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PubMedDate not supplied

[Percutaneous treatment of hilar cholangiocarcinoma completed by high-dose rate brachytherapy. Experience in the first 5 cases].

Cholangiocarcinoma at the confluence of the hepatic ducts (Klatskin tumor) is a slowly growing malignancy with early onset of symptoms and poor outcome since surgery allows radical resection in only a minority of cases. Percutaneously placed biliary stents offer a good palliation, but tend to obstruct after 6-8 months; then, retreatment requires exchange of the endoprosthesis or establishment of a permanent external-internal biliary drainage which offers, in some patients, a relatively long survival. Percutaneous intraluminal HDR brachytherapy might be a valid alternative as a definitive therapy or as a method to keep metallic stents patent for a long time. Five patients with hilar cholangiocarcinoma, diagnosed by means of ultrasound, Computed Tomography, percutaneous transhepatic cholangiography and transluminal biopsy, underwent double percutaneous external-internal biliary drainage. Dummy sources were introduced into the drainage catheters to allow dose distribution planning. The stepwise progression of the miniaturized high activity Iridium source inside the applicators, introduced into the drainage catheters, was controlled and monitored by a computer equipped with dedicated software. In the radiotherapy bunker, using the remote loading technique, percutaneous intracavitary high dose rate brachytherapy was delivered at the rate of 750 cGy per fraction, prescribed at 1 cm from the center of the catheter, once a week, for 4 weeks. Nevertheless, only 4 of 5 patients underwent the complete treatment. In one case, radiation treatment was discontinued after the first session because of digestive bleeding from a duodenal ulcer, supposingly as a consequence of the decubitus of a catheter tip. CT demonstrated rapid progression of the disease with neoplastic spread to the omentum and gallbladder wall thickening; a gallbladder malignancy was then suspected and the patient was no more eligibile for brachytherapy. Subsequently, Carey-Coons endoprostheses were inserted to prevent post-actinic strictures and removed after three months. After completing radiation therapy, control cholangiograms demonstrated in all cases improvement of neoplastic strictures. The first two patients we treated show no signs of tumor recurrence at 4 and 1 months, respectively, after endoscopic removal of the stents. The third patient is still bearing 2 Carey-Coons endoprostheses to be removed after 3 months. The last patient with supposingly partial success of bracytherapy, was treated with two Strecker nitinol stents.

Aged↗

PubMed1998

The next-generation emergency department.

The greatest advances in medicine over the next two decades will result from application of the tools and principles of informatics to the problems of clinical medicine. New developments in medical informatics will drive advances in clinical care administration, research, and education. Information flow in the emergency department a decade hence will be characterized by a transformation from a "hunter-gatherer" information model to a "publisher-subscriber" model in which the right information will always be available at the right time. In large part, information will be gathered automatically rather than manually. Computers will be ubiquitous and almost invisible. Invasive and attached monitoring and testing will yield to new remote and noninvasive technologies. Information will be shared and modified as needed, rather than recreated and reentered by each caregiver. Eventually, the use of information technologies in the emergency medicine workplace will enhance our traditional role as hands-on providers of direct patient care.

Emergency Service, Hospital↗

PubMedDate not supplied

Nurse acceptance of a computerized arrhythmia monitoring system.

Implementation of a sophisticated computerized arrhythmia monitoring system in our institution initially met with negative attitudes from the critical care nurses in the ICCU and IMCU. This negative response can be attributed to several factors: (1) reliability of a computer monitoring system, (2) requirement of extensive education and training in the operational aspects of the system, and (3) time-consuming interface to the system. The nurses' responsibility to direct patient care did not allow enough time to properly adjust program parameters and react to the system. However, the comparative study performed by Zencka and colleagues overwhelmingly supported the effectiveness of the use of this system in the clinical setting. The introduction of the Arrhythmia Monitoring Technician obviated these problems. The technicians are responsible for the total operation of the monitoring system. Interface to the system occurs on two levels: (1) technician interface to the system by the adjustment of parameters and the verification of detected abnormalities and (2) technician interface to the nurses by notification of detected arrhythmias via remote transmission. In a recent survey, a majority of the nurses in the ICCU and IMCU indicated their positive support of the effectiveness of this computerized arrhythmia monitoring system. Critical care nurses in our institution consider computerized arrhythmia monitoring an essential component in the provision of quality patient care.

