Use of high-frequency jet ventilation for percutaneous tumor ablation.

PURPOSE: To report feasibility and potential benefits of high-frequency jet ventilation (HFJV) in tumor ablations techniques in liver, kidney, and lung lesions. METHODS: This prospective study included 51 patients (14 women, mean age 66 years) bearing 66 tumors (56 hepatic, 5 pulmonary, 5 renal tumors) with a median size of 16 ± 8.7 mm, referred for tumor ablation in an intention-to-treat fashion before preoperative anesthesiology visit. Cancellation and complications of HFJV were prospectively recorded. Anesthesia and procedure duration, as well as mean CO2 capnea, were recorded. When computed tomography guidance was used, 3D spacial coordinates of an anatomical target <2 mm in diameter on 8 slabs of 4 slices of 3.75-mm slice thickness were registered. RESULTS: HFJV was used in 41 of 51 patients. Of the ten patients who were not candidate for HFJV, two patients had contraindication to HFJV (severe COPD), three had lesions invisible under HFJV requiring deep inspiration apnea for tumor targeting, and five patients could not have HFJV because of unavailability of a trained anesthetic team. No specific complication or hypercapnia related to HFJV were observed despite a mean anesthetic duration of 2 h and ventilation performed in procubitus (n = 4) or lateral decubitus (n = 6). Measured internal target movement was 0.3 mm in x- and y-axis and below the slice thickness of 3.75 mm in the z-axis in 11 patients. CONCLUSIONS: HFJV is feasible in 80 % of patients allowing for near immobility of internal organs during liver, kidney, and lung tumor ablation.

Incidents and complications of totally implanted vascular access devices in children: a prospective study.

BACKGROUND: Totally implanted vascular access devices are frequently used in children for repeated blood samples or intravenous treatments. This prospective study aims at identifying the risk factors associated with infections, obstructions and surgical complications of these devices in pediatric patients. METHODS: From January 2006 to January 2008, all children older than one year of age with a diagnosis of solid or blood cell malignancy were included in the study. Insertion was performed by the surgeon according to a standardized protocol after landmark-guided puncture of the subclavian or internal jugular vein by a senior anesthesiologist. Dressing and post-operative care were standardized. Every manipulation was prospectively recorded by specialized dedicated nurses, and all patients were screened for complications one month post-surgery. RESULTS: 45 consecutive patients 1 to 16 years old were enrolled in the study. Mean age at the time of procedure was 8.5 years (range 1.3-15.6; SD +/- 4.88). There were 12 peroperative adverse events in 45 procedures (27%), detailed as follows: 3 pneumothoraces (7%), 3 hematomas (7%), 6 arterial punctures (13%). Among these events, intervention was necessary for two pneumothorax and one arterial puncture. There was no air embolism. At one month, we recorded 5 post-operative complications (11%): 2 thrombotic obstructions, one unsightly scar, and one scapular pain of unknown etiology. One patient needed repositioning of the catheter. There was no catheter-related infection. CONCLUSION: Prospective recording of TIVA insertion in children reveals a significant number of early incidents and complications, mainly associated with the percutaneous puncture technique. We found no infection in this series. Results of a longer follow-up in the same population are pending.

Temporal Geobiotic Mapping: a conceptual mapping technique toward visualising geobiotic areas in cross-section

Geobiota are defined by taxic assemblages (i.e., biota) and their defining abiotic breaks, which are mapped in cross-section to reveal past and future biotic boundaries. We term this conceptual approach Temporal Geobiotic Mapping (TGM) and offer it as a conceptual approach for biogeography. TGM is based on geological cross-sectioning, which creates maps based on the distribution of biota and known abiotic factors that drive their distribution, such as climate, topography, soil chemistry and underlying geology. However, the availability of abiotic data is limited for many areas. Unlike other approaches, TGM can be used when there is minimal data available. In order to demonstrate TGM, we use the well-known area in the Blue Mountains, New South Wales (NSW), south-eastern Australia and show how surface processes such as weathering and erosion affect the future distribution of a Moist Basalt Forest taxic assemblage. Biotic areas are best represented visually as maps, which can show transgressions and regressions of biota and abiota over time. Using such maps, a biogeographer can directly compare animal and plant distributions with features in the abiotic environment and may identify significant geographical barriers or pathways that explain biotic distributions.

