First Year Of Experience Research Articles

Extracorporeal Life Support: First Year of Experience Implementing the Technique in Slovenia

Extracorporeal life support (ELS) is emerging as a standard treatment option for acute respiratory and/or cardiac failure. In this article we describe our first year of experience with ELS activity in adult medical patients in our center. Veno-venous extracorporeal membrane oxygenation (VV ECMO) support was applied in cases of severe acute respiratory distress syndrome (ARDS) not responsive to conventional treatments. The use of veno-arterial (VA) ECMO support was reserved for cases of cardiac shock refractory to standard treatment and cardiac arrests not responding to conventional resuscitation. A total of 19 patients were treated with ELS during the first year of activity. Eight of these received VV ECMO for ARDS of various etiologies, with a survival rate of 63%. Eleven patients received VA ECMO support due to cardiac failure (2 post-resuscitation). Survival in this group was 45%. We report our results, including complications and organizational issues that we encountered, and describe protocol improvements developed over the short period of time since ELS treatment has been implemented in our center.

Robotic Thyroidectomy: An Initial Experience with the Gasless Transaxillary Approach

Thyroid surgery has recently emerged as one of the most promising fields for the application of robotic surgery. We report the results of the first year of experience with a gasless transaxillary thyroidectomy. From January 2009 to December 2009, 10 consecutive patients (8 women) underwent robotic thyroidectomy through a gasless transaxillary approach. The median age was 44 years (range, 27-42 years). Eight total and two partial thyroidectomies (one left and one right) were performed using the da Vinci(®) Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Preoperative diagnosis included solitary nodules with a median size of 16±11 mm (range, 3-44 mm) at preoperative imaging. All procedures were successfully completed robotically, except one that was converted because of difficulty in achieving an optimal exposure. The overall mean operative time was 177.4±40 minutes (range, 120-240 minutes) with minimal blood loss (<10 mL). Pathological diagnoses included papillary carcinoma (n=6), colloid nodule (n=2), and multinodular goiter (n=2). The mean number of lymph nodes harvested in the cases of malignant disease was 4±5 (range, 3-15). The median postoperative length of stay was 1.05 days (range, 1-1.4 days). Thyroid surgery using a gasless transaxillary approach can be performed safely for selected benign and malignant pathology. This approach offers superior cosmetic results and a short hospital stay over conventional thyroid surgery. For selected patients, this technique offers a promising scarless option for minimally invasive thyroid surgery.

Results of laser therapy in twin-to-twin transfusion syndrome: our experience

Objective: The authors of this paper present the results of laser treatment in twin-to-twin transfusion syndrome. Methods: Laser photocoagulation of communicating vessels was performed on 91 patients from April 2005 to June 2010, at the Medical University of Gdansk (Poland). Results of treatment were analyzed. Results: The following results were achieved: at least one survival at delivery in 71 patients (83.5%), two survivors in 49 women (57.6%), and an overall survival rate of 70.6%. After the inclusion of neonatal deaths, at least one survival was reported in 65 women (76.5%) – 30 with two survivors (44.7%) and 27 with one survivor (31.8%). The incidence of preterm rupture of membranes (4 cases – 4.3%), dual intrauterine fetal demise (7 cases – 7.4%) and miscarriage or delivery (8 cases – 8.5%) during the first week after surgery were the main reasons of pregnancy loss in the analyzed group. The frequency of cerebral palsy diagnosed after 6 months was 7%. Conclusions: Despite a lower incidence of dual neonatal survivals than in other series, the results of the first years of experience with laser treatment of twin-twin transfusion syndrome are encouraging, and prompt us to improve our surgical skills to achieve better outcomes.

