Inappropriate placement of urinary catheters into the ureter: A case report and literature review.

OBJECTIVE: To emphasize preventive measures and outline management strategies for inadvertent ureteral cannulation. METHODS: We present a case report and conduct a literature review of 39 case reports on ureteral cannulation, examining a total of 48 patients. RESULTS: About 67% of the cases were female, and long-term catheterization was observed in 67% of the cases. Neurological conditions such as spinal cord injury (SCI), stroke, dementia, multiple sclerosis, and myasthenia gravis were the primary factors (48%) in ureteral cannulation. Symptoms included flank pain (46%), fever (31%), oliguria (27%), non-deflatable balloon issues (25%), hematuria (21%), abdominal pain (17%), urine leak (12.5%), and nausea/vomiting (8%). Complications varied, including acute pyelonephritis (35%), acute kidney injury (27%), urosepsis (21%), and ureter rupture (17%). Despite inadvertent catheter placement, 25% of patients had no complications. More than half of the patients (58%) were managed through catheter change, while 27% underwent cysto-ureteroscopy with or without balloon puncture or ureteral stenting. Additionally, 10% received interventional radiology procedures, 6.25% underwent surgical repair, and 4% underwent ultrasound-guided balloon puncture. CONCLUSIONS: Female gender, neurologic conditions, and long-term catheterization were identified as predominant risk factors. Early detection of ureteral cannulation can prevent severe complications, particularly in certain special populations such as patients with neurogenic bladder or SCI, who may have reduced sensation and expression capabilities.

Percutaneous kyphoplasty through unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fracture with scoliosis.

PURPOSE: To assess the clinical safety, accuracy, and efficacy of percutaneous kyphoplasty (PKP) surgery using an enhanced method of unilateral puncture on the convex side for the treatment of painful osteoporotic vertebral compression fractures (P-OVCF) with scoliosis. METHODS: Clinical and radiographic data of P-OVCF patients with scoliosis who underwent PKP via unilateral puncture on the convex side from January 2018 to December 2021 were retrospectively analyzed. This technique's detailed surgical steps and tips were described. The local kyphosis angle (LKA), scoliosis Cobb angle (SCA), and local scoliosis Cobb angle (LSCA) were measured using X-ray and compared at pre-operation, post-operation, and the last follow-up. The width of pedicle (POW), inner inclination angle (IIA), lateral distance (LD), and puncture course length (PCL) were measured on the axial computed tomography image and compared between two sides. Postoperative computed tomography was employed to evaluate the condition of cement distribution and puncture. Clinical outcomes were evaluated using the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back pain (BP). RESULTS: Thirty-six patients, 23 women and 13 men, with an average age of 76.31 ± 6.28 years were monitored for 17.69 ± 4.70 months. The median surgical duration of single vertebrae was 35 min. The volume of bone cement for single vertebrae was 3.81 ± 0.87 ml and the proportion of sufficient cement distribution of the patients was 97.22. LKA was considerably improved from pre-operation to post-operation and sustained at the last follow-up. SCA and LSCA were not significantly modified between these three-time points. IIA, PCL, and LD were lower on the convex side than on the concave side. POW was considerably wider on the convex side. The ODI and VAS-BP scores were significantly improved after surgery and sustained during the follow-up. CONCLUSIONS: Combining with the proper assessment of the pre-injured life status of patients, PKP surgery using unilateral puncture on the convex side for the treatment of P-OVCF with scoliosis can achieve safe, excellent clinical, and radiographic outcomes.

Single-cell RNA sequencing reveals Immune Education promotes T cell survival in mice subjected to the cecal ligation and puncture sepsis model.

