A Rare Case of Shunt Malfunction Due to the Needle Guard Coming Off During Ventriculoperitoneal Shunt Surgery.

We report a rare case of shunt valve failure due to obstruction during ventriculoperitoneal (VP) shunt surgery for hydrocephalus after subarachnoid hemorrhage due to aneurysm rupture. The hydrocephalus shunt surgery was started normally, and there was no bending or twisting of the valve, nor blood contamination. However, after irrigation of the shunt valve, the shunt valve obstructed and malfunctioned before catheter connection and insertion into the subcutaneous space. Shunt valves are rarely damaged during surgery. In this case, the cause of the malfunction could not be identified during surgery, and it was necessary to use a shunt valve made by another company for patient safety. The surgery was completed without incident, but the cause of the obstruction, which was discovered after surgery, was that the needle guard inside the valve had come off from the bottom. The CODMAN CERTAS Plus Programmable Valve (CCPPV) in particular has excellent functionality, but the regular type needle guard is attached to the bottom of the valve pump. Therefore, it cannot withstand the handling during surgery that other valves tolerate. In the future, improvements in medical equipment and more careful operation of shunt valves by surgeons are required for risk management during surgery.

The management of high flow arteriovenous fistula and possible solutions.

BACKGROUND: The development of a high flow rate arteriovenous fistula (AVF) can expose the patient to development of heart failure due to increased cardiac preload and pulmonary hypertension. OBJECTIVES: AVF flow measurement (Qa) is considered a screening tool for AVF surveillance, aiming to evaluate the access dysfunction and prevent complications, like a non-maturation, suspected stenosis, high-flow AVF, and distal ischemia. In the upper arm AVF, a high Qa may develops, which can expose the patient to the risk of high-output heart failure and ischemia. Although, the exact threshold to define high-flow access is not universally accepted, AVF with a Qa of 1-1.5 L/min or cardio-pulmonary recirculation (Qa/CO) >20% are considered at risk. SUBJECTS: In our work we describe the treatment performed in three patients with high flow AVF treated with DRIL technique with interposition of a Prosthetic Patch, revascularization procedures such as distal inflow revision or RUDI and with innovative technique a "tench snout," removal the previous anastomosis and reconstruction of the integrity of the radial artery at the terminal in pre and post anastomosis. A PTFE prosthetic segment measuring 5 cm in length and 5 mm in diameter was interposed, terminally anastomosed with the efferent cephalic vein and terminally lateral with the radial artery, reducing the anastomosis to approximately 4 mm. RESULTS: All treated patients showed a clear improvement in the clinical picture in particularly heart failure. The calculation of the post-intervention flow rate approximately 1500 mL/min. CONCLUSION: The patient on hemodialysis with arteriovenous fistula must be constantly monitored with clinical examination, monitoring during the hemodialysis session and color Doppler ultrasound of the AVF with calculation of the flow rate. The surgical technique used for flow reduction is chosen on the surgical experience of each operator with the main objective of preserving the autologous AVF.

Proposed Hypothesis of TWEAK/Fn14 Receptor Modulation in Autism Spectrum Disorder.

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder with a complex, multiple etiology that is marked by impaired social interaction, communication, and repetitive behaviour. There is presently no pharmaceutical treatment for the core symptoms of ASD, even though the prevalence of ASD is increasing worldwide. Treatment of autism spectrum disorder involves the interaction of numerous signalling pathways, such as the Wnt/beta-catenin pathway, probiotics and kynurenine pathway, PPAR pathway, PI3K-AKT-mTOR pathway, Hedgehog signaling pathway, etc. The scientific literature has revealed TWEAK/Fn14 to not be explored in the autism spectrum disorder. In vitro and in vivo, TWEAK can control a wide range of cellular responses. Recent research has revealed that TWEAK and Fn14 are expressed in the Central Nervous System (CNS) and upregulated in perivascular endothelial cells, astrocytes, neurons, and microglia in response to various stimuli, including cerebral ischemia. This upregulation is followed by cell death and an increase in Blood-brain Barrier (BBB) permeability. The study has revealed that Aurintricarboxylic Acid (ATA) acts as an agent that suppresses TWEAK/Fn14 signaling. Similarly, from the discussion, it has been emphasized that the proposed molecular TWEAK/Fn14 signalling pathway can be considered as a therapeutic approach in the management of autism spectrum disorder.