Allied Health Personnel↗

PubMed1999

Imaging adenoviral-mediated herpes virus thymidine kinase gene transfer and expression in vivo.

The feasibility of noninvasive imaging of adenoviral-mediated herpes virus type one thymidine kinase (HSV1-tk) gene transfer and expression was assessed in a well-studied animal model of metastatic colon carcinoma of the liver. Tumors were produced in syngeneic BALB/c mice by intrahepatic injection of colon carcinoma cells (MCA-26). Seven days later, three different doses (3 x 10(8), 1 x 10(8), and 3 x 10(7) plaque-forming units (pfu) of the recombinant adenoviral vector ADV. Rous sarcoma virus (RSV)-tk bearing the HSV1-tk gene were administered by intratumoral injection in separate groups of mice. Two control groups of tumor-bearing mice received intratumoral injections of the control adenoviral vector dl-312 or buffer alone, respectively. T2-weighted magnetic resonance (MR) images of mice were obtained before administering the virus and provided an anatomical reference of hepatic tumor localization. Eighteen h after the virus injection, one group of animals was given i.v. injections of 300 microCi of no-carrier-added 5-[131I]-2'-fluoro-1-beta-D-arabinofuranosyluracil (FIAU) and imaged 24 h later with a gamma camera. In some animals, the tumors were sampled and processed for histology and quantitative autoradiography (QAR). The gamma camera images demonstrated highly specific localization of [131I]FIAU-derived radioactivity to the area of ADV.RSV-tk-injected tumors in the liver, which was confirmed by coregistering the gamma camera and T2-weighted MR images. There was no accumulation of [131I]FIAU-derived radioactivity in tumors that were injected with the control vector or injection solution alone. A more precise distribution of radioactivity in the area of transfected tumor was obtained by histological and QAR comparisons. A heterogeneous pattern of radioactivity distribution in transfected tumors was observed. A punctate pattern of radioactivity distribution was observed in peritumoral liver tissue in animals given injections of 3 x 10(8) and 1 x 10(8) pfu of ADV.RSV-tk but not in animals given injections of 3 x 10(7) pfu nor in control animals. A QAR-microscopic comparison showed that the punctate areas of radioactivity colocalized with cholangial ducts. The level of [131I]FIAU-derived radioactivity accumulation (HSV1-tk expression) in the transfected tumors was viral dose-dependent. The viral dose-dependency of radioactivity accumulation was more pronounced in peritumoral liver, which was confirmed by reverse transcription-PCR analysis. A separate group of tumor-bearing animals received different doses of ADV.RSV-tk vector followed by treatment with ganciclovir (GCV), 10 mg/kg i.p. b.i.d. for 6 days. The ADV.RSV-tk transfected tumors significantly regressed with GCV treatment; the control tumors continued to grow. During the GCV treatment, the levels of liver transaminases (ALT and AST) were significantly increased in animals that received injections of 3 x 10(8) and 1 x 10(8) pfu of ADV.RSV-tk but not in animals that received injections of 3 x 10(7) pfu and in control animals. The observed liver toxicity confirms the results of gamma camera and QAR imaging, which demonstrated an unwanted spread of ADV.RSV-tk vector and HSV1-tk expression in peritumoral and remote liver tissue at higher doses. These and our previous results indicate that noninvasive imaging of adenoviral-mediated HSV1-tk gene expression is feasible for monitoring cancer gene therapy in patients.

Adenoviridae↗

PubMed1989

[Remote artificial respiration and anesthesia in nuclear magnetic resonance imaging].