Background: Individual T cell responses vary significantly based on the microenvironment present at the time of immune response and on prior induced T cell memory. While the cecal ligation and puncture (CLP) model is the most commonly used murine sepsis model, the contribution of diverse T cell responses has not been explored. We defined T cell subset responses to CLP using single-cell RNA sequencing and examined the effects of prior induced T cell memory (Immune Education) on these responses. We hypothesized that Immune Education prior to CLP would alter T cell responses at the single cell level at a single, early post-CLP time point. Methods: Splenic T cells were isolated from C57BL/6 mice. Four cohorts were studied: Control, Immune-Educated, CLP, and Immune-Educated CLP. At age 8 weeks, Immune-Educated and Immune-Educated CLP mice received anti-CD3ϵ antibody; Control and CLP mice were administered an isotype control. CLP (two punctures with a 22-gauge needle) was performed at 12-13 weeks of life. Mice were sacrificed at baseline or 24-hours post-CLP. Unsupervised clustering of the transcriptome library identified six distinct T cell subsets: quiescent naïve CD4+, primed naïve CD4+, memory CD4+, naïve CD8+, activated CD8+, and CD8+ cytotoxic T cell subsets. T cell subset specific gene set enrichment analysis and Hurdle analysis for differentially expressed genes (DEGs) were performed. Results: T cell responses to CLP were not uniform - subsets of activated and suppressed T cells were identified. Immune Education augmented specific T cell subsets and led to genomic signatures favoring T cell survival in unoperated and CLP mice. Additionally, the combination of Immune Education and CLP effected the expression of genes related to T cell activity in ways that differed from CLP alone. Validating our finding that IL7R pathway markers were upregulated in Immune-Educated CLP mice, we found that Immune Education increased T cell surface IL7R expression in post-CLP mice. Conclusion: Immune Education enhanced the expression of genes associated with T cell survival in unoperated and CLP mice. Induction of memory T cell compartments via Immune Education combined with CLP may increase the model's concordance to human sepsis.

Effectiveness of Histopathological Examination of Ultrasound-guided Puncture Biopsy Samples for Diagnosis of Extrapulmonary Tuberculosis.

Objective: To evaluate the diagnostic value of histopathological examination of ultrasound-guided puncture biopsy samples in extrapulmonary tuberculosis (EPTB). Methods: This study was conducted at the Shanghai Public Health Clinical Center. A total of 115 patients underwent ultrasound-guided puncture biopsy, followed by MGIT 960 culture (culture), smear, GeneXpert MTB/RIF (Xpert), and histopathological examination. These assays were performed to evaluate their effectiveness in diagnosing EPTB in comparison to two different diagnostic criteria: liquid culture and composite reference standard (CRS). Results: When CRS was used as the reference standard, the sensitivity and specificity of culture, smear, Xpert, and histopathological examination were (44.83%, 89.29%), (51.72%, 89.29%), (70.11%, 96.43%), and (85.06%, 82.14%), respectively. Based on liquid culture tests, the sensitivity and specificity of smear, Xpert, and pathological examination were (66.67%, 72.60%), (83.33%, 63.01%), and (92.86%, 45.21%), respectively. Histopathological examination showed the highest sensitivity but lowest specificity. Further, we found that the combination of Xpert and histopathological examination showed a sensitivity of 90.80% and a specificity of 89.29%. Conclusion: Ultrasound-guided puncture sampling is safe and effective for the diagnosis of EPTB. Compared with culture, smear, and Xpert, histopathological examination showed higher sensitivity but lower specificity. The combination of histopathology with Xpert showed the best performance characteristics.

A case report of atrial septal puncture "mistakenly" penetrated the aorta during left bypass radiofrequency ablation.

