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Safe Approach (safe + approach)
Selected AbstractsPractical questions in liver metastases of colorectal cancer: general principles of treatmentHPB, Issue 4 2007Héctor Daniel González Abstract Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases. [source] Mechanisms involved in the photosensitized inactivation of Acanthamoeba palestinensis trophozoitesJOURNAL OF APPLIED MICROBIOLOGY, Issue 5 2009S. Ferro Abstract Aims:, To advance our understanding of the mechanisms involved in the RLP068 phthalocyanine-photosensitized inactivation of Acanthamoeba palestinensis trophozoites through a precise identification of the targets of the photoprocess in both the cytosolic and mitochondrial compartments. Methods and Results:, We followed the activities of selected marker enzymes as well as we performed fluorescence and transmission electron microscopy investigations of the alterations induced by the photoprocess in the fine structure of subcellular compartments. RLP068 is preferentially located in the contractile vacuole: the fluorescence in that site is particularly evident in the unirradiated cells and becomes more diffused after irradiation. Electron microscopic analysis of photosensitized A. palestinensis cells clearly shows that the swelling of trophozoites and the appearance of vacuoles spread throughout the cytoplasm after phototreatment. The activity of a typical cytoplasmic enzyme, such as lactate dehydrogenase, underwent a 35% decrease as a consequence of the photoprocess, reflecting the photodamage induced by migrating phthalocyanine molecules in their micro-environment. Conclusions:, The presence of multiple targets for the phthalocyanine-photosensitized process is of utmost importance because this pattern of cell damage makes it unlikely that photoresistant A. palestinensis strains are gradually selected or mutagenic phenomena are developed as a consequence of the photoinduced damage. Significance and Impact of the Study:, Photosensitization via phthalocyanines appears to represent an efficient and safe approach for achieving a close control of the population of a potentially pathogenic protozoan such as A. palestinensis, opening new perspectives for the disinfection of microbiologically polluted waters. [source] Mitral Valve Replacement with the Beating Heart Technique in a Patient with Previous Bypass Graft from Ascending to Descending Aorta due to Aortic CoarctationJOURNAL OF CARDIAC SURGERY, Issue 2 2008Ferit Cicekcioglu M.D. In this case, MVR was performed with on-pump beating heart technique without cross-clamping the aorta because of the diffuse adhesion around the ascending aorta, and tube graft presence between ascending and descending aortas. Methods: A 47-year-old female patient had aorto-aortic bypass graft from ascending aorta to descending aorta with median sternotomy and left thoracotomy in single stage because of aortic coarctation 2 years ago in our cardiac center. She was admitted to the hospital with palpitation and dyspnea on mild exertion. Transthoracic echocardiography revealed 4th degree mitral insufficiency. Results: MVR was carried out through remedian sternotomy with on-pump beating heart technique without cross-clamping the aorta. Conclusions: MVR with on-pump beating heart technique offers a safe approach when excessive dissection is required to place cross-clamp on the ascending aorta. [source] The use of therapeutic plasmapheresis in the treatment of poisoned and snake bite victims: An academic emergency department's experiencesJOURNAL OF CLINICAL APHERESIS, Issue 4 2006Cuma Yildirim Abstract The objective of this study is to describe the clinical status, procedural interventions, and outcomes of critically ill patients with poisoning and snake bite injuries presenting to a tertiary-care emergency department for treatment with therapeutic plasmapheresis. Records of 20 patients who presented to our academic emergency department over a 2-year period and who underwent plasmapheresis for poisoning or snake bite were retrospectively reviewed. Plasmapheresis was performed using centrifugation technology via an intravenous antecubital venous or subclavian vein catheter access. Human albumin or fresh frozen plasma were used as replacement fluids. Data extracted from the patient record included demographic data, clinical status, and outcome measures. Sixteen patients underwent plasmapheresis because of toxicity from snake bite. Three patients were treated for drug poisoning (phenytoin, theophylline, bipyridene HCl) and one patient for mushroom poisoning. Haematologic parameters such as platelet count, PT, and INR resolved rapidly in victims of snake bite injuries after treatment with plasmapheresis. Loss of limbs did not occur in these cases. Seven patients required admission to the intensive care unit. One patient with mushroom poisoning died. Mean length of hospital stay was 14.3 days (range 3,28 days) for all cases. Plasmapheresis was a clinically effective and safe approach in the treatment of snake bite envenomation and other drug poisoning victims especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to established conventional therapies, emergency physicians should consider plasmapheresis among the therapeutic options in treatment strategies for selected toxicologic emergencies. J. Clin. Apheresis 2006. © 2006 Wiley-Liss, Inc. [source] Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learningBJU INTERNATIONAL, Issue 6 2003W. Farhat Minimally invasive surgery is not exclusive to the treatment of adult conditions. It has also been used in paediatric urology, and the authors from Toronto and Paris describe a mentorship-training model for laparoscopic retroperitoneal surgery. They confirmed that a mentored approach is the way to develop this procedure. They also found that ablative procedures are learned relatively early, but that reconstructive procedures require a high degree of skill in laparoscopic techniques, requiring formal training focusing mainly on suturing techniques. OBJECTIVE To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. METHODS The study included four paediatric urologists with 3,25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and ,hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. RESULTS Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. CONCLUSION Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques. [source] Opioid switching from transdermal fentanyl to oral methadone in patients with cancer painCANCER, Issue 12 2004Miguel Angel Benítez-Rosario M.D., Ph.D. Abstract BACKGROUND Patients with cancer often are rotated from other opioids to methadone to improve the balance between analgesia and side effects. To the authors' knowledge, no clear guidelines currently exist for the safe and effective rotation from transdermal fentanyl to methadone. METHODS The authors evaluated a protocol for switching opioid from transdermal fentanyl to oral methadone in 17 patients with cancer. Reasons for switching were uncontrolled pain (41.1% of patients) and neurotoxic side effects (58.9% of patients). Methadone was initiated 8,24 hours after fentanyl withdrawal, depending on the patient's previous opioid doses (from < 100 ,g per hour to > 300 ,g per hour). The starting methadone dose was calculated according to a 2-step conversion between transdermal fentanyl:oral morphine (1:100 ratio) and oral morphine:oral methadone (5:1 ratio or 10:1 ratio). The correlation between previous fentanyl dose and the final methadone dose or the fentanyl:methadone dose ratio was assessed by means of Pearson and Spearman correlation coefficients (r), respectively. A Friedman test was used to compare pain intensity before and after the switch and the use of daily rescue doses. RESULTS Opioid rotation was fully or partially effective in 80% and 20%, respectively, of patients with somatic pain. Neuropathic pain was not affected by opioid switching. Delirium and myoclonus were reverted in 80% and 100% of patients, respectively, after opioid switching. A positive linear correlation was obtained between the fentanyl and methadone doses (Pearson r, 0.851). Previous fentanyl doses were not correlated with the final fentanyl:methadone dose ratios (Spearman r, , 0.327). CONCLUSIONS The protocol studied provided a safe approach for switching from transdermal fentanyl to oral methadone, improving the balance between analgesia and side effects in patients with cancer. Cancer 2004. © 2004 American Cancer Society. [source] | ||||||||||