Indocyanine Green as a Beacon Light in Laparoscopy: A New Application in Transplant Surgery: A Case Report.

INTRODUCTION: Indocyanine green (ICG) fluorescence imaging system is a now a consolidated complementary technique for several surgical fields. The development of post-transplant lymphocele following lymph spread could affect kidney function; between therapeutic options, the literature reports a 12% overall conversion rate from laparoscopic to open surgery with a major risk of damaging the urinary tract. OBJECTIVE: The goal of the present study was to demonstrate that intraoperative ICG fluorescent imaging is a safe technique that can be used in laparoscopy establishing the exact location of the lymphocele and reducing intraoperative risks. METHOD: Fifty milligrams of ICG dissolved in 20 mL of saline solution was injected via percutaneous drainage placed into the lymphocele to decompress transplanted kidneys 2 weeks before a laparoscopic lymphocele marsupialization procedure. RESULTS: During the first exploratory laparoscopy, in the flank and right iliac fossa, near the 2 renal grafts, fluorescence was identified in 3 raised areas that were the internal side of the lymphocele lobes. The lymphocele wall was dissected and 300 mL of serous fluid was aspirated after puncturing. A 5 cm breach was then made in the cyst wall using the Ultracision harmonic scalpel (Ethicon US). Afterwards, a pedicle of the omentum in the lymphocele core was interfered with and fixed by 2 stitches. CONCLUSIONS: Laparoscopic surgery seems to be the preferred surgical option for the treatment of primary symptomatic lymphocele after kidney transplantation. Intraoperative ICG fluorescent imaging is a safe technique to establish the exact location of the lymphocele and reduces the risk of damaging urinary structures during surgery.

Antivirus immune activity in multiple sclerosis correlates with MRI activity.

OBJECTIVE: The objective of this study was to determine whether reactivation of Epstein-Barr (EBV) or activation of the anti-EBV immune response correlates with MS disease activity on MR imaging. METHODS: Subjects with early, active relapsing-remitting MS were studied for 16 weeks with blood and saliva samples collected every 2 weeks and brain MRI performed every 4 weeks. We isolated peripheral blood mononuclear cells from each blood sample and tested the immune response to EBV, autologous EBV-infected lymphoblastoid cell lines (LCL), human herpesvirus 6 (HHV6), varicella zoster virus (VZV), tetanus, and mitogens. We measured the proliferative response and the number of interferon-γ secreting cells with ELISPOT. We measured the amounts of EBV, HHV6, and VZV DNA in blood and saliva with quantitative PCR. On MRI, we measured number and volume of contrast enhancing and T2 lesions. We tested for correlation between the immunologic assays and the MRI results, assessing different time intervals between the MRI and immunologic assays. RESULTS: We studied 20 subjects. Ten had enhancing lesions on one or more MRI scans and one had new T2 lesions without enhancement. The most significant correlation was between proliferation to autologous LCL and the number of combined unique active lesions on MRI 4 weeks later. Both proliferation and number of cells secreting interferon-γ in response to LCL correlated with the number of enhancing lesions 8 weeks later. CONCLUSIONS: We find evidence for correlation of antiviral immune responses in the blood with subsequent disease activity on MRI scans.

How social context impacts on the development, identification and treatment of mental and substance use disorders among young people - a qualitative study of health care workers.

Introduction Social context has a major influence on the detection and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas, particularly where gang culture, community violence, normalisation of drug use and repetitive maladaptive family structures prevail. This paper aims to examine how social context influences the development, identification and treatment of youth mental and substance use disorders in socioeconomically disadvantaged urban areas from the perspectives of health care workers. METHOD: Semi-structured interviews were conducted with health care workers (n=37) from clinical settings including: primary care, secondary care and community agencies and analysed thematically using Bronfenbrenner's Ecological Theory to guide analysis. RESULTS: Health care workers' engagement with young people was influenced by the multilevel ecological systems within the individual's social context which included: the young person's immediate environment/'microsystem' (e.g., family relationships), personal relationships in the 'mesosystem' (e.g., peer and school relationships), external factors in the young person's local area context/'exosystem' (e.g., drug culture and criminality) and wider societal aspects in the 'macrosystem' (e.g., mental health policy, health care inequalities and stigma). CONCLUSIONS: In socioeconomically disadvantaged urban areas, social context, specifically the micro-, meso-, exo-, and macro-system impact both on the young person's experience of mental health or substance use problems and services, which endeavour to address these problems. Interventions that effectively identify and treat these problems should reflect the additional challenges posed by such settings.

Youth mental health in deprived urban areas: a Delphi study on the role of the GP in early intervention.