INTRODUCTION: Transseptal punctures (TSPs) are widely used in left atrium and left ventricle surgery. Accidental puncture of the puncture needle into the aorta is a rare complication that is rarely reported but has serious consequences. The appropriate management of this complication remains unclear. PATIENT CONCERNS: This report describes a case of a male with the chief complaint: paroxysmal palpitation for 1 year, aggravated for 1 month. DIAGNOSIS: The electrophysiological diagnosis was atrioventricular reentrant tachycardia caused by left-side bypass. INTERVENTIONS: Radiofrequency ablation of the heart was a necessary treatment and a TSP operation was needed, in which a puncture was mistakenly believed to have entered the aorta, a series of measures were taken urgently. Although the surgical procedure in this case was a false alarm, we still initiated a series of emergency plans. Emergency measures to address the complications were effectively implemented, and the emergency measures were promptly terminated after it was clear that complications had been misjudged. OUTCOMES: At last, it was confirmed that the angiogram was a pulmonary artery image, not an aorta image. Then the atrial septal puncture operation was successfully completed, and under the guidance of the Carto system, the ablation was successfully completed. Postoperative fluoroscopy showed no complications, such as pericardial effusion. After 2 years of follow-up, there was no reoccurrence of tachycardia, and there were no complications. It is crucial that emergency procedures are terminated in a timely manner after a clear miscarriage of performance. Although accidental puncture into the aorta is urgent and serious, performing a blockage or even thoracotomy in an emergency if complications are not clearly confirmed can cause further damage to the patient and would be a definitively wrong strategy. CONCLUSION: Strict and standardized TSP operations can avoid complications. Correct judgment of the authenticity of complications is crucial, and remedial measures that may cause further damage should not be blindly adopted. The retention of the aortic guide wire can provide convenient access for further differential diagnosis and remedial treatment.

Carrimycin ameliorates lipopolysaccharide and cecal ligation and puncture-induced sepsis in mice.

Carrimycin (CA), sanctioned by China's National Medical Products Administration (NMPA) in 2019 for treating acute bronchitis and sinusitis, has recently been observed to exhibit multifaceted biological activities, encompassing anti-inflammatory, antiviral, and anti-tumor properties. Despite these applications, its efficacy in sepsis treatment remains unexplored. This study introduces a novel function of CA, demonstrating its capacity to mitigate sepsis induced by lipopolysaccharide (LPS) and cecal ligation and puncture (CLP) in mice models. Our research employed in vitro assays, real-time quantitative polymerase chain reaction (RT-qPCR), and RNA-seq analysis to establish that CA significantly reduces the levels of pro-inflammatory cytokines, namely tumor necrosis factor-alpha (TNF-α), interleukin 1 beta (IL-1ß), and interleukin 6 (IL-6), in response to LPS stimulation. Additionally, Western blotting and immunofluorescence assays revealed that CA impedes Nuclear Factor Kappa B (NF-κB) activation in LPS-stimulated RAW264.7 cells. Complementing these findings, in vivo experiments demonstrated that CA effectively alleviates LPS- and CLP-triggered organ inflammation in C57BL/6 mice. Further insights were gained through 16S sequencing, highlighting CA's pivotal role in enhancing gut microbiota diversity and modulating metabolic pathways, particularly by augmenting the production of short-chain fatty acids in mice subjected to CLP. Notably, a comparative analysis revealed that CA's anti-inflammatory efficacy surpasses that of equivalent doses of aspirin (ASP) and TIENAM. Collectively, these findings suggest that CA exhibits significant therapeutic potential in sepsis treatment. This discovery provides a foundational theoretical basis for the clinical application of CA in sepsis management.

Therapeutic potential of ramipril, losartan, and spironolactone against sepsis-associated liver tissue injury induced by cecal ligation and puncture in rats.

