Transjugular Intrahepatic Portosystemic Shunt Creation Using a Radiofrequency Wire: Prospective Clinical Safety and Feasibility Trial in Cirrhosis.

PURPOSE: To assess the safety and feasibility of using a radiofrequency (RF) wire for portosystemic shunt creation. MATERIALS AND METHODS: Ten patients undergoing elective creation of a transjugular intrahepatic portosystemic shunt (TIPS) or a direct intrahepatic portosystemic shunt (DIPS) were prospectively enrolled. Primary outcomes were the safety and feasibility of RF wire used for the creation of TIPS and DIPS. Median age was 66.5 ± 6.1 years. Causes of liver disease included alcohol (n = 5), nonalcoholic steatohepatitis (n = 2), hepatitis C virus (n = 1), primary biliary cirrhosis (n = 1), autoimmune hepatitis (n = 1). The median score for model for end-stage liver disease was 11 ± 4.3. The Rosch-Uchida TIPS set was used with intravascular ultrasonography guidance in all cases. A 0.035-inch RF wire was used in lieu of the trocar needle through the 5-F TIPS set catheter to create a track between the hepatic vein and the portal vein. All shunts were created using stent grafts. RESULTS: Technical success rate was 100%. In 7 of 10 patients, portal vein access was achieved with a single pass. A DIPS was created in 2 patients based on anatomic favorability. Median fluoroscopy time was 13.3 ± 3.8 min, and median total procedure time was 102 ± 19 min. The wire passed through parenchyma without subjective deflection. There was 1 case of extracapsular puncture with no clinical consequence. The RF wire was too stiff to curve into the main portal vein, requiring wire exchange in all but 1 case. Mean portosystemic gradient decreased from 13.9 ± 3.3 to 5.9 ± 2.1 mm Hg. No immediate complications were encountered. Shunt patency was 100% at 30 days. CONCLUSIONS: Creation of TIPS and DIPS using an RF wire was safe and feasible, enabling creation of an intrahepatic track without subjective deflection in cirrhotic patients.

Safety protocols for interventional MRI.

RATIONALE AND OBJECTIVES: To review magnetic resonance safety protocols and supplement them for interventional applications. MATERIALS AND METHODS: The American College of Radiology White Papers on MR Safety are summarized. Elements relevant to interventional MR procedures are emphasized. Additional policies and procedures specifically for interventional MR applications covering safety, training, and MR compatibility are proposed. RESULTS: A comprehensive operational policy for an interventional MR department is proposed. The policies and procedures helped our department perform over 400 surgeries and maintain a perfect safety record for 5 years. CONCLUSION: Interventional MR departments can operate safely but require policies and procedures beyond those required for diagnostic MR departments.

Pulmonary artery thrombus and subcapsular liver hematoma in a patient with HELLP syndrome: a therapeutic conundrum.

HELLP syndrome (hemolysis, elevation of liver enzymes, and low platelet count) occurs during pregnancy. Intrahepatic hemorrhage and subcapsular liver hematoma with or without rupture are reported complications of this syndrome. The patient described in this report developed HELLP syndrome associated with a subcapsular liver hematoma and pulmonary artery thrombus, complications that created a therapeutic conundrum.

Phytoestrogens: a viable option?

Estrogen replacement therapy is one of the most commonly prescribed medicines in the United States by traditional medical professionals. Over the past decade, the market for complementary/ alternative therapies for hormone replacement has dramatically increased. Women are seeking more "natural" alternatives to treat menopausal symptoms. Well-designed randomized clinical trials are often lacking, as is the information on efficacy and safety. This article will review several popular herbal therapies for menopausal symptoms including phytoestrogens, black cohosh (Cimicifuga racemosa), dong quai (Angelica sinensis), chast tree (Vitex agnus-castus), and wild Mexican yam. Their use, mechanism of action, and adverse effects are outlined.

Asthma: a brief overview.

Asthma, a common chronic inflammatory disease of the airways characterized by reversible airway obstruction, is a substantial health problem without regard for age, gender, or ethnicity. Guidelines have been established to provide clinicians with evidence-based recommendations to assist in the diagnosis and management of asthma. This review offers a brief overview of the current understanding of the pathogenesis and definition of asthma, the diagnosis and classification of asthma, and the pharmacologic therapy of asthma in adults. Further studies are required to determine whether the development of new targeted treatments will be effective in the management of asthma.

