Pre-hepatectomy portal vein embolization: single center experience.

AIM: To evaluate the feasibility and the effectiveness of portal vein embolization (PVE) as preoperative treatment in patients scheduled to undergo right hepatectomy, when the volume of the future remnant liver (FRL) appears to be insufficient to prevent the risk of post-surgical hepatic failure. MATERIALS AND METHODS: Thirty-one consecutive patients (19 men, 12 women; age range: 54-77 years; mean age: 66.2 years) with liver malignancy (7 hepatocellular carcinoma, 13 metastases, 9 cholangiocarcinoma, and 2 gallbladder carcinoma) were selected after clinical-radiological evaluation for PVE. After the embolization changes in volume of FRL, portal pressure, liver enzymes, and complications before and after hepatectomy were assessed. RESULTS: PVE was successful in all patients without major complications. The mean volume of FRL, calculated before and 4 weeks after PVE, increased from 319.2 +/- 45.1 to 460.2 +/- 27.7 cm(3) (+44.2%) in the non-cirrhotic group and from 458.4 +/- 38.3 to 605.2 +/- 27 cm(3) (+32.1%) in the cirrhotic group. The FRL/TELV ratio increased by 9%. CONCLUSION: In our experience, PVE resulted feasible, safe, with a very low rate of complications, and effective to induce liver regeneration before right hepatectomy in patients with liver malignancy.

[Laparoscopic surgery of adrenal gland metastasis: case report]. / La chirurgia laparoscopica delle metastasi surrenaliche: case report.

OBJECTIVE: Laparoscopic adrenalectomy is unanimously recognised as the gold standard for the surgical treatment of adrenal lesion. Also the role of laparoscopic adrenalectomy (LA) for metastasis is controversial. This study, in according with literature dates, aimed to confirm that patients are most likely to have prolonged survival after resection of adrenal metastases and confirms that oncological outcome of laparoscopic adrenalectomy are similar with open adrenalectomy. PATIENT AND METHODS: The study included patients who underwent LA from 2000 to 2005. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structure, or solitary metastases with well-controlled primary cancer. The variable evaluated were port-site and intra-addominal recurrence, distant metastasis and survival time. Primary tumors were the followings: lymphoma non-Hodgkin, lung cancer. Patients age was mean 69 (range, 62-77), the lesions were at right adrenal gland. No conversion to open surgery occurred. No complication were observed. Mean operative time was 100 minutes (range, 90-110). No postoperative complication occurred. Mean diameter of the tumor was 4.5 cm (range, 4.2-4.8 cm). Tumor free margins were obtained. Mean hospital stay was 3 day. At follow-up mean of ten months (eight-twelve months) there was any sight of distant metastases and the patient was alive. CONCLUSION: LA seems to be a feasible option if the principles of oncological surgery are respected. Adrenalectomy for metastasis, with intent to prolong survival, should be offered to patient with favourable tumor biology, such as those with significant DFI.

The diffusion of decision support systems in healthcare: are we there yet?

Clinical decision support (CDS) systems, with the potential to minimize practice variation and improve patient care, have begun to surface throughout the healthcare industry. This study reviews historic patterns of information technology (IT) in healthcare, analyzes barriers and enabling factors, and draws three lessons. First, the widespread adoption of clinical IT, including CDS systems, depends on having the right organizational and individual financial incentives in place. Second, although CDS systems and clinical IT in general are powerful tools that can be used to support the practice of medicine, they alone cannot redefine the workflow or processes within the profession. Healthcare managers counting on technology to restructure or monitor clinicians' work patterns are likely to encounter substantial resistance to CDS systems, even those that generate valuable information. Third, while the pace of implementing IT systems in healthcare has lagged behind that of other industries, many of the obstacles are gradually diminishing. However, several factors continue to inhibit their widespread diffusion, including the organizational turmoil created by large numbers of mergers and acquisitions, and the lack of uniform data standards.

[Unusual pathology of the spleen]. / Patologie non frequenti della milza.

The Authors report 7 cases of unusual spleen pathology represented by 2 real cysts, 1 pseudocyst, 1 hydatid cyst, 2 abscesses, 1 splenic artery aneurysm. Pathophysiological hypotheses are examined, and clinical and diagnostic considerations are stressed, evaluating particularly anatomo-histologic characteristics and the differential diagnosis through non invasive imaging techniques. All patients were subjected to splenectomy via laparotomy, except for the case of real cyst where an inferior hemisplenectomy was performed. In the case of splenic artery aneurysm, an urgent aneurysmectomy was required together with splenectomy, considering the young age of the patient (29 years old), and the type of aneurysm presenting in a double rupture phase. Reoperation was necessary in only one patient to drain an hematic abscess. After a 9 year follow up all the patients are well.

Choosing a health plan: do large employers use the data?

