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Τρίτη, 3 Ιανουαρίου 2017

Electromagnetic Tracking Navigation to Guide Radiofrequency Ablation of a Tumor

Electromagnetic Tracking Navigation to Guide Radiofrequency Ablation of a Lung Tumor: imageRadiofrequency ablation (RFA) may be an option for patients with lung tumors who have unresectable disease and are not suitable for available palliative modalities. RFA electrode positioning may take several attempts, necessitating multiple imaging acquisitions or continuous use of computed tomography. Electromagnetic tracking uses miniature sensors integrated with RFA equipment to guide tools in real time, while referencing to preprocedure imaging. This technology was demonstrated successfully during a lung tumor ablation, and this was more accurate at targeting the tumor compared with traditional freehand needle insertion. It is possible, although speculative and anecdotal, that more accuracy could prevent unnecessary repositioning punctures and decrease radiation exposure. Electromagnetic tracking has theoretical potential to benefit minimally invasive interventions.






Journal of Bronchology & Interventional Pulmonology:
doi: 10.1097/LBR.0b013e31827157c9
Case Reports

Electromagnetic Tracking Navigation to Guide Radiofrequency Ablation of a Lung Tumor

Amalou, Hayet MD; Wood, Bradford J. MD

Article Outline
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Author Information

Center for Interventional Oncology, NIH Clinical Center, National Cancer Institute, National Institutes of Health, Bethesda, MD
B.J.W. and NIH have intellectual property in the field.
This study supportred in part by NIH Intramural research program. NIH and Philips have a cooperative research and development agreement. NIH may have intellectual property in the field.
Disclosure: There is no conflict of interest or other disclosures.
Reprints: Bradford J. Wood, MD, Center for Interventional Oncology, NIH Clinical Center, National Cancer Institute, National Institutes of Health, MSC 1182, Bethesda, MD 20892 (e-mail: bwood@nih.gov).
Received July 16, 2012
Accepted August 28, 2012
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Abstract

Radiofrequency ablation (RFA) may be an option for patients with lung tumors who have unresectable disease and are not suitable for available palliative modalities. RFA electrode positioning may take several attempts, necessitating multiple imaging acquisitions or continuous use of computed tomography. Electromagnetic tracking uses miniature sensors integrated with RFA equipment to guide tools in real time, while referencing to preprocedure imaging. This technology was demonstrated successfully during a lung tumor ablation, and this was more accurate at targeting the tumor compared with traditional freehand needle insertion. It is possible, although speculative and anecdotal, that more accuracy could prevent unnecessary repositioning punctures and decrease radiation exposure. Electromagnetic tracking has theoretical potential to benefit minimally invasive interventions.
Radiofrequency ablation (RFA) is increasingly used as a nonsurgical option in the management of primary and secondary lung tumors.1RFA in the lung often has minimal adverse effects with predicable outcomes.1,2 With conventional percutaneous RFA techniques, determining the required needle size, type, position of needle puncture, trajectory, and number of ablations is on the basis of a preprocedural and/or multiple periprocedural computed tomography (CT) scans. This process is nonstandardized, and it requires the interventional radiologist to develop a mental 3-dimensional (3D) map to guide the ablation process. Accurate needle placement can be difficult, even with ideal image guidance. In addition, prolonged use of CT or fluoroscopy during image acquisition exposes the patient (and potentially the operator) to ionizing radiation.
Electromagnetic tracking (EMT) of inner needle tips is a new application for real-time needle-tip positioning that is used in conjunction with standard imaging modalities. It has been enabled by the development of miniaturized sensor coils that can be embedded within the needle itself. EMT requires creating an electromagnetic field around the anatomic region of interest (Fig. 1A). A weak current is induced within the coil when an instrument moves within this electromagnetic field. The current in relation to multiple magnetic generators is detected by a computer and processed into reproducible, position coordinates. This location can be overlaid (in a software process known as “registration”) upon prior CT, magnetic resonance, or positron emission tomography for real-time navigation during RFA.3Analysis of such an EMT system in a previous 20-patient case series has demonstrated the accuracy of this system in retrospectivelycorrelating virtual needle position with actual needle position during conventional freehand needle insertion. The minimal extra time required to set up the system was also documented.4 The relative accuracy of this technique compared with freehand needle insertion is shown. Further, the ability of an EMT system to prospectively guideneedle insertion under clinical circumstances without the use of regular imaging input is assessed in this case.
Figure 1
Figure 1
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MATERIALS AND METHODS

