New method of catheter-port system implantation in hepatic arterial infusion chemotherapy

BACKGROUND: This report describes a novel method of implantation of the catheter-port system in hepatic arterial infusion chemotherapy, which is the inferior epigastric arterial approach. METHODS: Using this method, the length of incision is about 3 cm in lower abdomen. The inferior epigastric artery is exposed above the inguinal ligament. The half of the artery is cut, and a vascular sheath is inserted into the external iliac artery along a guide wire. A catheter is inserted into the hepatic artery through the vascular sheath. Coil occlusion of nontarget artery is performed by the technique of interventional radiology. Then the vascular sheath is removed and the catheter is fixed to the inferior epigastric artery. A port is connected to the catheter and placed above the incision in the lower abdomen. CONCLUSIONS: Using this method, the hip joint can be moved freely and port-related complications are few, which contributes to a good quality of life of patients during the therapy. The inferior epigastric arterial approach may give a benefit to those who are treated with hepatic arterial infusion chemotherapy.     

The influence of hemorrhagic shock on propofol: a pharmacokinetic and pharmacodynamic analysis

BACKGROUND: Propofol is a common sedative hypnotic for the induction and maintenance of anesthesia. Clinicians typically moderate the dose of propofol or choose a different sedative hypnotic in the setting of severe intravascular volume depletion. Previous work has established that hemorrhagic shock influences both the pharmacokinetics and pharmacodynamics of propofol in the rat. To investigate this further, the authors studied the influence of hemorrhagic shock on the pharmacology of propofol in a swine isobaric hemorrhage model. METHODS: After approval from the Animal Care Committee, 16 swine were randomly assigned to control and shock groups. The shock group was bled to a mean arterial blood pressure of 50 mmHg over a 20-min period and held there by further blood removal until 30 ml/kg of blood was removed. Propofol 200 microg. kg(-1). min(-1) was infused for 10 min to both groups. Arterial samples (15 from each animal) were collected at frequent intervals until 180 min after the infusion began and analyzed to determine drug concentration. Pharmacokinetic parameters for each group were estimated using a three-compartment model. The electroencephalogram Bispectral Index Scale was used as a measure of drug effect. The pharmacodynamics were characterized using a sigmoid inhibitory maximal effect model. RESULTS: The raw data demonstrated higher plasma propofol levels in the shock group. The pharmacokinetic analysis revealed slower intercompartmental clearances in the shock group. Hemorrhagic shock shifted the concentration effect relationship to the left, demonstrating a 2.7-fold decrease in the effect site concentration required to achieve 50% of the maximal effect in the Bispectral Index Scale. CONCLUSIONS: Hemorrhagic shock altered the pharmacokinetics and pharmacodynamics of propofol. Changes in intercompartmental clearances and an increase in the potency of propofol suggest that less propofol would be required to achieve a desired drug effect during hemorrhagic shock.     

Assessment of volume of hemorrhage and outcome from pelvic fracture

HYPOTHESIS: Measurement of pelvic hemorrhage on computed tomographic (CT) scans can estimate the pelvic fracture component of total patient blood loss and predict the need for angiography. DESIGN: Retrospective cohort study. SETTING: Large level 1 trauma center. PATIENTS: We examined data from 759 consecutive, nonreferral blunt trauma patients who sustained pelvic fracture. MAIN OUTCOME MEASURES: Pelvic-fracture-specific outcomes included estimation of extraperitoneal pelvic hemorrhage volume from emergency department CT scans and determination of arterial injury from angiograms. General patient outcomes determined from medical record review included transfusion requirement, estimated blood loss, and mortality. Subanalysis was performed on subjects with only pelvic fracture as a source of major hemorrhage (derived from discharge International Classification of Diseases, Ninth Revision, Clinical Modification codes). RESULTS: Overall mortality was 96 (13%) of 759 patients. Blood transfusion was given to 418 (55%) patients, and 258 (34%) received 6 or more units in the first 72 hours. Pelvic-fracture-related hemorrhage averaged 149 mL (range, 0-1423 mL). Angiography was performed on 163 patients, of whom 113 had arterial injury. Higher pelvic hemorrhage volumes on CT scans were seen in subjects with pelvic arterial injury demonstrated on angiograms (P<.001). In subjects without another source of major hemorrhage, pelvic CT hemorrhage volumes were strongly associated with transfusion requirement (P<.001). Subjects with large pelvic hemorrhage volumes (>500 mL) were more likely to have pelvic arterial injury (risk ratio, 4.8; 95% confidence interval, 3.0-7.8; P<.001) and require large-volume (>/=6 U) transfusions (risk ratio, 4.7; 95% confidence interval, 1.8-12.3; P<.001) than patients with smaller pelvic hemorrhage volumes. CONCLUSION: Pelvic hemorrhage volumes derived from pelvic CT scans were predictors of the need for pelvic arteriography and transfusions.     