The economic burden of ventriculoperitoneal shunt insertion and its complications: findings from a cohort in the Philippines.

PURPOSE: Ventriculoperitoneal shunt (VPS) insertion is the gold standard treatment for congenital hydrocephalus, but there is little data about the cost of this procedure in developing countries. We aimed to determine the in-hospitalization cost of initial VPS insertion and its complications (malfunction and infection) and identify predictors of increased cost. METHODS: We performed a retrospective cohort study by reviewing the medical and financial records of pediatric patients with congenital hydrocephalus and underwent shunt surgery at our institution between 2015 and 2019. We also performed multivariable linear regression analysis to determine clinical characteristics that were predictive of cost. RESULTS: A total of 230 cerebrospinal fluid diversion procedures were performed on 125 patients. The mean age during index VPS insertion was 9.8 months (range: 7 days-8 years). Over a median follow-up of 222 days, 15 patients (12%) developed shunt malfunction while 25 (20%) had a shunt infection. The mean in-hospitalization cost for all patients was PHP 94,573.50 (USD 1815). The predictors of higher cost included shunt infection (p < 0.001), shunt malfunction (p < 0.001), pneumonia (p = 0.006), sepsis (p = 0.004), and length of hospital stay (p = 0.005). Patients complicated by shunt infection had a higher mean cost (PHP 282,631.60; USD 5425) than uncomplicated patients (PHP 40,587.20 or USD 779; p < 0.001) and patients who had shunt malfunction (PHP 87,065.70 or USD 1671; p < 0.001). CONCLUSION: The study provided current data on the in-hospitalization cost of VPS insertion in a public tertiary hospital in a developing country. Shunt infection, malfunction, pneumonia, sepsis, and length of hospital stay were significant predictors of cost.

Analysis of 1027 Adverse Events Reports for Interspinous Process Devices From the US Food and Drug Administration Manufacturer and User Facility Device Experience Database.

BACKGROUND: Interspinous process devices (IPDs) introduce a new class of complications to surgical decompression without fusion: hardware-related complications. The purpose of this study was to describe the adverse events associated with IPDs. STUDY DESIGN: This was a retrospective review of the Food and Drug Administration Manufacturer and User Facility Device Experience database. METHODS: The database was queried from its inception to November 2022 for reports associated with "Prosthesis, Spinous Process Spacer/Plate." Entries were categorized by event type, patient impact, and interventions. RESULTS: A total of 943 surgery-related adverse events were identified. The most common intraoperative events were implant malfunctions (39.7%, n = 374) and fractures (2.2%, n = 21). The most common postoperative events were persistent pain (26.6%, n = 251), implant migration (19.1%, n = 180), and fracture (6.8%, n = 64). The most common resultant outcome of an adverse event was the need for revision surgery (48.8%, n = 460). The need for revision surgery was common in patients who experienced fracture (47.1%), implant migration (84.5%), infection (76.7%), and neurological complications (76.9%). Implant migration, fracture, and implant malfunction, 3 complications that are unique to decompression with an IPD as compared with traditional laminectomy, accounted for 45.9% of revisions (211/460), and revision was required in 33.0% of cases where 1 of these complications was reported (211/640). Implant malfunction made up 21.2% of Coflex complications, 47.3% of Superion complications, and 5.2% of X-Stop complications. CONCLUSIONS: The most common adverse events were implant malfunction, inadequate efficacy, implant migration, and fracture. Concerningly, these complications require revision surgery in one-third of cases when they occur. Implant-specific assessments demonstrate a high prevalence of implant malfunctions for the Coflex and Superion implants. CLINICAL RELEVANCE: Interspinous process devices introduce a new class of complications to isolated spinal decompression surgery: implant-related complications. These complications occur both intraoperatively and postoperatively, and they frequently necessitate revision surgery.

Outcome after left ventricular assist device exchange.