Maternagem: estratégia de prevenção em saúde para formação de sujeitos saudáveis

Após o primeiro ano de experiência do Núcleo de Apoio à Saúde da Família (NASF), realizou-se uma análise das principais demandas ou sintomas. Na população infantil, observaram-se dificuldades relacionadas à linguagem, aprendizagem, comportamento e vinculação. Na população adulta, foram encontradas dificuldades relacionadas à autonomia no processo saúde/doença, corpo e resolução de conflitos. Com base nas diretrizes da Atenção Básica, elaborou-se uma intervenção para lidar com as queixas provenientes dos vínculos frágeis que constituem as relações parentais, acarretando consequências para o desenvolvimento ou formação dos sujeitos. Para tanto, criou-se o grupo de Maternagem, que se trata da atividade de cuidar que propicia à criança atenção necessária e suporte emocional para um desenvolvimento neuropsicomotor saudável. Trata-se de um grupo terapêutico-educativo. Em relação às mães, observou-se mudança no posicionamento em relação à educação e colocação de limites, elaboração de conflitos familiares, reflexão sobre sua relação com seus pais, aprimoramento da escuta e vinculação. Nos bebês, observou-se melhora na vinculação, na aceitação do toque materno e nos limites, maior tranquilidade e aprimoramento das habilidades neuropsicomotoras. O desafio é tratar de maternagem com sujeitos que foram pouco maternados, portanto, vulneráveis, pouco autônomos, com dificuldade de estabelecer relações pautadas na confiança/segurança. Em muitos momentos, as mães é que são maternadas, ressignificando seus primeiros vínculos, recuperando o brincar e a fantasia. Acredita-se que a mudança do sujeito-mãe possa ocorrer por meio da transformação da relação mãe-bebê, o que será determinante na formação do sujeito-bebê e possibilitará a ressignificação das relações familiares, produzindo saúde.

Becoming a special education teacher: Journey or maze?

This paper discusses the beginning steps of the author as a special education teacher in a large Southwest public school district in the US. The author discusses his first year of experience in a large US middle school as an inclusion teacher by using self-reflective practice in the form of excerpts from his learning journal to become aware and understand the complexities of becoming a special education teacher. The metaphor of the maze is introduced and used as the lens through which the author experienced his becoming a special education teacher and how the metaphor of the maze dominates the professional growth and identity of the author in the field of special education.

Decreased Incidence of Vaginal Cuff Dehiscence after Laparoscopic Closure with Bidirectional Barbed Suture

Study Objective To estimate whether a new surgical technique is associated with lower incidence of postoperative breakdown of the vaginal cuff after laparoscopic hysterectomy or trachelectomy, compared with previous methods of closure. Design Retrospective cohort study, Canadian Task Force Classification II-3. Setting Tertiary-care university-based teaching hospital. Patients Patients who underwent laparoscopic vaginal closure after removal of the uterus and/or cervix by members of a subspecialty gynecologic laparoscopy division from January 2007 to January 2010 (n = 387). Interventions Use of bidirectional barbed suture for laparoscopic vaginal cuff closure. Measurements and Main Results A total of 387 patient records were reviewed. The incidence of vaginal cuff dehiscence among those with other methods of closure was 4.2%, while there were no cases of dehiscence among those who had closure with bidirectional barbed suture (p = .008). Postoperative bleeding (OR 2.3, 95% C.I. 1.3–3.9), presence of granulation tissue (OR 1.9, 95% C.I. 0.92–3.9), and cellulitis (OR 4.6, 95% C.I. 1.0–21.1) all occurred more frequently in patients without barbed suture closure. Conclusion Dehiscence of the vaginal cuff after laparoscopic closure is a rare but important complication in gynecologic surgery. Use of bidirectional barbed suture eliminated the problem in our first year of experience with the technique. We also observed a decreased incidence of other common problems of the vaginal cuff. This method is easy to learn and inexpensive and does not require advanced skills such as laparoscopic knot-tying.

Transkateter aortaventilimplantasjon ved aortastenose

Short-term results are presented from our first year of experience with transcatheter aortic-valve implantation [corrected] (TAVI) at the University Hospital of North Norway. TAVI was used to treat 25 patients with aortic stenosis [corrected] from September 2008 to August 2009. 25 patients operated with conventional aortic valve replacement (AVR) served as controls. The TAVI group had a significantly higher EuroSCORE (p < 0.001) than the AVR group. No patients in the TAVI group were treated in the intensive care unit while those in the AVR group received 38 days of intensive care in total. The TAVI group had shorter operating times (p < 0.001), larger mean valve sizes (p < 0.001) and significantly fewer postoperative transfusions (p < 0.001) than the ACR group. Peri-operative stroke and myocardial infarction did not occur in the TAVI group while there was one incidence of stroke and one myocardial infarction in the AVR group. The postoperative transvalvular mean gradient decreased in both groups (p < 0.001) and was significantly lower in the TAVI group (p = 0.001). The NYHA class improved significantly in the TAVI group (p < 0.001). No patients needed implantation of a permanent pacemaker. 30-day mortality was four patients in the AVR group and one patient in the TAVI group. After discharge one patient died in each group. TAVI is safe and effective for selected patients with aortic stenosis [corrected] who are assessed as high risk for AVR. Long-term results are needed and will be decisive for use of this approach in the future.

