The societal impact of individual placement and support implementation on employment outcomes for young adults receiving temporary health-related welfare benefits: a difference-in-differences study

BACKGROUND

Individual placement and support (IPS) is an evidence-based practice that helps individuals with mental illness gain and retain employment. IPS was implemented for young adults at a municipality level through a cross-sectoral collaboration between specialist mental healthcare, primary mental healthcare, and the government funded employment service (NAV). We investigated whether IPS implementation had a causal effect on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation (work assessment allowance, WAA) welfare benefit, measured at the societal level compared to municipalities that did not implement IPS.

METHOD

We used a difference in differences design to estimate the effects of IPS implementation on the outcome of workdays per year using longitudinal registry data. We estimate the average effect of being exposed to IPS implementation during four-years of implementation compared to ten control municipalities without IPS for all WAA recipients.

RESULTS

We found a significant, positive, causal effect on societal level employment outcomes of 5.6 (p = 0.001, 95% CI 2.7-8.4) increased workdays per year per individual, equivalent to 12.7 years of increased work in the municipality where IPS was implemented compared to municipalities without IPS. Three years after initial exposure to IPS implementation individuals worked, on average, 10.5 more days per year equating to 23.8 years of increased work.

CONCLUSIONS

Implementing IPS as a cross sectoral collaboration at a municipality level has a significant, positive, causal, societal impact on employment outcomes for all young adults in receipt of a temporary health-related rehabilitation welfare benefit.

Changes in health-related rehabilitation trajectories following a major Norwegian welfare reform

BACKGROUND

In this study we investigated the health-related rehabilitation trajectories of young Norwegian adults between 2004-2019. The study period is interesting because it overlaps with an extensive welfare system reform that occurred in Norway between 2006-2011. In parallel with the reform there was a substantial increase in health-related welfare dependency among young people due to mental health conditions. To better understand this group, we addressed three questions: 1) what were the most typical health-related rehabilitation trajectories for young Norwegians aged 23-27 between 2004-2019, 2) did the trajectories and composition of health-related benefit recipients change overtime and 3) in parallel with the welfare reform, do we see improved labour market outcomes in our study population?

METHODS

Using high-quality Norwegian registry data, we established four cohorts of Norwegian health-related rehabilitation benefit recipients aged 23-27 in either 2004 (cohort 1), 2008 (cohort 2), 2011 (cohort 3) or 2014 (cohort 4). The follow-up period for each cohort was six years. We used sequence and cluster analyses to identify typical health-related rehabilitation trajectories. In addition, descriptive statistics and multinomial logistic regression were used to scrutinise the relationship between trajectory types, sociodemographic characteristics and cohort membership.

RESULTS

The majority follow trajectories consisting of welfare dependency, unemployment and unstable, low-income work. Both the trajectories and composition of the study population changed across cohorts. Over the observation period there was a 1) three-fold increase in the proportion following a trajectory ending in permanent disability benefits, 2) nine-fold increase in the proportion following trajectories characterised by long periods of health-related rehabilitation, 3) five-fold decrease in the share following unemployment occupational handicap trajectories 4) 6.9% increase in the proportion of early school leavers and 5) 8.9% decrease in the share with disabled parents.

CONCLUSION

Our study population is a vulnerable group with suboptimal mental health, functioning and employment outcomes. In conjunction with the welfare reform, we witnessed a significant drop in use of work-related benefits, accompanied by a substantial increase in uptake of health-related rehabilitation- and disability benefits. Thus, it appears that rather than improving employment outcomes, welfare policy changes have created a new problem by steering a greater proportion into disability benefits.

Genomic landscape of treatment refractory metastatic colorectal cancer

BACKGROUND

Metastatic colorectal cancer (mCRC) is a complex and heterogeneous disease with few standard and targeted treatment options. Next-generation sequencing of tumor tissue was performed to identify cancer driver mutations to discover possible personalized treatment options, as targeted treatment possibilities are limited for this patient population. Results of genomic sequencing in patients with treatment-refractory mCRC are described in this retrospective analysis.