OBJECTIVE: Sepsis-associated liver injury is responsible for the high morbidity and mortality rates seen with septic shock. Activation of the renin-angiotensin-aldosterone system (RAAS) is an essential counteractive mechanism during the hypotensive phase of sepsis; however, excessive activation is associated with exaggerated pro-oxidant and inflammatory response, which aggravates organ damage. This study aimed to evaluate the effect of RAAS inhibition on sepsis-induced liver damage. MATERIALS AND METHODS: The cecal ligation and puncture (CLP) model was employed as a model of sepsis. Rats were divided into five groups: sham-operated, vehicle-treated septic rats, septic rats treated with ramipril in a dose of 10 mg/kg, septic rats treated with losartan in a dose of 20 mg/kg, and finally septic rats treated with spironolactone in a dose of 25 mg/kg. Rats received the treatment one hour after induction. Twenty-four hours later, rats were euthanized, and serum samples and liver tissue were collected to evaluate liver function and hepatic oxidative, anti-oxidative, inflammatory, and apoptotic markers. The microscopic integrity of the hepatic tissue was also assessed. RESULTS: The results of our study showed that all the treatments used ameliorated sepsis-induced liver injury. This was reflected by improved liver function parameters and histopathological appearance of liver tissue. Treatment with ramipril, losartan, or spironolactone reduced tissue malondialdehyde (MDA), nitric oxide, activated caspase-3, and TNF-α. Moreover, these drugs increased hepatic reduced-glutathione (GSH) levels, superoxide dismutase (SOD) activity, and proliferating cell nuclear antigen (PCNA) expression. CONCLUSIONS: Administration of ramipril, losartan, or spironolactone after CLP produced a hepatoprotective effect in rats, possibly by reducing oxidative stress, inflammation, and apoptosis.

Impacts of continuous quality improvement on wound pain in the puncture site of arteriovenous fistula in haemodialysis patient.

This study analyses the effects of a continuous quality improvement nursing model on wound pain at the arteriovenous fistula (AVF) puncture site in patients undergoing haemodialysis. Forty haemodialysis patients from the First Affiliated Hospital of Chongqing Medical University, from September 2020 to December 2022, were selected as study subjects. They were randomly divided into an observation group and a control group. The control group received conventional nursing care, while the observation group was treated with a continuous quality improvement nursing model. The study compared the impact of these nursing approaches on pain intensity post-AVF puncture, wound visual analogue scale scores, self-rating anxiety scale, self-rating depression scale, quality of life scores and patient satisfaction with nursing care. In the observation group, the proportion of patients experiencing moderate to severe pain during AVF puncture was lower than that in the control group, whereas the proportion of patients with no pain or mild pain was higher (P = 0.008). After nursing, the observation group exhibited significantly lower wound visual analogue scale scores, self-rating anxiety scale scores, and self-rating depression scale scores compared to the control group (P < 0.001), with a significantly higher quality of life score (P < 0.05). The nursing satisfaction rate was 95.00% in the observation group, significantly higher than the 65.00% in the control group (P = 0.018). The continuous quality improvement nursing model significantly reduces wound pain at the AVF puncture site in haemodialysis patients, alleviates negative emotions, enhances the quality of life, and achieves high patient satisfaction. It is thus a highly recommendable approach in nursing practice.

Direct superior sagittal sinus puncture via a surgical burr hole for curative embolization of the complex transverse-sigmoid sinus dural arteriovenous fistula: How I do it.

BACKGROUND: Transvenous embolization of high-grade dural arteriovenous fistulas (dAVFs) is challenging particularly when the direct sinus access is favorable due to the complex venous anatomy which prohibits endovascular access via the transfemoral approach. METHOD: The procedure was conducted in the hybrid operating suite, where a burr hole was performed, followed by direct catheterization of the superior sagittal sinus. Coil embolization was then executed to achieve complete obliteration of the fistula. CONCLUSION: The direct puncture of the superior sagittal sinus is a safe and effective method for treating complex dAVFs. This approach grants access to the fistula channel which facilitates curative embolization.

Pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic arteriovenous fistulas maturation.