Introducing New Technology into the Clinic: The First Year of Experience in Proton Therapy with a Uniform Scanning System

The introduction of new and unique technology into routine clinical practice needs critical attention to its functionality and constant improvement. We wish to summarize some parameters relevant to clinical practice from our experience of the first year of clinical operation of a treatment room with a unique proton beam scanning system at the Midwest Proton Radiotherapy Institute (MPRI) constructed by Indiana University Cyclotron Facility.

In the field of cardiac resynchronization therapy is left ventricular pacing via the coronary sinus a mature technique

In the first reported case of cardiac resynchronization therapy (CRT) in 1994, left ventricular (LV) pacing was performed using an epicardial approach.1 The use of a lead inserted into a coronary sinus (CS) tributary vein to pace the LV was initially proposed in patients in whom right ventricular (RV) pacing could not be performed by a transvenous approach and later by Blackburn and Gibbs2 and Daubert et al. 3 for cardiac resynchronization. The CS approach was used rather than the epicardial one because it was less invasive and did not require general anaesthesia in very delicate patients, but this new technique involved several difficulties: (i) to catheterize the CS in a usually marked dilated heart; (ii) to reach a CS tributary vein to pace the LV; (iii) to insure lead stability into the vein. The transvenous route aims to reach the target vein with an acceptable pacing threshold and without phrenic nerve stimulation in order to obtain the best mechanical resynchronization. During the first years of experience with LV pacing via the CS, … *Corresponding author. Tel: +33 141 120712, Fax: +33 141 120715, Email: alonso{at}inparys.com

My first year of experience in the cosmetic field – problems and future hopes

Citation: IFSCC Magazine, 10 (2007) (4) 331–3336Where do I begin to tell my adventures as a new research and development chemist? It has been a mixed bag of excitement, frustration, hope, pride in achievement and much potential. Before I take you through the obstacle course that I have been exposed to in the cosmetic industry let me give you background information on myself. I have always been inclined towards the sciences. I took up science subjects for my A‐Level Cambridge exams, but surprised my father for a little while by registering for a BA in psychology. After two weeks I decided that was not for me and registered for a BSc in natural and environmental sciences with biochemistry and psychology as my majors with the notion that one day after my studies I would become a neuropsychologist. When I had to decide between taking my honors in psychology or biochemistry, I chose biochemistry mainly because I thought I had better prospects of finding a job soon after completing the degree, which would free my parents from the financial burden of paying for tuition through to a PhD in psychology (you have to be a doctor first before earning any real money in psychology, I had been told). Boy was I wrong! The carefree, self‐assured graduate with the world at her feet slowly changed into a grasping‐at‐straws, ‘I will do anything to pay the bills’ nobody until nearly 2 years after graduation the advertisement for a junior R&amp;D chemist magically appeared in my email! That opened up the floodgates for my childhood dreams of making people feel better by making them look better through makeup and fashion, my adult inclination towards psychology with a scientific twist. I felt this was the opportunity I had been waiting for but had not known it! Thus, my adventure began… This essay won the 2007 Maison G. de Navarre Young Scientist Prize that is awarded for either the first or second paper in cosmetic science or a specially written essay on a topic selected by the 2006–2007 IFSCC President for an author of 35 years or younger. This Prize was awarded to Muchaneta G. Mutasa during the Openings Ceremony of the 2007 IFSCC Conference »Building on Water«, Amsterdam, The Netherlands on 24 September 2007. The purpose of the Maison G. de Navarre Young Scientist Prize is to stimulate young cosmetic scientists to write scientific papers/essays. The prize covers all expenses to attend the first IFSCC Congress or Conference that is held after the prize was awarded.