MATERIAL AND METHODS

Clinico-pathological characteristics and genomic sequence results of consecutive patients with refractory mCRC, referred to the Experimental Cancer Therapy Unit (ECTU) at Department of Oncology, Herlev & Gentofte Hospital in the period from 1 October 2015 to 14 December 2018 were reviewed in this retrospective analysis. Tumor tissue from the patients was analyzed by next-generation sequencing using the Oncomine Comprehensive primer panel to detect actionable variants of cancer driver mutations and microsatellite instability status. From August 2018 tumor mutational burden was also analyzed.

RESULTS

A total of 80 patients with treatment-refractory mCRC and in a fairly good performance were referred to the ECTU during this period. Genomic sequencing of tumor tissue was performed for all 80 patients and a cancer driver mutation was identified in 90% (n = 72) of the patients. A total of 31.3% (n = 25) of the patients received therapy either as targetable therapy outside an available trial (n = 2), FDA approved therapy (n = 2), or treatment in phase 1 or 2 trials, independent of the genomic signature 26.3% (n = 21).

CONCLUSION

Most mCRC patients refractory to standard anti-neoplastic therapies, presented with a cancer driver mutation, however, only a few of these mutations gave rise to matched therapies as only 2.5% of the patients from this period received targeted therapy.

Immigration and Integration Policy and Labour Market Attainment Among Immigrants to Scandinavia

Insufficient integration of immigrants into the labour market has been identified as a major problem in the Scandinavian countries Denmark, Norway and Sweden. Integration depends, inter alia, on immigration and integration policy, and for most of the post-war period the policies of the three countries displayed strong similarities. However, in the early 2000s Denmark increasingly deviated from its two neighbours, introducing more restrictive immigration and stricter integration policies. Comparing both pre- and post-reform immigrants across Scandinavia, we assess the wider impact of this comprehensive policy reversal by tracking the evolution of employment and earnings gaps between 1993 and 2006. We use large data sets with individual-level register information allowing us to account for immigrant labour force composition and to examine sub-groups of immigrants. The results do not indicate that the Danish reforms had any clear-cut effect on either employment or earnings among non-Western immigrants. Moreover, integration in Norway and Sweden was not unequivocally worse despite the absence of similar reforms, raising questions regarding the aptness of the Danish reversal.

Percutaneous Gastrostomy Guided by Ultrasound and Fluoroscopy

Percutaneous gastrostomy, utilizing a dedicated catheterization kit, with a combination of ultrasonographic (US) and fluoroscopic guidance, was carried out in 27 patients. The main indication for gastrostomy was the need for nutritional support in malignant esophageal stricture. After distending the stomach with water via a nasogastric tube, the gastric antrum was punctured under US guidance and a guide wire was inserted, followed by fluoroscopically guided tract dilatation and insertion of a 2.5-mm Cope-loop catheter. In all patients but one (96%) the procedure was successfully completed in one or 2 attempts. Two complications occurred: one case of a small subcutaneous abscess near the puncture site, and one late incident of dislodgement of a catheter without string-loop fixation, which had been inserted at a catheter exchange after 6 weeks. Percutaneous gastrostomy guided by US and fluoroscopy is a safe and efficacious alternative to endoscopic and surgical gastrostomy.

Artificial Urinary Sphincters

A small selected group of patients with urinary incontinence can be treated effectively with an artificial urinary sphincter. Since the fluid in the hydraulic system of this device is radiopaque, radiography is useful in its evaluation. An immediate postoperative radiogram should be performed to control the position and integrity of the system. It also serves as a useful baseline study in case of later complications. It should include radiograms both in the deactivated and activated state. A few cases of tube kinking may be overlooked when exposures in only one projection are used. Experience with 110 implanted sphincters is presented.

Ultrasonically Guided Insertion of a Peritoneo-Gastric Shunt in Patients with Malignant Ascites

Purpose:

A new method for internal drainage of malignant ascites is presented in 5 patients with symptomatic malignant ascites.

Material and Methods:

US-guided percutaneous gastrostomy and paracentesis were performed using the Seldinger technique. A 2.5-mm Cope-loop catheter was inserted in the fluid-filled stomach. In the lower abdomen the proximal part of a Denver peritoneo—venous shunt was introduced after dilation up to 4.8 mm. The pump chamber was sutured to the skin. The distal part of the Denver shunt was cut a few cm from the pump chamber and connected to the gastrostomy catheter. When pumping, ascites is shunted to the stomach lumen.