Significant private and public resources go into the production of various types of performance measures: from patient satisfaction with nonclinical service to clinical outcomes. While recent investigations have focused on the effect of clinical outcomes information on clinical practice, almost no work examines its effect on purchasers' decisions. This study examines how large employers use performance information, including clinical outcomes, in purchasing decisions. Representatives of thirty-three large employers that purchase for 1.8 million covered lives were interviewed in early 1997. Findings suggest that purchasers are not always aware of clinical outcomes data and that measures do not meet their decision-making needs. Further, the variety and amount of performance information to process for purchasing decisions is a barrier to effective decision making. Recommendations for supporting purchasers' use of performance information, especially clinical outcomes data, are included.

[Gynecomastia]. / Ginecomastia.

Gynaecomastia is a benign enlargement of the male breast commonly occurring in healthy adolescent boys and in adults (50 to 80 years old). It is a source of cosmetic and psychologic problems. The secondary forms usually require no therapy other than the removal of any identified inciting cause. Most of the idiopathic forms last only a few months and then gradually disappear. In secondary gynaecomastia and idiopathic forms present for more than 12 months a medical hormonal treatment often fails and the only therapy is surgery consisting in a subtotal subcutaneous mastectomy. In the last years the surgical treatment is often completed with suction lipectomy: this procedure reduces the surgical traumatism. The authors present their experience concerning 47 patients: 27 were surgical treated with subcutaneous subtotal mastectomy and 18 had an abjunctive liposuction treatment with good results.

Carotid bifurcation stenosis: a comparative study between MR angiography and duplex scanning with respect to digital subtraction angiography.

PURPOSE: This study compared sensitivity, specificity and diagnostic accuracy of Echoduplex and Magnetic Resonance Angiography (MRA) in the evaluation of carotid bifurcation stenosis. MATERIAL AND METHODS: Twenty-five patients with clinical signs suggestive for cerebrovascular insufficiency (CVI) were studied with Duplex scan, MRA and Digital Subtraction angiography (DSA). Gold standard was the angiographic examination. RESULTS: on equal value of sensitivity (80.5%), MRA showed 96% specificity versus 81% of Duplex scan, 89.4% diagnostic accuracy versus 80.9% for Duplex scan. As for stenosis over 31%, the value of sensitivity did not change i.e., 80.5%; MRA showed 100% specificity versus 97.1% for Duplex, 91.2% diagnostic accuracy versus 89.1% respectively. These values compared by the test for categorial analysis and correspondence analysis (p < 0.05) did not indicate any statistically significant difference. DISCUSSION: on the basis of our experience and as shown by current literature [2, 12] we can state that both MR-angiography and Duplex scan fail in quantifying correctly carotid stenosis with consequent over- and underestimation [3, 4]. However, they can be considered effective diagnostic procedures in a screening program [12, 16]; they are accurate, safe and accepted by the population. CONCLUSIONS: on the basis of the cost in planning the screening of a population at risk for CVI, Duplex scanning is still to be considered the elective procedure.

Developing leaders vs training administrators in the health services.

In these difficult times, health care institutions need leaders, not simply managers. Leaders' breadth of skills and perspective come from understanding the values involved in health care delivery; managers know the right way to do things, but leaders know which are the right things to do. Schools of public health are moving away from their potential contribution to leadership development in health services administration. The result is a lack of accountability to the community. Leadership skills and an examination of values should be part of health services administration programs in schools of public health, which should see their mission as helping to identify and train leaders, not simply technical specialists in management.

[Carotid thromboendarterectomy. The authors' personal experience]. / La tromboendoarteriectomia carotidea. Esperienza personale.

Carotid endarterectomy is the most frequently employed surgical intervention in the treatment of strokes due to atherosclerosis obstruction of the blood flow in extracranial carotid district. The presence of cerebrovascular clinical symptoms is accepted indication for surgical treatment. For the patients without symptoms there is, however, not yet a complete agreement on the treatment modalities. The authors believe that, due to the low morbidity and mortality of carotid endarterectomy, a surgical approach can be used in patients in which is present a degree of stenosis > 75% and, moreover, in patients where the degree of stenosis is > 50%, but in which the atherosclerotic plaque is non homogeneous due to the presence of ulceration or hemorrhage. Non invasive ultrasonic techniques constitute the mainstay of the diagnostic procedures for carotid artery disease and in recent years they have led to improved sensitivity and ability in differentiating between the operable carotid stenoses and the inoperable obstructions. With these techniques it is possible to arrive to a 90% diagnostic accuracy. Also the recently introduced angio-RM has comparable results, but the high costs do not make it possible to use it in screening procedures. Many doubts are present regarding the possibility of evaluating the occurrence of neurologic deficits during the surgical procedures. Local anaesthetic techniques are somewhat popular among vascular surgeons in that they allow an immediate evaluation of the neurologic activity of the patients during surgical treatment. However reports have been published in the literature of neurologic deficits arising after the period of test occlusion.

The treadmill test in the assessment of peripheral arterial occlusive disease.

