Abdominal Vascular Evaluation.

The vascular lab (VL) is instrumental in diagnosing vascular diseases such as renal artery stenosis and mesenteric ischemia or following a patient after transjugular intrahepatic portal systemic shunt (TIPS) creation. This article discusses indications, protocol, and diagnostic criteria for abdominal vascular ultrasound. The vascular lab can be used to investigate pathology in the abdomen either as a preliminary screening tool to evaluate for a pathology such as mesenteric artery stenosis in a patient with food fear and weight loss, renal artery stenosis in a patient with refractory hypertension or renal failure, or as a diagnostic tool in follow up after a patient has undergone a transjugular intrahepatic portal systemic shunt (TIPS) for portal hypertension. The technical success of duplex ultrasonography of the abdomen can be compromised by respiratory motion, obesity, and intestinal gas. Therefore, duplex scanning is performed in the fasting state particularly in elective outpatient cases. In emergent cases when pathology such as acute mesenteric ischemia is suspected evaluation with CT angiography may be best.

Evaluation of Knee Cartilage Diurnal, Activity, and BMI-Related Variations Using Quantitative T2 Mapping MRI and Fitbit Activity Tracking.

The aim of this study is to evaluate diurnal variation in knee cartilage 3 Tesla magnetic resonance imaging (MRI) T2 mapping relaxation times, as well as activity- and body mass index (BMI)-dependent variability, using quantitative analysis of T2 values from segmented regions of the weight-bearing articular surfaces of the medial and lateral femoral condyles and tibial plateaus. Ten healthy volunteers' daily activity (steps) were tracked with Fitbit pedometers. Sagittal MRI T2 maps were obtained in the morning and afternoon on days 2 and 3. Mean T2 values were analyzed for variation related to the number of steps taken (activity), time of day (diurnal variation), and BMI using mixed effect model. Significant (albeit small) differences in the medial femoral and medial tibial cartilage regions were identified between morning and afternoon scans (diurnal variation). Daily activity did not result in significant changes and increasing BMI only demonstrated a slight increase in T2 values for the lateral tibial plateau. These findings suggest that it may be necessary to control diurnal variation when using quantitative MRI T2 mapping to assess articular cartilage longitudinally in healthy participants. Further investigation is needed to confirm these findings and determine if they also apply to symptomatic patients.

Invitation to the dance: lessons from Susan Sontag's death.

The standard model for end-of-life decision-making gives roles to two parties--the physician, who explains the medical options, and the patient, who selects from among those options. The model can be harmful not only for individuals but also for the state, if the patient's right to control her own choices is understood as a positive right of access to whatever is available.

Law's effect on the quality of end-of-life care: lessons from the Schiavo case.

The political circus surrounding Terri Schiavo's death is unlikely to repeat itself soon in other cases but the underlying event that precipitated the furor is a recurrent clinical problem-the problem of conflict among family members about withdrawing or withholding life-prolonging treatment for an incompetent patient who had left no advance directive or appointed healthcare proxy. The laws of most states purport to solve this problem by automatic appointment of one person among the disputing family members. However, this forced resolution of the family conflict does not clearly reflect the prior values of the incompetent patient and is likely to intensify rather than ease that conflict, providing no demonstrable benefit to the incompetent patient and complicating the psychological processes of mourning for the surviving family. This article explores the benefits of a different legal rule that would require family consensus before life-prolonging treatment is withdrawn or withheld for an incompetent patient who has indicated no prior wishes regarding the resolution of family conflict.

Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.

For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Association's Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.

Evaluation of 111In-DTPA-folate as a receptor-targeted diagnostic agent for ovarian cancer: initial clinical results.

UNLABELLED: The cell-membrane folate receptor is a potential molecular target for tumor-selective drug delivery, including radiolabeled folate-chelate conjugates for diagnostic imaging. We report here the initial clinical study of such an agent, (111)In-diethylenetriaminepentaacetic acid (DTPA)-folate, evaluated for diagnosis of ovarian malignancy. METHODS: Thirty-five women were enrolled in a phase I/II clinical study, with 33 completing the surgical follow-up required by the study protocol for definition of disease status. Patients either had a pathologically proven malignancy or were scheduled for surgery for suspected new ovarian cancer (n = 26), recurrent ovarian cancer (n = 5), or endometrial cancer (n = 2). (111)In-DTPA-folate was administered as an intravenous bolus, and whole-body images were obtained at 30 min, 4 h, and (for the first 19 patients) 24 h after injection; SPECT also was done at the delayed imaging times. For 19 of the patients, unlabeled free folic acid was injected before administration of (111)In-DTPA-folate to also assess the impact of folate loading on tracer biodistribution. Masked and unmasked readings of the images by 2 nuclear medicine physicians were compared with the pathologic findings after surgery. RESULTS: Among 33 patients who had surgical intervention, 14 had new or recurrent malignant tumors. All of 7 newly diagnosed ovarian carcinomas were identified by both masked readers (sensitivity, 100%). The sensitivity for detection of 7 recurrent malignancies was 38% for masked readings and 85% for unmasked readings, indicating that correlation with anatomic imaging studies (CT) was highly important in diagnosis of these lesions. Eighteen of the studied patients were found to have benign masses; for this limited population, the specificity of (111)In-DTPA-folate scintigraphy was 76% and 82% for the masked and unmasked analyses, respectively. CONCLUSION: (111)In-DTPA-folate is safe, and possibly effective, for scintigraphy differentiating between malignant and benign ovarian masses.