An EMT system was used to guide RFA of a 12-mm-right lung melanoma metastasis in a 56-year-old patient (Fig. 1B). The patient opted for RFA over surgery because of the potential morbidities in light of multiple previous surgeries and the presence of slower growing extrapulmonary metastases. The use of EMT was approved by the institutional investigational review board to assess the feasibility and accuracy of this technology. The patient gave written informed consent. The system consisted of a field generator (Fig. 1A), a control unit, and a sensor device (Aurora; Northern Digital Inc., Waterloo, ON), interfaced with registration and display custom software (Philips Research, Briarcliff, NY), and a commercially available tracked 22-G stylet inside a standard 19-G outer biopsy guider needle (Philips Healthcare, Toronto, ON). The patient was first anesthetized, intubated, and ventilated. Five adhesive active fiducial markers with 2 embedded 5 degree-of-freedom tracking sensors per fiducial were placed near the expected skin entry point (Fig. 1A). The tracking coordinates of these sensors, which are necessary for the registration process, are obtained automatically during interruption of ventilation. Moreover, these sensors facilitate dynamic motion compensation during breathing. Seven passive conical fiducial markers (Pinpoint; Beekley, Bristol, CT) were also placed as a backup method of manual registration, which was performed by placing the tracked needle sequentially in each sterile cone, a process that takes, on average, 35 seconds,4 and that can be carried out automatically through skin patches as well. A planning CT scan (3-mm-thick sections, 1.5-mm overlap, and 16-slice CT MX 8000; Philips Medical Systems, Cleveland, OH) was obtained during interruption of ventilation. Using custom software on the workstation, the skin fiducials were identified manually on the CT scan (Fig. 1B). The skin entry site was estimated using a radio-opaque grid (E-Z-EM Inc., Lake Success, NY).
Both conventional techniques and tracking-assisted techniques were used sequentially to estimate needle angulations. The conventional technique involved using the most recent axial CT image of the target and the skin entry point, as determined from the CT skin grid. The 19-G guider needle was placed 5 mm below the skin surface by an interventional radiologist experienced in RFA. Thereafter, the appropriate angle for straight needle advancement was produced using freehand manipulation of the needle. In the usual conventional manner, once it was felt that the appropriate needle trajectory had been achieved, the virtual position of the needle and the expected straight-line trajectory were captured using tracking software (Fig. 2). Ventilation was interrupted during trajectory tracking. The operator was blinded to the tracking display throughout this manual process.
Figure 2
Figure 2
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To assess and compare the accuracy of EMT guidance, the physician was then unblinded and the tracking-assisted approach was attempted. The 19-G guider needle was removed and reinserted using tracking software guidance only. Through real-time updated display of the virtual needle position, and by assuming a straight insertion, the operator aligned the guider needle with the tracked target center (Fig. 3). Once a satisfactory needle trajectory was achieved, a CT scan of the tracked guider needle in the chest wall was performed. To estimate the accuracy of tracking, the virtual position was retrospectively compared with this actual CT position (Fig. 4).
Figure 3
Figure 3
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Figure 4
Figure 4
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A single 3-cm 17.5-G impedance-controlled active-tip Cooltip RFA electrode (Valley Lab, Covidien, Boulder, CO) was then placed immediately adjacent to the guider needle (tandem technique) and inserted in a single motion into the lung and tumor (Fig. 5A). CT confirmation of RFA needle position was performed at 3-mm collimation with 50% overlap. RFA of the tumor was followed for 12 minutes, using a sequentially increasing current ramping algorithm with 5 W power increments delivered. A CT scan taken immediately after the ablation illustrated a hazy density surrounding the original location of the tumor (Fig. 5B). A review CT scan taken 22 months post-RFA shows a stable scar and a complete treatment (Fig. 5C).
Figure 5
Figure 5
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ANALYSIS