Informed consent: information or knowledge?

A fiduciary relationship should be nurtured between patient and physician. This requires effective communication throughout all aspects of care - especially pertaining to treatment decisions. In the context of illness as experienced by the patient a unique set of circumstances is presented. However, communication in an illness context is fraught with problems. The patient is vulnerable and the situation may be overwhelming. Voluminous amounts of information are available to patients from a host of health care providers, family members, support groups, advocacy centers, books, journals, and the internet. Often conflicting and confusion, frequently complex, this information may be of greater burden than benefit. Some information is of high validity and reliability while other information is of dubious reliability. The emotional freight of bad news may further inhibit understanding. An overload of information may pose an obstacle in decision-making. To facilitate the transformation of information into knowledge, the health care provider must act on some occasions as a filter, on other occasions as a conduit, and on still other occasions simply as a reservoir. The evolution of patient rights to receive or refuse treatment, the right to know or not to know calls for a change in processing of overwhelming information in our modem era. In this paper we will discuss the difference between information and knowledge. How can health care providers ensure they have given their patients all necessary and sufficient information to make an autonomous decision? How can they facilitate the transformation of information into knowledge? The effect of knowledge to consent allows a more focused, relevant and modern approach to choice in health care.     

2003 AUR Joseph E. And Nancy O. Whitley Award. Developing tomorrow's academic radiologists: a 3-month residency elective in education

RATIONALE AND OBJECTIVES: The shortage of academic radiologists reveals an urgent need to attract more residents into academic careers. A great deal of attention has been focused on research, but few programmatic initiatives have addressed the development of the next generation of radiology educators. The purpose of this study was to develop and test a new 3-month residency elective in education. MATERIALS AND METHODS: A large academic radiology department developed a 3-month education elective, during which two residents would be relieved of clinical duties and focus full-time on tasks related to their development as educators, including the completion of a major educational project. RESULTS: Two residents, in their 3rd year and 4th year of residency, respectively, proposed to collaborate in developing a Web-delivered tutorial for the department's senior medical student clerkship. At the end of 3 months, their radiology tutorial was introduced. In its 1st month, it received a mean rating of 4.3 on a five-point scale. The residents stated that the elective had enabled them to develop important skills in instructional technology, put into practice their enhanced understanding of learning psychology, and substantially strengthened their overall commitment to academic careers. CONCLUSION: It is vital that residency programs focus on developing the next generation of radiology educators. This ongoing education elective represents one successful model.     

Primary localized amyloidosis of the urinary bladder

We report a rare case of localized form of primary amyloidosis (amyloidoma) of the urinary bladder with CT and MR findings. Clinically, it is difficult to distinguish from invasive transitional cell carcinoma and inflammatory lesion. We think that the MR intensity on T2-weighted images is helpful in making the diagnosis.     

Transjugular liver biopsy effecting changes in clinical management

Although transjugular liver biopsies are frequently performed in patients with impaired blood coagulation, their impact on effecting changes in clinical management has not been assessed. We reviewed our experience with 43 consecutive transjugular liver biopsies performed over 3 years (1998-2000) at Westmead Hospital, Sydney, Australia. The technical success, procedural complication rates and subsequent management of these patients were ascertained from the medical case records. Forty-two (28 men) patients were studied. The indications for liver biopsy were as follows: assessment of hepatitis/cirrhosis status (n = 21), evaluation of liver dysfunction following bone marrow transplantation (n = 19) and miscellaneous (n = 2). All liver biopsies were performed with a Cook 20-G transjugular cutting needle device. Adequate histological samples were obtained in 42 (98%) of the 43 biopsies performed. The pre-biopsy diagnoses were confirmed by histology in 28 cases (65%). A change in clinical diagnosis was observed in 12 (28%) patients, and there were changes to subsequent management in all 12 patients. Four patients developed procedural complications, including small neck haematomas in two patients and a self-limiting biliary fistula in one. The only major complication was an extracapsular bleed from a hepatic laceration. This patient required emergency surgery but recovered. Transjugular liver biopsies can be effectively and safely performed in high-risk patients with impaired coagulation. They aid accurate histological appraisal of liver dysfunction in these patients and influence clinical decision-making.