PURPOSE: The aim of this study was to investigate the effectiveness and safety of the pull-through technique through antegrade radial artery puncture without sheath insertion in balloon-assisted radiocephalic AVF maturation. METHODS: We retrospective studied a total of 62 patients with immature radiocephalic AVF, who received balloon-assisted maturation in our hospital. 15 patients received pull-through technique through radial artery without sheath insertion and 47 patients received treatment through a regular venous approach. RESULTS: The success rate of pull-through technique group and control group was 86.7% (13 out of 15), 89.1% (41 out of 46) respectively. There was no significant difference between two groups (P > 0.05). In our study, there were 2 patients in the pull-through technique group and 3 patients in the control group, which had hematoma in the vein puncture site (P = 0.59). There were also no differences in the primary patency rate between two groups at 6 months and 12 months (76.9% vs 70.7%, 38.4% vs 41.5%, respectively, P > 0.05). CONCLUSION: The pull-through technique through antegrade radial artery without sheath insertion in promoting radiocephalic AVF maturation is effective and safe.

Feasibility of stereotactic optical navigation for needle positioning in percutaneous nephrolithotomy.

BACKGROUND: This study assessed the feasibility of acquiring single-attempt access to the pelvicalyceal system during percutaneous nephrolithotomy (PCNL) using stereotactic optical navigation combined with cone-beam CT (CBCT) imaging. METHODS: Patients with a PCNL indication were prospectively included in this IRB approved study. After sterile preparation, fiducial markers were attached to patients' skin. An initial intraprocedural CBCT scan was acquired, on which the urologist planned the needle trajectory using the navigation software. After verifying that no critical structures were crossed, the needle guide was aligned with the plan. A needle was manually inserted through the needle guide to the indicated depth and a second CBCT scan was performed for needle position confirmation. Both, scanning and needle insertion, were performed under apnea. The study evaluated technical success, accuracy, procedure time, complication rate, and radiation dose. RESULTS: Between June 2022 and April 2023, seven patients were included. In all patients, the navigation system allowed safe puncture. However, the technical success rate was only 29%. In 42% of the cases, pelvicalyceal access was achieved by a small manual adjustment. In the remaining 29%, the needle was retracted and positioned per clinical standard. The average deviation between the needle and target was 5.9 ± 2.3 mm. The average total procedure time was 211 ± 44 min. The average radiation exposure was 6.4 mSv, with CBCT scanning contributing to 82% of this exposure. CONCLUSIONS: The optical navigation system facilitated safe needle insertion but did not consistently ensure accurate one-attempt needle positioning for PCNL. Real-time visualization and trajectory correction may improve the technical success rate.

Effect of photobiomodulation therapy on pain perception during anesthetic puncture of dental local anesthesia: A systematic review.

BACKGROUND: Local anesthetic puncture is often related to the experience of pain. This study aimed to systematically analyze the literature on changes in pain perception during the anesthetic puncture of dental local anesthesia after Photobiomodulation Therapy (PBMT). MATERIAL AND METHODS: An electronic search was performed in eight primary databases (Embase, LILACS, BBO, LIVIVO, MedLine via PubMed, SciELO, Scopus, and Web of Science) and three additional ones (EASY, Google Scholar, and OATD) to partially capture the "gray literature". The PICO strategy was used to identify randomized clinical trials evaluating the analgesic effect of PBMT in the anesthetic puncture site of dental local anesthesia compared to placebo or control groups, without restrictions on publication language and year. Two reviewers extracted the data and assessed the individual risk of bias of the eligible studies using the Cochrane Collaboration Risk of Bias Tool version 2.0. RESULTS: The electronic search found 3,485 records, of which eight met the eligibility criteria and were included in the qualitative synthesis. The studies were published from 2011 to 2022. None of the included studies had a low risk of bias. PBMT groups showed no significant difference in pain scores compared to placebo and control groups of most studies. CONCLUSION: Based on a low to very low certainty of evidence, PBMT seems to have no effect on pain perception during anesthetic puncture in patients undergoing dental local anesthesia.

Assessment of the MANTA closure device in real-life transfemoral transcatheter aortic valve replacement: A single-centre observational study.