After the procedure, the final virtual needle position was compared with the actual needle position on the postinsertion CT scan to assess the accuracy of the EMT system. There was near-perfect alignment of the virtual and actual guider needles on the postinsertion CT (Fig. 4). The overall accuracy of EMT-guided RFA can be quantitatively represented by the tracking error (target to registration error), which is the difference between the actual and the virtual (EMT-derived) needle-tip positions. This error was 3.9 mm.
We then compared the relative accuracy of conventional and tracking-assisted approaches by assessing how closer the trajectories passed relative to the center of the tumor. Figure 2 demonstrates that the conventional technique of freehand positioning of the needle for insertion would have resulted in significant needle misalignment with the tumor in 2 orthogonal planes, had the procedure occurred in conventional manner, perhaps even requiring further needle repositioning. Using tracking-assisted navigation (Fig. 3), the operator viewed the trajectory of the needle in 3 planes and accurately targeted the tumor in a single insertion along the intended trajectory.
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DISCUSSION

The lung is an ideal tissue for RFA, because the inherent airspace outside the tumor provides an insulating effect for the thermal energy produced during the procedure, which may help concentrate heat and energy in the tumor.1,2 Numerous clinical trials on lung tumor RFA have been reported.2 Indications for RFA in the lung are often based upon the size of the tumor and the staging characteristics. RFA may eradicate locally confined disease, and local, short-term control is high in tumors <3 cm in diameter and in favorable locations.1 Tumors >3 cm in diameter may require overlapping ablations.
The EMT system was successfully used in prospectively guiding needle insertion in a patient without the use of regular imaging input. Assuming a straight trajectory, tracking-assisted needle insertion targeted the tumor more accurately compared with that by the conventional freehand methods in this patient. This could be because of 3D multiplanar reconstruction and real-time feedback. Multiplanar reconstructions are produced easily by rotating the plane around the needle, allowing the operator to appreciate needle trajectory in 3D, and view the target and any other critical structures in 3D. In addition, multiplanar reconstruction allows the operator to perform preprocedural path planning. This is an advantage that can be particularly helpful in complex needle insertions, which require steeper angles of approach, where it may be difficult to keep the needle in the same image plane as the target.5 Meanwhile, real-time feedback of needle position relative to the ideal trajectory improves the operator’s ability to accurately redirect the needle as planned. Earlier feasibility studies of this system on both phantom and swine models have shown a statistically significant reduction of both the number of required needle passes and the overall radiation exposure.5
The 3.9-mm tracking error quantifies the accuracy of EMT alone by measuring the distance between the virtual and actual positions of the guider needle tip in 3 different planes (Fig. 4). It is within acceptable limits for clinical utility and correlates well with a tracking error of 3.6 to 5.8 mm from the larger retrospective series.4 The causes for this error include inherent inaccuracy of the registration process (eg, the nonuniform spatial accuracy of tracking within the magnetic field, interference from nearby metal structures) and intraprocedural causes such as respiratory motion or patient or organ shift.3,4,6,7 It is unknown at this time whether this error could increase with more central location.
EMT is a robust and relatively inexpensive and accurate technology that is widely used in nonmedical fields. It is a potentially useful tool that has yet to be fully applied to interventional radiologic and percutaneous procedures. Miniaturization of sensor coils has allowed the tracking of instruments as fine as 22-G needles and 0.018-inch guide wires required for interventional radiology.3 Future research is required to enhance respiratory motion modeling, reduce susceptibility to metal interference, and develop deformable modeling algorithms to better predict organ shift. Further, real-time mapping and feedback of overlapping ablation zones could reduce treatment gaps when treating larger tumors.4,7,8 Although speculative, EMT could potentially improve clinical outcomes by reducing the number of confirmation CTs to monitor needle progression or minimizing the number of needle insertions.
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REFERENCES

1. Rose SC, Thistlethwaite PA, Sewell PE, et al. Lung cancer and radiofrequency ablation. J Vasc Interv Radiol. 2006;17:927–951

