Contrast-enhanced 3-D MRA in decision making for carotid endarterectomy: a 6-year experience

BACKGROUND: Systematic need for angiography in diagnosis of carotid artery stenosis and indication of surgical therapy is still debated. Noninvasive imaging techniques such as MR angiography (MRA) or CT angiography (CTA) offer an alternative to digital subtraction angiography (DSA) and are increasingly used in clinical practice. In this study, we present the radiological characteristics and clinical results of a series of patients operated on the basis of combined ultrasonography (US)/MRA. METHODS: This observational study included all the patients consecutively operated for a carotid stenosis in our Department from October 1998 to December 2004. The applied MRA protocol had previously been established in a large correlation study with DSA. DSA was used only in case of discordance between US and MRA. The preoperative radiological information furnished by MRA was compared with intraoperative findings. The outcome of the operation was assessed according to ECST criteria. RESULTS: Among 327 patients, preoperative MRA was performed in 278 (85%), DSA in 44 (13.5%) and CT angiography in 5 (1.5%). Most of DSA studies were performed as emergency for preparation of endovascular therapy or for reasons other than carotid stenosis. Eleven additional DSA (3.3%) complemented US/MRA, mostly because diverging diagnosis of subocclusion of ICA. No direct morbidity or intraoperative difficulty was related to preoperative MRA. Combined mortality/major morbidity rate was 0.9% (3 patients) and minor morbidity rate 5.5% (18 patients). CONCLUSIONS: This observational study describes a well-established practice of carotid surgery and supports the exclusive use of non invasive diagnostic imaging for indicating and deciding the operation.

First clinical experience with anecortave acetate (Retaane)

BACKGROUND: Anecortave acetate is an angiostatic cortisene which is injected as a posterior juxtascleral depot and has been shown to be effective in the treatment of exudative age-related macular degeneration (AMD). The compound is not yet approved in Switzerland but can be used as "compassionate use" in individual cases. PATIENTS AND METHODS: An uncontrolled case series with standardised documentation of ETDRS visual acuity, near acuity, need for magnification and fluorescein angiography was performed. RESULTS: 22 eyes of 19 patients (8 male, 11 female, average age 78.8 years) were treated with a posterior juxtascleral depot injection (PJD) of 15 mg anecortave acetate. The mean change in visual acuity after 3 months in eyes treated with anecortave acetate was -2.6 ETDRS letters corresponding to 0.52 Snellen lines. 3/20 eyes gained more than 1 line. 11/20 eyes showed stable visual acuity (+/- 1 Snellen line, +/- 5 ETDRS letters). 5/20 eyes developed moderate vision loss (one to two Snellen lines, 6-10 ETDRS letters). 1/20 lost 18 ETDRS letters (> 3 Snellen lines). There were no moderate or severe adverse events. CONCLUSIONS: A PJD of 15 mg anecortave acetate is safe and well tolerated. In eyes with occult CNV without recent progression or with residual neovascular activity after photodynamic therapy anecortave acetate may be an alternative therapeutic option before considering intravitreal anti-VEGF agents due to the much less invasive character and lower risk profile.

Closing the gap between coil and balloon in the neurointerventional armamentarium? Initial clinical experience with a nitinol vascular occlusion plug

INTRODUCTION: The use of vascular plug devices for the occlusion of high-flow lesions is a relatively new and successful procedure in peripheral and cardiopulmonary interventions. We report on the use and efficiency of the Amplatzer vascular plug in a small clinical series and discuss its potential for occlusion of large vessels and high-flow lesions in neurointerventions. METHODS: Between 2005 and 2007 four patients (mean age 38.5 years, range 16-62 years) were treated with the device, in three patients to achieve parent artery occlusion of the internal carotid artery, in one patient to occlude a high-flow arteriovenous fistula of the neck. The application, time to occlusion, and angiographic and clinical results and the follow-up were evaluated. RESULTS: Navigation, positioning and detachment of the device were satisfactory in all cases. No flow-related migration of the plug was seen. The cessation of flow was delayed by a mean of 10.5 min after deployment of the first device. In the procedures involving vessel sacrifice, two devices had to be deployed to achieve total occlusion. No patient experienced new neurological deficits; the 3-month follow-up revealed stable results. CONCLUSION: The Amplatzer vascular plug can be adapted for the treatment of high-flow lesions and parent artery occlusions in the head and neck. In this small series the use of the devices was uncomplicated and safe. The rigid and large delivery device and the delayed cessation of flow currently limit the device's use in neurointerventions.

