Pseudoaneurysms complicating organ transplantation: Roles of CT, duplex sonography, and angiography

In a retrospective study of proved pseudoaneurysms (PAs) in 15 patients with transplanted organs (11 liver, three kidney, one pancreas), the results of computed tomography (CT), duplex sonography, and angiography were reviewed. Of the 15 cases of PA, eight occurred at the arterial anastomosis and seven were nonanastomotic. Three of the eight anastomotic PAs were caused by infection. Of the seven nonanastomotic PAs, four were caused by percutaneous biopsy, two were caused by infection, and one was of undetermined cause. In nine (60%) of the 15 patients the PAs were incidentally detected at imaging studies performed for other reasons. Diagnosis requires a high degree of suspicion. CT was performed in nine cases and duplex sonography in ten. The diagnosis of PA was made with CT in six (67%) patients and with duplex sonography in five (50%). CT and duplex sonography could not enable diagnosis when the PA was small, when the arterial anastomosis was not included in the field of study, or when enhancement with intravenously administered contrast material was suboptimal. Angiography depicted the PAs in all 15 patients. In three liver transplant recipients with gastrointestinal tract bleeding, the causative PAs were detected only with angiography

How often do surgeons obtain the critical view of safety during laparoscopic cholecystectomy?

BackgroundThe reported incidence (0.16–1.5 %) of bile duct injury (BDI) during laparoscopic cholecystectomy (LC) is higher than during open cholecystectomy and has not decreased over time despite increasing experience with the procedure. The “critical view of safety” (CVS) technique may help to prevent BDI when certain criteria are met prior to division of any structures. This study aimed to evaluate the adherence of practicing surgeons to the CVS criteria during LC and the impact of a training intervention on CVS identification.MethodsLC procedures of general surgeons were video-recorded. De-identified recordings were reviewed by a blinded observer and rated on a 6-point scale using the previously published CVS criteria. A coaching program was conducted, and participating surgeons were re-assessed in the same manner.ResultsThe observer assessed ten LC videos, each involving a different surgeon. The CVS was adequately achieved by two surgeons (20 %). The remaining eight surgeons (80 %) did not obtain adequate CVS prior to division of any structures, despite two surgeons dictating that they did; the mean score of this group was 1.75. After training, five participating surgeons (50 %) scored > 4, and the mean increased from 1.75 (baseline) to 3.75 (p < 0.05).ConclusionsThe CVS criteria were not routinely used by the majority of participating surgeons. Further, one-fourth of those who claimed to obtain the CVS did so inadequately. All surgeons who participated in training showed improvement during their post-assessment. Our findings suggest that education of practicing surgeons in the application of the CVS during LC can result in increased implementation and quality of the CVS. Pending studies with larger samples, our findings may partly explain the sustained BDI incidence despite increased experience with LC. Our study also supports the value of direct observation of surgical practices and subsequent training for quality improvement

Conceptualizing Equity in the Implementation of California Education Finance Reform

We examine how district administrators’ conceptions of equity relate to the implementation of finance reform. We use sensemaking theory and four views of equity—libertarian, liberal, democratic liberal, and transformative—to guide a case study of two districts, finding evidence of two conceptions of equity: (1) greater resources for students with greater needs and (2) equal distribution of resources for all students. One district demonstrated an organization-wide belief in the first conception, whereas the other conveyed individual-level understandings of both conceptions. These beliefs were mirrored in resource allocation decisions and informed by districts’ student demographics, organizational identities, and perceptions of adequacy

Ultrasound-guided thrombin injection for the treatment of an iatrogenic hepatic artery pseudoaneurysm: a case report

<p>Abstract</p> <p>Introduction</p> <p>Percutaneous transhepatic portal embolization is often performed to expand the indications for hepatic resection. Various etiologies of hepatic artery pseudoaneurysm have been reported, but regardless of the etiology, hepatic artery pseudoaneurysm is usually managed with an endovascular approach or open surgery, depending on the location and clinical symptomatology. However, it is difficult to manage hepatic artery pseudoaneurysm after percutaneous transhepatic portal embolization, since embolization of the hepatic artery may cause hepatic infarction</p> <p>Case presentation</p> <p>A 58-year-old Japanese man with hilar bile duct cancer underwent percutaneous transhepatic portal embolization to expand the indication for hepatic resection. Two days after percutaneous transhepatic portal embolization, our patient suddenly complained of abdominal pain. Contrast-enhanced computed tomography confirmed a pseudoaneurysm arising from a segmental branch of his right hepatic artery. Since embolization of the hepatic arterial branches may cause hepatic infarction, ultrasound-guided thrombin injection therapy was successfully performed for the pseudoaneurysm.</p> <p>Conclusion</p> <p>We performed a thrombin injection instead of arterial embolization to avoid hepatic infarction. The rationale of this choice may be insufficient. However, ultrasound-guided percutaneous thrombin injection therapy may be considered as an alternative to percutaneous transarterial embolization or surgical intervention for an iatrogenic hepatic artery pseudoaneurysm.</p

Mid-infrared passively switched pulsed dual wavelength Ho3+ -doped fluoride fiber laser at 3 μm and 2 μm