OBJECTIVES: Left ventricular assist device (LVAD) therapy has evolved from a short-term bridge-to-transplant strategy into a long-term and often chronic therapy due to long waiting times for heart transplantation and application as destination therapy. Consequently, patients are at risk of developing complications necessitating LVAD exchange. The aim of this study is to assess patient outcomes after LVAD exchange. METHODS: Patients who underwent LVAD exchange between January 2010 and December 2022 were included. Logistic and cox regression analyses were used to identify potential risk factors for short and long-term adverse events, respectively. Survival after exchange was assessed using Kaplan-Meier estimates. RESULTS: Sixty-one patients underwent a total of 80 LVAD exchanges. Most frequently observed short-term complications were pulmonary infections (16.3%) and right heart failure (16.3%). Exit-site infections (34.7%) and device malfunctions (25.3%) were the most often observed long-term complications. HeartWare ventricular assist device as index device was associated with a higher risk of right heart failure [hazard ratio 6.42, 95% confidence interval (CI) 1.80-22.90] and respiratory failure (hazard ratio 7.81, 95% CI 1.95-31.23) compared to HeartMate II and HeartMate 3. Survival was 83% (95% CI 75.5-95.3%) at 1 year and 67% (95% CI 53.9-84.7%) at 6 years after exchange. After 5 years, 25.0% was transplanted, 23.8% had undergone a re-exchange and 32.5% was alive without new intervention. CONCLUSIONS: Although LVAD exchange can be performed with a relatively low mortality, other post-operative adverse events are common. Patients with the HeartWare ventricular assist device as index device may be at higher risk of developing right heart failure and respiratory failure after exchange.

Breakage and detachment of the rigid cystoscope's distal tip: an unusual case of urological instrument malfunction.

Herein, we describe an unusual case of cystoscope damage during a planned laser cystolithotripsy in a 65-year-old male with a previous history of radical prostatectomy for prostate cancer and subsequent serial urethral dilations for bladder neck contracture. Upon crossing the penile urethra without exerting significant pressure, we noticed the cystoscope's distal metallic tip detachment. Therefore, we re-introduced another 22Fr cystoscope and removed the broken part with alligator forceps. Fortunately, no urethral injury or associated complications were noticed on gently re-entering the bladder. Hence, we managed to complete the endoscopic laser cystolithotripsy shortly thereafter. Review of the relevant literature revealed three similar cases. All related to the same manufacturer. Urologists should not lose sight of the fact that such an unexpected instance may tremendously impact the procedure's success, requiring vigilance and adherence to safety protocols.

Parental diagnosis of shunt malfunction in children.

IntroductionEvaluation of shunt for malfunction and blockage is a common neurosurgical clinical scenario in day-to-day paediatric neurosurgery practice. Parental concern for shunt malfunction is normally considered a reliable indication for undertaking further assessment of a child with a shunt. Accuracy of parental diagnosis of shunt malfunction likely is dependent on combination of parental knowledge and patient symptomatology and familiarity of symptoms in relation to previous shunt malfunction symptoms. There are currently no UK studies on accuracy of parental diagnosis of shunt malfunction. We undertook this study to investigate sensitivity and specificity of parental diagnosis in our tertiary paediatric neurosurgical unit to identify any factors that can be used for further education and raising awareness in parents with children with shunts.MethodsWe undertook a review of all referrals with suspected shunt malfunction to our tertiary paediatric neurosurgical unit over a period of 10 months. All referrals and presentations were evaluated for parental concern for likelihood of shunt malfunction and marked as yes or no. Further information gathered included demographics, age, sex, symptoms at presentation, previous history of shunt revision, cases of shunt malfunction and part of the shunt revised. Sensitivity, specificity, positive and negative predictive values and accuracy were then calculated and factors associated with positive diagnosis of shunt malfunction analysed.ResultsOverall, 100 referrals with suspected shunt malfunction were made over 10 months period. Mean age for children at the time of referral was 6.3 years with an M/F ratio of 42M:58F. Twenty-one shunt malfunction cases were identified leading to overall revision rate of 21%. Parental evaluation of shunt function had sensitivity of 90.4%, specificity of 10.1%, positive predictive value of 21.1% and negative predictive value of 80%. Drowsiness and higher number of symptoms at presentation were associated with true positive diagnosis of shunt malfunction. No link was identified with true diagnosis of shunt malfunction with other symptoms of shunt malfunction or previous history of shunt revision and age of the patient.ConclusionParental diagnosis of shunt malfunction has high sensitivity and negative predictive value and low specificity and positive predictive value. Increased number of symptoms as well as drowsiness were associated with correct parental diagnosis of shunt malfunction. Educational programs and parental training can be valuable in increasing awareness about shunt malfunction signs.