Long‐Term Effects of Highly Active Antiretroviral Therapy on CD4+Cell Evolution among Children and Adolescents Infected with HIV: 5 Years and Counting

Lower percentages of CD4(+) T lymphocytes are associated with adverse clinical outcomes among children and adolescents infected with human immunodeficiency virus (HIV). CD4(+) lymphocyte percentage generally increases with receipt of highly active antiretroviral therapy (HAART), but long-term follow-up is required to assess whether these increases in CD4(+) cell percentage are maintained and whether they lead to normal CD4(+) cell percentages in children with severe immunosuppression. The study population included 1236 children and adolescents perinatally infected with HIV who were enrolled in a US-based multicenter prospective cohort study (Pediatric AIDS Clinical Trials Group 219/219C) and who were not receiving HAART at study initiation. We estimated the effects of HAART, HAART with protease inhibitors, and HAART with nonnucleoside reverse-transcriptase inhibitors on CD4(+) cell percentage, using marginal structural models to account for confounding by severity. Initiation of any type of HAART increased CD4(+) cell percentage by 2.34% (95% confidence interval, 1.35%-3.33%) in the first year, relative to noninitiation of HAART. The substantial increases in CD4(+) cell percentage observed after the first year of experience with these combination therapies were followed by relatively smaller increases that continued for 5 years after initiation. Although larger increases in CD4(+) cell percentage were observed among children with a greater degree of immunosuppression at baseline, the mean CD4(+) cell percentage after 5 years of HAART did not reach normal levels. Our study supports the initiation of HAART in children before severe immunosuppression occurs for long-term maintenance of normal CD4(+) cell percentages. This beneficial result must be weighed against the evidence of potential adverse events associated with the prolonged use of such therapy.

Virus-inactivated plasma - Plasmasafe: a one-year experience.

Fresh-frozen plasma (FFP) is a widely used blood transfusion product. The transfusion safety of this product is ensured by legally obligatory tests, but can be further improved by using some technical procedures, such as methylene blue (MB) and solvent-detergent (SD) viral inactivation methods. Mainly organisational criteria led us to introduce the SD viral inactivation technique as a service activity. In this report we describe our first year of experience, following the introduction of the SD technique, and thus the use of SD-virally inactivated plasma (PlasmaSafe). IN ORDER TO EVALUATE THE APPROPRIATE USE AND THE THERAPEUTIC EFFICACY OF PLASMASAFE IN OUR BLOOD TRANSFUSION UNIT, THE FOLLOWING PROGRAMME WAS PLANNED: quality control [prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen] of the FFP units (N=312); evaluation of the clinical effectiveness on 490 patients (879 transfusion events); pre- and post-treatment monitoring of indicators of coagulation (PT, aPTT, fibrinogen, proteins S and C, factor VIII) on 15 patients; treatment of three patients with thrombotic thrombocytopenic purpura (TTP) undergoing plasma-exchange; haemovigilance of adverse reactions provoked by SD-plasma. THE INDICATORS OF COAGULATION IN THE FFP UNITS VARIED GREATLY: the PT ranged from 50-120%, the aPTT from 24-41 seconds and the fibrinogen concentration from 1.42-6.84 g/L. Seventy-six percent of the patients responded to the plasma administration; moreover, two of 15 patients in whom protein S was assayed, showed no increase of this haemostatic protein. The TTP patients responded to plasma exchange treatment following four sessions of apheresis. During the observation period 8,422 PlasmaSafe units were transfused and no adverse reactions were recorded. PlasmaSafe, a pharmaceutical-like product with a standardised content of coagulation factors, was found to be effective at correcting coagulation defects and for treating TTP. No thrombotic complications or transfusion-related adverse reactions were recorded.