Ferromagnetic equipment and equipment driven by alternate current cannot be used close to patients undergoing magnetic resonance imaging. Therefore, we tested a ventilator (Siemens Servo 900-D) that was placed more than 7 m away from the patient (outside the magnetic influence of 1.5 teslas) using tubing measuring 9 m in length. Tubing for children above the age of 8 and adults had a width of 22 mm; for neonates and children up to the age of 8 the width was 10 mm. Since the compressed air in such long tubes must be taken into consideration, we plotted nomograms for children and adults that helped to estimate respiratory minute volume including the compressed volume and a table to read the volume of compressed air that has to be added to respiratory volumes already established for ventilated patients from the ICU. In eight patients aged 7 weeks to 56 years (4 to 75 kg body wt.), capnography and blood gases showed that the nomograms were sufficiently accurate to allow safe ventilation. To improve safety, remote monitoring is recommended using long tubing or lines for oscillometric blood pressure measurement, capnography, and pulse oximetry as well as telemetric ECG.

Adult↗

PubMed1986

Implementation of an advanced clinical and administrative hospital information system.

Over the last six years since University Hospital opened, the University Hospital Information System (UHIS) has continued to evolve to what is today an advanced administrative and clinical information system. At University Hospital UHIS is the way of conducting business. A wide range of patient care applications are operational including Patient Registration, ADT for Inpatient/Outpatient/Emergency Room visits, Advanced Order Entry/Result Reporting, Medical Records, Lab Automated Data Acquisition/Quality Control, Pharmacy, Radiology, Dietary, Respiratory Therapy, ECG, EEG, Cardiology, Physical/Occupational Therapy and Nursing. These systems and numerous financial systems have been installed in a highly tuned, efficient computer system. All applications are real-time, on-line, and data base oriented. Each system is provided with multiple data security levels, forward file recovery, and dynamic transaction backout of in-flight tasks. Sensitive medical information is safeguarded by job function passwords, identification codes, need-to-know master screens and terminal keylocks. University Hospital has an IBM 3083 CPU with five 3380 disk drives, four dual density tape drives, and a 3705 network controller. The network of 300 terminals and 100 printers is connected to the computer center by an RF broadband cable. The software is configured around the IBM/MVS operating system using CICS as the telecommunication monitor, IMS as the data base management system and PCS/ADS as the application enabling tool. The most extensive clinical system added to UHIS is the Physiological Monitoring/Patient Data Management System with serves 92 critical care beds. In keeping with the Hospital's philosophy of integrated computing, the PMS/PDMS with its network of minicomputers was linked to the UHIS system. In a pilot program, remote access to UHIS through the IBM personal computer has been implemented in several physician offices in the local community, further extending the communications horizons of University Hospital's Information System. The implications of remote access to PDMS through the IBM PC emulating a Siemens Model 420 Patient Data Management Terminal are being examined.

Artificial Intelligence↗

PubMed2006

The RIONI study rationale and design: validation of the first stored electrograms transmitted via home monitoring in patients with implantable defibrillators.

Appropriate and inappropriate therapies of implantable cardioverter defibrillators (ICDs) have a major impact on morbidity and quality of life in ICD recipients. The recently introduced home monitoring of ICD devices is a promising new technique which remotely offers information about the status of the system. Stored intracardiac electrograms (IEGMs), which are essential for correct classification of appropriate and inappropriate ICD discharges, have until now not been available with ICD home monitoring on a day-by-day basis because of limitations of transferable data. We demonstrate the first compressed IEGMs daily transferable via home monitoring (IEGM-online). Validation of these electrograms will be performed in the Reliability of IEGM-Online Interpretation (RIONI) study. A total of 210 episodes of stored IEGMs will be collected by at least 12 European centres. The primary endpoint of this study is to investigate whether the IEGM-online based evaluation of the appropriateness of the ICDs therapeutic decision following episode detection is equivalent to the evaluation based on the complete ICD episode Holter extracted from the IEGM stored. The evaluation is independently done by an expert board of three experienced ICD investigators. The equivalence of the two methods is accepted if the evaluations yield a different conclusion for <10% of all evaluated IEGMs. The conclusion of the study is expected at the beginning of 2007. If RIONI successfully validates IEGMs transmitted via home monitoring, a strong basis for the use of this promising technique will be established.