Laparoscopic inguinal hernia repair with extraperitoneal double-mesh technique.

Totally extraperitoneal laparoscopic hernia repair is an efficient but technically demanding procedure. As mechanisms of hernia recurrence may be related to these technical difficulties, we have modified a previously described double-mesh technique in an effort to simplify the procedure. Extraperitoneal laparoscopic hernia repairs were performed in 82 male and 17 female patients having inguinal, femoral, and recurrent bilateral hernias. A standard propylene mesh measuring 15 x 15 cm was cut into two pieces of 4 x 15 cm and 11 x 15 cm. The smaller mesh was placed over both inguinal rings without splitting. The larger mesh was then inserted over the first mesh and stapled to low-risk zones, reinforcing the large-vessel area and the nerve transition zone. The mean procedure duration was 60 minutes for unilateral and 100 minutes for bilateral hernia repair. Patients were discharged from the hospital within 48 hours. The mean postoperative follow-up was 22 months, with no recurrences, neuralgia, or bleeding complications. Over a 2-year period, this technique was found to be satisfactory without recurrences or significant complications. In our hands, this technique was easier to perform: it allows for a less than perfect positioning of the meshes and avoids most of the stapling to crucial zones.

Efficiency of the induced mating technique for Toxorhynchites theobaldi (Diptera, Culicidae)

Toxorhynchites mosquitoes play important ecological roles in aquatic microenvironments, and are frequently investigated as potential biological control agents of mosquito disease vectors. Establishment of Toxorhynchites laboratory colonies can be challenging because for some species, mating and insemination either do not occur or require a prohibitive amount of laboratory space for success. Consequently, artificial insemination techniques have been developed to assist with mass rearing of these species. Herein we describe an adapted protocol for colony establishment of T. theobaldi, a species with broad distribution in the Neotropics. The success of the technique and its implications are discussed.

Lean IT Application of 5S/6S Technique in a SME

O Lean não é apenas uma prática. É uma revolução nas Tecnologias de Informação (TI) proporcionando uma maior e melhor utilização dos recursos e procurando alcançar custos mais baixos dos que existem atualmente. É muito mais do que uma lista de ferramentas e metodologias e para que seja estabelecido é necessário mudar comportamentos culturais e incentivar todas as organizações a pensarem de forma diferente sobre o poder da informação versus o valor do negócio. Normalmente associa-se o Lean à criação de valor para a organização. Mas o valor é significativo quando é trazido com eficiência e resultando na eliminação de processos que consomem tempo, recursos e espaço desnecessário. Os princípios Lean podem ajudar as organizações na melhoria da qualidade, redução de custos e no alcance da eficiência através de uma melhor produtividade. Existem vários conceitos Lean que podem ser associados a diferentes objetivos de resolução de problemas. Em particular, este trabalho é uma dissertação programada para analisar um novo paradigma sobre o Lean que surgiu recentemente - Lean para Tecnologias de Informação (Lean IT). Esta dissertação apresenta uma abordagem para o Lean IT (enquadramento, objetivos e metodologia) para realizar o trabalho e utiliza um único estudo de caso, com abordagem à técnica 5S/6S (até o terceiro nível de avaliação), numa Pequena, Média Empresa (PME), de forma a demonstrar a agregação de valor e as vantagens na eliminação de resíduos/desperdícios nos seus processos. A técnica também mostra a evolução da avaliação antes e depois da sua aplicação. Este estudo de caso individual avalia um Departamento de TI (com uma equipe de cinco colaboradores e um chefe de Departamento) através da observação direta, documentação e arquivos de registos e os equipamentos analisados são computadores, postos de trabalho e projetos (código desenvolvido, portais e outros serviços de TI). x Como guia, a metodologia inclui a preparação da avaliação em conjunto com o responsável/chefe do Departamento de TI, o desenrolar das operações, a identificação do fluxo de valor para cada atividade, o desenvolvimento de um plano de comunicação e a análise de cada passo da avaliação do fluxo de processamento. Os principais resultados estão refletidos nas novas ferramentas de trabalho (Microsoft SharePoint e Microsoft Project em detrimento do Microsoft Excel) que fornecem comunicação remota e controlo de projetos para todos os stakeholders, tais como, a gestão de topo, parceiros e clientes (algumas organizações incluem o Outsourcing no desenvolvimento de funcionalidades específicas). Os resultados também refletem-se na qualidade do trabalho, no cumprimento de prazos, na segurança física e lógica, na motivação dos colaboradores e na satisfação dos clientes. A técnica 5S/6S ajuda a esclarecer os conceitos e princípios Lean, exequibilidade e aumenta a curiosidade sobre a implementação da técnica noutros departamentos tais como o Financeiro e ou o de Recursos Humanos. Como forma de consolidação do trabalho tornou-se possível organizar a avaliação para que a organização possa candidatar-se a uma certificação na norma ISO/IEC 25010:2011, no modelo de qualidade de software (software é o core business desta PME). Mas tal só será possível se toda a organização atingir a padronização dos seus processos. Este estudo de caso mostra que os conceitos Lean e a aplicação de uma ou mais das suas técnicas (neste caso particular a técnica 5S/6S) ajuda a obter melhores resultados através da gestão e melhoria dos seus principais serviços.