BACKGROUND: GPs, as healthcare professionals with whom young people commonly interact, have a central role in early intervention for mental health problems. However, successfully fulfilling this role is a challenge, and this is especially in deprived urban areas. AIMS: To inform a complex intervention to support GPs in this important role, we aim to identify the key areas in which general practice can help address youth mental health and strategies to enhance implementation. METHODS: We conducted a modified Delphi study which involved establishing an expert panel involving key stakeholders/service providers at two deprived urban areas. The group reviewed emerging literature on the topic at a series of meetings and consensus was facilitated by iterative surveys. RESULTS: We identified 20 individual roles in which GPs could help address youth mental health, across five domains: (1) prevention, health promotion and access, (2) assessment and identification, (3) treatment strategies, (4) interaction with other agencies/referral, and (5) ongoing support. With regard to strategies to enhance implementation, we identified a further 19 interventions, across five domains: (1) training, (2) consultation improvements, (3) service-level changes, (4) collaboration, and (5) healthcare-system changes. CONCLUSIONS: GPs have a key role in addressing youth mental health and this study highlights the key domains of this role and the key components of a complex intervention to support this role.

The external review of quality improvement in health care organizations: a qualitative study.

OBJECTIVE: To explore the use of external approaches to quality improvement in health care organizations, through a descriptive evaluation of the process and impact of external reviews of clinical governance arrangements at health care provider organizations in the National Health Service (NHS) in England. DESIGN: A qualitative study, involving the use of face-to-face and telephone interviews with senior managers and clinicians in health care provider organizations and with members of a regional clinical governance review team. SETTING: The West Midlands region of England, in which there are 47 NHS trusts (health care provider organizations). STUDY PARTICIPANTS: A total of 151 senior clinicians and managers at NHS trusts in the West Midlands and 12 members of a specially constituted regional clinical governance review team. INTERVENTION: Clinical governance review visits which were undertaken by the regional clinical governance review team to all NHS trusts between April 1999 and February 2000. Interviews with senior managers and clinicians took place before and after the review visits had taken place; interviews with members of the clinical governance review team took place when they had undertaken most of their visits. RESULTS: The prospect of external review produced mixed reactions in health care provider organizations, and preparing for such a review was a substantial and time-consuming task. The review itself was often productive, although differences in attitudes and expectations between health care provider organizations and review team members created tensions, especially when the results of the review were reported back. External reviews rarely generated wholly new knowledge, were more confirmatory than revelatory, and did not usually lead to major changes in policy, strategy or practice. CONCLUSIONS: External review systems are widely used in health care to promote quality improvement in health care provider organizations, but their effectiveness is little researched and the optimal design of systems of external review is not well understood. More attention to the design and impact of external review would help to maximize its benefits and minimize costs and adverse effects.

Organisational strategies for changing clinical practice: how trusts are meeting the challenges of clinical governance.

OBJECTIVES: To describe the use, perceived effectiveness, and predicted future use of organisational strategies for influencing clinicians' behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. DESIGN AND SETTING: Whole population postal survey conducted between March and June 1999. SUBJECTS: Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. METHOD: A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/no) and Likert type ratings were used to assess the use, perceived effectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. RESULTS: All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as effective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as effective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be effective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived effectiveness. Barriers to change included lack of resources, mainly of money and staff time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). CONCLUSIONS: Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived effectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are effective from their own data and from external comparison.

Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior.

The aim of this study was to identify factors associated with vocally disruptive behavior (VDB) in nursing home patients referred to aged care services for treatment, using a case-control methodology. Characteristics of the VDB, reasons for referral, perceived causal factors, and psychotropic use were noted. Twenty-five subjects and controls were examined with the Screaming Behavior Mapping Instrument, the Cornell Scale for Depression in Dementia, the Dementia Behavior Disturbance Scale, and measures of cognition, functional capacity, social activities, and emotional reactions of nursing staff. VDB was associated with other disturbed behaviors, depression, anxiety, severe dementia, functional impairment, communication difficulties, use of psychotropic medication, social isolation, and emotional distress in the nursing staff. Reasons for referral may relate more to the stress experienced by nursing home staff in managing VDB than to specific attributes of the VDB itself.

Clinical governance. Scope to improve.

A survey of all 47 trusts in the West Midlands found that clinical governance had not been advanced beyond the production of strategies, establishing committees and appointing leads. There is little evidence of the cultural change clinical governance requires. Clinical governance has yet to make a real difference at the clinical workface.

Preanesthetic evaluation.

A thorough preanesthetic evaluation is the most important function an anesthesiologist can perform to prevent anesthetic morbidity and mortality and ensure a smooth course of anesthetic administration. This evaluation is best accomplished by a thoughtful review of the patient's history, examination of the patient's airway, and anticipation of the effect of anesthesia on the patient.

Biotechnologies and acute hepatic failure.

Orthotopic liver transplantation survival for patients with acute liver failure is poor (50%). Mortality on the waiting list is high due to the lack of donors. For these reasons, the possibility of sustaining hepatic function by extra-corporeal liver perfusion must be considered. In this experimental research, two groups of pigs have been submitted to total de-vascularisation of the liver causing acute hepatic failure. In the first group (4 pigs) no extra-corporeal assistance has been used after total de-vascularisation. All pigs died between 16 and 33 hours after the acute hepatic failure was induced. In the second group (8 pigs) after complete hepatic de-vascularisation an extra-corporeal hepatic support by continuous allo-perfusion of isolated liver was performed using the Abouna-Costa extra-corporeal circuit. All pigs were observed during the acute hepatic failure which lasted from 6.30 to 7.30 hours. The data that were more positively influenced by the extra-corporeal assistance were ammonia and lactates that improved after the application of hepatic assistance.