Hormone replacement therapy and coronary heart disease in women: a review of the evidence.

It is well documented that coronary heart disease (CHD) is the leading cause of death in women-especially postmenopausal women. The role of hormone replacement therapy (HRT) in prevention of CHD has been considered for many years. Early epidemiological studies suggested estrogen to have a potential cardioprotective role, noting that premenopausal women have a decreased risk of developing CHD compared with men. Later observational studies showed decrease of CHD risk in postmenopausal women on HRT. By 1996, estrogen (specifically Premarin) was one of the most dispensed medications in the United States. Major medical organizations such as the American College of Physicians and American College of Obstetricians and Gynecologists widely endorsed and encouraged HRT for CHD risk reduction, along with using HRT for other potential benefits (such as osteoporosis prevention). Unfortunately, recent clinical trials seem to raise more questions than provide definitive proof in the protective role of estrogen in CHD. A review of recent and ongoing observational studies and clinical trials may help guide physicians in their recommendation and discussion of the role of HRT in postmenopausal women. As this article was being prepared for publication, reports from both the Heart and Estrogen/Progestin Replacement Study Follow-up (HERS II) and the Women's Health Initiative (WHI) were published. Both studies concluded that HRT has no role in primary or secondary prevention of CHD in women.

An internist's update on cholesterol management.

Coronary heart disease (CHD) remains the leading cause of death in the United States. It is now well established that cholesterol is an important, reversible risk factor for CHD. This article provides a brief background on classification of the dyslipidemias, then discusses current recommendations for the evaluation and treatment of hyperlipidemia. Other risk factors currently being investigated as they relate to the development of CHD are discussed.

Low back pain.

Low back pain is a very common condition, with about 80% of people suffering from it at some point in their lives. It is usually self-limited, resolving in 4 to 8 weeks in more than 50% of patients, yet the recurrence rate is high, about 85%. Because of the complexity of the bony, muscular ligamentous, and neural elements of the back, a specific anatomic diagnosis often cannot be made. Evaluation should include a careful history and physical examination, paying particular attention to alarm symptoms or "red flags" mentioned in the text. Imaging procedures are usually not necessary because of the lack of specificity and the high rate of early, spontaneous remission. Exceptions to this include history of recent trauma, presence of red flags or chronic unremitting course. Many treatment modalities, including physical therapy, ultrasound, thermal therapy, and local injection have been tried, but most studies are inconclusive as to their effectiveness. Prolonged bed rest is not indicated. Nonsteroidal anti-inflammation agents, judicious use of muscle relaxers, and patient education about the cause and prognosis are justified.

Effect of an individualized treatment protocol on restoration of competency in pretrial forensic inpatients.

In this study, we evaluated the effectiveness of individualized treatment on restoration of competency in patients adjudicated incompetent to stand trial. Treatment groups included deficit-focused remediation (six individual sessions and four group sessions; n = 8), legal rights education (control group; six individual sessions and four group sessions; n = 10), and standard hospital treatment (control group; four group sessions; n = 8). There were no significant baseline differences among groups. All groups differed significantly on competency measures obtained before and after testing. The deficit-focused remediation and the legal rights education groups both demonstrated significantly higher post-treatment scores on competency measures than the standard hospital treatment group. Both groups demonstrated approximately 50 percent more improvement on the competency measures than the standard hospital treatment group. There were no significant differences between the deficit-focused remediation and legal rights education groups on post-test competency scores, suggesting that focus on individual deficits may not be a useful treatment strategy. Results demonstrate, however, that more frequent legal rights education is a worthwhile endeavor in treatment of incompetency.

Intraoperative magnetic resonance imaging safety considerations.

Patient safety considerations are a priority for perioperative nurses. In the intraoperative magnetic resonance imaging (MRI) chamber, additional safety precautions for both patients and staff members must be taken. This article provides a brief overview of the intraoperative MRI environment and details safety considerations for surgical staff members and patients.