Strategies for the management of SVC stent migration into the right atrium.

PURPOSE: Stent migration into the right atrium is a potentially fatal complication of stenting in the venous system and is most likely to occur during the treatment of superior vena cava obstruction. Endovascular approaches that can salvage this hazardous situation are described and the keys to successful treatment are highlighted. MATERIALS AND METHODS: Four different strategies are reviewed: (1) snaring the stent directly, (2) angioplasty balloon-assisted snaring of the stent, (3) guide wire-assisted snaring of the stent, and (4) superior vena cava-to-inferior vena cava bridging stent. RESULTS: These techniques have been employed in the successful management of four cases. No short- or long-term complications as a result of these maneuvers have been identified. Additional treatment of the underlying disease was possible at the same time in each case. CONCLUSION: We conclude that prompt management of right atrial stent migration is essential and can be successfully achieved by a variety of "bale-out" techniques which are within the technical range of most interventional radiologists.

Endovascular embolization of visceral artery aneurysms with ethylene-vinyl alcohol (Onyx): a case series.

We report the application of the liquid embolic agent ethylene-vinyl alcohol (Onyx; MicroTherapeutics, Irvine, CA, USA) in the management of visceral artery aneurysms. The technique and indications for using Onyx are discussed with emphasis on the management of wide-necked aneurysms and maintenance of patency of the parent vessel. None of the cases was considered suitable for stent-grafting or embolization with conventional agents. Two aneurysms of the renal artery bifurcation and one aneurysm of the inferior pancreaticoduodenal artery were treated. Following treatment there was complete exclusion of all aneurysms. There was no evidence of end-organ infarction. Follow-up with intervals up to 6 months has shown sustained aneurysm exclusion. Onyx is known to be effective in the management of intracranial aneurysms. Our experience demonstrates the efficacy and applicability of the use of Onyx in the treatment of complex visceral artery aneurysms.

A prospective randomised-controlled pilot study for evaluating the teaching utility of interactive educational diabetes simulators.

AIDA is an interactive educational diabetes simulator that is useful for recreating clinically realistic diabetes situations. It is available without charge from http://www.2aida.org on the Web. This paper describes a prospective, clinical randomised-controlled trial (RCT) run at the Ospedale di Marino (Italy) for evaluating the educational utility of AIDA in small group teaching sessions. Twenty-four volunteers (12 male and 12 female) with Type 1 diabetes of more than 6-year duration, aged 19-48 years, who gave written informed consent, were randomly assigned to one of two study groups, each receiving different teaching interventions. Group A was exposed to the AIDA diabetes simulator, while Group B (the control group) received conventional lessons with slides and transparencies. Six lessons were held for each group (one per week). At the end of the conventional lessons, after a 'washout' period of 4 weeks, Group B entered a partial cross-over phase with the simulator during a further 6-week block of lessons. Before and after the 6 weeks of lessons, twice for Group A and 3 times for Group B, all subjects had their HbA1c measured. The subjects also carefully documented the incidence of any symptomatic hypoglycaemic episodes ('hypos'), whether mild (sweating, dizziness), moderate (nausea, vomiting), or severe (requiring assistance). All data were analysed using non-parametric statistics (Wilcoxon signed rank tests). HbA1c levels in Group A dropped significantly from 7.2% to 6.4% after lessons with the diabetes simulator (p = 0.01). No significant changes in HbA1c were observed in Group B between baseline (7.1%) and the end of the control lessons (7.0%), or the end of the cross-over phase lessons (6.8%). The number of 'hypos' decreased significantly from 31 to 14 in Group A (p = 0.03) after AIDA lessons, but did not change significantly in Group B from baseline (n = 20) to after the control lessons (n = 22). However, the number of 'hypos' did decrease significantly (to n = 10) in Group B after exposure to the simulator during the cross-over phase (p = 0.03 vs 6-week data). Larger trials involving more patients in more centres are clearly needed, but this proof-of-concept (pilot) study does demonstrate the feasibility of using a prospective RCT approach for the evaluation of educational diabetes simulation software such as AIDA.

Questionnaires for a randomized controlled trial methodology to evaluate the teaching utility of diabetes simulation programs.

