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PubMed2005

Application, feasibility, and efficacy of a combined intravascular ultrasound and stent delivery system: results from a prospective multicenter trial.

BACKGROUND: Intravascular ultrasound (IVUS) is the reference method for in vivo assessment of vessel dimensions and coronary plaque composition, which can influence device selection as well as stent sizing. OBJECTIVES: The objective of this prospective multicenter-study was to test the application, safety, and feasibility of a new combined IVUS and stent delivery system. METHODS: A total of 32 patients with planned direct stent implantation under IVUS guidance were included in the study. Procedural as well as angiographical and IVUS characteristics of the stent implantation with the combined IVUS and stent delivery system were assessed and compared to a historical control cohort where IVUS-guided stenting was performed with a separate IVUS catheter. RESULTS: Direct stent placement was successfully performed in all patients and no malfunctions of the system were noted. A post-interventional IVUS assessment was possible in 27 (87%) of the 31 patients. The IVUS information led to a change in therapeutic strategy in 16 (50%) of the 32 patients. In the study group, both the procedural time and the amount of contrast dye were significantly lower than in the historical IVUS-guided stenting control group. A clinical 12-month follow-up revealed a 89% event-free survival and a target vessel revascularization rate of 7%. CONCLUSION: The use of a combined IVUS and stent delivery device is safe, easy to handle, and can provide helpful additional information to guide a percutaneous coronary interventions procedure. Beyond angiography, these informations had significant impact on the interventional strategy in these patients, which resulted in a low rate of major adverse cardiac events. The concept of combining IVUS information and a stent delivery system may be increasingly attractive with evolving imaging modalities like virtual histology or a combination with drug-eluting stents.

Aged↗

PubMed1995

Aortoiliac occlusive disease.

The effects of gender on patient selection and results of intervention for aortoiliac atherosclerotic occlusive disease have received little attention in published reports. Review of our experience with aortobifemoral, femorofemoral, and axillofemoral bypass identified consistently more isolated anatomic aortoiliac disease in women, but virtually indistinguishable levels of preoperative ischemia as measured by clinical and hemodynamic indices. The performance of each of these three methods of reconstruction did not appear to be affected by gender. Review of other investigators' experience with these techniques as well as unilateral aortofemoral bypass, iliofemoral bypass, and PTBA did not find any evidence of discrepant performance of these latter techniques in women and men. This is in contrast to the results with infrainguinal reconstruction, which in our hands appear to be inferior in women. Concerns that results of aortoiliac reconstruction would be inferior in women due to small arteries or other differences appear unfounded. Women may be less likely to receive a recommendation for intervention for nonlimb-threatening ischemia due to gender biases on the part of the patient, primary physician, or vascular specialist, just as they are clearly less likely to be considered for intervention for coronary artery atherosclerosis. Our observations suggest that these biases are unfounded when formulating recommendations for women with aortoiliac atherosclerotic occlusive disease.

Aortic Diseases↗

PubMed1998

The Fresno Asthma Project: a model intervention to control asthma in multiethnic, low-income, inner-city communities.

The Fresno Asthma Project targeted the entire low-income, inner-city, multiethnic population of Fresno, California. For 36 months following a 6-month planning phase, continuing education was provided to a high proportion of physicians, pharmacists, nurses/respiratory therapists, emergency medical technicians, school personnel, and allied health professionals involved in asthma care in Fresno, including virtually all those providing care/services to the target population. Small group patient education was made available and provided in age- and culturally appropriate formats to patients/families in clinics, hospitals, and schools. General and ethnic media and a Speakers Bureau were used to raise public awareness of asthma as a serious but controllable health problem. This community intervention model is particularly appropriate to multiethnic communities. It is relatively low cost (total direct costs were $140,000 per year), uses existing educational resources, and appears to have minimized counterproductive competition. Although morbidity and mortality trend data are not yet available to monitor program impact, penetration into the target community has been substantial: community physicians refer patients to asthma classes, asthma educator training is ongoing through the local American Lung Association chapter, hospitals and managed care systems serving low- income/MediCal patients offer asthma classes, and public schools and HeadStart are institutionalizing asthma awareness and self-management classes.