Effect of echo time pair selection on quantitative analysis for adrenal tumor characterization with in-phase and opposed-phase MR imaging: initial experience

PURPOSE: To determine the effect of two pairs of echo times (TEs) for in-phase (IP) and opposed-phase (OP) 3.0-T magnetic resonance (MR) imaging on (a) quantitative analysis prospectively in a phantom study and (b) diagnostic accuracy retrospectively in a clinical study of adrenal tumors, with use of various reference standards in the clinical study. MATERIALS AND METHODS: A fat-saline phantom was used to perform IP and OP 3.0-T MR imaging for various fat fractions. The institutional review board approved this HIPAA-compliant study, with waiver of informed consent. Single-breath-hold IP and OP 3.0-T MR images in 21 patients (14 women, seven men; mean age, 63 years) with 23 adrenal tumors (16 adenomas, six metastases, one adrenocortical carcinoma) were reviewed. The MR protocol involved two acquisition schemes: In scheme A, the first OP echo (approximately 1.5-msec TE) and the second IP echo (approximately 4.9-msec TE) were acquired. In scheme B, the first IP echo (approximately 2.4-msec TE) and the third OP echo (approximately 5.8-msec TE) were acquired. Quantitative analysis was performed, and analysis of variance was used to test for differences between adenomas and nonadenomas. RESULTS: In the phantom study, scheme B did not enable discrimination among voxels that had small amounts of fat. In the clinical study, no overlap in signal intensity (SI) index values between adenomas and nonadenomas was seen (P < .05) with scheme A. However, with scheme B, no overlap in the adrenal gland SI-to-liver SI ratio between adenomas and nonadenomas was seen (P < .05). With scheme B, no overlap in adrenal gland SI index-to-liver SI index ratio between adenomas and nonadenomas was seen (P < .05). CONCLUSION: This initial experience indicates SI index is the most reliable parameter for characterization of adrenal tumors with 3.0-T MR imaging when obtaining OP echo before IP echo. When acquiring IP echo before OP echo, however, nonadenomas can be mistaken as adenomas with use of the SI index value.

Simulation in training: one-year experience using an efficiency index to assess interventional radiology fellow training status

PURPOSE: To compare objective fellow and expert efficiency indices for an interventional radiology renal artery stenosis skill set with the use of a high-fidelity simulator. MATERIALS AND METHODS: The Mentice VIST simulator was used for three different renal artery stenosis simulations of varying difficulty, which were used to grade performance. Fellows' indices at three intervals throughout 1 year were compared to expert baseline performance. Seventy-four simulated procedures were performed, 63 of which were captured as audiovisual recordings. Three levels of fellow experience were analyzed: 1, 6, and 12 months of dedicated interventional radiology fellowship. The recordings were compiled on a computer workstation and analyzed. Distinct measurable events in the procedures were identified with task analysis, and data regarding efficiency were extracted. Total scores were calculated as the product of procedure time, fluoroscopy time, tools, and contrast agent volume. The lowest scores, which reflected efficient use of tools, radiation, and time, were considered to indicate proficiency. Subjective analysis of participants' procedural errors was not included in this analysis. RESULTS: Fellows' mean scores diminished from 1 month to 12 months (42,960 at 1 month, 18,726 at 6 months, and 9,636 at 12 months). The experts' mean score was 4,660. In addition, the range of variance in score diminished with increasing experience (from a range of 5,940-120,156 at 1 month to 2,436-85,272 at 6 months and 2,160-32,400 at 12 months). Expert scores ranged from 1,450 to 10,800. CONCLUSIONS: Objective efficiency indices for simulated procedures can demonstrate scores directly comparable to the level of clinical experience.