BACKGROUND: Vascular complications increase morbidity and mortality in transcatheter aortic valve replacement (TAVR). Data involving suture-based percutaneous vascular closure devices (VCDs) have been extensive. Although promising, data regarding the efficacy and safety of the MANTA VCD (Teleflex) are scarce. We sought to assess the safety and effectiveness of the MANTA device in a real-life unselected cohort of patients undergoing transfemoral-TAVR (TF-TAVR). METHODS: This single-center retrospective observational study included a cohort of consecutive patients with severe aortic stenosis (AS) treated by our team using TAVR between January 2020 to December 2022. The primary outcome measure was access-related major and minor vascular complications according to the Valve Academic Research Consortium (VARC-3) definition criteria. RESULTS: From January 2020 to December 2022, a total of 347 patients underwent TF-TAVR were treated using the MANTA 18 Fr VCD system for vascular closure. Mean age was 82.4 ± 6.1 years (56-98 years). There were no significant differences in preoperative and procedural characteristics between patients with and without VCD-related major vascular complications. Access site-related major and minor vascular complications occurred in 20 of 347 patients (5.7%). Overall, major vascular complications occurred in 5 patients (1.4%) and device failure was seen in 17 patients (4.9%). CONCLUSION: This French real world evaluation of large-bore arteriotomy closure in TF-TAVR indicated that MANTA VCD is a feasible alternative with an acceptable low rate of access-site-related complications.

[Modified reverse puncture technique for esophagojejunostomy during totally laparoscopic total gastrectomy for gastric cancer].

Objective: To evaluate the value of implementing a modified reverse puncture procedure for esophagojejunostomy during totally laparoscopic total gastrectomy. Methods: This was a descriptive case series. Relevant clinical data, including the operative procedure, recovery, and pathological findings of 35 patients with gastric cancer who had undergone esophagojejunostomy with a modified reverse puncture technique during totally laparoscopic total gastrectomy in the Department of Gastrointestinal Surgery, Fujian Provincial Hospital, from June 2022 to January 2023, were prospectively collected and retrospectively analyzed. The age of all patients in the group was (64.9±8.0) years old, with 22 males (62.9%) and a body mass index of (23.2±2.4) kg/m2. The tumors were located in the upper and middle parts of the stomach in 24 cases (68.6%) and in the junction of the esophagus and stomach in 11 cases (31.4%). Important technical aspects of the modified reverse puncture procedure are as follows. (1) Site of the esophageal incision: a transverse incision is made across the right lateral wall of the esophagus at the expected site of esophageal disjunction. (2) Technique for inserting an anvil: after threading a silk thread through the tip of anvil, the end of the thread is knotted and fixed as the traction thread, after which an anvil is inserted into the esophagus through the esophageal incision, leaving the end of the traction line exposed. Next, a 60-mm linear cutter is placed through the right midclavicular trocar to straighten the opened esophagus vertically, after which the rod of the anvil is pulled out of a small incision that has been made in the esophagus by pulling the traction thread, thus completing anvil placement. (3) Jejunal binding: the jejunum on the central bar of the stapler is fastened with silk thread to the stump of the jejunum, and then tied to the output loop of the jejunum with a gauze strip. Results: All 35 surgeries were successful, with no mortality or conversion to laparotomy. The operation time, anvil insertion time, and digestive tract reconstruction time were (232.7±34.4), (8.5±1.4), and (40.5±4.8) minutes, respectively. The intraoperative blood loss was 100 (20-250) mL and the incision was (5.3±0.9) cm long. The upper surgical margin was negative in all patients and the mean distance between the upper and tumor margins was (3.5±1.2) cm. The mean number of lymph nodes dissected per patient was 33.9±7.1. The times to initial ambulation, initial passage of flatus , postoperative fluid intake, and length of postoperative hospital stay were (3.2±1.1), (3.7±1.5), (4.6±2.3), and (9.8±3.2) days, respectively. Postoperative complications occurred in five patients: one case of anastomotic leak, two of anastomotic stenosis, one of pulmonary infection, and one of incomplete intestinal obstruction, all of which were successfully managed conservatively. Conclusion: Esophagojejunostomy using a modified reverse puncture technique during totally laparoscopic total gastrectomy is safe and feasible for gastric cancer, requiring only a small incision and achieving higher upper esophageal resection margins and good postoperative recovery, and therefore warrants further implementation.

