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PubMed1993

Public opinion regarding consent to treatment.

OBJECTIVE: To examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy. DESIGN: Cross-sectional random-digit-dialing telephonic survey. SETTING: General public. PARTICIPANTS: One thousand randomly-selected adults living in Ontario. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Self-reported attitudes and behaviors. RESULTS: Of 5,708 telephone numbers drawn, 641 were non-valid or non-residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would went their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life-saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling. CONCLUSIONS: These data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent-related issues including disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.

Adult↗

PubMed2007

Patient dose from 3D rotational neurovascular studies.

The use of image-guided interventional radiological techniques is increasing in prevalence and complexity. Imaging system developments have helped improve the information available to interventionalists to plan and guide procedures. Information on doses to patients resulting from alternative imaging techniques or protocols is useful for both the process of justifying particular procedures and in optimizing the resultant exposures. Such information is not always available, especially for new or developing imaging techniques. We have undertaken a study of doses to patients associated with two alternative imaging methods for pre-intervention assessment of intracranial aneurysms. In the first technique the aneurysm is assessed from a series of digital subtraction angiography (DSA) runs taken at different imaging projections. The second technique involved acquiring images from one single image run while the imaging system rotated 180 degrees around the patient's head. In this technique, the aneurysm was then evaluated from a 3D reconstruction of the projection images. Effective doses were calculated using a computer model to simulate the exposure geometry and parameters. The mean dose from the DSA protocol used at our centre was 3.4 mSv and from the 3D rotational angiography (RA) technique was 0.20 mSv.

Angiography, Digital Subtraction↗

PubMedDate not supplied

Effectiveness of directional microphones and noise reduction schemes in hearing aids: a systematic review of the evidence.

A systematic review of the literature was undertaken to find evidence of real-world effectiveness of directional microphone and digital noise reduction features in current hearing aids. The evidence was drawn from randomized controlled trials, nonrandomized intervention studies, and descriptive studies. The quality of each study was evaluated for factors such as blinding, power of statistical analyses, and use of psychometrically strong outcome measures. Weaknesses in the identified studies included small sample size, resultant poor power to detect potentially worthwhile differences, and overlapping experimental conditions. Nine studies were identified for directional microphones, and the evidence (albeit weak) supports effectiveness. Two studies were identified for the noise reduction feature, and the evidence was equivocal. For the researcher, such a systematic review should encourage the careful consideration of appropriate methodologies for assessing feature effectiveness. For the clinician, the outcomes reported herein should encourage use of such a systematic review to drive clinical practice.

Amplifiers, Electronic↗

PubMedDate not supplied

[Aspiration biopsy of thoracic lesions using the Chiba needle under CT guidance].

Percutaneous transthoracic aspiration biopsy (PTAB) is an interventional radiologic procedure for histologic confirmation or elimination of malignant nature of the lesion. The development of digital techniques (introduction of CT and US) and small gauge needles increased the interest for this method. CT scanner enables the accurate determination of the entry point of the puncture guide, precise visualisation of the needle tip and reliable analyses of complications. The type of the puncture needle is very important for establishment of the correct diagnosis. Of 163 Chiba needle punctures the cytologically representative samples were obtained in 84.7% and pathohistologically representative samples in 56%. Of complications the most common was pneumothorax found in 9.7% and alveolar hemorrhage in 9.1% cases. In this paper the method and contribution of the Chiba needles are analysed compared to the results of other authors obtained by other types of needles. Our results are satisfying with small number of complications.

Adolescent↗

PubMed1989

[Surgical treatment possibilities in cerebrovascular insufficiency--status and future prospects].

After a short synopsis of the at present ascertained knowledge of the anatomy and pathophysiology of the cerebral blood supply the possibilities of the vascular-surgical treatment are discussed. The desobliteration of extracranial vessels, PTA, vascular resections and appliances of bypass are no concurrent operation techniques, but such ones which are individually to be adapted. The importance of the clinical and non-invasive diagnostics is put before the digital subtraction angiography and the direct angiography. On the basis of the experience of 461 own surgical interventions the stage-conditioned diagnosis is required. Stage II of the transitory ischaemic attack is preferred. In unilocular mediastenoses the extra-intracranial anastomosis now as ever hat its qualification.