Results:

The insertion presented no complications, and all shunt systems initially functioned well. However, the shunts had to be removed within the first 2 weeks because of mechanical problems such as clotting, leakage, and peritoneal septum formation. No infections were reported.

Conclusion:

The peritoneo—gastric shunt may present a therapeutic alternative in selected patients, but the mechanical problems have first to be solved.

Transrectal Ultrasound Findings of Prostate Cancer Mimicking Primary Rectal Tumor

Two patients with disseminated prostatic cancer underwent transrectal ultrasonographic examination. In the rectal wall, at the prostatic level, tumor infiltration was seen without obvious communication to the prostate. Biopsy demonstrated adenocarcinoma, and immunohistochemic staining for prostatic specific antigen (PSA) was positive. We recommend the application of PSA staining in biopsy specimens of unclear rectal masses.

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V - EUS-Guided Therapeutic Interventions (short version)

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V

The fifth section of the Guidelines on Interventional Ultrasound (INVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) assesses the evidence for all the categories of endoscopic ultrasound-guided treatment reported to date. Celiac plexus neurolysis and block, vascular intervention, drainage of fluid collections, drainage of biliary and pancreatic ducts, and experimental tumor ablation techniques are discussed. For each topic, all current evidence has been extensively analyzed and summarized into major recommendations for reader consultation in clinical practice (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided Interventions: General aspects and EUS-guided sampling (Long Version)

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part IV - EUS-guided interventions: General Aspects and EUS-guided Sampling (Short Version)

The fourth part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound describes general aspects of endoscopic ultrasound-guided diagnostic and therapeutic interventions and assesses the evidence for endoscopic ultrasound-guided sampling. Endoscopic ultrasound combines the most advanced high-resolution ultrasound imaging of lesions within the wall and in the vicinity of the gastrointestinal tract and safe and effective fine needle-based tissue acquisition from these lesions. The guideline addresses the indications, contraindications, techniques, adverse events, training and clinical impact of EUS-guided sampling. Advantages and drawbacks are weighed in comparison with image-guided percutaneous biopsy. Based on the most current evidence, clinical practice recommendations are given for crucial preconditions and steps of EUS-guided sampling as well as for safe performance. Additionally, the guideline deals with the principles and reliability of cytopathological reporting in endoscopic ultrasound-guided sampling (short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Long Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound (INVUS) assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, and safe and effective performance of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part III - Abdominal Treatment Procedures (Short Version)

The third part of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) Guidelines on Interventional Ultrasound assesses the evidence for ultrasound-guided and assisted interventions in abdominal treatment procedures. Recommendations for clinical practice are presented covering indications, contraindications, safety and efficacy of the broad variety of these techniques. In particular, drainage of abscesses and fluid collections, interventional tumor ablation techniques, interventional treatment of symptomatic cysts and echinococcosis, percutaneous transhepatic cholangiography and drainage, percutaneous gastrostomy, urinary bladder drainage, and nephrostomy are addressed (short version; a long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Long Version)

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part II. Diagnostic Ultrasound-Guided Interventional Procedures (Short Version)

This is the second part of the series on interventional ultrasound guidelines of the Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB). It deals with the diagnostic interventional procedure. General points are discussed which are pertinent to all patients, followed by organ-specific imaging that will allow the correct pathway and planning for the interventional procedure. This will allow for the appropriate imaging workup for each individual interventional procedure (Long version/ short version; the long version is published online).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (long Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (long version).

EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part I. General Aspects (Short Version)

This is the first part of the Guidelines on Interventional Ultrasound of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) and covers all general aspects of ultrasound-guided procedures (short version; the long version is published online).

Ectopic decidual reaction mimicking inguinal lymphoma on ultrasound

Ectopic decidual reaction has been described in various intraperitoneal locations. We present a case of unusual ectopic decidual reaction in the groin mimicking inguinal lymphoma on ultrasound in a pregnant woman. This case contributes evidence illustrating the variability of the clinical presentation of ectopic decidual reaction.