Adult↗

PubMed2002

Transcranial magnetic stimulation: new insights into representational cortical plasticity.

In the last decade, transcranial magnetic stimulation (TMS) has been used increasingly as a tool to explore the mechanisms and consequences of cortical plasticity in the intact human cortex. Because the spatial accuracy of the technique is limited, we refer to this as plasticity at a regional level. Currently, TMS is used to explore regional reorganization in three different ways. First, it can map changes in the pattern of connectivity within and between different cortical areas or their spinal projections. Important examples of this approach can be found in the work on motor cortex representations following a variety of interventions such as immobilization, skill acquisition, or stroke. Second, TMS can be used to investigate the behavioural relevance of these changes. By applying TMS in its "virtual lesion" mode, it is possible to interfere with cortical function and ask whether plastic reorganization within a distinct cortical area improves function. Third, TMS can be used to promote changes in cortical function. This is achieved by using repetitive TMS (rTMS) to induce short-term functional reorganization in the human cortex. The magnitude and the direction of rTMS-induced plasticity depend on extrinsic factors (i.e. the variables of stimulation such as intensity, frequency, and total number of stimuli) and intrinsic factors (i.e. the functional state of the cortex targeted by rTMS). Since conditioning effects of rTMS are not limited to the stimulated cortex but give rise to functional changes in interconnected cortical areas, rTMS is a suitable tool to investigate plasticity within a distributed functional network. Indeed, the lasting effects of rTMS offer new possibilities to study dynamic aspects of the pathophysiology of a variety of diseases and may have therapeutic potential in some neuropsychiatric disorders.

Animals↗

PubMed2000

Computers in radiology. The sedation, analgesia, and contrast media computerized simulator: a new approach to train and evaluate radiologists' responses to critical incidents.

BACKGROUND: Awareness and preparedness to handle sedation, analgesia, and contrast-media complications are key in the daily radiology practice. OBJECTIVE: The purpose is to create a computerized simulator (PC-Windows-based) that uses a graphical interface to reproduce critical incidents in pediatric and adult patients undergoing a wide spectrum of radiologic sedation, analgesia and contrast media complications. MATERIALS AND METHODS: The computerized simulator has a comprehensive set of physiologic and pharmacologic models that predict patient response to management of sedation, analgesia, and contrast-media complications. Photorealistic images, real-time monitors, and mouse-driven information demonstrate in a virtual-reality fashion the behavior of the patient in crisis. RESULTS: Thirteen pediatric and adult radiology scenarios are illustrated encompassing areas such as pediatric radiology, neuroradiology, interventional radiology, and body imaging. The multiple case scenarios evaluate randomly the diagnostic and management performance of the radiologist in critical incidents such as oversedation, anaphylaxis, aspiration, airway obstruction, apnea, agitation, bronchospasm, hypotension, hypertension, cardiac arrest, bradycardia, tachycardia, and myocardial ischemia. The user must control the airway, breathing and circulation, and administer medications in a timely manner to save the simulated patient. On-line help is available in the program to suggest diagnostic and treatment steps to save the patient, and provide information about the medications. A printout of the case management can be obtained for evaluation or educational purposes. CONCLUSION: The interactive computerized simulator is a new approach to train and evaluate radiologists' responses to critical incidents encountered during radiologic sedation, analgesia, and contrast-media administration.

Adult↗

PubMed1985

S-adenosylmethionine decarboxylase as target of chemotherapy.