Brain Ischemia↗

PubMed1998

The brave new world of quantum health care: some thoughts on the anatomy and physiology of a medical entity and the culture in which it is immersed. Part I.

In the absence of government intervention, the marketplace has taken over control of the health care sector in response to double-digit cost inflation. In the process, physician autonomy has waned. Health decisions are often made by corporate administrators; secretly hidden, less trained health personnel, and rigid protocols. Physician response as a profession has included dismay, anxiety, and depression. To return health care decisions back to physicians and to enhance the doctor/patient relationship, two suggestions are made. The first is the development of a task-oriented structure, energized by an implementation mechanism and information technology. This will allow for state-of-the-art, effective use of resources with care then judged by service, not by cost or access. The second is an introspective assessment of the physician's own personal psyche and the mission of the Profession. Redefining the mission and the motives behind it will allow the physician to "heal thyself" and move on to better and more satisfying patient care. The social contract with the Profession will then likely be reaffirmed, reestablished, and strengthened.

Delivery of Health Care↗

PubMed1998

[Angioplasty in the stenosed hemodialysis shunt: experiences with 100 patients and 166 interventions].

PURPOSE: Failing dialysis fistulas are a severe complication for patients treated by chronic haemodialysis. This study was undertaken to evaluate the technical aspects of percutaneous transluminal angioplasty (PTA) of shunts and to report on our experience in 100 patients. PATIENTS AND METHODS: In a 4-year period a total of 166 PTA procedures was performed in 100 haemodialysis patients with stenosis and occlusion of Brescia Cimino shunts and PTFE grafts (polytetrafluoroethylene). Patency rates were retrospectively evaluated for type and location of lesions, patient age, sex and the success of PTA. RESULTS: Technical success was achieved in 97% (n = 161). Complications appeared in 11 cases (6.6%). Shunt occlusion or rupture of a vein is rare. The cumulative patency rate for primary PTA treatment was 55% at 6 months, 47% at 12 months and 32% at 24 months and for repeat PTA treatment 87% at 6 months, 80% at 12 months and 70% at 24 months. Residual stenosis and diabetes mellitus significantly reduced the patency rate. CONCLUSION: PTA is an ideal method for accomplishing recurrent fistula failure due to its cost effectiveness and minimally invasive procedure. Recurrent stenosis has been a major problem of PTA as also in equal measure with surgical intervention.

Adult↗

PubMed2006

Liver abscess associated with hepatic artery pseudoaneurysm with arteriovenous fistula: imaging and interventional management.

Hepatic artery pseudoaneurysm is an infrequently encountered entity that is usually seen secondary to trauma or surgical procedures. The clinical presentation is often due to complications such as massive intrahepatic or intraperitoneal bleeding as a result of rupture of the pseudoaneurysm into the biliary tree or peritoneal cavity, respectively. Hepatic artery pseudoaneurysm, associated with a liver abscess, has very rarely been described in the literature. We present the imaging features of a case of liver abscess associated with a hepatic artery pseudoaneurysm and complicated by rupture and formation of an arteriovenous fistula. The case was successfully managed by percutaneous endovascular embolization. The association between a hepatic artery pseudoaneurysm and a liver abscess must not be overlooked, bearing in mind the potentially fatal associated complications which can be averted or treated by timely intervention.

Aneurysm, False↗

PubMed2002

Complementary use of computed tomographic angiography in treatment planning for posterior fossa subarachnoid hemorrhage.