Establishing glycaemic control with continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes: experience of the PedPump Study in 17 countries

AIMS/HYPOTHESIS: To assess the use of paediatric continuous subcutaneous infusion (CSII) under real-life conditions by analysing data recorded for up to 90 days and relating them to outcome. METHODS: Pump programming data from patients aged 0-18 years treated with CSII in 30 centres from 16 European countries and Israel were recorded during routine clinical visits. HbA(1c) was measured centrally. RESULTS: A total of 1,041 patients (age: 11.8 +/- 4.2 years; diabetes duration: 6.0 +/- 3.6 years; average CSII duration: 2.0 +/- 1.3 years; HbA(1c): 8.0 +/- 1.3% [means +/- SD]) participated. Glycaemic control was better in preschool (n = 142; 7.5 +/- 0.9%) and pre-adolescent (6-11 years, n = 321; 7.7 +/- 1.0%) children than in adolescent patients (12-18 years, n = 578; 8.3 +/- 1.4%). There was a significant negative correlation between HbA(1c) and daily bolus number, but not between HbA(1c) and total daily insulin dose. The use of <6.7 daily boluses was a significant predictor of an HbA(1c) level >7.5%. The incidence of severe hypoglycaemia and ketoacidosis was 6.63 and 6.26 events per 100 patient-years, respectively. CONCLUSIONS/INTERPRETATION: This large paediatric survey of CSII shows that glycaemic targets can be frequently achieved, particularly in young children, and the incidence of acute complications is low. Adequate substitution of basal and prandial insulin is associated with a better HbA(1c).

Bloodstream infections in pediatric ECLS: usefulness of daily blood culture monitoring and predictive value of biological markers. The British Columbia experience

INTRODUCTION: The incidence of bloodstream infection (BSI) in extracorporeal life support (ECLS) is reported between 0.9 and 19.5%. In January 2006, the Extracorporeal Life Support Organization (ELSO) reported an overall incidence of 8.78% distributed as follows: respiratory: 6.5% (neonatal), 20.8% (pediatric); cardiac: 8.2% (neonatal) and 12.6% (pediatric). METHOD: At BC Children's Hospital (BCCH) daily surveillance blood cultures (BC) are performed and antibiotic prophylaxis is not routinely recommended. Positive BC (BC+) were reviewed, including resistance profiles, collection time of BC+, time to positivity and mortality. White blood cell count, absolute neutrophile count, immature/total ratio, platelet count, fibrinogen and lactate were analyzed 48, 24 and 0 h prior to BSI. A univariate linear regression analysis was performed. RESULTS: From 1999 to 2005, 89 patients underwent ECLS. After exclusion, 84 patients were reviewed. The attack rate was 22.6% (19 BSI) and 13.1% after exclusion of coagulase-negative staphylococci (n = 8). BSI patients were significantly longer on ECLS (157 h) compared to the no-BSI group (127 h, 95% CI: 106-148). Six BSI patients died on ECLS (35%; 4 congenital diaphragmatic hernias, 1 hypoplastic left heart syndrome and 1 after a tetralogy repair). BCCH survival on ECLS was 71 and 58% at discharge, which is comparable to previous reports. No patient died primarily because of BSI. No BSI predictor was identified, although lactate may show a decreasing trend before BSI (P = 0.102). CONCLUSION: Compared with ELSO, the studied BSI incidence was higher with a comparable mortality. We speculate that our BSI rate is explained by underreporting of "contaminants" in the literature, the use of broad-spectrum antibiotic prophylaxis and a higher yield with daily monitoring BC. We support daily surveillance blood cultures as an alternative to antibiotic prophylaxis in the management of patients on ECLS.