2. Zhu JC, Yan TD, Morris DL. Systematic review of radiofrequency ablation for lung tumors. Ann Surg Oncol. 2008;15:1765–1774

3. Wood BJ, Zhang H, Durrani A, et al. Navigation with electromagnetic tracking for interventional radiology procedures: a feasibility study. J Vasc Interv Radiol. 2005;16:493–505

4. Krücker J, Xu S, Glossop N, et al. Electromagnetic tracking for thermal ablation and biopsy guidance: clinical evaluation of spatial accuracy. J Vasc Interv Radiol. 2007;18:1141–1150

5. Banovac F, Wilson E, Zhang H, et al. Needle biopsy of anatomically unfavorable liver lesions with an electromagnetic navigation assist device in a computed tomography environment. J Vasc Interv Radiol. 2006;17:1671–1675

6. Frantz DD, Wiles AD, Leis SE, et al. Accuracy assessment protocols for electromagnetic tracking systems. Phys Med Biol. 2003;48:2241–2251

7. Borgert J, Kruger S, Timinger H, et al. Respiratory motion compensation with tracked internal and external sensors during CT-guided procedures. Comput Aided Surg. 2006;11:119–125

8. Wood BJ, Locklin JK, Viswanathan A, et al. Technologies for guidance of radiofrequency ablation in the multimodality interventional suite of the future. J Vasc Interv Radiol. 2007;18:9–24
Keywords:
electromagnetic tracking; radiofrequency ablation; RFA; lung; tumor
© 2012 Lippincott Williams & Wilkins, Inc.


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Below is an alphabetical list of the educational picture slideshows available on eMedicineHealth. Each slideshow covers a medical or health topic and includes images, illustrations, or pictures and summary information discussing the topic. Scroll through each slide by clicking on the Next button. At the end of each slideshow you'll find links to additional related information on the topic.


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Tinnitus

1. Chadha NK, Gordon KA, James AL, Papsin BC. Tinnitus is prevalent in children with cochlear implants. International Journal of Pediatric Otorhinolaryngology. 2009;73:671-675. [abstract]

2. Akdogan O, Ozcan I, Ozbek C, Dere H. Tinnitus after cochlear implantation. Auris Nasus Larynx. 2009;36:210-212. [abstract]

3. Pan T, Tyler RS, Ji H, Coelho C, Gehringer AK, Gogel SA. Changes in the tinnitus handicap questionnaire after cochlear implantation. American Journal of Audiology. 2009;18:144-151. [abstract]

4. Andersson G, Freijd A, Baguley DM, Idrizbegovic E. Tinnitus distress, anxiety, depression, and hearing problems among cochlear implant patients with tinnitus. Journal of the American Academy of Audiology. 2009;20:315-319. [abstract]

5. Rothholtz VS, Tang Q, Wu EC, Fine EL, Djalilian H, Zeng F-G. Exploring the parametric space of tinnitus suppression in a patient with a cochlear implant. Laryngoscope. 2009;119.

6. Di NW, Cianfrone F, Scorpecci A, Cantore I, Giannantonio S, Paludetti G. Transtympanic electrical stimulation for immediate and long-term tinnitus suppression. International Tinnitus Journal. 2009;15:100-106.[abstract]

7. Litre CF, Theret E, Tran H et al. Surgical treatment by electrical stimulation of the auditory cortex for intractable tinnitus. Brain Stimulation. 2009;2:132-137. [abstract]

8. Evans RW, Ishiyama G. Migraine with transient unilateral hearing loss and tinnitus. Headache: The Journal of Head & Face Pain. 2009;49:756-759. [abstract]

9. Pirodda A, Brandolini C, Raimondi MC, Ferri GG, Borghi C. Tinnitus as a warning for preventing vasovagal syncope. Medical Hypotheses. 2009;73:370-371. [abstract]

10. Anderson JE, Teitel D, Wu YW. Venous hum causing tinnitus: case report and review of the literature. Clinical Pediatrics. 2009;48:87-89. [abstract]

11. Liess BD, Lollar KW, Christiansen SG, Vaslow D. Pulsatile tinnitus: a harbinger of a greater ill? Head & Neck. 2009;31:269-273. [abstract]