Death, Sudden, Cardiac↗

PubMed1995

Robotics and automated workstations for rapid response testing.

Rapid-response testing can help the critical care physician provide more medically relevant decisions when treating critically ill patients. Many technologies have appeared on the market to help deliver rapid analytical tests, including transportation systems, hand-held analyzers, or clinical instruments that have simple user interfaces. Each of these methods can be used to provide the necessary medical information but often at the expense of turnaround time, quality of service, or cost. A robotically automated laboratory system was created that provides rapid turnaround time and low cost, and each result is monitored and reviewed by a laboratory professional. To provide the best quality laboratory services at the lowest cost, we created a remotely controlled robotic clinical laboratory that provides whole-blood analysis of blood gases (pCO2,pO2), pH, electrolytes (sodium, potassium, and chloride), glucose, and hemoglobin near the patient beside yet maintains the distinct advantage of central laboratory control. The automated remote laboratory provides extremely rapid turnaround time, eliminates the costly steps involved with specimen processing, reduces the risk from contaminated specimens, reduces staff training, ensures that every result is reviewed by a professional, and improves patient care.

Automation↗

PubMed2003

Influences on doctors' prescribing: is geographical remoteness a factor?

OBJECTIVE: To identify factors influencing the prescribing of medicines by general practitioners in rural and remote Australia. DESIGN: A qualitative study using a questionnaire to determine attitudes about prescribing, specific prescribing habits and comments on prescribing in 'rural practice'. SETTING: General practice in rural and remote Queensland. SUBJECTS: General practitioners practising in rural and remote settings in Queensland (n = 258). MAIN OUTCOME MEASURES: The factors perceived to influence the prescribing of medicines by medical practitioners in rural environments. RESULTS: A 58% response rate (n = 142) was achieved. Most respondents agreed that they prescribe differently in rural compared with city practice. The majority of respondents agreed that their prescribing was influenced by practice location, isolation of patient home location, limited diagnostic testing and increased drug monitoring. Location issues and other issues were more likely to be identified as 'influential' by the more isolated practitioners. Factors such as access to continuing medical education and specialists were confirmed as having an influence on prescribing. The prescribing of recently marketed drugs was more likely by doctors practising in less remote rural areas. CONCLUSION: Practising in rural and remote locations is perceived to have an effect on prescribing. These influences need to be considered when developing quality use of medicines policies and initiatives for these locations.

Adult↗

PubMed1979

Remote television viewing: an ultrasound teaching device.

Remote viewing of ultrasound scans facilitates assessment of a student's technique while minimizing anxiety for both him and the patient. This method may also be effective for the busy physician who must monitor several procedures at the same time.

Humans↗

PubMed1993

Long-term prediction of birth weight.

On the basis of the hypothesis that undisturbed individual growth in fetal life keeps a constant proportional difference with the standard population 50th percentile, birth weight can be predicted with a single sonographic exploration after the 16th week of pregnancy. Data on 135 singleton pregnancies with accurate dates and delivery at term were used. Sonography was performed between the 17th and 36th weeks of pregnancy, in every case at least 4 weeks before delivery. The observed measurements of BPD, FL, and AC were used for the prediction of their values on the day of delivery, applying the Hadlock equation for the estimation of birth weight. The mean error of birth weight predictions was -1 +/- 11% (SD), with a correlation coefficient between observed and predicted birth weights of 0.62 (P < 0.001). The accuracy was not influenced by the gestational age at the time of exploration. The model underpredicts birth weight of larger fetuses while overpredicting that of lighter ones, but a part of the error could be explained by a change in the growth pattern after modeling. Regardless of the classification considered (i.e., gestational age at sonography or birth weight), over 83% of predictions had an error below 15%. The underlying hypothesis could be useful clinically in modeling and monitoring fetal growth, allowing application of the results of remote sonographic explorations in clinical management. In addition, being able to project fetal weight to the 40th week also is valuable in improving the patient's understanding of fetal growth.