OBJECTIVE: The goal of this study was to determine whether the complementary use of computed tomographic angiographic (CTA) assessments would provide additional benefits in the evaluation and treatment of ruptured vertebrobasilar artery aneurysms. METHODS: In the past 4.5 years, 35 patients with an infratentorial dominant pattern of subarachnoid hemorrhage were complementarily examined with CTA scanning, after undergoing one or more three-dimensional rotational projection digital subtraction angiographic (DSA) studies. The results of these studies were interpreted by the treating neurosurgeon and an interventional radiologist, to examine the usefulness of the findings for the detection of aneurysms and to determine the grade of parent artery vascular filling and the optical definition of the aneurysm. This information provided additional benefits for case management. RESULTS: Thirty-three aneurysms were detected. For 10 patients, no aneurysm was identified in repeated examinations with the two methods. We detected only 16 of the 25 ruptured aneurysms (64%) on the first DSA scans and, even with repeated examinations, 6 aneurysms were not clearly identified with this technique. CTA scanning revealed the ruptured aneurysms in 25 cases and demonstrated increased vascular filling and improved optical definition of the aneurysms, compared with DSA scanning, in 12 cases (48%). The information obtained from the CTA scans allowed the selection of five patients for endovascular treatment and facilitated the surgical procedures in five cases. CONCLUSION: Complementary CTA examination of the vertebrobasilar complex provides a higher rate of aneurysm detection and improves the optical definition and anatomic projection of these aneurysms, compared with DSA scanning alone. This facilitates therapeutic decision-making (surgical versus endovascular procedures) and allows neurosurgeons to use more restricted surgical exposures.

Adult↗

PubMed1996

Interventional radiology for the non-surgical removal of sialoliths.

OBJECTIVES: To clarify the usefulness and limitations of interventional radiology for sialolithiasis. METHODS: Sixteen patients (5 with parotid and 11 with submandibular sialolithiasis) were treated with a stone retrieval catheter (Dormia basket) under fluoroscopy. Digital subtraction sialography (DSS) and direct digital dental imaging (RVG) were performed in addition for 11 of the cases (DSS for 7 and RVG for 4 cases). RESULTS: The sialolith was successfully removed in 10 cases. DSS and RVG were useful. Four cases failed because the stone was adherent to the ductal wall and two because the catheter could not reach the stone because of the ductal anatomy. CONCLUSION: Interventional radiology is less invasive than surgical treatment and is the recommended first choice for treatment in the majority of cases of sialolithiasis.

Adult↗

PubMed2005

Preparing African-American men in community primary care practices to decide whether or not to have prostate cancer screening.

BACKGROUND: This study was a randomized trial to test the impact of an informed decision-making intervention on prostate cancer screening use. METHODS: The study population included 242 African-American men from three primary care practices who were 40-69 years of age and had no history of prostate cancer. Participants completed a baseline survey questionnaire and were randomly assigned either to a Standard Intervention (SI) group (N=121) or an Enhanced Intervention (EI) group (N=121). An informational booklet was mailed to both groups. EI group men were also offered a screening decision education session. Two outcomes were considered: (1) complete screening (i.e., having a digital rectal exam (DRE) and prostate specific antigen (PSA) testing), and (2) complete or partial screening (i.e., having a PSA test with or without DRE). An endpoint chart audit was performed six months after initial intervention contact. The data were analyzed via exact logistic regression. RESULTS: Overall, screening use was low among study participants. EI group men had a screening frequency two times greater than that of SI group men, but the difference was not statistically significant: 8% vs. 4 % (OR = 1.94) fo rcomplete screening, and 19% vs. 10% (OR = 2.08) for complete or partial screening. Multivariable analyses showed that being in the EI group and primary care practice were significant predictors of complete or partial screening (OR = 3.9 and OR = 5.64, respectively). CONCLUSION: Prostate cancer screening use may be influenced by exposure to decision education and the influence of screening-related primary care practice factors.

Adult↗

PubMed2006

A heart failure self-management program for patients of all literacy levels: a randomized, controlled trial [ISRCTN11535170].