Failure to treat ventricular tachycardia or ventricular fibrillation by implantable cardioverter-defibrillators.

BACKGROUND: Normally functioning implantable cardioverter-defibrillators (ICDs) with intact lead systems occasionally fail to deliver therapy for ventricular tachycardia/fibrillation (VT/VF) or deliver it only after clinically significant delays (failure-to-treat). OBJECTIVE: We aimed to investigate ICD failure-to-treat VT/VF in a large patient cohort. METHODS: We searched the US Food and Drug Administration's online Manufacturer and User Facility Device Experience (MAUDE) database from 2019 to 2023 for manufacturer-verified reports in which normally functioning ICDs failed to treat VT/VF. RESULTS: We identified 854 reports classified as deaths (n = 96 [11.2%]), injuries (n = 585 [68.5%]), or malfunctions (n = 173 [20.3%]) for normally functioning ICDs. The most common causes were misclassification as supraventricular tachycardia (SVT) or atrial fibrillation (AF; 54.8%), undersensing (21.1%), and failure to satisfy programmed rate/duration criteria (8.7%). Most events caused by misclassification as SVT/AF (89.5%) and failure to satisfy rate/duration criteria (70.3%) were VT; most caused by undersensing were either VF (54.4%) or not specified as VT or VF (19.4%). Undersensing caused 65.6% of deaths, although it represented only 21.1% of reports. In the United States, the number of reports increased faster than that of ICD patients. CONCLUSION: In the largest reported series of failure-to-treat VT/VF by normally functioning ICDs, the most common cause was misclassification of VT as SVT/AF; the most common cause of death was undersensing of VF. Although relatively few patients with normally functioning ICDs experience failure-to-treat VT/VF, the absolute number of verified MAUDE reports suggests that more work is needed to quantify the magnitude of the problem, to identify root causes, and to develop solutions.

Turner Syndrome where are we?

Turner syndrome (TS) results from the loss of one X chromosome in phenotypic females, leading to a range of complications such as short stature, cardiovascular issues, autoimmune disorders, metabolic imbalances, osteoporosis, neurocognitive deficits, hearing loss, abnormalities in endocrine functions, infertility, disruptions in bone metabolism, and neurocognitive deficits. These diverse clinical manifestations necessitate a comprehensive and multidisciplinary approach to diagnosis and management. Growth hormone therapy stands out as a fundamental treatment for addressing the challenges associated with TS. Ongoing clinical and genomic advancements contribute to an evolving understanding of TS, shedding light on its complexities and potential therapeutic interventions. Despite progress, further research is crucial to identify candidate pathways and critical biomarkers that can alleviate the syndrome's burden. By uncovering these insights, we aim to empower individuals with TS, enhancing their overall functioning and quality of life. In this review, we have explored the prevalent co-morbidities associated with TS, drawing insights from the current literature.

Salvaging intraluminal peritoneal dialysis catheter obstruction from blood clot with a targeted thrombolytic agent: an innovation.

Peritoneal dialysis (PD) catheter malfunction commonly leads to the removal of the catheter and eventually to a transfer to hemodialysis. The most common cause is intraluminal obstruction caused by blood and fibrin clots. Recommended interventions include irrigation of the catheter with heparinized saline; if this method fails, thrombolytic agents may be used. Mechanical methods such as intraluminal brushing are also utilized, typically after medical treatment fails. Here, we present a case of a patient who developed an intraluminal blood clot that persisted despite attempts with intraluminal thrombolytic drugs and intraluminal brushing. To salvage the catheter, targeted thrombolysis was performed using an endoscopic retrograde cholangiopancreatography (ERCP) guidewire to reinforce the coiled PD catheter and puncture the clots. Additionally, a Swing Tip cannula was employed for direct injection of the thrombolytic agent. These interventions successfully preserved the catheter, resolving the clot and ensuring continued functionality.