Birth Weight↗

PubMed2004

Morbidity and mortality related to anaesthesia outside the operating room.

PURPOSE OF REVIEW: The purpose of this review is to provide information related to morbidity and mortality associated with anaesthesia outside the operating room. RECENT FINDINGS: There is an increasing demand for anaesthesia at remote locations. Because of its specific characteristics, resulting from the location and the patient, morbidity and mortality rates of remote location anaesthesia could differ from conventional operating room anaesthesia. However, no studies are currently available. On the basis of morbidity and mortality data from conventional operating room anaesthesia, we reached some important conclusions with regard to the safety of anaesthesia outside the operating room. A well-equipped anaesthesia machine, standard monitoring (electrocardiogram, oxygen saturation and non-invasive blood pressure), trained personnel and adequate planning should be standard for all out of the operating room procedures. When all these are in place, the incidence of morbidity or mortality should be comparable to that of anaesthesia provided in the operating room. SUMMARY: There is certainly a need for studies concerning morbidity and mortality at remote location anaesthesia. Special care for the prevention of hypothermia should be given to those patients undergoing long-lasting diagnostic procedures, e.g. magnetic resonance imaging scans or cardiological investigations.

Journal Article↗

PubMed2001

Real time information from bedside monitors as part of a web-based patient record.

Traditional paper-based Medical Records, and even most of their digital counterparts, represent historical patient information. On the other hand new generations of Point-of-Care devices can be connected to standard networks and deliver streams of real time data through an Intranet, or even the Internet. Vital signs provided by IP-based devices can then be viewed at remote stations. Merging both worlds, real time and historical, in the pursuit of a comprehensive EPR is the main challenge of the present project. The basic infra-structure is composed of three main components: an existing Web-based EPR viewing station1 (Web-EPR); a fully integrated HIS/PACS system1; and a monitoring network (Siemens Infinity Network 2). Communication between the components was obtained by developing interfaces based on both HL7 and Siemens protocols the later only for waveforms. For the graphical display a web-browser-based application of the streamed signals was developed and integrated into the existing Web-EPR. This addition expanded the Web-EPR capabilities providing means to include real time signals and calculated parameters on the set of information already available. Some extra features of this project include: one-way SMS messaging of the parameters, interactive WAP access and a DICOM compliant storage of signal waveforms.

Computer Security↗

PubMed1988

[The staged rehabilitation of patients with complicated injury to the cervical spine].

The results of rehabilitation in 93 cases of complicated cervical vertebrae trauma are presented. The patients were divided into three groups depending on the remoteness of the trauma and the degree of actual neurological deficit. The necessary amount and stages of rehabilitation therapy are defined for each group. Electrophysiological monitoring (EMG, RVG) in the course of treatment and successive follow-up are strongly suggested.

Adolescent↗

PubMed1997

A noninvasive method for monitoring renal status at bedside.

RATIONALE AND OBJECTIVES: The authors demonstrate the feasibility of monitoring renal status continuously and noninvasively at a patient's bedside, avoiding both radioactivity and blood and urine samples. METHODS: Gadolinium-153-labeled ProHance and a glomerular filtration rate (GFR) standard technetium-99m-DTPA were coadministered to anesthetized normal and nephrectomized rats with their tails hanging in a PC 20 spin analyzer. Blood samples and T1 measurements were collected and analyzed. RESULTS: Log time plots of 153Gd, 99mTc (from blood samples) and T1 of the rat tails were all linear and parallel. Halftimes were 32 +/- 2, 32 +/- 6, and 32 +/- 6 minutes for the decay of the T1, 153Gd and 99mTc, respectively. The halftime of the nephrectomized animal was 2000 +/- 4000 minutes. CONCLUSIONS: T1 of an appendage remote from the kidneys reflects the concentration of gadolinium in the blood, which is in rapid equilibrium with tissue interstitial space gadolinium. The decay in T1 of the appendage reflects glomerular filtration. Thus, it is feasible to detect changes in renal status at a patient's bedside by monitoring T1 of a finger or wrist using a small, inexpensive magnet.