12. Singh DP, Forte AJ, Brewer MB, Nowygrod R. Bilateral carotid endarterectomy as treatment of vascular pulsatile tinnitus. Journal of Vascular Surgery. 2009;50:183-185. [abstract]

13. Delgado F, Munoz F, Bravo-Rodriguez F, Jurado-Ramos A, Oteros R. Treatment of dural arteriovenous fistulas presenting as pulsatile tinnitus. Otology and Neurotology. 2009;30:897-902. [abstract]

14. Cowley PO, Jones R, Tuch P, McAuliffe W. Pulsatile tinnitus from reversal of flow in an aberrant occipital artery: Resolved after carotid artery stenting. American Journal of Neuroradiology. 2009;30:995-997. [abstract]

15. Stimmer H, Borrmann A, Loer C, Arnold W, Rummeny EJ. Monaural tinnitus from a contralateral inferior colliculus hemorrhage. Audiology & Neurotology. 2009;14:35-38. [abstract]

16. Latifpour DH, Grenner J, Sjodahl C. The effect of a new treatment based on somatosensory stimulation in a group of patients with somatically related tinnitus. International Tinnitus Journal. 2009;15:94-99. [abstract]

17. Department of Health. Provision of services for adults with tinnitus: a good practice guide. 2009. [full text]

18. DH. Tinnitus Map of Medicine care pathway. 2010. [Full text]

19. BTA. Tinnitus: guidelines for primary care. 2010. [Full text]

20. Schneider P, Andermann M, Wengenroth M et al. Reduced volume of Heschl's gyrus in tinnitus. NeuroImage. 2009;45:927-939. [abstract]

21. Landgrebe M, Langguth B, Rosengarth K et al. Structural brain changes in tinnitus: grey matter decrease in auditory and non-auditory brain areas. NeuroImage. 2009;46:213-218. [abstract]

22. Melcher JR, Levine RA, Bergevin C, Norris B. The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research. 2009;257:63-74. [abstract]

23. Lanting CP, de KE, van DP. Neural activity underlying tinnitus generation: Results from PET and fMRI. Hearing Research. 2009;255:1-13. [abstract]

24. Kaltenbach JA. Insights on the origins of tinnitus: an overview of recent research. Hearing Journal. 2009;62:26-31. [Full text]

25. Shulman A, Goldstein B, Strashun AM. Final common pathway for tinnitus: theoretical and clinical implications of neuroanatomical substrates. International Tinnitus Journal. 2009;15:5-50. [abstract]

26. Schutte NS, Noble W, Malouff JM, Bhullar N. Evaluation of a model of distress related to tinnitus. International Journal of Audiology. 2009;48:428-432. [abstract]

27. Hesser H, Pereswetoff-Morath CE, Andersson G. Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology. 2009;54:381-390.[abstract]

28. Argstatter H, Krick C, Bolay HV. Music therapy for chronic tinnitus. Heidelberg treatment model. Psychotherapeut. 2009;54:17-26. [abstract]

29. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: A new empirical approach for an effective personalized treatment of tinnitus. International Tinnitus Journal. 2009;15:51-61.[abstract]

30. Langguth B, Salvi R, Elgoyhen AB. Emerging pharmacotherapy of tinnitus. Expert Opinion on Emerging Drugs. 2009;14:687-702. [abstract]

31. Campbell KCM. Emerging pharmacologic treatments for hearing loss and tinnitus. ASHA Leader. 2009;14:14-18. [Full text]

32. Hesser H, Westin V, Hayes SC, Andersson G. Clients' in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research & Therapy. 2009;47:523-528. [abstract]

33. Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology. 2009;48:295-299. [abstract]

34. Shulman A, Goldstein B. Subjective idiopathic tinnitus and palliative care: a plan for diagnosis and treatment. Otolaryngologic Clinics of North America. 2009;42:15-38. [abstract]

35. Forti S, Costanzo S, Crocetti A, Pignataro L, Del BL, Ambrosetti U. Are results of tinnitus retraining therapy maintained over time? 18-month follow-up after completion of therapy. Audiology & Neuro-Otology. 2009;14:286-289. [abstract]