Performance of a Continuous Subcutaneous Insulin Infusion (CSII) Pump With Acoustic Volume and Flow Sensing in Simulated High-Consequence Situations.

Goal: An insulin pump's failure to deliver insulin in the right amount at the right time is a preventable cause of hospitalization. We evaluated key performance metrics of a novel insulin pump that prevents "silent insulin non-delivery" caused by blockage, delivery of air and site leakage. This is accomplished via an acoustic sensor that measures the volume of insulin delivered with each pulse in real-time. Methods: We tested long and short-term flow accuracy, occlusion-detection time and pressure, and air management of the new device (ND) versus 3 U.S. commercial insulin pumps (CIPs) using standardized methods. Results: The ND outperformed CIPs on long-term basal flow rate error. Occlusion detection was 5 to 22.5 times faster depending on the basal rate and resulted in significantly lower (2 to 5x) pressures at time of occlusion. With air included in the drug reservoir, the tested CIPs can infuse air without detection, while the ND prevented air delivery without interruption. Conclusions: Bench tests of the ND versus 3 commercially available pumps showed improved occlusion detection and air management without flow performance tradeoffs. Additionally, the lower delivery pressure measured at time of occlusion suggests a substantially lower potential for site leakage at both basal and bolus rates. These enhancements combine to decrease the likelihood of silent insulin non-delivery.

Fallopian tube wrapping as a cause of catheter malfunction in peritoneal dialysis: a report of two cases and management strategies.

Background: Catheter malfunction is a common problem following the placement of a peritoneal dialysis (PD) catheter, and it is characterized by inadequate dialysate drainage, which can also limit infusion. Common causes include constipation, catheter migration, catheter kinking, omental wrapping, and fibrin obstruction. However, catheter obstruction by other intra-abdominal organs has been observed infrequently. Case Description: We present two cases of female PD patients experiencing catheter dysfunction after catheter implantation. The first case involves a 28-year-old female who suffered from problematic drainage and infusion of dialysate 1 month after catheter insertion, evidenced by catheter displacement from the pelvis on abdominal X-ray. The second case concerns a 49-year-old female PD patient who also encountered a bidirectional catheter malfunction 40 days post-implantation. Conservative methods failed to restore the catheter function in both patients. Laparoscopic examination revealed fallopian tube, not the omentum, was tightly wrapped around the PD catheter in both cases. Finally, laparoscopic surgery with catheter fixation restored the catheter function, enabling continued continuous ambulatory peritoneal dialysis (CAPD) with favorable outcomes. Conclusions: Our findings indicate that healthcare providers should consider fallopian tube wrapping as a potential cause of catheter dysfunction. Prompt consideration and utilization of laparoscopy with catheter fixation can play an important role in restoring catheter function and improving patient outcomes.

A modified open surgical revision technique for malfunctioning peritoneal dialysis catheter.

Backgrounds: The malfunction of peritoneal dialysis (PD) catheter is still an intractable problem. A modified open surgical revision technique with suturing fixation and without catheter removal for malfunctioning catheter was developed to evaluated the efficacy and safety between simultaneous catheter replacement technique.Methods: A total of 167 PD patients with malfunctioning catheter were retrospectively reviewed. For the salvage of PD catheters, patients underwent modified open surgical revision (group A) or simultaneous catheter replacement (group B). The baseline characteristics before operation, perioperative condition, complications and outcomes were compared between both groups.Results: Patients of group A showed significantly shorter operative time (67.4 ± 22.1 versus 82.8 ± 21.1 min, p = 0.009), less postoperative pain score within 24 h (median 0.0 versus 2.0, p < 0.001), quicker start of PD (1.06 ± 0.31 versus 1.89 ± 0.89 days, p < 0.001), shorter length of stay (9.89 ± 5.11 versus 12.55 ± 7.37 days, p = 0.020) than group B. In terms of complications, the incidence of recurred catheter malfunction in group A was significantly lower than those in group B (1/114 versus 12/53, p < 0.001). There were no significant differences in mechanical complications (bloody effluent, dialysate leakage, and hernia) and early peritonitis between the groups. The group A patients had a favorable catheter survival rate compared with group B (log-rank, p = 0.004).Conclusions: Our modified open surgical revision technique is a safe, simple and fast method, and offers a better outcome with minimal risk of recurrence of catheter malfunction without additional cost and equipment. This technique is worthy of clinical application.