The effect of hospital mergers on long-term sickness absence among hospital employees: a fixed effects multivariate regression analysis using panel data

Background

Hospitals are merging to become more cost-effective. Mergers are often complex and difficult processes with variable outcomes. The aim of this study was to analyze the effect of mergers on long-term sickness absence among hospital employees.

Methods

Long-term sickness absence was analyzed among hospital employees (N = 107 209) in 57 hospitals involved in 23 mergers in Norway between 2000 and 2009. Variation in long-term sickness absence was explained through a fixed effects multivariate regression analysis using panel data with years-since-merger as the independent variable.

Results

We found a significant but modest effect of mergers on long-term sickness absence in the year of the merger, and in years 2, 3 and 4; analyzed by gender there was a significant effect for women, also for these years, but only in year 4 for men. However, men are less represented among the hospital workforce; this could explain the lack of significance.

Conclusions

Mergers has a significant effect on employee health that should be taken into consideration when deciding to merge hospitals. This study illustrates the importance of analyzing the effects of mergers over several years and the need for more detailed analyses of merger processes and of the changes that may occur as a result of such mergers.

Microwave ablation of liver metastases guided by contrast-enhanced ultrasound: experience with 125 metastases in 39 patients

PURPOSE

The aim of our study was to evaluate the efficacy of microwave (MW) ablation of liver metastases guided by B-mode ultrasound (US) and contrast-enhanced US (CEUS).

MATERIALS AND METHODS

39 patients (17 women and 22 men) with a total of 125 liver metastases were treated with percutaneous or intraoperative CEUS-guided MW ablation. The primary tumor was colorectal cancer (n = 31), breast cancer (n = 6), carcinoid tumor (n = 1), and gastrointestinal stromal tumor (GIST) (n = 1). The median number of metastases ablated in the 45 treatment sessions was 2 (range 1 - 11). The median size (maximum diameter) of the 125 metastases was 1.5 cm (range, 0.6 - 4.0 cm). Nineteen (15 %) of the 125 metastases were bigger than 2 cm. Metastases smaller than 2 cm were treated with a single needle, metastases bigger than 2 cm were treated with 2 or 3 parallel needles.

RESULTS

The 45 MW ablation sessions were performed percutaneously (n = 30), during laparotomy (n = 3), or during laparotomy combined with liver resection (n = 12). The 39 patients were followed up for at least 4 months with a median duration of 11 months (range, 4 - 20 months). The technical success rate was 100 %. The clinical effectiveness was 100 % with complete coverage of the metastasis by the avascular coagulation zone evaluated on immediate post-ablation CEUS. Local tumor progression (local recurrence) was seen in 12 (9.6 %) of the 125 treated metastases, and affected 10 (26 %) of the 39 patients. One major complication was observed in the form of a liver abscess that easily resolved after percutaneous drainage. Four minor complications were observed: Three cases of pain located at the puncture site and one case of ascites. CEUS was valuable in all phases of ablation including pre-ablation staging and procedure planning, placement of MW needles in the tumor, immediate post-ablation control of coagulation size, and finally in the long term follow-up regime.

CONCLUSION

CEUS-guided MW ablation of liver metastases is an efficient and safe ablation technique with several advantages compared to other ablation modalities.

Percutaneous radiologic gastrostomy with a simplified gastropexy technique under ultrasonographic and fluoroscopic guidance: experience in 154 patients

PURPOSE

To evaluate the effectiveness and safety of percutaneous radiologic gastrostomy (PRG) under ultrasonographic (US) and fluoroscopic guidance using a simplified gastropexy technique.

MATERIAL AND METHODS

One hundred and fifty-four (154) patients (mean age 73, range 22-93 years) were referred for PRG. Indication for PRG was neurologic disease, head/neck cancer, and other disease in 73%, 15%, and 12%, respectively. Initially, the stomach was filled with 300-500 cm3 of tap water via a nasogastric tube. The fluid-filled stomach was punctured under US guidance. A guidewire and a single T-fastener were introduced. Under fluoroscopic guidance, the tract was dilated over the guidewire until a 16F dilator with a peel-away sheath could be introduced. During dilatation, the external suture string to the T-fastener was held tight to fixate the gastric wall. A 14F balloon-retained gastrostomy tube was introduced and inflated. The T-fastener was then released, and the gastrostomy tube was retracted gently to affix the gastric wall to the abdominal wall (tube gastropexy). Technical success was assured by aspiration of gastric fluid and fluoroscopically by injection of a water-soluble contrast medium.