Although ornithine decarboxylase under most conditions is the rate-controlling enzyme of polyamine biosynthesis and thus the most logical target for chemical intervention, the inhibition of the enzyme triggers a series of compensatory reactions all aimed to circumvent the inhibition. These include secondary induction of adenosylmethionine decarboxylase, enhanced accumulation of extracellular polyamines and an overproduction of ornithine decarboxylase resulting from enhanced expression and gene amplification. Thus chemotherapy based on an intervention of polyamine formation has also to be directed to reactions other than the decarboxylation of ornithine. Adenosylmethionine decarboxylase is the second natural target for chemotherapy. Virtually all effective inhibitors of this enzyme are members of the family of bis(guanylhydrazones). Small modifications, such as increased hydrophobicity at the glyoxal portion of the parent compound glyoxal bis(guanylhydrazone), greatly enhance the inhibition of adenosylmethionine decarboxylase and diminish the undesirable inhibition of diamine oxidase. However, although ethylglyoxal and propylglyoxal bis(guanylhydrazone) appear to utilize the putative polyamine carrier for their cellular entry, their cellular accumulation, in contrast to that of glyoxal and methylglyoxal bis(guanylhydrazone), is not stimulated by putrescine and spermidine deprivation produced by inhibitors of ornithine decarboxylase. It is obvious that the cellular accumulation of each of the bis(guanylhydrazones) is determined by their different efflux rates: GBG and MGBG are effectively retained whereas EGBG is rapidly excreted by the tumor cells. GBG and MGBG, but possibly not EGBG, behave as mitochondrial poisons and rapidly produce extensive morphological damage of the mitochondria. The bis(guanylhydrazones) likewise inhibit carnitine-dependent mitochondrial oxidation of long-chain fatty acids, competitively in respect to carnitine. It is possible that this inhibition has something to do with the mitochondrial damage, as carnitine protects tumor cells from the early mitochondrial damage produced by MGBG. Carnitine also protects experimental animals from MGBG-induced acute toxicity and death.

Adenosylmethionine Decarboxylase↗

PubMed2006

A preliminary report on the use of virtual reality technology to elicit craving and cue reactivity in cocaine dependent individuals.

In the present feasibility study, we developed a 3-dimensional virtual "crack" cocaine environment and evaluated the environment's ability to elicit subjective craving and cue reactivity (i.e., subjective emotional responding, heart rate and skin conductance) in 11 crack cocaine dependent individuals. Each of the seven 3-D crack cocaine scenes in the cocaine environment depicted actors engaging in a range of using-related behaviors (i.e., smoking crack) whereas the neutral environment contained scenes depicted 3-D aquariums with active aquatic life (baseline measures were obtained following immersion in the neutral environment). Results indicated that craving was significantly elevated during the cocaine-related scenes as compared to baseline. Craving varied by scene content, with scenes depicting active cocaine use eliciting the highest levels of craving. Heart rate was significantly higher in four of the scenes with drug use content and positive affect (i.e., happiness) ratings were significantly lower during cocaine scenes as compared to baseline. Overall, the results suggest that a standardized and stimulus rich virtual reality environment effectively elicits craving and physiologic reactivity. Such technology has potential utility in the development and refinement of exposure-based behavioral and pharmacological interventions for substance use disorders.

Adult↗

PubMed2000

Evaluating health promotion: a tale of three errors.

The main purpose of this article is to question the relevance of the Randomised Controlled Trial for the evaluation of health promotion programmes. In its concern to manage Type 1 error, the RCT underestimates or virtually ignores Type 2 and 3 errors. Because of the peculiar complexities of health promotion programmes and the importance of gaining insights into the effect of interventions--rather than merely recording whether or not they achieve their goals--a new kind of validity is needed. The central assertion here is that we should adopt a principle of "judicial review" which is based on a broad spectrum of triangulated evidence.

Bias↗

PubMed2000

Bleak and hopeless no more. Engagement Of reluctant substance-abusing runaway youth and their families.