Cascade transitions of rare earth ions involved in infrared host fiber provide the potential to generate dual or multiple wavelength lasing at mid-infrared region. In addition, the fast development of saturable absorber (SA) towards the long wavelengths motivates the realization of passively switched mid-infrared pulsed lasers. In this work, by combing the above two techniques, a new phenomenon of passively Q-switched ~3 μm and gain-switched ~2 μm pulses in a shared cavity was demonstrated with a Ho3+-doped fluoride fiber and a specifically designed semiconductor saturable absorber (SESAM) as the SA. The repetition rate of ~2 μm pulses can be tuned between half and same as that of ~3 μm pulses by changing the pump power. The proposed method here will add new capabilities and more flexibility for generating mid-infrared multiple wavelength pulses simultaneously that has important potential applications for laser surgery, material processing, laser radar, and free-space communications, and other areas

Performing Arts Factorydesign for a Centre for Performing Arts in Amsterdam-Noord

Exterior: building assimilates into location The project is located on an old shipyard, the NDSM-wharf, in the North of Amsterdam. The area is home to different artists and craftsmen who work in collaboration and inspire each other. By doing so new initiatives emerge. Subculture dominates the space and its character is a mixture of industrial remains and the ‘just-happening’ of objects and events. The building assimilates into this context by showing respect for its big dimensions and by relating to the liberal and industrial atmosphere by means of a straightforward organization, a furnishing determined by ‘production’ and a just let things happen attitude. Interior: separate institute and representation towards public & distinguish between working space and social space The CPA has a strong internal component as well as a strong external one. It is important to clearly separate between the two of them. Important to the users of the institute: they have their own space in which they are not hampered in their thoughts and doings. To the visitor this separation is also important: it shows where they are and are not allowed to be. The building supports the perception of accessibility. Both user and visitor do not want to feel disturbed; the user during his work, the visitor by his presence. Working as an artist consists of two moments. One is when you are working on your project turning ideas into a performance. The other one is when you are discussing with fellow artists. The former is mainly concentrated and introverted while the latter is very social and reflective. The distinction between these moments results in social spaces and working spaces. Building: five components translate ideas into the building Open public floor: continuation of the outside space into the public parts of the building. Concrete plates cover the transportation zones while smooth concrete surfaces point out the zones for occupation. Floating Volumes: The engine rooms of the building. They contain the working spaces in which ideas are transformed into performances. The volumes define the in-between-space and its variations allow for different kind of use. On the outside all volumes have the same rough metal-plate cladding. Their interiors are made of wood-panels on wooden structures and allow for flexible spaces. The furnishings of the rooms obey to its specific program and contain the bare necessities. Pantries and lounges are located in the in between space. Structure and cores: carriers of the institute. They literally keep the volumes suspended in the building. The visually present structure also circumscribes the institute and therefore demarcates and dramatizes the separation between the centre’s internal and external component. When you are in-between the structure, you know you are at the institute. Service space: occupies the in-between space. Wide corridors from core to core service the transportation of people, goods, heat/cold, air, electricity and data. Here the people of the institute meet. They are the catalyst of the institute and contain sheltered spaces for informal meeting as well as open spaces to relax and enjoy the view through the building. Enclosure: unites the institute and public areas into one Performing Arts Factory. The glazed shed makes the institute as well as the continuous public space noticed. A saw-tooth roof allows for sun shading: south facing parts of the roof and façade contain a pattern of photovoltaic cells which in the act of filtering sunlight also produce energy. Theatrevolume The theatre has to house performances of different disciplines. Also future projects, which originate from the collaboration between disciplines, should be able to perform in the theatre. What these performances could look like is yet unknown. The theatre is understood as a free-floor theatre. Different arrangements of seating can be composed. Adjustable panels are installed in the walls and provide for different acoustical conditions. Footbridges, towing systems and fixation points underneath the whole ceiling ensure maximum freedom for equipment.Interiors, Buildings and CitiesArchitectur

Moving the Oil and Gas Sector into the Video Age: Vision Assisted Well Interventions Reduce Cost and Add Value

Abstract Economic challenges, within the oil and gas industry, make the optimization of production from existing wells more important than ever. Increasing the number of active wells and maximizing their production can be achieved through integrity-restoring and production-enhancing well intervention projects. The challenge faced by well operators under today’s economic conditions is achieving cost effective, high efficiency operations to maximize return on their investment. Through the presentation of case studies, this paper will demonstrate how the application of innovative downhole camera technologies enabled well operators to bring wells back on-line that had previously been shut in. High definition, battery powered, memory cameras were deployed on slickline to provide cost effective operations without compromise to image quality. Full color video was downloaded and analyzed after each run to enable well site decision making regarding specific well issues, including tubing to annulus communication, a failed safety valve and diagnosing the results of multiple failed fishing attempts over several years. By providing fast-response, high-clarity visual information, an engineered solution would be tailored to suit the specific well conditions to maximize the effectiveness of remediation and increase the efficiency of restoration of production. Results from the camera surveys immediately revealed clear evidence of the wellbore status in each case. Conclusive images of parted tubing, the position and condition of a fish and the top of a completion string provided valuable inputs into the decision making process for subsequent remedial work. As a direct result, fishing operations could be tailored to suit the specific situation and a work-over could be conclusively decided upon or avoided, providing significant time and cost saving as a result. In one case, a well, previously shut-in for several years, was brought back to life with a significant uplift in oil production. Traditionally downhole cameras have been regarded as emergency tools to address immediate, unexpected problems. However, with advances in image clarity and data density, combined with carefully planned interventions, camera technologies provide highly intuitive and accurate diagnostic and surveillance information that reduces uncertainty and increases the effectiveness of resulting remedial work. Efficiency is now enhanced further through the integration of quantitative logging data with the camera in a single run to offer a truly robust interpretation answer and effectively provide vision to downhole data. The Oil and Gas sector has truly moved into the video age.</jats:p