Path planning algorithm for percutaneous puncture lung mass biopsy procedure based on the multi-objective constraints and fuzzy optimization.

Objective. The percutaneous puncture lung mass biopsy procedure, which relies on preoperative CT (Computed Tomography) images, is considered the gold standard for determining the benign or malignant nature of lung masses. However, the traditional lung puncture procedure has several issues, including long operation times, a high probability of complications, and high exposure to CT radiation for the patient, as it relies heavily on the surgeon's clinical experience.Approach.To address these problems, a multi-constrained objective optimization model based on clinical criteria for the percutaneous puncture lung mass biopsy procedure has been proposed. Additionally, based on fuzzy optimization, a multidimensional spatial Pareto front algorithm has been developed for optimal path selection. The algorithm finds optimal paths, which are displayed on 3D images, and provides reference points for clinicians' surgical path planning.Main results.To evaluate the algorithm's performance, 25 data sets collected from the Second People's Hospital of Zigong were used for prospective and retrospective experiments. The results demonstrate that 92% of the optimal paths generated by the algorithm meet the clinicians' surgical needs.Significance.The algorithm proposed in this paper is innovative in the selection of mass target point, the integration of constraints based on clinical standards, and the utilization of multi-objective optimization algorithm. Comparison experiments have validated the better performance of the proposed algorithm. From a clinical standpoint, the algorithm proposed in this paper has a higher clinical feasibility of the proposed pathway than related studies, which reduces the dependency of the physician's expertise and clinical experience on pathway planning during the percutaneous puncture lung mass biopsy procedure.

Mechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report.

BACKGROUND: Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak. CASE PRESENTATION: We report the case of a peripartum patient who developed a severe and persistent CSF leak unresponsive to multiple EBPs following a UDP during epidural catheter placement for labor analgesia. Lumbar MRI revealed a ventral rather than dorsal epidural fluid collection suggesting that the needle had crossed the thecal sac and punctured the ventral dura, creating a puncture site not readily accessible to blood injected in the dorsal epidural space. The location of this persistent ventral dural defect was confirmed with digital subtraction myelography, permitting a transdural surgical exploration and repair of the ventral dura with resolution of the severe intracranial hypotension. CONCLUSIONS: A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.

Enhancing proficiency in ascites puncture through procedural simulation: an audit type study investigating medium-term skill retention.

INTRODUCTION: Medical simulation has become an essential teaching method for all health professionals. It not only allows to acquire technical and non-technical knowledge, but also helps the maintenance of acquired knowledge in the medium and long term. Ascites puncture is part of the basic technical procedures learned by medical students during their internship. OBJECTIVES: To evaluate the role of simulation-based learning of ascites puncture on the improvement of theoretical knowledge and maintenance of skills at 3 months. METHODS: We conducted an audit type study with two cycles of data collection at the simulation center at the Faculty of Medicine of Sousse between November 2020 and June 2021. We included learners in their third year of medical studies who had a hospital internship in the gastroenterology department at Sahloul Hospital in Sousse. All learners attended the initial simulation session on ascites fluid puncture. Thereafter, they were free to accept or refuse participation in the evaluation session that was scheduled after 3 months, depending on their availability. RESULTS: Forty learners participated in the procedural simulation of the ascites fluid puncture technique. Thirty-four (85%) were female and six (5%) were male. In our study, we showed that following procedural simulation training of ascites puncture, there was a significant improvement in the theoretical knowledge of the learners (p < 0.000). Objective assessment of technical skills after 3 months showed the benefit of performance maintenance (p < 0.000). CONCLUSION: Our study confirmed the benefit of simulation-based learning on the improvement of theoretical knowledge and the maintenance of technical performance in the medium term.