BACKGROUND: Self-management programs for patients with heart failure can reduce hospitalizations and mortality. However, no programs have analyzed their usefulness for patients with low literacy. We compared the efficacy of a heart failure self-management program designed for patients with low literacy versus usual care. METHODS: We performed a 12-month randomized controlled trial. From November 2001 to April 2003, we enrolled participants aged 30-80, who had heart failure and took furosemide. Intervention patients received education on self-care emphasizing daily weight measurement, diuretic dose self-adjustment, and symptom recognition and response. Picture-based educational materials, a digital scale, and scheduled telephone follow-up were provided to reinforce adherence. Control patients received a generic heart failure brochure and usual care. Primary outcomes were combined hospitalization or death, and heart failure-related quality of life. RESULTS: 123 patients (64 control, 59 intervention) participated; 41% had inadequate literacy. Patients in the intervention group had a lower rate of hospitalization or death (crude incidence rate ratio (IRR) = 0.69; CI 0.4, 1.2; adjusted IRR = 0.53; CI 0.32, 0.89). This difference was larger for patients with low literacy (IRR = 0.39; CI 0.16, 0.91) than for higher literacy (IRR = 0.56; CI 0.3, 1.04), but the interaction was not statistically significant. At 12 months, more patients in the intervention group reported monitoring weights daily (79% vs. 29%, p < 0.0001). After adjusting for baseline demographic and treatment differences, we found no difference in heart failure-related quality of life at 12 months (difference = -2; CI -5, +9). CONCLUSION: A primary care-based heart failure self-management program designed for patients with low literacy reduces the risk of hospitalizations or death.

Adult↗

PubMed2001

Cardiac catheterization laboratory imaging quality assurance program.

With the recent approval of the National Electrical Manufacturers Association (NEMA) standard for "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," comprehensive cardiac image assurance control programs are now possible. This standard was developed by a joint NEMA/Society for Cardiac Angiography and Interventions (SCA&I) working group of imaging manufacturers and cardiology society professionals over the past 4 years. This article details a cardiac catheterization laboratory image quality assurance and control program that includes the new standard along with current regulatory requirements for cardiac imaging. Because of the recent proliferation of digital imaging equipment, quality assurance for cardiac imaging fluoroscopy and digital imaging are critical. Included are the previous works recommended by the American College of Cardiology (ACC) and American Heart Association (AHA), Society for Cardiac Angiographers and Interventions (SCA&I), and authors of previous image quality subjects.

Cardiac Catheterization↗

PubMed2001

Noninvasive follow-up of GDC-treated saccular aneurysms by MR angiography.

The aim of this study was to determine sensitivity and specificity of magnetic resonance angiography (MRA) for the assessment of durable occlusion of intracranial aneurysms with Guglielmi detachable coils (GDC) and to point out the influence of MRA results in re-intervention strategies. Forty-five patients with 54 aneurysms that were previously treated by endovascular occlusion with GDC were selected for this study. All patients underwent digital subtraction angiography (DSA) and MRA examinations on the same day. The time-of-flight MRA studies were performed on a 1-T scanner. The MRA images were first read by radiologists who were not aware of the DSA results. In a second consensus reading by the neuroradiologists who had performed all interventional procedures of this series, the decision was made as to whether re-treatment was necessary. The distribution of aneurysm sizes, configurations and treatment results were sufficient for an unbiased evaluation. The first blinded evaluation revealed a sensitivity of 71% and a specificity of 95% for MRA assessment of aneurysm reperfusion. In the second consensus reading, the sensitivity increased to 92% and the specificity was 98%. The blinded reading indicates that MRA is a useful adjunct to DSA for the assessment of durable results after endovascular treatment of intracranial aneurysms. In the consensus reading it became obvious that sensitivity and specificity of MRA can be increased to 92 and 98%, respectively, if the results were evaluated by experienced neuroradiologists, including prior knowledge of all other examinations. We have already increased the follow-up intervals for DSA and use MRA intermittently, based on these results.

Adult↗

PubMedDate not supplied

Use of gadolinium-based angiography for renal artery stenting in a patient with renal insufficiency: A case report.