Retroperitoneal laparoscopic partial nephro-urereterectomy in infants and children: analysis of risk factors and age related complications

Purpose Laparoscopic partial nephrectomy is a technically demanding procedure. Recently, there is increasing concern on the risks and outcome especially in young children. We analysed in detail our series and in particular young children to evaluate their specific risks and the operative steps to define the optimal technique to avoid complications. Material and methods Between 1997 and 2006, 29 partial nephro-ureterectomies were performed, 21 upper poles (UPN) at mean age of 36 months (3-156) and 8 lower poles (LPN) at 39 months (1-121). The lateral retroperitoneal approach was used in all cases. Routine follow-up with renal ultrasound and Doppler of the remaining moiety were performed. For the past five years the technique was standardized to reduce complications: the kidney is kept attached to peritoneum, the pathological ureter is kept dilated by ligature at the beginning of surgery, and retrograde insertion of a ureteral catheter to allow methylene blue injection in cases of LPN or atypical UPN. Results Our first patient, aged 7 yr, had an early postoperative renal artery thrombosis after UPN and required a total nephrectomy. Among the 10 UPN done in children under 1 yr, none had complications. One needed conversion in our first year of experience to identify the line of parenchymal section. 3 children underwent LPN under one yr, none had complications and no conversion even for a 60 mm dilated pelvis in a one month old child. Mean operative time was 150min (120-180) for LPN, and 150min (75-180) for UPN. All children had a well vascularized remaining moiety after a mean follow up of 36 months (6-60). Conclusions Partial nephro-ureterectomy remains a challenging laparoscopic procedure. The main limiting factor is the learning curve and not the age at surgery. We have learned from our early complications that few tips are necessary to make the retroperitoneal approach easier and safer. The procedure is now standardized and safely feasible even in young infants.

First Year of Mandatory Reporting of Healthcare-Associated Infections, Pennsylvania An Infection Control—Chart Abstractor Collaboration

In 2004, the Commonwealth of Pennsylvania mandated hospitals to report healthcare-associated infections (HAIs). The increased workload led our Infection Control staff to collaborate with Atlas, a group of chart abstractors. The objective of this study was to assess our first year of experience with mandatory reporting of HAIs--specifically, to assess Atlas' contribution to surveillance. Cases were selected if they had 1 or more of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes designated by Pennsylvania as a possible HAI. After training by the Infection Control staff, Atlas applied National Nosocomial Infection Surveillance (NNIS) system case definitions for catheter-associated urinary tract infections (UTIs) and surgical site infections (SSIs), and they applied NNIS chest imaging criteria to eliminate cases that were not ventilator-associated pneumonia (VAP). To assess Atlas' performance, Infection Control staff conducted a parallel review. For discharges from the hospital during the fourth quarter of 2004, a total of 410 UTIs, 59 SSIs, and 56 VAPs were identified on the basis of state-designated ICD-9-CM codes; review by Atlas/Infection Control determined that 15%, 15%, and 16% of cases met case definitions, respectively. Of cases reviewed by both Infection Control and Atlas, 87% of the assessments made by Atlas were correct for UTI, and 96% were correct for SSI. For VAP, Infection Control concluded that 39% of cases could be ruled out on the basis of chest imaging criteria; Atlas correctly dismissed these 12 cases but incorrectly dismissed an additional 6 (error, 19%). Surveillance was not timely: 1-2 months elapsed between the time of HAI onset and the earliest case review. With ongoing training by Infection Control, Atlas successfully demonstrated a role in retrospective HAI surveillance. However, despite a major effort to comply with mandates, time lags and other design limitations rendered the data of low utility for Infection Control. States that are planning HAI-reporting programs should standardize an efficient surveillance methodology that yields data capable of guiding interventions to prevent HAI.

The initial Mayo Clinic experience using high-frequency oscillatory ventilation for adult patients: a retrospective study