RESULTS

The primary technical success rate was 98%. At 30-day follow-up, 3.2% had major complications and 14% minor complications. Three patients (1.9%) died of complications related to the procedure. Thirteen cases (8%) of simple tube displacement without other complications occurred.

CONCLUSION

PRG guided by US and fluoroscopy is a relatively safe technique with a high success rate, provided the stomach can be properly distended with fluid. However, tube gastropexy alone does not seem to protect against early dislodgement.

Dendritic cell based vaccination in combination with IL-2 as a treatment for advanced renal cell carcinoma patients: Results from a phase I/II trial

2575

Background: Autologous dendritic cells (DC) pulsed with tumor-associated antigens as peptides or tumor lysate derived proteins can induce generation of cytotoxic T-cells in cancer patients. Survivin and telomerase are tumor-associated antigens overexpressed in renal cell carcinoma, and telomerase and survivin derived HLA-A2 binding peptides are able to induce effector T-cells cytotoxic to tumor cells. Tumor lysate can be generated from allogeneic renal carcinoma cell lines and has a natural high amount of antigens potentially enabling the induction of a polyclonal immune response against multiple targets on tumor cells. Methods: Twenty-two patients with progressive metastatic renal cell carcinoma were included and toxicity and efficacy of DC-based immunotherapy were evaluated. HLA-A2 positive patients were treated with mature autologous DCs pulsed with a broad panel of HLA binding telomerase and survivin peptides and PADRE; HLA-A2 negative patients received DCs pulsed with allogeneic tumor lysate and KLH. The vaccines were administered intradermally or intranodally weekly/biweekly ten times and repeated monthly until tumor progression. Patients received low dose IL-2 as an adjuvant. Immune response was monitored using ELISPOT assay. IL-6 and the biomarker YKL-40 were measured in serum using ELISA assay. Results: Vaccinations were well tolerated. 17/22 patients were evaluable and 10 patients had stable disease (SD) for up to 11+ months (range 2–11+ months). Interestingly, serum IL-6 increased in patients with progressive disease compared with a decrease in patients with SD. After vaccination mean values of YKL-40 were 91ng/ml in patients with SD and 208ng/ml in patients with PD. Immune monitoring is ongoing and preliminary data demonstrate that peptide specific CTLs are induced by the treatment. Conclusions: This pilot study demonstrates, that vaccination with autologous DCs pulsed with tumour antigens is safe and without severe toxicity. Disease stabilization was observed in half of the treated patients. Serum IL-6 and YKL-40 values might be useful parameters to predict clinical response during vaccination therapy.

No significant financial relationships to disclose.

Three-dimensional maps of grain boundaries and the stress state of individual grains in polycrystals and powders

A fast and non-destructive method for generating three-dimensional maps of the grain boundaries in undeformed polycrystals is presented. The method relies on tracking of micro-focused high-energy X-rays. It is verified by comparing an electron microscopy map of the orientations on the 2.5 × 2.5 mm surface of an aluminium polycrystal with tracking data produced at the 3DXRD microscope at the European Synchrotron Radiation Facility. The average difference in grain boundary position between the two techniques is 26 µm, comparable with the spatial resolution of the 3DXRD microscope. As another extension of the tracking concept, algorithms for determining the stress state of the individual grains are derived. As a case study, 3DXRD results are presented for the tensile deformation of a copper specimen. The strain tensor for one embedded grain is determined as a function of load. The accuracy on the strain is Δ∊ ≃ 10−4.

