significant changes in dyspnea severity and pain. Dyspnea was often assessed subjectively with observational methods only. Use of inhalants, oxygen, positioning, steroids, and oral opioids were the most frequent therapies for dyspnea. Relaxation, guided imagery, and other complementary therapies were rarely used (five percent or less). Measurement of dyspnea needs to be done frequently by using standardized instruments to assess severity and degree of symptom distress as well as the effects of treatment. Clinical trials are needed to determine which dyspnea interventions are most effective in terminally ill patients. Guidelines such as those developed for pain management are needed for effectively managing dyspnea.