BackgroundHigh-frequency oscillatory ventilation (HFOV) was introduced in our institution in June 2003. Since then, there has been no protocol to guide the use of HFOV, and all decisions regarding ventilation strategies and settings of HFOV were made by the treating intensivist. The aim of this study is to report our first year of experience using HFOV.MethodsIn this retrospective study, we reviewed all 14 adult patients, who were consecutively ventilated with HFOV in the intensive care units of a tertiary medical center, from June 2003 to July 2004.ResultsThe mean age of the patients was 56 years, 10 were males, and all were whites. The first day median APACHE II score and its predicted hospital mortality were 35 and 83%, respectively, and the median SOFA score was 11.5. Eleven patients had ARDS, two unilateral pneumonia with septic shock, and one pulmonary edema. Patients received conventional ventilation for a median of 1.8 days before HFOV. HFOV was used 16 times for a median of 3.2 days. Improvements in oxygenation parameters were observed after 24 hours of HFOV (mean PaO2/FIO2 increased from 82 to 107, P < 0.05; and the mean oxygenation index decreased from 42 to 29; P < 0.05). In two patients HFOV was discontinued, in one because of equipment failure and in another because of severe hypotension that was unresponsive to fluids. No change in mean arterial pressure, or vasopressor requirements was noted after the initiation of HFOV. Eight patients died (57 %, 95% CI: 33–79); life support was withdrawn in six and two suffered cardiac arrest.ConclusionDuring our first year of experience, HFOV was used as a rescue therapy in very sick patients with refractory hypoxemia, and improvement in oxygenation was observed after 24 hours of this technique. HFOV is a reasonable alternative when a protective lung strategy could not be achieved on conventional ventilation.

First Experience with Advanced Nurse Practitioners and Physician Assistants in Dutch Emergency Departments; (Dis)Advantages to the Development

Background: Emergency Departments (EDs) are confronted with progressive crowding. One of the main reasons is found in the growing number of “self-referrals” caused by a growing shortage in general practitioners. To cope with crowding, cost-effective solutions are being sought that preserve quality of care. Up to now, the most successful initiative is the development of Advanced Nurse Practitioners (ANPs) and Physician Assistants (PAs). Aim: The aim of this study is to compare the role and development of ANPs and PAs in Emergency Departments in the Netherlands and put it in a European perspective. Methods: An inventory concerning the first experiences with ANPs and PAs on Dutch EDs was performed. Attention was focused on the differences and similarities in responsibilities and scope of practice of both professions and the (dis)advantages observed with this development. Furthermore, information was obtained from educational institutes, national nurses' associations and governmental organisations in the Netherlands and other European countries to complete the picture, enabling the formulation of a perspective on the future. Results: In Europe (mainland), the development of ANP/PA programmes is still in a very early stage. In the Netherlands, the first year of experience with ANPs working on the ED has come to a close. In the past year, some PAs also graduated and are working in the ED as well. For both groups, liability is still an issue and legislation concerning the new professions has not yet passed. Apart from a significant overlap in job description, there are some differences to be addressed. The background of ANPs must be a masters degree in nursing, as for the PAs a different paramedical background is also allowed. The following can be said about the scope of practice and responsibilities: ANPs have a disease-focused approach, while PAs are being trained to have a speciality-focused approach. Furthermore, PAs purely do clinical work, whereas ANPs are also trained to investigate and improve the efficiency of delivered care. (Dis)advantages of ANPs/PAs: In Anglo-Saxon countries, ANPs and PAs have contributed to the relief of physician shortage and therefore it is likely that this will also be the case in the Netherlands. Furthermore, it is shown that the implementation of ANPs/PAs can occur with preservation of quality of care and patient satisfaction. However, in both professions the educational program is relatively long and expensive. Moreover, although basic medical issues are dealt with, the programmes are not aimed at preparing the trainees for specific (diagnostic) tasks. Another disadvantage concerns the loss of these practitioners for regular nursing tasks, contributing to the shortage in regular nurses. This is why an alternative is sought that maintains the benefits of ANPs and PAs and gets rid of the disadvantages. Alternative Solution: An alternative concept is to provide regular ED-nurses with short injury-specific courses, teaching them how to assess and treat specific injuries according to a protocol. Apart from regular nursing tasks, treatment of minor injuries could then be taken over from physicians. This creates flexible employees, and would help deliver cost-effective quality of care with prevention of further nurse shortage.

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

Objective. The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). Material and methods. A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. Results. There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p<0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p<0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50–99 registered colonoscopies. Conclusions. In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.

