MR imaging of blood vessels using three-dimensional reconstruction: methodology

Multisection, dual-echo magnetic resonance (MR) transaxial images of blood vessels contain both anatomic and qualitative information about flow. Even so, the images are produced as a series of two-dimensional tomographic sections from which full visualization of connected structures is difficult. A computer algorithm was developed that automatically detects flowing blood based on pixel intensity and calculated T2 and provides reconstructed views of vessels while analyzing and displaying flow characteristics. Images of abdominal vessels, aortic aneurysms, and the heart were encoded by flow and color to demonstrate depth. In addition, these data were reconstructed to derive a more accurate assessment of patency. With this technique, transaxial images can be used to analyze flow patterns, determine patent areas, and visualize all levels of vessels in a single image.     

A prospective evaluation of treatment with Selective Internal Radiation Therapy (SIR-spheres) in patients with unresectable liver metastases from colorectal cancer previously treated with 5-FU based chemotherapy

Background  

To prospectively evaluate the efficacy and safety of selective internal radiation (SIR) spheres in patients with inoperable liver metastases from colorectal cancer who have failed 5FU based chemotherapy.     

Dermatologic Surgical Research and the Institutional Review Board

BACKGROUND: Dermatologic surgical techniques have transformed cosmetic surgery over the last two decades. Many of the advances in cutaneous laser surgery, botulinum toxin injections, tumescent liposuction, and the latest filler agents have been evaluated on willing volunteers as part of organized trials under the auspices of an Institutional Review Board (IRB). OBJECTIVES: To review the developmental history of today's IRB and to provide relevance to cosmetic dermatologic research. RESULTS: Although an IRB must evaluate the "voluntariness" of a proposed research protocol, the risk-benefit ratio, particularly of elective cosmetic dermatologic surgical human studies, is of even greater importance. CONCLUSION: As more dermatologic surgeons become involved in clinical research, an understanding of the function and purpose of the IRB has become increasingly important. Research relating to cosmetic dermatologic procedures raises challenging and perplexing problems for an IRB.     

Salvage of a difficult situation: method for conversion of failed endograft

Complications of endovascular aneurysm repair can be difficult to manage. One of the more difficult situations is conversion to open surgery because of a failed endograft. We describe a technique for conversion that allows the proximal attachment system to remain intact. It may also enable infrarenal clamping of the aorta during the operation. The anastomosis is performed by incorporating the proximal attachment system of the endograft. This technique simplifies both vascular control of the aorta and the necessary reconstruction during creation of the proximal anastomosis. We believe this technique has important advantages when conversion of a failed endograft is required.     

Treatment of abdominal aortic aneurysms

Three treatment options are available for an asymptomatic abdominal aortic aneurysm (AAA): an expectant approach with ultrasonographic check-ups, reconstruction of the abdominal aorta via the conventional ('open') approach and endovascular repair. For aneurysms less than 5.5 cm in diameter the annual rupture risk is less than 1%. For these patients a better alternative to the expectant approach does not seem to exist. The risk of rupture needs to be weighed up against the risks of a conventional operation. The operation mortality of patients with a non-ruptured AAA is about 7% while other serious complications occur in about 10%. The short to medium-term results of endovascular aneurysm repair are characterized by high reintervention rates, material fatigue and device failure. The three treatment options described are currently being investigated in several large-scale randomised studies for AAAs greater than 5.5 cm in diameter.     

Endovascular treatment of 4 patients with a traumatic rupture of the thoracic aorta

OBJECTIVE: To present our initial results with the endovascular treatment of traumatic rupture of the thoracic aorta. DESIGN: Retrospective. METHOD: Between April and October, 2002, 4 men between the ages of 22 and 46 were treated endovascularly for a traumatic rupture of the thoracic aorta. The diagnosis 'rupture of the thoracic aorta' was made on the basis of CT-angiography in all cases. In the first case, a thoracic Gore TAG-endoprosthesis (Gore & Associates; Den Bosch) was used, and in 3 cases a Talent-endoprosthesis (Medtronic AVG; Heerlen). RESULTS: There was an average of 2.5 days (limits: 0-5 days) between admission and the placement of the endoprosthesis. There was one intra-operative complication in the form of a dissection of the right femoral artery when the endoprosthesis was inserted. In 3 cases, the left subclavian artery was occluded by the prosthesis. This had no negative consequences for the patients during the follow-up period (limits: 4-12 months). The CT-angiogram taken 3 months after the operation consistently showed a good position of the endoprosthesis with no signs of leakage. CONCLUSION: For a limited follow-up period, the endovascular treatment of a traumatic rupture of the thoracic aorta has been shown to be safe and effective. The long term results must be awaited.     

Decision-making in follow-up after endovascular aneurysm repair based on diameter and volume measurements: a blinded comparison.

OBJECTIVE: to assess whether volume, in addition to diameter, measurements facilitate decision-making after endovascular aneurysm repair (EVAR). Material/Methods: patients (n = 82) with an immediately post-EVAR, and at least one follow-up (3-60 months), computed tomographic angiogram (CTA) were studied. The actual and all preceding proportional sac size changes were recorded. The resulting 347 diameter and 347 volume data were placed in random order and reviewed by three blinded observers who then recommended one of three treatment policies: "good/wait", "uncertain/intensify follow-up" or "not good/further diagnostics (Dx) or intervention (Rx)". The observers were instructed to consider changes of 10% relevant. One observer reviewed the graphs twice. RESULTS: the interobserver agreements (kappa) for the diameter were 0.92, 0.81 and 0.76 and for volumes 0.91, 0.88 and 0.86. The intra-observer agreement was 0.93 for both diameter and volume. Volume data resulted in significantly more "good/wait" decisions out to 36 months. Diameter data resulted in more "not good/Dx or Rx"-decisions out to 36 months (all p < 50.005). CONCLUSION: post-EVAR aneurysm sac volume data appears to provide earlier reassurance, reduce unnecessary interventions and to be more sensitive to secondary problems than diameter data alone.     

Considerations for implementing pre‐dispute arbitration agreements in provider contracts

Due in part to the historical increase in large compensatory awards and punitive damages in jury verdicts in medical malpractice/long‐term care cases and the concomitant increase in the costs of defending these claims, healthcare providers have sought to reduce litigation costs and avoid exposure to runaway jury verdicts in medical malpractice trials by implementing arbitration agreements in healthcare admission contracts. Risk managers should be aware of the evolving law in this area and recognize that a successful arbitration program requires a commitment to ensuring that the program is administered in accordance with evolving laws.     

Integrating disclosure,patient safety and risk management activities

National Quality Forum safe‐practice guidelines encourage hospitals to integrate disclosure, patient safety and risk management activities. Combining collaborative law with a patient safety program in a parallel process makes it possible to achieve this integration. This combination provides for physician‐led guidance in determining whether disclosure is required — and, if so, provides mentor assistance with actual disclosure. It offers proactive error prevention by offering a means to quickly utilize information to make safety changes. Additionally, the combination provides an opportunity to access collaborative law at a time when it is still possible to resolve issues without resort to litigation.