Social circus program (Cirque du Soleil) promoting social participation of young people living with physical disabilities in transition to adulthood: a qualitative pilot study.

PURPOSE: To explore the perceived impact of a social circus program on the participation level of young adults' living with physical disabilities from their own and their parents' perspective. METHOD: Exploratory phenomenological qualitative design. A social circus program was offered for nine months. Perceived participation level was documented through pre and post semi-structured interviews. A pretested interview guide was used. Interviews were transcribed and coded by two independent researchers. RESULTS: The average age of the participants (n = 9) was 20.0 ± 1.4 years with 2/9 being female. Participation was perceived as being improved after the intervention from both perspectives (participants and parents) mainly for communication, mobility, relationships, community life and responsibilities. The intervention was perceived as strengthening self-perception and self-efficacy, which in turn enhanced participation level and decreased parents' bounding. CONCLUSION: The results show promises for social circus as a new approach in adult physical rehabilitation for this population in transition.

The transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension: current status.

The transjugular intrahepatic portosystemic shunt (TIPS) represents a major advance in the treatment of complications of portal hypertension. Technical improvements and increased experience over the past 24 years led to improved clinical results and a better definition of the indications for TIPS. Randomized clinical trials indicate that the TIPS procedure is not a first-line therapy for variceal bleeding, but can be used when medical treatment fails, both in the acute situation or to prevent variceal rebleeding. The role of TIPS to treat refractory ascites is probably more justified to improve the quality of life rather than to improve survival, except for patients with preserved liver function. It can be helpful for hepatic hydrothorax and can reverse hepatorenal syndrome in selected cases. It is a good treatment for Budd Chiari syndrome uncontrollable by medical treatment. Careful selection of patients is mandatory before TIPS, and clinical followup is essential to detect and treat complications that may result from TIPS stenosis (which can be prevented by using covered stents) and chronic encephalopathy (which may in severe cases justify reduction or occlusion of the shunt). A multidisciplinary approach, including the resources for liver transplantation, is always required to treat these patients.

Chest tube drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital: Review of 51 cases.

BACKGROUND: Chest tube drainage under radiological guidance has been used with increasing frequency as a treatment option for pleural effusions and pneumothoraxes. OBJECTIVE: To evaluate the safety and usefulness of pleural drainage under radiological guidance for pleural effusion and pneumothorax in a tertiary care university teaching hospital. METHODS: A retrospective study of cases of chest tube placement under radiological guidance over a 12-month period in a university hospital. RESULTS: Fifty-one percutaneous pigtail catheter drainage cases were reviewed (30 patients). Forty-six (90%) chest tubes were inserted as a first-line treatment. The overall success rate of radiological drainage was 88%. Specific success rates were 92%, 85% and 91% for loculated pleural effusion, pneumothorax and empyema, respectively. The complications were few and minor. CONCLUSIONS: Pigtail catheter insertion under radiological guidance is a useful procedure for the treatment of sterile pleural effusion, empyema and pneumothorax. This technique can be used as a first-line procedure in the majority of cases.

Octreotide in hepatorenal syndrome: a randomized, double-blind, placebo-controlled, crossover study.

The hepatorenal syndrome (HRS) is related to vasoconstriction of the renal cortex induced by systemic hypovolemia that follows splanchnic vasodilatation as the primary event in the cascade of hemodynamic changes associated with portal hypertension. We evaluated the effects of octreotide, a splanchnic vasoconstrictor, on HRS in cirrhotic patients. We compared the effects of octreotide infusion (50 microg/h) to placebo using a randomized, double-blind, cross-over design over 2, 4-day periods. Nineteen patients were included, and 14 patients could complete the 2 phases of the study (group 1: placebo first; n = 8 and group 2: octreotide first; n = 6) The end point of the study was to evaluate improvement in renal function as defined by a 20% decrease in serum creatinine value after a 4-day treatment as compared with baseline. In all the patients, a normal central venous pressure was maintained by daily intravenous administration of 2 units of albumin. The 2 groups were similar with regard to demographic data and liver and kidney function parameters at baseline. Improvement in renal function was observed in 2 patients after the placebo and 1 patient after octreotide infusion in group 1 and in 2 patients after octreotide infusion and 1 patient after placebo in group 2 (P = not significant). In addition, treatment with octreotide infusion did not result in significant changes in creatinine clearance, daily urinary sodium, plasma renin activity, plasma aldosterone and glucagon levels, or renal and mesenteric artery resistance indices as measured by Doppler ultrasonography. In conclusion, the present study demonstrates that, under our experimental conditions, octreotide infusion combined with albumin is not effective for the treatment of HRS in cirrhotic patients.

Improved detection of hepatic metastases with pulse-inversion US during the liver-specific phase of SHU 508A: multicenter study.