Budesonide in the treatment of inflammatory bowel disease: The first year of experience in clinical practice

Delayed release budesonide was approved by the FDA for the treatment of mildly to moderately active Crohn's disease involving the ileum and ascending colon. Controlled trials have demonstrated that budesonide is effective in inducing remission and for maintenance of remission, with less frequent steroid side effects than conventional steroids. We sought to determine the benefit of this medication in clinical practice and to identify any non-FDA-approved uses that may warrant further study. Patients in whom oral budesonide was prescribed between November 1, 2001 and October 31, 2002, were identified and medical records were reviewed. Patients were categorized by indication for therapy: ileocolonic Crohn's disease (group 1), Crohn's disease elsewhere (group 2), and other conditions (group 3). A total of 225 patients were identified (108 in group 1, 62 in group 2, and 55 in group 3). Group 3 included patients with microscopic colitis (n = 28), pouchitis (n = 13), ulcerative colitis (n = 12), and celiac disease (n = 2). A favorable outcome occurred in 61% of group 1 patients but only 24% of patients in group 2. In group 3, only microscopic colitis patients and pouchitis patients experienced response rates >50% (77% and 60%, respectively). Budesonide is effective in a majority of patients with ileocolonic Crohn's disease and microscopic colitis, which is consistent with results reported from clinical trials. A majority of patients with pouchitis also benefit from budesonide therapy, but prospective controlled trials are necessary to clarify the benefit in this group.

Preliminary experience with the frontrunner coronary catheter: Novel device dedicated to mechanical revascularization of chronic total occlusions

The novel device Frontrunner coronary catheter (FCC), dedicated to recanalization of chronic total occlusions (CTOs), relies on blunt microdissections inside the plaque, allowing passage of guidewire through the lesion and adjunctive angioplasty. In order to evaluate efficacy and safety of recanalization using the FCC device, we included patients with de novo or restenotic CTOs in a native coronary artery with prior failure using a guidewire or considered unsuitable for guidewire attempt in which the FCC was attempted first. Between October 2000 and June 2003, 50 patients with 50 CTOs were included in the study. Thirty-two patients had prior failure with a mechanical wire. Device and angiographic success were obtained in 25 (50%) occlusions: 53% in lesions with prior guidewire failure and 44% when FCCs were attempted first (P = 0.8). During the first year of experience, angiographic success was 42% (5 occlusions) and in the third year 75% (12 occlusions; P = 0.12). Coronary perforation occurred in nine (18.0%) patients, leading to tamponade in two (4%) patients. Perforations occurred in 5 out of 12 attempted patients during the first year and in 4 out of 38 patients in the following period (41.7% vs. 10.5%; P = 0.04). Serious adverse events occurred in five (10%) patients within 30-day follow-up. Four non-Q-wave myocardial infarctions occurred in hospital (clinical success 42%) and one death 7 days after the index procedure. The use of FCC increases the success to open chronic total occlusions refractory to mechanical guidewires or that were considered unsuitable for an attempt with a guidewire. The risk of coronary perforation due to FCC use is relatively high and it can decrease with experience.

Consultations for holistic pediatric services for inpatients and outpatient oncology patients at a children's hospital.

As demand increases for complementary and alternative medical care, pediatric institutions face the need to answer patients' and clinicians' questions about integrating these therapies in hospital settings. To describe the first year of experience in providing holistic medicine consultations in an urban tertiary care teaching hospital. Prospective cohort. Patients seeking consultation from the Center for Holistic Pediatric Education and Research, Boston, Mass, from July 16, 1999, to July 15, 2000. Review of consultation notes and medical records. Of the 70 physician consultations, most (n = 43) were for oncology patients. Most consultations (n = 44) were accomplished with a single visit. The most common goal for consultation was to obtain help in managing symptoms such as nausea, pain, insomnia, or agitation (n = 50). The most common questions about specific therapies had to do with herbs (n = 41) or dietary supplements (n = 42), but there were also frequent questions about diet and nutrition (n = 33) and mind-body therapies such as guided imagery and biofeedback (n = 28) and massage (n = 25). Approximately 0.3 full-time equivalents of physician time was required to provide clinical consultations, and $7315 was collected of the $26 638 billed for these services. The complementary medicine consultation service was primarily consulted by oncology patients requesting assistance with pain and symptom management. Patients had questions about various therapies, particularly herbs and dietary supplements. Additional research is necessary to determine the cost-effectiveness of an integrated approach to care, particularly for institutions without access to reliable community resources for complementary and alternative medical therapies.