Invitational rhetoric : alternative rhetorical strategy for transformation of perception and use of energy in the residential built environment from the Keweenaw to Kerala

This dissertation explores the viability of invitational rhetoric as a mode of advocacy for sustainable energy use in the residential built environment. The theoretical foundations for this study join ecofeminist concepts and commitments with the conditions and resources of invitational rhetoric, developing in particular the rhetorical potency of the concepts of re-sourcement and enfoldment. The methodological approach is autoethnography using narrative reflection and journaling, both adapted to and developed within the autoethnographic project. Through narrative reflection, the author explores her lived experiences in advocating for energy-responsible residential construction in the Keweenaw Peninsula of Michigan. The analysis reveals the opportunities for cooperative, collaborative advocacy and the struggle against traditional conventions of persuasive advocacy, particularly the centrality of the rhetor. The author also conducted two field trips to India, primarily the state of Kerala. Drawing on autoethnographic journaling, the analysis highlights the importance of sensory relations in lived advocacy and the resonance of everyday Indian culture to invitational principles. Based on field research, the dissertation proposes autoethnography as a critical development in encouraging invitational rhetoric as an alternative mode of effecting change. The invitational force of autoethnography is evidenced in portraying the material advocacy of the built environment itself, specifically the sensual experience of material arrangements and ambience, as well as revealing the corporeality of advocacy, that is, the body as the site of invitational engagement, emotional encounter, and sensory experience. This study concludes that vulnerability of self in autoethnographic work and the vulnerability of rhetoric as invitational constitute the basis for transformation. The dissertation confirms the potential of an ecofeminist invitational advocacy conveyed autoethnographically for transforming perceptions and use of energy in a smaller-scale residential environment appropriate for culture, climate, and ultimately part of the challenge of sustaining life on this planet.

Pediatric cranio-facial surgery. First-year's experience with a gun applying bioabsorbable tacks

AIM: In 2001 a prototype of a gun to apply bioabsorbable tacks in cranio-facial surgery has been developed. METHODS: From May 2001 to May 2002 this device has been used in the University Hospital of Innsbruck (Austria) for different cranioplasty procedures, in 34 children, showing its reliability for cranio-facial bone fixation. The children were affected by isolated craniosynostosis or by syndromical synostosis (Apert, Crouzon) and in a case of benign tumor of the parietal skull vault. The range of age, at the time of surgery, was between 3 months and 204 months of age. Bone segments were fixed using self-reinforced polylactide plates and tacks. RESULTS: Firm fixation was obtained intra-operatively and the operative time was reduced about 25-30 minutes as compared to use of plates and screws. This device has just one limitation in its own spring force: sometimes the bone thinner than 1 mm has been broken applying the tacks. CONCLUSION: After the first-year's experience it is possible to confirm that this device reduces, in selected cases, operative time, blood loss, risk of infection and, as a result, the costs.

An Experience-Driven Pedagogy for the Instruction of Software Testing in Computer Science

In the realm of computer programming, the experience of writing a program is used to reinforce concepts and evaluate ability. This research uses three case studies to evaluate the introduction of testing through Kolb's Experiential Learning Model (ELM). We then analyze the impact of those testing experiences to determine methods for improving future courses. The first testing experience that students encounter are unit test reports in their early courses. This course demonstrates that automating and improving feedback can provide more ELM iterations. The JUnit Generation (JUG) tool also provided a positive experience for the instructor by reducing the overall workload. Later, undergraduate and graduate students have the opportunity to work together in a multi-role Human-Computer Interaction (HCI) course. The interactions use usability analysis techniques with graduate students as usability experts and undergraduate students as design engineers. Students get experience testing the user experience of their product prototypes using methods varying from heuristic analysis to user testing. From this course, we learned the importance of the instructors role in the ELM. As more roles were added to the HCI course, a desire arose to provide more complete, quality assured software. This inspired the addition of unit testing experiences to the course. However, we learned that significant preparations must be made to apply the ELM when students are resistant. The research presented through these courses was driven by the recognition of a need for testing in a Computer Science curriculum. Our understanding of the ELM suggests the need for student experience when being introduced to testing concepts. We learned that experiential learning, when appropriately implemented, can provide benefits to the Computer Science classroom. When examined together, these course-based research projects provided insight into building strong testing practices into a curriculum.