The number of percutaneous diagnostic and interventional procedures performed continues to increase. Despite the use of various methods to reduce the incidence of contrast-induced nephropathy, the development of renal failure remains a significant problem with iodinated-based contrast agents. Patients with a baseline renal insufficiency are at considerably higher risk of permanent renal deterioration following exposure to iodinated contrast. The authors report a successful case of percutaneous stenting of the renal artery using a gadolinium-based contrast agent in a high-risk patient with renal insufficiency.

Aged, 80 and over↗

PubMedDate not supplied

Changes in blood cholesterol awareness: final results from the South Carolina Cardiovascular Disease Prevention Project.

We examined changes in five indicators of blood cholesterol awareness in two comparable biracial communities in South Carolina. One community received three years of cholesterol education and intervention activities implemented by a state health department and the other served as a comparison. Cross-sectional, interviewer-administered, random digit-dialed telephone surveys of 11,070 adults 18 years and older were conducted in 1987, 1988, 1989, and 1991. Changes in community levels of knowledge, preventive behavior, risk awareness, and treatment were assessed and compared between the two communities with analysis of covariance techniques that adjusted for age, race, and sex. Significant increases in knowledge, behavior, and risk awareness were observed for most groups defined by race, sex, or age in both communities. Significant net intervention increases between 1987 and 1991 were seen for knowledge of good cholesterol level (+16.4%, P < .001); behavioral action of ever having blood cholesterol checked (+18.6%, P < .001); and knowledge of personal level of blood cholesterol (+16.0%, P < .01). These results suggest that a community-wide blood cholesterol screening and education program can be effective in increasing blood cholesterol knowledge, risk awareness, and preventive behavior, thus serving as part of a public health strategy to lower and treat high blood cholesterol levels in a community.

Adolescent↗

PubMed1996

[Central retinal vein occlusion after embolization for spontaneous carotid cavernous sinus fistula].

A patient with spontaneous carotid-cavernous sinus fistula, who developed central retinal vein occlusion (CRVO) after interventional surgery, was reported. A 78-year-old woman was admitted with symptoms of right abducens palsy and conjunctival injection. Digital subtraction angiography (DSA) revealed bilateral carotid cavernous sinus fistulas supplied by dural branches of the carotid arteries. After embolization of the feeding arteries and the right cavernous sinus using PVA and platinum coils respectively, her symptom improved gradually. Six months after the embolization, she was readmitted because of blurred vision and abducens palsy on the left side. Engorgements of the cavernous sinuses and draining veins, and the shunt flow of the fistula were much less on DSA than those seen previously, but ophthalmologic studies showed an impending central retinal vein occlusion (CRVO) in her left eye. Prognosis of CRVO is generally poor. We discussed the mechanism of CRVO occurring after interventional surgery for CCF and the tactics for preventing it, and early detection of its development.

Aged↗

PubMed2002

Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners.

OBJECTIVE: To explore the suitability of a screening based intervention for excessive alcohol use by describing the experiences of general practitioners who tried such an intervention in their everyday practice. DESIGN: Qualitative interviews with general practitioners who had participated in a pragmatic study of a combined programme of screening and a brief intervention for excessive alcohol use. Doctors were interviewed either individually or in focus groups. A computer based, descriptive, phenomenological method was used to directly analyse the digitally recorded interviews. SETTING AND PARTICIPANTS: 24 of 39 general practitioners in four Danish counties who volunteered to take part in the pragmatic study were interviewed. RESULTS: The doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on the screening and to ensure compliance with the intervention. Although the doctors considered the doctor-patient relationship robust enough to sustain targeting of alcohol use, they often failed to follow up on initial interventions, and some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues. The doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviour. The programme needed considerable resources, and it interrupted the natural course of consultations and was inflexible. The doctors could not recommend the screening and brief intervention programme, although they thought it important to counsel their patients on drinking. CONCLUSIONS: Screening for excessive alcohol use created more problems than it solved for the participating doctors. The results underline the value of carrying out pragmatic studies on the suitability of seemingly efficacious healthcare programmes.

Adult↗