Animals↗

PubMed1999

Progress with the HeartSaver Ventricular Assist Device.

BACKGROUND: Ventricular assist devices (VADs) have been shown to be effective for short- or long-term circulatory support. Devices are either being adapted or newly designed for longer term or permanent support, with the goal to provide patients with improved quality of life. Since 1990, a program has been in place to develop a totally implantable, permanent VAD. METHODS: A multidisciplinary team is developing this VAD with specific goals in mind: (1) that it have an intrathoracic position, (2) that it be a totally implantable device without any percutaneous connections, and (3) that it be possible to communicate with the device from remote locations. These goals would allow for complete patient mobility and flexibility for follow-up. RESULTS: The electrohydraulically actuated VAD combines the blood pump, volume displacement chamber, energy converter, and internal electronic module into a single compact unit. The device called the HeartSaver VAD is powered by a transcutaneous energy transfer system and can be remotely monitored and controlled. Prototypes of different versions of the device have been tested in vitro and in vivo with satisfactory performance. CONCLUSIONS: The prototypes of the HeartSaver VAD have functioned well under test conditions and fulfilled the outlined goals. Further development and testing of the design are being conducted before clinical availability.

Animals↗

PubMed2004

Clinical utility of 11C-flumazenil positron emission tomography in intractable temporal lobe epilepsy.

BACKGROUND: 11C-flumazenil (FMZ) positron emission tomography (PET) is a new entrant into the armamentarium for pre-surgical evaluation of patients with intractable temporal lobe epilepsy (TLE). AIMS: To analyze the clinical utility of FMZ PET to detect lesional and remote cortical areas of abnormal benzodiazepine receptor binding in relation to magnetic resonance imaging (MRI), 2-Deoxy-2 [18F] fluoro-D-glucose, (18F FDG) PET, electrophysiological findings and semiology of epilepsy in patients with intractable TLE. MATERIALS AND METHODS: Patients underwent a high resolution MRI, prolonged Video-EEG monitoring before 18F FDG and 11C FMZ PET studies. Regional cortical FMZ PET abnormalities were defined on co-registered PET images using an objective method based on definition of areas of abnormal asymmetry (asymmetry index {AI}>10%). SETTINGS AND DESIGN: Prospective. STATISTICAL ANALYSIS: Student's "t" test. RESULTS: Twenty patients (Mean age: 35.2 years [20-51]; M:F=12:8) completed the study. Mean age at seizure onset was 10.3 years (birth-38 years); mean duration, 23.9 years (6-50 years). Concordance with the MRI lesion was seen in 10 patients (nine with hippocampal sclerosis and one with tuberous sclerosis). In the other 10, with either normal or ambiguous MRI findings, FMZ and FDG uptake were abnormal in all, concordant with the electrophysiological localization of the epileptic foci. Remote FMZ PET abnormalities (n=18) were associated with early age of seizure onset (P=0.005) and long duration of epilepsy (P=0.01). CONCLUSIONS: FMZ-binding asymmetry is a sensitive method to detect regions of epileptic foci in patients with intractable TLE.

Adult↗

PubMed1999

A web-based approach for electrocardiogram monitoring in the home.

A Web-based electrocardiogram (ECG) monitoring service in which a longitudinal clinical record is used for management of patients, is described. The Web application is used to collect clinical data from the patient's home. A database on the server acts as a central repository where this clinical information is stored. A Web browser provides access to the patient's records and ECG data. We discuss the technologies used to automate the retrieval and storage of clinical data from a patient database, and the recording and reviewing of clinical measurement data. On the client's Web browser, ActiveX controls embedded in the Web pages provide a link between the various components including the Web server, Web page, the specialised client side ECG review and acquisition software, and the local file system. The ActiveX controls also implement FTP functions to retrieve and submit clinical data to and from the server. An intelligent software agent on the server is activated whenever new ECG data is sent from the home. The agent compares historical data with newly acquired data. Using this method, an optimum patient care strategy can be evaluated, a summarised report along with reminders and suggestions for action is sent to the doctor and patient by email.

Data Collection↗