AIDA is an interactive educational diabetes simulator which has been made available without charge on the Internet. Since its launch on the World Wide Web in 1996 over 87,000 people have visited the AIDA Website--http://www.2aida.org--and over 22,000 copies of the program have been downloaded from there free-of-charge. The AIDA software is believed to be of use in recreating clinically realistic diabetes situations for interactive simulation. However, despite its widespread application, its actual utility for supporting the education of patients with type 1 diabetes mellitus remains to be objectively demonstrated in a clinical randomised controlled trial (RCT) setting. The current "Diabetes Information Technology & WebWatch" column overviews a prospective RCT methodology for formally evaluating the educational utility of an interactive diabetes simulator, like AIDA. The protocol makes use of two study arms--each receiving different educational interventions. During lessons, arm A of the study will be exposed to the AIDA simulator (the active intervention), while arm B (the control group) will benefit from conventional educational methods using standard presentations with slides and transparencies. Six lessons will be held for each study arm (one per week). At the beginning and end of the study self-monitoring blood glucose (SMBG) data will be collected, details of any hypoglycemic episodes recorded, and assessments made of glycosylated hemoglobin (HbA1c) levels. Participants will also be required to complete a detailed questionnaire to assess their self-confidence, quality of life and metabolic control, attitudes towards SMBG, and knowledge about insulin dosage calculation. Comparisons will be made between arm A and arm B using unpaired statistical analyses. A partial cross-over study design is also proposed whereby subsequently the control group will be exposed to the AIDA simulator during a further 6-week course of lessons. This will ensure that the maximum number of subjects will eventually receive the active intervention, and will also allow further within group paired analyses to be applied (with greater statistical power). This current "Diabetes Information Technology & WebWatch" column documents two of the questionnaires which are intended to be used for this RCT approach.

Utility of the AIDA diabetes simulator as an interactive educational teaching tool for general practitioners (primary care physicians).

In previous "Diabetes Information Technology & WebWatch" columns, various user experience with an interactive educational "virtual diabetes patient" simulator called AIDA have been documented. The simulator is available free of charge from http://www.2aida.org on the Web, and user comments that have been received to date about the program have highlighted some of the many and varied ways in which a range of people have been applying the diabetes simulations in their own particular situations and practices. Inevitably, up to now, a great deal of attention has focused on use by individuals with diabetes and their relatives, as well as by health-care professionals such as diabetologists/endocrinologists and diabetes educators. However, an important group of health-carers involved in the provision of day-to-day care for many people with diabetes are primary care physicians (general practitioners). The current "Diabetes Information Technology & WebWatch" column addresses this area, overviewing a workshop which was held in September 2000 in Italy to gain experience with application of the AIDA diabetes simulation approach as a teaching tool for general practitioners (GPs). Feedback obtained from participants attending the workshop was very positive, with GPs reporting the simulation approach to be both of interest and use. Further workshops involving other healthcare professionals--in particular, nurses--are planned.

The freeware AIDA interactive educational diabetes simulator--http://www.2aida.org--(1). A download survey for AIDA v4.0.

UNLABELLED: The purpose of this paper is to report a survey of 1,360 downloads of the AIDA interactive educational diabetes simulator. AIDA is a diabetes computer program which permits the interactive simulation of plasma insulin and blood glucose profiles for educational, demonstration and self-learning purposes. It has been made freely available, without charge, on the Internet as a non-commercial contribution to continuing diabetes education. Since its launch in 1996 over 74,000 visits have been logged at the AIDA Website--http://www.2aida.org--and over 20,000 copies of the AIDA program have been downloaded free-of-charge. This report documents a preliminary survey of downloaders of the software. The intended goals of the study were: (i) to establish the feasibility of using the Internet for auditing and surveying diabetes software users; (ii) to identify the proportion of patients with diabetes and their relatives who are actually making use of the program; and (iii) to establish certain technical details about downloaders' computer setups to facilitate the distribution of upgrades to the software. RESULTS: The Internet-based survey methodology was found to be robust and reliable. 1,360 responses were received over an 8 month period (from November 1999 to July 2000). During the corresponding period 3,821 actual downloads of the software were independently logged at the Website--giving a response rate to this survey of 35.6%. Responses were received from participants in 67 countries--although over half of these (n = 730, 54%) originated from the USA and UK. 762 responses (56%) were received from patients with diabetes and 184 (13.5%) from relatives of patients, with lesser numbers from doctors, students, diabetes educators, nurses, pharmacists, and other end users. Useful technical information about computers and operating systems being used were also obtained. This study has established the feasibility of using the Internet to survey, at no real cost, a large number of medical software downloaders/users. In addition it has yielded interesting data in terms of who are the main downloaders of the AIDA program, and has also provided technical (computer) information which has aided the recent release of a freeware upgrade to the software.

The freeware AIDA interactive educational diabetes simulator--http://www.2aida.org--(2). Simulating glycosylated haemoglobin (HbA1c) levels in AIDA v4.3.

In 1996 an interactive educational diabetes simulator called AIDA was released without charge on the Internet as a non-commercial contribution to continuing diabetes education. Over the past 4+ years over 74,000 people have visited the AIDA Web pages at http://www.2aida.org and over 20,000 copies of the program have been downloaded from there free-of-charge. This article builds on the experience gained from the AIDA development, and the World Wide Web distribution of the software, and highlights some of the problems which users have reported with the program. An updated release of the software (AIDA v4.3) is described and the method applied for modelling glycosylated haemoglobin (HbA1c) levels within this new version of AIDA is documented. An overview is provided of the trialling and beta-testing of this latest release of the program, and the general concept of a 'virtual diabetic patient' that provides an electronic representation of a patient with diabetes--and which can be used for self-learning/teaching/demonstration purposes--is highlighted.