Steady-state equilibrium phase inversion recovery ON-resonant water suppression (IRON) MR angiography in conjunction with superparamagnetic nanoparticles. A robust technique for imaging within a wide range of contrast agent dosages.

PURPOSE: To investigate the ability of inversion recovery ON-resonant water suppression (IRON) in conjunction with P904 (superparamagnetic nanoparticles which consisting of a maghemite core coated with a low-molecular-weight amino-alcohol derivative of glucose) to perform steady-state equilibrium phase MR angiography (MRA) over a wide dose range. MATERIALS AND METHODS: Experiments were approved by the institutional animal care committee. Rabbits (n = 12) were imaged at baseline and serially after the administration of 10 incremental dosages of 0.57-5.7 mgFe/Kg P904. Conventional T1-weighted and IRON MRA were obtained on a clinical 1.5 Tesla (T) scanner to image the thoracic and abdominal aorta, and peripheral vessels. Contrast-to-noise ratios (CNR) and vessel sharpness were quantified. RESULTS: Using IRON MRA, CNR and vessel sharpness progressively increased with incremental dosages of the contrast agent P904, exhibiting constantly higher contrast values than T1 -weighted MRA over a very wide range of contrast agent doses (CNR of 18.8 ± 5.6 for IRON versus 11.1 ± 2.8 for T1 -weighted MRA at 1.71 mgFe/kg, P = 0.02 and 19.8 ± 5.9 for IRON versus -0.8 ± 1.4 for T1-weighted MRA at 3.99 mgFe/kg, P = 0.0002). Similar results were obtained for vessel sharpness in peripheral vessels, (Vessel sharpness of 46.76 ± 6.48% for IRON versus 33.20 ± 3.53% for T1-weighted MRA at 1.71 mgFe/Kg, P = 0.002, and of 48.66 ± 5.50% for IRON versus 19.00 ± 7.41% for T1-weighted MRA at 3.99 mgFe/Kg, P = 0.003). CONCLUSION: Our study suggests that quantitative CNR and vessel sharpness after the injection of P904 are consistently higher for IRON MRA when compared with conventional T1-weighted MRA. These findings apply for a wide range of contrast agent dosages.

Endoscopic Approach and Management of Parasellar Lesions

The parasellar region is the location of a wide variety of inflammatory and benign or malignant lesions. A pathological diagnostic strategy may be difficult to establish relying solely on imaging data. Percutaneous biopsy through the foramen ovale using the Hartel technique has been developed for decision-making process. It is an accurate diagnostic tool allowing pathological diagnosis to determine the best treatment strategy. However, in some cases, this procedure may fail or may be inappropriate particularly for anterior parasellar lesions. Over these past decades, endoscopy has been widely developed and promoted in many indications. It represents an interesting alternative approach to parasellar lesions with low morbidity when compared to the classic microscopic sub-temporal extradural approach with or without orbito-zygomatic removal. In this chapter, we describe our experience with the endoscopic approach to parasellar lesions. We propose a complete overview of surgical anatomy and describe methods and results of the technique. We also suggest a model of a decision-making tree for the diagnosis and treatment of parasellar lesions.