36. Bessman P, Heider T, Watten VP, Watten RG. The tinnitus intensive therapy habituation program: a 2-year follow-up pilot study on subjective tinnitus. Rehabilitation Psychology. 2009;54:133-138. [abstract]

37. Gudex C, Skellgaard PH, West T, Sorensen J. Effectiveness of a tinnitus management programme: A 2-year follow-up study. BMC Ear, Nose and Throat Disorders. 2009;9. [Full text]

38. Henry J, Zaugg T, Myers P, Kendall C, Turbin M. Principles and application of educational counseling used in progressive audiologic tinnitus management. Noise and Health. 2009;11:33-48. [abstract]

1. Hazell JW, Jastreboff PJ. Tinnitus. I: Auditory mechanisms: a model for tinnitus and hearing impairment. J Otolaryngol. 1990;19:1-5. [Abstract]

2. Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol. 2000 Mar;11(3):162-77. [Abstract]

3. Marcondes RA, Sanchez TG, Kii MA, Langguth et al. Repetitive transcranial magnetic stimulation improve tinnitus in normal hearing patients: a double-blind controlled, clinical and neuroimaging outcome study. Eur J Neurol. 2009. [Epub ahead of print] ) [Abstract]

4. Cannon SC Pathomechanisms in channelopathies of skeletal muscle and brain. Annu Rev Neurosci. 2006;29:387-415. [Abstract]

5. Davies E, Knox E, Donaldson I. The usefulness of nimodipine, an L-calcium channel antagonist, in the treatment of tinnitus. Br J Audiol. 1994;28:125-129. [Abstract]

6. Baguley DM, Jones S, Wilkins I, Axon PR, Moffat DA. The inhibitory effect of intravenous lidocaine infusion on tinnitus after translabyrinthine removal of vestibular schwannoma: a double-blind, placebo-controlled, crossover study. Otol Neurotol. 2005;26:169-176. [Abstract]

Eggermont JJ. Cortical tonotopic map reorganization and its implications for treatment of tinnitus. Acta Otolaryngol Suppl. 2006;9-12. [Abstract]

Hoke ES, Muhlnickel W, Ross B, Hoke M. Tinnitus and event-related activity of the auditory cortex. Audiol Neurootol. 1998;3:300-331. [Abstract]

Mirz F, Pedersen B, Ishizu K et al. Positron emission tomography of cortical centers of tinnitus. Hear Res. 1999;134:133-144. [Abstract]

Muhlnickel W, Elbert T, Taub E, Flor H. Reorganization of auditory cortex in tinnitus. Proc Natl Acad Sci U S A. 1998;95:10340-10343. [Abstract]

Norena AJ, Eggermont JJ. Enriched acoustic environment after noise trauma abolishes neural signs of tinnitus. Neuroreport. 2006;17:559-563. [Abstract]

Schlee W, Hartmann T, Langguth B, Weisz N. Abnormal resting-state cortical coupling in chronic tinnitus. BMC Neurosci. 2009;10:11. [Full text]

Schlee W, Mueller N, Hartmann T, Keil J, Lorenz I, Weisz N. Mapping cortical hubs in tinnitus. BMC Biol. 2009;7:80. [Full text]

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HIPPOCRATE'S OATH

"I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:

To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.

I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessaryto cause an abortion.

But I will preserve the purity of my life and my arts.

I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.

In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.

All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.

If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot."

MAIMONIDE'S PRAYER

"Almighty God, Thou has created the human body with infinite wisdom. Ten thousand times ten thousand organs hast Thou combined in it that act unceasingly and harmoniously to preserve the whole in all its beauty the body which is the envelope of the immortal soul. They are ever acting in perfect order, agreement and accord. Yet, when the frailty of matter or the unbridling of passions deranges this order or interrupts this accord, then forces clash and the body crumbles into the primal dust from which it came. Thou sendest to man diseases as beneficent messengers to foretell approaching danger and to urge him to avert it.