Hello, is it me you're Stopping for? The Effect of external Human Machine Interface Familiarity on Pedestrians' Crossing Behaviour in an Ambiguous Situation.

OBJECTIVE: We investigated how different deceleration intentions (i.e. an automated vehicle either decelerated for leading traffic or yielded for pedestrians) and a novel (Slow Pulsing Light Band - SPLB) or familiar (Flashing Headlights - FH) external Human Machine Interface (eHMI) informed pedestrians' crossing behaviour. BACKGROUND: The introduction of SAE Level 4 Automated Vehicles (AVs) has recently fuelled interest in new forms of explicit communication via eHMIs, to improve the interaction between AVs and surrounding road users. Before implementing these eHMIs, it is necessary to understand how pedestrians use them to inform their crossing decisions. METHOD: Thirty participants took part in the study using a Head-Mounted Display. The independent variables were deceleration intentions and eHMI design. The percentage of crossings, collision frequency and crossing initiation time across trials were measured. RESULTS: Pedestrians were able to identify the intentions of a decelerating vehicle, using implicit cues, with more crossings made when the approaching vehicles were yielding to them. They were also more likely to cross when a familiar eHMI was presented, compared to a novel one or no eHMI, regardless of the vehicle's intention. Finally, participants learned to take a more cautious approach as trials progressed, and not to base their decisions solely on the eHMI. CONCLUSION: A familiar eHMI led to early crossings regardless of the vehicle's intention but also led to a higher collision frequency than a novel eHMI. APPLICATION: To achieve safe and acceptable interactions with AVs, it is important to provide eHMIs that are congruent with road users' expectations.

Use of the "Two-Three Click" Protocol in Screw Stabilization of a Patient With Loosened Nuts and Dislocation of Rods - A Case Report.

Vertebral fixation, utilizing titanium screws, is a highly prevalent technique employed to address spinal instability. Screw stabilization malfunction due to pedicle screw nuts loosening is rare. Under tightening the internal nut in the pedicle screw head may increase the likelihood of rod movement within the system resulting in severe pain when moving. Our goal is to raise the attention of surgeons when tightening the screws nuts of the screw stabilization because the consequences for the patient can be subsequent additional operations and complications.  This report describes a clinical case of a 40-year-old man who underwent three surgeries at different clinics several years ago for disc herniation at the L4-L5 level and screw stabilization at the same level. The patient presents to the neurosurgery clinic of Saint Marina University Hospital with a clinical manifestation of low back pain escalating with movement, with a pain intensity rating of six on the Visual Analogue Scale (VAS). From the CT scan, it was revealed a malfunction in the screw stabilization with loosening of the screw nuts and dislodgement of the rods. Screw stabilization was restored using intraoperative X-ray guidance and following the "two-three click" protocol. The patient was mobilized on the first day after surgery and discharged on the fifth day with neurological improvement (VAS=1). The patient was followed up for a period of six months, and no further complications were observed. Surgeons must use caution while tightening the screw nuts, as not doing so may result in additional surgeries and complications for the patient in the future. The "two-three click" protocol for screw stabilization is an effective method for minimizing the issues associated with inner loosening and rod migration.

Extrinsic outflow graft obstruction of the HeartMate 3 LVAD: A state-of-the-art review.

While notable improvements in survival, the incidence of hemocompatibility-related adverse events, hospitalizations, and cost have been demonstrated with the only commercially available durable left ventricular assist device, a category of pump malfunctions characterized by outflow graft obstruction has been noted with broader use and clinical follow-up of recipients of this technology. Of particular concern is the accumulation of acellular biodebris between the outflow graft and bend relief covering the outflow graft at its origin with the pump (which we term extrinsic outflow graft obstruction at the bend relief). This process tends to be insidious, occurs late in the postoperative course, can be challenging to diagnose, and can result in significant morbidity and mortality. Herein, we provide a review of this complication and outline diagnostic, treatment, and preventive strategies.

Minimizing and managing needle and instrument loss during pediatric robotic surgery.