Runaway/homeless shelters document high levels of substance abuse among runaway youth, at least double that of school youth. These youth present a constellation of problems and research suggests that this population may be unique in the range and intensity of associated problems. Most studies to date have collected self-report data on these youth; virtually no research has examined treatment effectiveness with the population. Given the void of treatment outcome research with these youths, there is need for identifying potent interventions. Given that issues of engagement and retention must assume prominence in the development of new treatments, this article presents a family-based treatment engagement strategy successfully employed with a sample of substance-abusing youth staying in a southwestern shelter. Youth and primary caretakers are engaged separately by the therapist utilizing motivating factors appropriate to context of the families' lives and to the developmental position of the client.

Adolescent↗

PubMed2001

Bilevel anesthesia and blunt dissection: rapid and safe surgery.

BACKGROUND: A new concept of bilevel anesthesia, initially instilling a subcutaneous tumescent solution followed by surface anesthesia, and then dissection limited to blunt instrumentation has been developed. OBJECTIVE: The purpose of these developments has been to evolve more rapid and safe surgical intervention. METHODS: This work has included a wide variety of surgeries on patients over several years, including grafts, flaps, and hair transplantation. RESULTS: Excellent anesthesia with virtually bloodless surgical fields has followed the adoption of bilevel anesthesia with blunt dissection practices. CONCLUSION: Adoption of the previously described tumescent anesthetic infiltration with blunt dissection principles combined now with stronger epidermal-dermal anesthetic and epinephrine solutions allows the safest and most rapid surgery described to date.

Anesthesia, Local↗

PubMed2003

Threats to "informed" advance directives for the severely physically challenged?

The neuromuscular diseases, such as infantile spinal muscular atrophy, Duchenne's muscular dystrophy, and amyotrophic lateral sclerosis, are widely considered to be terminal illnesses. However, as with many neuromuscular and neurologic diseases, morbidity and mortality are caused by dysfunction of inspiratory, expiratory, and bulbar musculature. This article will discuss how inspiratory and expiratory musculature can be supported by simple, noninvasive means that are rarely considered when, as with the general population, individuals with disabilities are counseled about advance directives. Failure to use noninvasive aids almost invariably results in respiratory failure, intubation, and tracheostomy or death. When noninvasive aids are available, invasive measures referred to in advance directives (eg, intubation) are often needed only temporarily. Yet, ill-informed patients are often advised to refuse intubation and die or to be intubated and left to decide whether to undergo tracheostomy for long-term ventilatory support. Further, despite severe disability, ventilator users with neuromuscular disease report normal life satisfaction. Health care professionals, on the other hand, tend to ignore the patient's life satisfaction and consider quality of life measures not designed for the disabled to justify withholding life-saving interventions. Advance directives, although sometimes appropriate for patients with irretractable pain and advanced cancer, are inappropriate for patients with severe disability because of muscle weakness, and virtually no patients are appropriately counseled about all therapeutic options.

Advance Directives↗

PubMed2000

Co-occurrence of nutrition problems in Honduran children.

We used data from the 1996 Honduras National Micronutrient Survey to investigate the co-occurrence of vitamin A deficiency (VAD), anemia and stunting in a representative sample of Honduran children 1-5 y old. Observed frequencies of co-occurrence were compared with frequencies expected by chance in children 12-35.9 mo old (n = 633) and 36-59.9 mo old (n = 610) for the three possible two-way combinations of the problems and the three-way combination. Observed frequencies were greater than expected frequencies for all eight comparisons, and all comparisons except for that of stunting and anemia in younger children were significant. The observed frequency of the three-way co-occurrence was 8.4% compared with an expected co-occurrence of 8.1% in younger children (P: < 0.05) and 4.8% compared with 4.2%, respectively, in older children (P: < 0.001). Although there was statistical evidence for co-occurrence, differences between expected and observed prevalences were small for most comparisons. Our findings suggest that having one or two problems does not appreciably increase the probability of having another. The efficiency of nutrition interventions aimed at these conditions would not be improved by targeting children with any one of the conditions; rather, the three conditions should be treated as virtually independent when designing programs. Replication of this study in other settings is warranted.