Perioperative Doppler ultrasonography: renal detection of renal graft perfusion

Irreversible damage of renal transplants may be prevented if insufficient graft perfusion can be detected perioperatively. Colour and spectral Doppler ultrasonography were performed in 30 consecutive renal transplants. The perfusion of the graft and the Resistive Index (RI) were evaluated perioperatively (perioperatively and less than 15 min postoperatively) and 24 h after the operation in all patients. In four cases (13.3%) RI > 0.9 was detected and immediate surgical correction of the cause led to a normalization (RI < 0.8) in all four cases. A RI < 0.9 required no intervention in 26 cases (86.7%). All renal grafts in this series were functioning 1 month postoperatively. In a comparative group, 30 consecutive transplants carried out at our institution without perioperative Doppler ultrasonography evaluation, a loss of four renal grafts perioperatively was recorded retrospectively. We conclude that perioperative ultrasonography Doppler evaluation may provide an easy applicable and reliable method for early detection of insufficient renal graft perfusion, allowing surgical correction before irreversible damage of the graft occurs. RI > 0.9 is pathological. A continuation of the study is required to clarify the long-term value of perioperative Doppler ultrasonography graft monitoring.

Extracranial arteriovenous malformation diagnosed on color Doppler imaging

Arteriovenous (AV) malformations are rare and may occur at various locations, like in the brain, liver, lungs, or in the subcutaneous tissue. This case report describes an AV malformation from the right occipital artery. The value of combined B-mode ultrasonography and color Doppler mode imaging of masses in the neck region is discussed.

Applications of high-energy synchrotron radiation for structural studies of polycrystalline materials

The large penetration power of high-energy X-rays (>60 keV) raises interesting prospects for new types of structural characterizations of polycrystalline materials. It becomes possible in a non-destructive manner to perform local studies, within the bulk of the material, of the fundamental materials physics properties: grain orientations, strain, dislocation densities etc. In favourable cases these properties may be mapped in three dimensions with a spatial resolution that matches the dimensions of the individual grains. Imbedded volumes and interfaces become accessible. Moreover, the high energies allow better in-situ studies of samples in complicated environments (industrial process optimization). General techniques for research in this energy range have been developed using broad-band angle-dispersive methods, on-line two-dimensional detectors and conical slits. Characterizations have been made at the level of the individual grains and grain boundaries as well as on ensembles of grains. The spatial resolution is presently of the order of 10-100 micom. Four examples of applications are presented along with an outlook.

Radiofrequency tissue ablation with a cooled needle in vitro: ultrasonography, dose response, and lesion temperature

RATIONALE AND OBJECTIVES

Radiofrequency (RF) tissue ablation with a cooled needle electrode (probe) can produce large lesions. By using this technique on ex vivo calf livers, the authors evaluated the role of ultrasound (US), dose response, and temperature course with time.

METHODS

RF ablation was produced with a 14-gauge probe with a 2-cm exposed tip. The lesions were examined with US and macroscopically after various treatment durations. Tissue temperature was measured with thermosensors inserted 1, 2, and 3 cm from the probe.

RESULTS

Before treatment the tip of the probe was easy to visualize with US, but treatment microbubbles obscured the lesion and probe. After treatment, the lesions appeared hypoechoic. Lesion size was underestimated based on US findings. Lesion size was logarithmically correlated to treatment duration. Lesion temperature increased at an increased rate with higher wattage applied and with decreased distance from the probe.

CONCLUSION

US is useful for probe placement before treatment and might be of value after treatment. Lesion size increases reproducibility with treatment duration.

[Phlegmasia alba dolens diagnosed with Doppler ultrasonography]

Differential diagnostic problems may occur in a patient with a cold, pale and swollen leg. Especially when the peripheral blood pressure is reduced, it is particularly difficult to distinguish cases caused by venous thrombosis from those caused by arterial embolism. Colour-Doppler ultra-sonography might be helpful for establishing the correct diagnosis. A case history is presented.

A cooled needle electrode for radiofrequency tissue ablation: thermodynamic aspects of improved performance compared with conventional needle design

RATIONALE AND OBJECTIVES

I developed and tested a cooled needle electrode (CNE) for radiofrequency (RF) tissue ablation in vitro.

METHODS

A 2-mm needle electrode with two lumina for internal water perfusion and irrigation of the needle tip and a conventional needle electrode were tested in ex vivo calf liver during different levels of output power (wattage). RF lesions produced by the two needle types were further evaluated with a thermal camera.