PURPOSE: To compare conventional B-mode ultrasonography (US) alone with the combination of conventional B-mode US and contrast material-enhanced (SHU 508A) late-phase pulse-inversion US for the detection of hepatic metastases by using dual-phase spiral computed tomography (CT) as the standard of reference. MATERIALS AND METHODS: One hundred twenty-three patients underwent conventional US, US in the liver-specific phase of SHU 508A, and single-section spiral CT. US and CT images were assessed by blinded readers. Differences in sensitivity, specificity, and the number and smallest size of metastases at conventional and contrast-enhanced US were compared by using CT as the standard of reference. Lesion conspicuity was assessed objectively (quantitatively) and subjectively by one reader before and after contrast material administration. RESULTS: In 45 of 80 (56%) patients with metastases, more metastases were seen at contrast-enhanced US than at conventional US. In three of these patients, conventional US images appeared normal. The addition of contrast-enhanced US improved sensitivity for the detection of individual metastases from 71% to 87% (P <.001). On a patient basis, sensitivity improved from 94% to 98% (P =.44), and specificity improved from 60% to 88% (P <.01). Contrast enhancement improved the subjective conspicuity of metastases in 66 of 75 (88%) patients and the objective contrast by a mean of 10.8 dB (P <.001). Contrast-enhanced US showed more metastases than did CT in seven patients, and CT showed more than did contrast-enhanced US in one of 22 patients in whom an independent reference (magnetic resonance imaging, intraoperative US, or pathologic findings) was available. CONCLUSION: Contrast-enhanced US improved sensitivity and specificity in the detection of hepatic metastases.

Impact of Levovist ultrasonographic contrast agent on the diagnosis and management of hypertensive patients with suspected renal artery stenosis: a Canadian multicentre pilot study.

OBJECTIVES: To compare the diagnoses obtained with unenhanced ultrasonography (US), contrast-enhanced US and captopril-enhanced renal scintigraphy and to determine whether use of a contrast agent improves ability to assess the renal arteries with duplex Doppler US. SUBJECTS AND METHODS: The study was an open-label controlled trial involving 78 patients with hypertension suspected to have a renovascular cause. The patients underwent captopril-enhanced scintigraphy or routine unenhanced US (the usual diagnostic methods at the centres where the study was conducted) and contrast-enhanced US (with Levovist, Berlex Canada, Lachine, Que.). The patients were followed for 3 months after the diagnostic tests were performed. RESULTS: Enhanced US yielded a diagnosis for a significantly greater proportion of patients than did unenhanced US (77 [99%] v. 64 [82%] of 78 patients; p = 0.002) or captopril-enhanced scintigraphy (71 [99%] v. 58 [81%] of 72 patients; p = 0.002). Diagnosis was possible with both enhanced and unenhanced duplex Doppler US in only 64 (82%) of the 78 patients, and the diagnosis was the same with both methods for 63 (98%) of these 64 patients. In contrast, diagnosis was possible for only 58 (81%) of the 72 patients who underwent both enhanced US and captopril-enhanced scintigraphy; the same diagnosis was reported in 53 (91%) of these 58 cases. During follow-up, 11 patients (21 kidneys) underwent angiography. Significant stenosis was detected in 6 (55%) of the patients (8 [38%] of the kidneys). Both the enhanced and unenhanced US results agreed more often with angiography than did captopril-enhanced scintigraphy (9 [82%] v. 8 [73%] of the 11 patients). The proportion of patients in whom the left and right renal artery could be assessed by duplex Doppler US increased significantly (by 58% and 43%, respectively) with use of the contrast agent. CONCLUSION: Enhanced US had a higher rate of successful diagnosis than unenhanced US and captopril-enhanced renal scintigraphy. Enhanced US might therefore be suitable as a screening method for hypertensive patients with suspected renal artery stenosis.

Economic impact of an ultrasonographic contrast agent on the diagnosis and initial management of patients with suspected renal artery stenosis.

OBJECTIVES: To determine resource use in the diagnosis and management of Canadian hypertensive patients with suspected renal artery stenosis and to estimate the impact of diagnosis with contrast-enhanced duplex Doppler ultrasonography (US) on resource use. SUBJECTS AND METHODS: Seventy-eight patients with suspected renal artery stenosis underwent usual diagnostic tests (captopril-enhanced renal scintigraphy or duplex Doppler US) and contrast-enhanced US. A management pathway ("planned") describing the medical resources required for further patient care was outlined on the basis of results from each test (separately), and a modified management pathway ("recommended"), which considered data from both diagnostic methods, was also outlined. Medical resources and productivity losses were assessed prospectively for a 3-month period after patients underwent both tests ("actual" management pathway). RESULTS: With usual diagnostic methods, 14 (18%) of the tests were inconclusive, whereas only 1 (1%) of the enhanced US examinations was inconclusive; the cost-efficacy ratio was $422 and $343 per successful diagnosis, respectively. Further management costs for patients with an inconclusive diagnosis were estimated at $6370 after the usual diagnostic tests, but only $1278 with enhanced US. Although the costs of the planned and recommended management pathways were similar ($227 and $294 per patient respectively), the proportion of patients requiring further resources was lower with enhanced US (56% v. 46%). Three-month actual management costs ranged from $121 to $1605 per patient (mean $360). Diagnostic tests and surgical procedures were the major cost drivers in all pathways, and costs were highest for patients in whom stenosis was diagnosed. CONCLUSIONS: For patients with suspected renal artery stenosis, contrast-enhanced US had a higher diagnostic success rate than usual diagnostic methods and afforded savings through lower administrative costs and lower medical resource consumption for patients whose diagnosis was unclear after usual diagnostic tests.