Comparison of left ventriculography and coronary arteriography with positron emission tomography in assessment of myocardial viability.

BACKGROUND: Assessment of viability of myocardium after an ischemic insult is an important clinical question that affects decisions pertaining to potential revascularization. The results of contrast left ventriculograms and coronary angiography were compared to positron emission tomography (PET) in 64 patients with coronary artery disease and reduced left ventricular function. HYPOTHESIS: The study was undertaken to determine the relative utility of the invasive studies in the assessment of viability. METHODS: Right anterior oblique ventriculograms were assessed for hypokinesis, akinesis, or dyskinesis in six segments. The PET scans were assessed for viability by visual estimation of flourodeoxyglucose (FDG) uptake in six segments that corresponded to the segments analyzed on the ventriculograms. RESULTS: Of a total of 373 segments successfully analyzed by PET, 272 were judged to be viable (normal or hypokinetic) by contrast ventriculography. Of these, 253 (93%) were considered viable by PET. Of 177 segments deemed either normal or mild-to-moderately hypokinetic by ventriculography, 170 (94%) were viable by PET. Of 95 severely hypokinetic segments, 83 (84%) were viable by PET. Of 79 akinetic segments, 44 (56%) were considered viable by PET. For segments that were dyskinetic and thought to be nonviable by ventriculography, 19 of 22 (86%) were also considered nonviable by PET. For 294 segments for which a determination on viability was made based on the presence of wall motion on the ventriculogram (normal, hypokinetic, ordyskinetic; not akinetic), there was excellent agreement with PET (93%; p < 0.001). In 49 patients there was akinesis in no more than one segment in either the anterior or inferior territories, indicating the potential for assessment of viability by ventriculography in at least two of three segments in each territory. Coronary anatomy was analyzed to assess whether coronary patency could help in assessing viability. Segments supplied by patent arteries were more likely to be viable by PET than segments supplied by occluded arteries (p < 0.001). Akinetic segments were more likely to be supplied by occluded arteries (56 vs. 23, 72%). Dyskinetic segments were predominantly nonviable by PET (86%) and were usually supplied by occluded arteries (77%). CONCLUSION: In patients in whom the assessment of viability is clinically relevant, the presence of systolic inward motion on the contrast left ventriculogram correlates well with segment viability by PET, while outward or dyskinetic movement correlates well with nonviability. Thus, the use of PET to assess viability in many patients may be unnecessary.

Resolving disputes between clinicians and family about "futility" of treatment.

Family resistance to withdrawal of life support from children presents difficult issues of clinical practice and of principle. Legal recognition of unilateral physician authority for withdrawal on grounds of clinical "futility"-even in the most extreme circumstance of brain death-creates inappropriate incentives for clinicians' avoidance of prolonged, emotionally taxing interactions likely to persuade parents to accept the reality of their child's impending or actual death. Although unilateral physician action withdrawing support may sometimes be necessary in response to intractable family resistance, clinicians should nonetheless always understand this course not only as a clinical failure in dealing with families but also as unjustified in principle.

The medical futility debate: patient choice, physician obligation, and end-of-life care.

Physicians' use of the "medical futility" concept to override the treatment demands of patients or their family/surrogates is difficult to justify in principle. At the same time, patient demands for obviously futile treatments can conflict with physicians' professional obligation to do no harm to their patients. There is no clear general principle available to resolve this conflict between patient self-determination and physician autonomy; extended negotiation between patient or family/surrogates and physicians provides the only prospect for satisfactory resolution. Though such negotiation will not invariably succeed in reaching agreement, the legal system should ensure that each side has some practical measure of independent authority and power to exert against the other in order to maximize the likelihood that the negotiating process will be seriously engaged.