RESULTS

When the CNE was used, a significant increase in the duration of ablation was observed, which caused a significant increase in delivered energy and lesion size when compared with the conventional needle electrode. The largest lesion produced with the CNE was almost spherical and measured 41 x 37 mm (longitudinal x transverse). The cooling effect was reflected in the image obtained with the thermal camera.

CONCLUSION

This technique produced very large lesions compared with conventional methods and may have a role in many different kinds of RF needle ablation.

The loop electrode: in vitro evaluation of a device for ultrasound-guided interstitial tissue ablation using radiofrequency electrosurgery

RATIONALE AND OBJECTIVES

I developed and tested in vitro a device for ultrasound-guided monopolar radiofrequency (RF) electrosurgical interstitial tissue ablation.

METHODS

The current was applied to an electrode with a distal loop form (radius = 1 cm). The superelastic properties of the electrode allowed cannula introduction in the experimental medium (calf liver) before subsequent rotation of the electrosurgical cutting electrode, resulting in cutting off and isolation of a spherical lesion interstitially. The optimal setting of the RF unit and the optimal cutting speed were evaluated. Under ultrasonographic guidance and monitoring, approximately 150 lesions were produced with different loop designs and sizes. The gross appearance was evaluated and correlated to ultrasonography.

RESULTS

An output effect of 200 W was optimal for resection and cutting with the loop electrode. An ellipsoid loop configuration could produce an almost spherical lesion with a diameter of 2.0 cm interstitially. Ultrasonography could guide the introduction of the loop electrode into tissue and visualize the upper part of the lesion.

CONCLUSION

The loop electrode is a technique for percutaneous ultrasonographically guided tissue ablation. It was proved to be efficient in vitro by producing 2-cm liver lesions.

[Ultrasonic angiography: principles and clinical use]

A new technique for detecting blood flow called Colour Doppler Energy (CDE), Power Doppler or Ultrasound Angio, is based on the integrated power spectrum of the standard Doppler signal used for Colour Flow Mapping (CFM). CDE is independent of the insonation angle, has no aliasing artefacts and improves the sensitivity with respect to detection of the presence or absence of flow compared to CFM. However, CDE provides no directional or quantitative information about the flow. CDE is superior to CFM in detection of low velocity flow, perfusion in small vessels, flow in torsioned vessels and flow in multiple vessels in the same image plane. The clinical applications are reviewed. Complicated stenosis, renal perfusion, penile Doppler and scanning of the vessels of the extremities are examples where CDE improves sensitivity in detecting flow compared to CFM.

Ultrasonically guided insertion of a peritoneo-gastric shunt in patients with malignant ascites

PURPOSE

A new method for internal drainage of malignant ascites is presented in 5 patients with symptomatic malignant ascites.

MATERIAL AND METHODS

US-guided percutaneous gastrostomy and paracentesis were performed using the Seldinger technique. A 2.5-mm Cope-loop catheter was inserted in the fluid-filled stomach. In the lower abdomen the proximal part of a Denver peritoneo-venous shunt was introduced after dilation up to 4.8 mm. The pump chamber was sutured to the skin. The distal part of the Denver shunt was cut a few cm from the pump chamber and connected to the gastrostomy catheter. When pumping, ascites is shunted to the stomach lumen.

RESULTS

The insertion presented no complications, and all shunt systems initially functioned well. However, the shunts had to be removed within the first 2 weeks because of mechanical problems such as clotting, leakage, and peritoneal septum formation. No infections were reported.

CONCLUSION

The peritoneo-gastric shunt may present a therapeutic alternative in selected patients, but the mechanical problems have first to be solved.