Enhanced radar precipitation estimates using a combined clutter and beam blockage correction technique

Weather radar observations are currently the most reliable method for remote sensing of precipitation. However, a number of factors affect the quality of radar observations and may limit seriously automated quantitative applications of radar precipitation estimates such as those required in Numerical Weather Prediction (NWP) data assimilation or in hydrological models. In this paper, a technique to correct two different problems typically present in radar data is presented and evaluated. The aspects dealt with are non-precipitating echoes - caused either by permanent ground clutter or by anomalous propagation of the radar beam (anaprop echoes) - and also topographical beam blockage. The correction technique is based in the computation of realistic beam propagation trajectories based upon recent radiosonde observations instead of assuming standard radio propagation conditions. The correction consists of three different steps: 1) calculation of a Dynamic Elevation Map which provides the minimum clutter-free antenna elevation for each pixel within the radar coverage; 2) correction for residual anaprop, checking the vertical reflectivity gradients within the radar volume; and 3) topographical beam blockage estimation and correction using a geometric optics approach. The technique is evaluated with four case studies in the region of the Po Valley (N Italy) using a C-band Doppler radar and a network of raingauges providing hourly precipitation measurements. The case studies cover different seasons, different radio propagation conditions and also stratiform and convective precipitation type events. After applying the proposed correction, a comparison of the radar precipitation estimates with raingauges indicates a general reduction in both the root mean squared error and the fractional error variance indicating the efficiency and robustness of the procedure. Moreover, the technique presented is not computationally expensive so it seems well suited to be implemented in an operational environment.

Myocardial no-reflow treatment.

No-reflow phenomenon is a consequence of percutaneous coronary intervention (PCI) which arises most of the time in the setting of myocardial infarction, but can be also the consequence of PCI in stable angina patients (rotatablator ablation technique or angioplasty in saphenous vein grafts). In this review, we summarize two ways of treating the no-reflow according to the current literature. First through the pharmacological approach where several compounds have been assessed like adenosine, nitroprusside, verapamil, nicorandil, dipyridamole, epinephrine or cyclosporine. Second through the mechanical approach where few strategies have been examined like intra-aortic balloon pumping or postconditioning. Finally, we provide an algorithm for treating a no-reflow even though no studies showed a beneficial effect in terms of clinical endpoints.

Comparison of clinical and angiographic prognostic risk scores in elderly patients presenting with acute coronary syndrome and referred for percutaneous coronary intervention.

BACKGROUND: Multiple risk prediction models have been validated in all-age patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI); however, they have not been validated specifically in the elderly. METHODS: We calculated the GRACE (Global Registry of Acute Coronary Events) score, the logistic EuroSCORE, the AMIS (Acute Myocardial Infarction Swiss registry) score, and the SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) score in a consecutive series of 114 patients ≥75 years presenting with ACS and treated with PCI within 24 hours of hospital admission. Patients were stratified according to score tertiles and analysed retrospectively by comparing the lower/mid tertiles as an aggregate group with the higher tertile group. The primary endpoint was 30-day mortality. Secondary endpoints were the composite of death and major adverse cardiovascular events (MACE) at 30 days, and 1-year MACE-free survival. Model discrimination ability was assessed using the area under receiver operating characteristic curve (AUC). RESULTS: Thirty-day mortality was higher in the upper tertile compared with the aggregate lower/mid tertiles according to the logistic EuroSCORE (42% vs 5%; odds ratio [OR] = 14, 95% confidence interval [CI] = 4-48; p <0.001; AUC = 0.79), the GRACE score (40% vs 4%; OR = 17, 95% CI = 4-64; p <0.001; AUC = 0.80), the AMIS score (40% vs 4%; OR = 16, 95% CI = 4-63; p <0.001; AUC = 0.80), and the SYNTAX score (37% vs 5%; OR = 11, 95% CI = 3-37; p <0.001; AUC = 0.77). CONCLUSIONS: In elderly patients presenting with ACS and referred to PCI within 24 hours of admission, the GRACE score, the EuroSCORE, the AMIS score, and the SYNTAX score predicted 30 day mortality. The predictive value of clinical scores was improved by using them in combination.