Technical advances improved outcome in patients undergoing surgery of the ascending aorta and/or aortic arch: ten years experience

BACKGROUND: Several technical advances in thoracic aortic surgery, such as the use of antegrade cerebral perfusion, avoidance of cross-clamping and the application of glue, have beneficially influenced postoperative outcome. The aim of the present study was to analyse the impact of these developments on outcome of patients undergoing surgery of the thoracic aorta. METHODS AND RESULTS: Between January 1996 and December 2005, 835 patients (37.6%) out of 2215 aortic patients underwent surgery on the thoracic ascending aorta or the aortic arch at our institution. All in-hospital data were assessed. Two hundred and forty-one patients (28.8%) suffered from acute type A dissection (AADA). Overall aortic caseload increased from 41 patients in 1996 to 141 in 2005 (+339%). The increase was more pronounced for thoracic aortic aneurysms (TAA) (+367.9%), than for acute type A aortic dissections (+276.9%). Especially in TAA, combined procedures increased and the amount of patients with impaired left ventricular function (EF <50%) raised up from 14% in 1996 to 24% in 2005. Average age remained stable. Logistic regression curve revealed a significant decrease in mortality (AADA) and in the overall incidence of neurological deficits. CONCLUSIONS: Technical advances in the field of thoracic aortic surgery lead to a decrease of mortality and morbidity, especially in the incidence of adverse neurological events, in a large collective of patients. Long-term outcome and quality of life are better, since antegrade cerebral perfusion has been introduced.

Meta-Environment and Executable Meta-Language using Smalltalk: an Experience Report

Object-oriented modelling languages such as EMOF are often used to specify domain specific meta-models. However, these modelling languages lack the ability to describe behavior or operational semantics. Several approaches have used a subset of Java mixed with OCL as executable meta-languages. In this experience report we show how we use Smalltalk as an executable meta-language in the context of the Moose reengineering environment. We present how we implemented EMOF and its behavioral aspects. Over the last decade we validated this approach through incrementally building a meta-described reengineering environment. Such an approach bridges the gap between a code-oriented view and a meta-model driven one. It avoids the creation of yet another language and reuses the infrastructure and run-time of the underlying implementation language. It offers an uniform way of letting developers focus on their tasks while at the same time allowing them to meta-describe their domain model. The advantage of our approach is that developers use the same tools and environment they use for their regular tasks. Still the approach is not Smalltalk specific but can be applied to language offering an introspective API such as Ruby, Python, CLOS, Java and C#.

Experience and attitudes towards CAM--a survey of internal and psychosomatic patients in a German university hospital

Complementary and alternative medicine (CAM) is popular in Germany. In a consecutive survey the experiences with CAM and the need for a CAM consultation among inpatients of the departments of cardiology (CL), gastroenterology (GE), oncology (OL) and psychosomatics (PS) of the University Hospital Freiburg (FUH) were questionned. Exclusion criteria were inability to understand the questions or a Karnofsky Index < 30%. Four hundred thirty-five patients were included. Three hundred and fifty patients, 100 each in the departments of CL, GE and OL, and 50 in PS answered the questionnaires. Eighty-five patients (20%) refused. Among the 350 patients 26% had previously visited a CAM physician and 19% had visited a CAM therapist (Heilpraktiker). Information about CAM was obtained mainly by television, radio and family members. Frequently used therapies for the current disease were physical training (21%), diet (19%), massage (19%), vitamins/trace elements (19%), herbs (13%), acupuncture (10%) and homeopathy (7%). The highest frequency of CAM use had PS patients, followed by GE, OL and CL patients. High effectivity (> or = 70%) for the current disease, rated on a scale of 4 degrees, had for CL patients physical exercise and massage, for GE patients herbal treatment and for OL patients diet. Physical exercise, diet, massage and herbal treatment generally had better ratings than homeopathy, acupuncture and vitamins. 65% would welcome a CAM center and 53% asked for a consultation about CAM at FUH. OL and GE patients had the strongest (58%), PS patients a lower (52%) and patients with cardiovascular diseases the lowest (43%) interest in a CAM consultation. Twenty-five percent believed, that CAM can help to cope better with their disease. Predictors for a positive attitude towards CAM were young age, aversion to chemical medications (Spearman correlation r = 0.22), desire to participate in therapeutic decisions (r = 0.29), motivation to change, if recommended, the life style (r = 0.31) and desire for a holistic treatment (r = 0.37).