Percutaneous gastrostomy guided by ultrasound and fluoroscopy

Percutaneous gastrostomy, utilizing a dedicated catheterization kit, with a combination of ultrasonographic (US) and fluoroscopic guidance, was carried out in 27 patients. The main indication for gastrostomy was the need for nutritional support in malignant esophageal stricture. After distending the stomach with water via a nasogastric tube, the gastric antrum was punctured under US guidance and a guide wire was inserted, followed by fluoroscopically guided tract dilatation and insertion of a 2.5-mm Cope-loop catheter. In all patients but one (96%) the procedure was successfully completed in one or 2 attempts. Two complications occurred: one case of a small subcutaneous abscess near the puncture site, and one late incident of dislodgement of a catheter without string-loop fixation, which had been inserted at a catheter exchange after 6 weeks. Percutaneous gastrostomy guided by US and fluoroscopy is a safe and efficacious alternative to endoscopic and surgical gastrostomy.

[Functional treatment of surgically treated empyema of the knee joint]

Knee-joint empyema requires prompt surgical management. After debridement the joint needs to be irrigated for several days. Functional follow-up treatment with electromotive splints according to the CPM concept should begin soon after surgery. Follow-up examination of patients treated in this way for knee-joint empyema showed a protracted course with worse results for empyemas subsequent to arthrotomy, while joint infections after less severe injuries (skin lesions, puncture) healed successfully.

Gastric and duodenal wall thickening on abdominal ultrasonography. Positive predictive value

In a retrospective study, 79 patients with gastric (n = 59) or duodenal (n = 20) wall thickening on conventional abdominal ultrasonograms were included. To reduce bias, patients with a microscopic diagnosis of upper GI neoplasia present at the time of scanning were excluded. The final diagnosis was based upon endoscopy, operation, upper GI series, or autopsy. Among the 59 cases of gastric wall thickening, 33 (56%) proved to be gastric cancer, one (2%) was benign neoplasia, and 17 (29%) showed nonneoplastic pathology (ulcer, gastritis, fibrosis). In eight cases (13%) no gastric pathology was present in the final diagnosis, thus producing false-positive sonographic diagnoses. Among the 20 cases of duodenal wall thickening, five (25%) proved to be duodenal cancer and seven (35%) showed nonneoplastic duodenal pathology. We concluded that gastric or duodenal wall thickening shown on abdominal sonography is a significant finding indicating upper GI pathology (malignant or nonmalignant) in a high percentage of the gastric (86%) and duodenal (60%) cases.

Prevalence of Helicobacter pylori in gastrointestinal disorders and concentrations of ciprofloxacin in serum and gastric mucosa

Endoscopic antral biopsies were obtained from 30 patients with several gastrointestinal disorders and analysed for the presence of H. pylori. This bacterium was present in 80% and 58%, respectively, of patients with either gastric and duodenal ulcers and gastric neoplasm. In none of the healthy individuals, H. pylori could be found. Another 14 patients with various diseases of the stomach, undergoing a major gastric resection, had been treated with 200 mg ciprofloxacin intravenously immediately before the operation. Blood and various tissues samples were taken during the operation. The prevalence of IgG antibodies against H. pylori in these patients was 93%. H. pylori could be determined in 71% of the cases by the urease production; by culture, this was possible in only one case. The mean peak concentration of ciprofloxacin in serum was 5.31 mg/l and 1.17 mg/l, respectively, immediately and 60 min after the end of infusion; in tissues of antrum and duodenum, 1.59 to 1.64 mg/kg and 1.41 to 1.72 mg/kg, respectively, 45-270 min after the infusion. The results show that ciprofloxacin rapidly penetrates into tissues and attains concentrations greater than the MIC90 for H. pylori. However, these concentrations can inhibit the isolation of this microorganism but not its urease activity. This fact could be interpreted by the existence of a nonculturable but metabolically active form of H. pylori. This would explain the high rate of recrudescence following most types of currently applied therapeutic schemes.

Secretin and portal blood flow

Using a duplex Doppler technique, we investigated the effect of low doses of secretin on the portal blood flow. In eight healthy volunteers successive intravenous secretin infusions of 0, 8, and 32 pmol x kg-1 x h-1 resulted in proportional increases in plasma secretin levels. The portal venous flow, however, was unaffected. A bolus injection of 930 pmol of secretin caused plasma secretin levels to increase 100-fold, whereas blood flow in the portal vein increased only by a factor three. This suggests that secretin in the present dose range is of no quantitative importance as a regulator of portal venous flow under physiologic conditions.