Results of a study using the treadmill test on 32 patients with peripheral Fontaine's stage II arterial disease are described. The aim of the study was to evaluate the utility of the test in assessing useful information concerning the site of the lesion. Patients were divided in three classes depending on the arterial segment involved (iliac-femoral, femoro-popliteal, associated lesions) as resulted from the velocimetric and angiographic evaluation. Ankle pressure and WI, at rest and after stress test, PFWD and RT were evaluated. The authors conclude that data achieved with the dynamic test are related to the arterial involvement, allowing to differentiate obstructive and stenotic lesions, but do not give information concerning the site of the lesion. Nevertheless it is a valuable means of highlighting arterial lesions well compensated at rest and with normal pressure values.

Changes in Connecticut hospital use rates: have small-area variations been affected?

This paper examines the extent to which changes (prospective payment, alternative delivery systems, etc.) in the hospital environment and the general decline in hospital days affect small-area variations in hospital use rates for 18 selected diagnoses in nine hospital service areas in Connecticut. After adjusting for coding changes between DRGs, we found that variation across the service areas did not, in general, differ for any one of the years 1981-86. In one instance (cardiac catheterization), however, we found that a DRG-specific change in knowledge and technology decreased the extent of small-area variation for that diagnosis.

Clinical evaluation of defibrotide in the treatment of arterial and venous vascular disease. A preliminary report.

Defibrotide is a new compound with antithrombotic and profibrinolytic activity. It increases the endogenous fibrinolytic activity by promoting the cellular activator of plasminogen from endothelial cells and by decreasing the concentration of its inhibitors. In this study we evaluated a total of 223 patients for a mean period of 43 days for the following vascular conditions: (a) superficial venous thrombosis; (b) prophylaxis against deep venous thrombosis; (c) peripheral vascular disease (ischaemic foot and intermittent claudication; (d) prophylaxis against TIAs in patients with carotid plaques determining embolization; (e) treatment of venous ulcerations determined by chronic venous incompetence; (f) patients with Raynaud's phenomenon and disease. The tolerability observed was good. No side effects were observed even in more prolonged treatments. The overall efficacy was good for all groups especially in comparison with other treatment already in use for these vascular conditions. In conclusion defibrotide is a particularly useful drug in these vascular diseases and can be used both for acute and chronic treatments.

Evaluation of flow in nodular tumors of the breast by Doppler and duplex scanning.

Evaluation of flow in nodular tumors of the breast may be performed by Doppler and computerized frequency analysis. In 46 nodules of the breast (22 malignant) the nodular flow velocity and frequency analysis revealed a faster flow with a significantly higher peak frequency and mean velocity. The intensity of sound which may be considered an index of the entity of flow in the nodule was larger than that observed in the normal surrounding breast tissue. In malignant nodules and generally in fast growing nodules the flow velocity and intensity was even larger. The flow intensity and velocity was also well correlated with the growth rate as reported by single patients. In elder patients a slow rate of growth even in tumors of larger size was associated with a significantly increased flow in comparison with the normal breast tissue but this increase was not particularly large when compared with fast growing nodules in younger subjects. In conclusion the evaluation of flow characteristics (mainly velocity, frequency analysis and intensity) may be a useful index of the growth rate of nodular tumors of the breast and these data may be useful to evaluate and monitor the evolution and pathophysiology of these nodules.

Evaluation of the effects of elastic compression in patients with chronic venous hypertension by laser-Doppler flowmetry.

The evaluation of the effects of elastic compression in patients with venous hypertension and perimalleolar ulceration may be performed using laser-Doppler flowmetry (LDF). This technique may reveal microcirculatory positive variations which are not evident by standard methods as Doppler, plethysmography and ambulatory venous pressure (AVP). In this study we demonstrated the good correlation between AVP values and laser-Doppler parameters, particularly the resting flow and the venous vasomotor response. Also the response of the skin of the perimalleolar region to a local increase of skin temperature was well correlated with AVP parameters. By evaluation of laser-Doppler parameters it was possible to differentiate normals from abnormals (patients with venous hypertension) and it was possible to show variations of microcirculation associated with the decrease of the areas of ulceration after 3 week elastic compression. No significant variations have been recorded by AVP before and after 3 weeks of treatment with elastic compression in 80 patients with venous ulcerations. Laser-Doppler flowmetry was useful to evaluate the positive changes produced by elastic compression.

Smoking among Yale medical school faculty.

A 1985 survey of a random sample of faculty at the Yale University School of Medicine investigated smoking prevalence and attitudes. The overall prevalence of cigarette smoking was estimated to be 9.8 percent, much lower than the prevalence in the general population. A higher proportion of women than men were current cigarette smokers. With regard to department affiliation, surgeons were most frequently current cigarette smokers, with psychiatrists having the lowest prevalence of current cigarette smoking and the highest percentage of people who had never smoked. In general, attitudes toward smoking were negative.