Age Distribution↗

PubMed1999

An ergonomics program designed to reduce the incidence of upper extremity work related musculoskeletal disorders.

In 1992, the Johns Hopkins Hospital and University initiated a program aimed at the early diagnosis and treatment of potential upper extremity work related musculoskeletal disorders (UEWMSDs), ergonomic assessment and abatement of work areas where individuals with UEWMSDs are employed, as well as the identification and correction of areas throughout the hospital and university where UEWMSDs could possibly occur. The program resulted in an initial increase in the number and cost for the treatment of UEWMSDs. Subsequently, there was a significant decrease in the number of UEWMSDs reported and virtual elimination of the need to use surgical procedures to correct these conditions. This article suggests that a coordinated program of medical care, ergonomic assessment, and intervention can be efficacious in the primary, secondary, and tertiary prevention of UEWMSD.

Continuity of Patient Care↗

PubMed2004

The EAG tool: a decision support system for selection of abdominal aorta aneurysm endografts.

This article describes a decision support system (the EAG tool = Effective AAA Graftmanship) that assists the vascular surgeon in deciding whether a patient is fit for an endograft procedure and that assists the vascular surgeon in selecting the proper graft and in planning the endograft procedure. The EAG tool is the first step in the development of a learning environment for AAA procedures. As such the EAG tool is part of the VREST development project aiming to create a complete set of Virtual Reality Educational Surgical Tools. The EAG tool has been validated by using the expert knowledge of five experienced AAA physicians: three vascular surgeons and two interventional radiologists. In over 3,000 assessments, the EAG tool showed a false-positive rate of 0.2%, or in other words: in only 1 out of 500 cases the EAG tool indicated the possible use of an endograft, whereas the combined group of experts believed that it was not possibe. The EAG tool proved to be more prudent than the group of experts in having a false-negative rate of 3.7%. The EAG tool thus proved to be useful in daily clinical practice. Further developments are ongoing to use the EAG tool in a learning environment, specifically for unexperienced physicians.

Aortic Aneurysm, Abdominal↗

PubMed1993

Should physicians screen for depression in elderly medical inpatients?: Results of a decision analysis.

OBJECTIVE: We wish to determine whether or not elderly medical inpatients should be screened for depressive disorder using either 1) a self-rated depression scale (Geriatric Depression Scale), 2) "usual clinical assessment," or 3) neither, assuming that treatment with tricyclic antidepressants (TCAs) is the primary mode of intervention. METHOD: Based on recent data from epidemiological studies on the prevalence and course of depression, the test characteristics of available screening tests, and the efficacy and side-effects of traditional antidepressants, decision analysis is used to help decide whether or not clinicians should screen for depression in this setting. RESULTS: These calculations indicate that if screening is done solely to identify depressed patients for treatment with TCAs, then the highest utility lies in not screening; however, the difference in utilities between that decision and the decisions to either screen with GDS or screen by usual clinical assessment was only .04 units on a 0 to 100 scale, making the decision virtually a toss-up. Furthermore, even a small variation in one of several clinical factors or test characteristics could give screening a higher utility. In particular, if psychotherapy is considered as the primary intervention, then the utility of screening exceeds that of not screening. CONCLUSION: Characteristics of the screening test, clinical setting, types and safety of available treatments, each impact on the usefulness of screening and must be kept in mind when diagnosing and treating depressed medically ill elders hospitalized in acute care settings.

Aged↗

PubMed2001

Principles of computer-assisted arthroscopy of the temporomandibular joint with optoelectronic tracking technology.