"Thou has blest Thine earth, Thy rivers and Thy mountains with healing substances; they enable Thy creatures to alleviate their sufferings and to heal their illnesses. Thou hast endowed man with the wisdom to relieve the suffering of his brother, to recognize his disorders, to extract the healing substances, to discover their powers and to prepare and to apply them to suit every ill. In Thine Eternal Providence Thou hast chosen me to watch over the life and health of Thy creatures. I am now about to apply myself to the duties of my profession. Support me, Almighty God, in these great labors that they may benefit mankind, for without Thy help not even the least thing will succeed.

"Inspire me with love for my art and for Thy creatures. Do not allow thirst for profit, ambition for renown and admiration, to interfere with my profession, for these are the enemies of truth and of love for mankind and they can lead astray in the great task of attending to the welfare of Thy creatures. Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend. In the sufferer let me see only the human being. Illumine my mind that it recognize what presents itself and that it may comprehend what is absent or hidden. Let it not fail to see what is visible, but do not permit it to arrogate to itself the power to see what cannot be seen, for delicate and indefinite are the bounds of the great art of caring for the lives and health of Thy creatures. Let me never be absent- minded. May no strange thoughts divert my attention at the bedside of the sick, or disturb my mind in its silent labors, for great and sacred are the thoughtful deliberations required to preserve the lives and health of Thy creatures.

"Grant that my patients have confidence in me and my art and follow my directions and my counsel. Remove from their midst all charlatans and the whole host of officious relatives and know-all nurses, cruel people who arrogantly frustrate the wisest purposes of our art and often lead Thy creatures to their death.

"Should those who are wiser than I wish to improve and instruct me, let my soul gratefully follow their guidance; for vast is the extent of our art. Should conceited fools, however, censure me, then let love for my profession steel me against them, so that I remain steadfast without regard for age, for reputation, or for honor, because surrender would bring to Thy creatures sickness and death.

"Imbue my soul with gentleness and calmness when older colleagues, proud of their age, wish to displace me or to scorn me or disdainfully to teach me. May even this be of advantage to me, for they know many things of which I am ignorant, but let not their arrogance give me pain. For they are old and old age is not master of the passions. I also hope to attain old age upon this earth, before Thee, Almighty God!

"Let me be contented in everything except in the great science of my profession. Never allow the thought to arise in me that I have attained to sufficient knowledge, but vouchsafe to me the strength, the leisure and the ambition ever to extend my knowledge. For art is great, but the mind of man is ever expanding.

"Almighty God! Thou hast chosen me in Thy mercy to watch over the life and death of Thy creatures. I now apply myself to my profession. Support me in this great task so that it may benefit mankind, for without Thy help not even the least thing will succeed."

Information for Health Professionals

Information for Patients

Modern challenged parts of the oath:

  1. To teach medicine to the sons of my teacher. In the past, medical schools gave preferential consideration to the children of physicians.
  2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them. This beneficial intention is the purpose of the physician. However, this item is still invoked in the modern discussions of euthanasia.
  3. I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan. Physician organizations in most countries have strongly denounced physician participation in legal executions. However, in a small number of cases, most notably the U.S. states of Oregon,[10] Washington,[11]Montana,[12] and in the Kingdom of the Netherlands,[13] a doctor can prescribe euthanasia with the patient's consent.
  4. Similarly, I will not give a woman a pessary to cause an abortion. Since the legalization of abortion in many countries, the inclusion of the anti-abortion sentence of the Hippocratic oath has been a source of contention.
  5. To avoid violating the morals of my community. Many licensing agencies will revoke a physician's license for offending the morals of the community ("moral turpitude").
  6. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. The "stones" referred to are kidney stones or bladder stones, removal of which was judged too menial for physicians, and therefore was left for barbers (the forerunners of modern surgeons). Surgery was not recognized as a specialty at that time. This sentence is now interpreted as acknowledging that it is impossible for any single physician to maintain expertise in all areas. It also highlights the different historical origins of the surgeon and the physician.
  7. To keep the good of the patient as the highest priority. There may be other conflicting 'good purposes,' such as community welfare, conserving economic resources, supporting the criminal justice system, or simply making money for the physician or his employer that provide recurring challenges to physicians
http://www.worldallergy.org/educational_programs/world_allergy_forum/barcelona2008/rabe/

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