A randomised-controlled clinical trial methodology for evaluating the teaching utility of interactive educational diabetes simulators.

AIDA is an interactive educational diabetes simulator which has been made available without charge on the Internet. Since its launch on the World Wide Web in 1996 over 58,000 people have visited the AIDA Web site (http://www.2aida.org) and over 17,500 copies of the program have been downloaded from there free-of-charge. The AIDA software is believed to be of use in recreating clinical (diabetes) situations for interactive simulation. However, despite its widespread usage, its actual utility for supporting the education of patients with Type 1 diabetes mellitus remains to be objectively demonstrated in a randomised-controlled clinical trial setting. This paper describes a prospective, randomised-controlled trial (RCT) methodology for formally evaluating the educational utility of an interactive diabetes simulator, like AIDA. The protocol makes use of two study arms, each receiving different educational interventions. During lessons, Arm A of the study will be exposed to the AIDA simulator (the active intervention), while Arm B (the control group) will benefit from conventional educational methods using standard presentations with slides and transparencies. Six lessons will be held for each study arm (one per week). At the beginning and end of the study self-monitoring blood glucose (SMBG) data will be collected, details of any hypoglycaemic episodes recorded, and assessments made of HbA1c. Participants will also be required to complete a detailed questionnaire to assess their self-confidence, quality of life and metabolic control, attitudes towards SMBG, and knowledge about insulin dosage calculation. Comparisons will be made between Arm A and Arm B using unpaired statistical analyses. A partial cross-over study design is also proposed whereby subsequently the control group will be exposed to the AIDA simulator during a further 6-week course of lessons. This will ensure that the maximum number of subjects will eventually receive the active intervention, and will also allow further within group paired analyses to be applied (with greater statistical power). An initial evaluation study using this RCT approach has just recently commenced in the Ospedale di Marino in Marino (Rome), Italy.

Simulating glycosylated hemoglobin (HbA1c) levels in diabetes using an interactive educational virtual diabetes patient simulator.

In 1996, an interactive educational diabetes simulator called AIDA was released without charge on the Internet as a noncommercial contribution to continuing diabetes education. Over the past 5 years, over 100,000 people have visited the AIDA Web pages at http://www.2aida.org and over 25,000 copies of the program have been downloaded free-of-charge. Previous Diabetes Information Technology & WebWatch columns have described various user feedback comments about the AIDA software. This current column overviews the method applied for modelling glycosylated hemoglobin (HbA1c) levels within an updated version of the AIDA program (v4.3). The result seems to be a useful and novel addition to the diabetes simulations, providing a parameter with which most users will be familiar, and able to relate. It is expected that the HbA1c indicator may prove useful in enhancing the educational value of the diabetes simulations.

Use of the AIDA diabetes simulation software--www.2aida.org--as an interactive educational tool for teaching student nurses.

In previous "Diabetes Information Technology & WebWatch" columns, various user experiences with an interactive educational virtual diabetes patient simulator, called AIDA, have been documented. The simulator is available free of charge from www.2aida.org on the Web. In the 5+ years since the program was first made available on the Internet, over 125,000 people have visited the AIDA Website and over 27,000 copies of the program have been downloaded, gratis. User comments that have been received about the program have highlighted some of the many and varied ways in which a range of people have been applying the diabetes simulations in their own particular situations and practices. Inevitably, up to now, a great deal of attention has focused on use of the program by individuals with diabetes and their relatives, as well as by health-care professionals such as diabetologists/endocrinologists, diabetes educators, and primary care physicians (general practitioners [GPs]). However, an important group of health-carers involved in the provision of day-to-day care for many people with diabetes are nurses. The current "Diabetes Information Technology & WebWatch" column overviews a workshop held in June 2001 in Italy to gain experience with application of the AIDA diabetes simulation approach as a teaching tool for student nurses. Feedback obtained from participants attending the workshop was generally very positive, with the student nurses reporting the simulation approach to be both of interest and of use. Further workshops involving other health-care students and professionals-in particular, medical students and qualified nurses-are planned.

Spontaneous comments from users of the AIDA interactive educational diabetes simulator.

The user experience with the AIDA simulator demonstrates one of the advantages of making such diabetes software readily available for free via the Internet. The comments collectively provide a picture of some of the many and varied ways in which the simulator has been applied by different users. These comments also demonstrate the potential for empowerment that some people feel can result from the use of the software. The experience with this approach is sufficiently encouraging to warrant formal evaluation studies to quantify the clinical utility of such an interactive educational diabetes simulation program. For this reason, a formal survey of 200 AIDA users (patients, relatives, and healthcare professionals) from at least 15 different countries is currently ongoing, and further formal evaluation studies in the clinic setting are planned.