INTRODUCTION: Lost objects and equipment malfunctions during robotic and laparoscopic cases can lead to an increase in operating time and potential risk to the patient. The literature on the management of foreign bodies during pediatric robotic-assisted surgery is limited. The purpose of the video is to review proper instrument handling to prevent loss of an object and to propose our technique for retrieving lost objects through two pediatric case examples. MATERIALS AND METHODS: The first case is a robotic-assisted laparoscopic left pyeloplasty in a 6-week-old male with congenital uteropelvic junction obstruction during which a needle was lost. In the video, we describe our techniques for safe needle passage, proper suturing technique, and recovering a lost needle. The second case is a robotic-assisted right upper pole heminephrectomy in a 14-month-old female with a duplicated renal collecting system and hydroureteronephrosis. We present the management of a rare case during which a harmonic scalpel jaw malfunctioned leading to a lost foreign body. We describe our technique for retrieving the lost fragment. RESULTS: All objects were safely removed, and patients were discharged post-op day one without complication. CONCLUSION: Our video presents two case examples of foreign bodies lost during pediatric robotic surgeries and approaches to manage each of these incidents.

Pacemaker-mediated reentrant arrhythmia facilitated by an atrial-tracking leadless pacemaker.

INTRODUCTION: Pacemaker-mediated tachycardia is a known arrhythmia in patients with dual chamber pacemakers and defibrillators and intact ventriculoatrial (VA) conduction. We report a case of pacemaker-mediated reentrant arrhythmia (PMRA) in a patient with an atrioventricular (AV) synchronous leadless pacemaker. METHODS AND RESULTS: A 91-year-old female presented with 2:1 AV conduction and received an AV synchronous leadless pacemaker. She had atrial mechanical sense-ventricular paced beats between heart rates of 80-100 bpm more than 80% of the time. She was found to have a new cardiomyopathy and was referred for placement of biventricular pacemaker. At the time of device implantation, her electrocardiogram showed ventricular pacing with a short RP interval and superiorly directed P waves. Changes in the ventricular pacing rate resulted in changes in the atrial rate. Following device placement, her heart rate decreased to the lower rate limit of her pacemaker. The atrial mechanical sense impulse most likely was generated by a retrograde conducted P wave resulting in near incessant PMRA. CONCLUSION: PMRA may occur in patients who receive an AV synchronous leadless pacemaker with intact VA conduction and sinoatrial node dysfunction. Due to the lower rates of PMRA, this arrhythmia may be underrecognized. Interventions for and implications of PMRA need further investigation.

Uncovering the rate and risk factors of intrathecal baclofen pump-associated complications in the adult population.

OBJECTIVE: The aim of this study was 1) to describe the rate of intrathecal baclofen (ITB)-associated complications at a large tertiary center, and 2) to evaluate the impact of patient-related factors on the likelihood of developing such complications. METHODS: A retrospective single-center study was carried out. A total of 301 eligible patients were included in the analysis. Univariate regression models were used to evaluate the impact of age, sex, diagnosis, ambulation status, modified Ashworth scale score, body mass index, diabetes status, and pain level on the likelihood of developing a device-related infection, pump malfunction, catheter malfunction, and other clinically significant complications. RESULTS: Overall, 27% of patients experienced an ITB-related complication. The most common complications included infection (6%, 18/301), pump malfunction (7.3%, 22/301), and catheter malfunction (14%, 42/301). The univariate analyses revealed that the patient's ambulatory status had a significant impact on the likelihood of developing a catheter-related malfunction. Furthermore, a trend toward significance was identified between patients' preoperative body mass index and device-related infection. Finally, the risk of suffering any ITB-related complications was statistically correlated with the number of years that had passed since the initial pump implantation. CONCLUSIONS: The authors' analysis reveals a previously underrecognized association between ambulatory status at the time of ITB pump implantation and the incidence of catheter-related complications, and confirms the impact of time since surgery on the risk of developing any ITB-related complication. The patient's age, sex, diagnosis, diabetes status, or pain level at baseline were not associated with the risk of complications. Collectively, these insights contribute novel information to the existing literature, providing practical value for physicians in guiding patient selection for ITB therapy.