PURPOSE: This preliminary clinical study evaluated the applicability, accuracy, and benefits of computer-assisted arthroscopy of the temporomandibular joint (TMJ) with optoelectronic tracking technology. MATERIALS AND METHODS: A hybrid of reality and virtual reality is built as a composite-reality environment by extracting 3-dimensional anatomical structures through use of computed tomography, magnetic resonance imaging, radiography, and other types of imaging procedures commonly used in clinical praxis. These various independent sources of imaging data of a particular patient can be combined with and complemented by complex graphic simulations. Intraoperatively they are merged with online position data of surgical instruments inside the patient's TMJ. This hybrid model of detailed anatomical structures, guidelines, and real-time instrument positions allows the surgeon to accurately plan the arthroscopic intervention as well as to navigate effectively intraoperatively. RESULTS: In the first 10 cases of computer-assisted TMJ arthroscopy, composite reality environment technology permitted the online visualization of TMJ structures, puncture sites, instrument positions, and virtual pathways in relation to anatomical landmarks with high spatial accuracy (minimum, 0.0 mm; maximum, 2.5 mm; mean, 1.4 mm; SD, 0.6 mm) and high temporal resolution (100 ms). Past, present, and possible future instrument positions can be displayed. The application of computer-assisted arthroscopy caused little immobility for either surgeon or patient. CONCLUSION: Even experienced surgeons profit from improved precision in the handling of the arthroscope; thus this technology was found to be particularly useful in degenerative temporomandibular disorders and for triangulation procedures.

Arthroscopes↗

PubMedDate not supplied

Virtual reality training for the operating room and cardiac catheterisation laboratory.

CONTEXT: High-profile cases of medical errors in the USA and UK, and major reports from organisations such as the US Institute of Medicine and UK Senate of Surgery, have sensitised the public and medical profession. Training is a key area that must be tackled to positively affect the problem of medical errors, especially in surgery and interventional cardiology. Despite the radically novel skills required for minimally invasive surgery or interventional cardiology, current training has gone largely unchanged. At the end of the 20th century, the public and the medical profession have concluded that training on patients is no longer acceptable. STARTING POINT: Recently, Teodor Grantcharov and colleagues (Br J Surg 2004; 91: 146-50) did a randomised double-blind trial which showed that training by virtual reality (VR) significantly reduces objectively assessed intraoperative errors in laparoscopic cholecystectomy. They used a low-fidelity VR simulator. Much more sophisticated VR simulators exist for endoscopy, gynaecology, laparoscopy, orthopaedics, otolaryngology, robotics, and urology. There are few studies on the efficacy of these simulators in improving the safety of procedures on patients. WHERE NEXT: There needs to be more large and multicentre studies. Technical skills training for procedural based medicine continues to be an ad-hoc mentor-based experience for the trainee, with experience gained by practising on patients. The skills required now are so difficult to learn that this type of training is no longer acceptable. VR-simulator-based training does work, but further empirical evidence is required to convince the more conservative members of the medical community.

Cardiac Catheterization↗

PubMed2005

Surgical education and Internet-based simulation: The World Virtual University.

The new means and modalities of communication and information technologies have significantly revolutionized access to surgical education. The introduction of the Internet information highway into mainstream clinical practice as an information sharing medium offers a wide range of opportunities to healthcare professionals. High-speed Internet broadcasting allows the display of high-quality full-screen videos. Access to surgical procedures through the Internet already plays a major role in continuing medical education nowadays and will undoubtedly be gaining grounds in the future. WebSurg.com, the World Virtual University, a web-based surgical university, is dedicated to minimally invasive laparoscopic surgery. Using brand-new multimedia data, the electronic university provides thorough descriptions of over 150 procedures in minimal access surgery and 265 videos of surgical interventions. Such a teaching tool recreates all the prerequisites and requirements of a traditional School of Medicine, incorporating the manifold standpoints of world-renowned experts about specific topics and hands-on hints in various surgical specialities. Following the evolution of technologies, recent advances have made it possible to display items of Websurg.com on handheld devices (personal data/digital assistance also known as PDAs, Pocket PCs, and smart phones). Integrating all these elements into a unique World Virtual University, Websurg.com epitomizes the concept of a unified academic center providing teaching and tutorials administered by international experts. The Internet assuredly contributes to the worldwide diffusion of scientific information in an easy and user-friendly way.

Journal Article↗