The use of learning management systems: A Longitudinal Case Study

In this article the use of Learning Management Systems (LMS) at the School of Engineering, University of Borås, in the year 2004 and the academic year 2009-2010 is investigated. The tools in the LMS were classified into four groups (tools for distribution, tools for communication, tools for interaction and tools for course administration) and the pattern of use was analyzed. The preliminary interpretation of the results was discussed with a group of teachers from the School of Engineering with long experience of using LMS. High expectations about LMS as a tool to facilitate flexible education, student centered methods and the creation of an effective learning environment is abundant in the literature. This study, however, shows that in most of the surveyed courses the available LMS is predominantly used to distribute documents to students. The authors argue that a more elaborate use of LMS and a transformation of pedagogical practices towards social constructivist, learner centered procedures should be treated as an integrated process of professional development.

Constructing a user experience user experience-based mobile learning environment

Mobile learning, in the past defined as learning with mobile devices, now refers to any type of learning-on-the-go or learning that takes advantage of mobile technologies. This new definition shifted its focus from the mobility of technology to the mobility of the learner (O'Malley and Stanton 2002; Sharples, Arnedillo-Sanchez et al. 2009). Placing emphasis on the mobile learner’s perspective requires studying “how the mobility of learners augmented by personal and public technology can contribute to the process of gaining new knowledge, skills, and experience” (Sharples, Arnedillo-Sanchez et al. 2009). The demands of an increasingly knowledge based society and the advances in mobile phone technology are combining to spur the growth of mobile learning. Around the world, mobile learning is predicted to be the future of online learning, and is slowly entering the mainstream education. However, for mobile learning to attain its full potential, it is essential to develop more advanced technologies that are tailored to the needs of this new learning environment. A research field that allows putting the development of such technologies onto a solid basis is user experience design, which addresses how to improve usability and therefore user acceptance of a system. Although there is no consensus definition of user experience, simply stated it focuses on how a person feels about using a product, system or service. It is generally agreed that user experience adds subjective attributes and social aspects to a space that has previously concerned itself mainly with ease-of-use. In addition, it can include users’ perceptions of usability and system efficiency. Recent advances in mobile and ubiquitous computing technologies further underline the importance of human-computer interaction and user experience (feelings, motivations, and values) with a system. Today, there are plenty of reports on the limitations of mobile technologies for learning (e.g., small screen size, slow connection), but there is a lack of research on user experience with mobile technologies. This dissertation will fill in this gap by a new approach in building a user experience-based mobile learning environment. The optimized user experience we suggest integrates three priorities, namely a) content, by improving the quality of delivered learning materials, b) the teaching and learning process, by enabling live and synchronous learning, and c) the learners themselves, by enabling a timely detection of their emotional state during mobile learning. In detail, the contributions of this thesis are as follows: • A video codec optimized for screencast videos which achieves an unprecedented compression rate while maintaining a very high video quality, and a novel UI layout for video lectures, which together enable truly mobile access to live lectures. • A new approach in HTTP-based multimedia delivery that exploits the characteristics of live lectures in a mobile context and enables a significantly improved user experience for mobile live lectures. • A non-invasive affective learning model based on multi-modal emotion detection with very high recognition rates, which enables real-time emotion detection and subsequent adaption of the learning environment on mobile devices. The technology resulting from the research presented in this thesis is in daily use at the School of Continuing Education of Shanghai Jiaotong University (SOCE), a blended-learning institution with 35.000 students.