Evaluation of vascular accesses in the neonatal intensive care unit. Is the midline catheter a useful long-term alternative?

OBJECTIVE: Analyze the usefulness of the midline catheter in terms of efficacy and safety for treatments lasting more than 3 days in the neonatal population requiring admission to the NICU. DESIGN: Analytical and observational of a prospective cohort (December 2021-November 2023) compared to a historical cohort (January 2020-November 2021). SETTING: 9-bed Neonatal Intensive Care Unit (NICU, level III hospital. PATIENTS OR PARTICIPANTS: 288, 66 midline group and 222 control group. INCLUSION CRITERIA: newborns from 24 to 42 weeks of gestation who required short peripheral or midline cannulation and treatment longer than 3 days. INTERVENTIONS: Follow-up during NICU stay and comparison with retrospective data from a historical cohort. MAIN VARIABLES OF INTEREST: Sociodemographics, success rate (permanence of the same vascular catheter without complications until finish the prescribed treatment), number of catheters, cannulation rate per patient, indwell time, complications. RESULTS: The midline group showed a higher success rate (54.2% vs 5.6%, p < 0.001), a lower number of canalizations per patient (p < 0.001), a longer indwell time (p < 0.001) and a lower number of extravasations (p < 0.001). CONCLUSIONS: The midline catheter has advantages over short peripheral catheters, being a useful alternative in terms of efficacy and safety for treatments lasting more than 3 days in the neonatal population that requires admission to the NICU.

Photodynamic therapy for the treatment of complex anal fistula.

BACKGROUND: Photodynamic therapy (PDT) is a new procedure for the treatment of anal fistula. This preliminary study was designed to investigate the safety and effectiveness of this new technique in the treatment of anal fistula. METHODS: Ten patients were treated with PDT. Intralesional 5-aminolevulinic acid (ALA) 2% was directly injected into the fistula. The internal and external orifices were closed. After an incubation period of 2 h, the fistula was irradiated using an optical fibre connected to a red laser (MULTIDIODE 630 PDT, INTERmedic, Spain) operating at 1 W/cm for 3 min (180 Joules). Patient demographics, operation notes and complications were recorded. RESULTS: There were no complications. The average length of patient follow-up was 14.9 months (range 12-20 months). We could observe primary healing in eight patients (80%). Two patients (20%) showed persistence of suppuration after the operation. No patient reported incontinence postoperatively. CONCLUSIONS: PDT is a potential sphincter-saving procedure that is safe, simple and minimally invasive and has a high success rate.

[Surfactant replacement therapy with a minimally invasive technique: Experience in a tertiary hospital]. / Terapia con surfactante con técnica mínimamente invasiva: experiencia en un hospital terciario.

INTRODUCTION: Surfactant delivered using a minimally invasive technique, known as MIST (Minimally Invasive Surfactant Therapy) is a method which allows surfactant to be administered to a patient connected to non-invasive respiratory support. This is an increasingly used therapy in Neonatal Units that reduces the intubation rate and the pathology associated with intubation and allows the surfactant to be administered to the patients who clinically need it. PATIENTS AND METHODS: In years 2013 and 2014 in the Hospital General Universitario de Elche surfactant was delivered using this method to 19 patients, five of whom were 28 or less weeks of gestation age at birth. A comparison is made with a historical cohort consisting of 28 patients with Respiratory Distress Syndrome treated initially with non-invasive respiratory support. RESULTS: No incidents were recorded that caused the interruption of the administration. A reduction in the fraction of inspired oxygen was observed in all cases after surfactant administration. Fewer intubations in the first 72 hours of life were found in the treatment group compared to the control group (42% vs. 54%). DISCUSSION: The experience recorded in the Hospital General Universitario de Elche shows that the administration of surfactant using a MIST technique is a reproducible method of treatment, which allows the surfactant distribution during spontaneous breathing with non invasive respiratory support.

Sacral nerve stimulation in the treatment of severe faecal incontinence: long-term clinical, manometric and quality of life results.

BACKGROUND: Faecal incontinence (FI) is a complex and multifactorial health problem. Treatment has to be individualised, analysing the aetiology and gravity in every case. Sacral nerve stimulation (SNS) has been shown to effectively improve treatment of FI. METHODS: Fifty patients with severe FI treated with SNS between March 2002 and December 2010 were analysed. Preoperative assessment included physical examination, anorectal manometry and anal endosonography. Anal continence was evaluated using the Wexner continence grading system. Quality of life was evaluated using the Fecal Incontinence Quality of life Scale (FIQLS). Follow-up appointments were scheduled at 1, 6 and 12 months and annually thereafter. Wexner score, FIQLS and the ability to defer defecation were assessed at each visit. RESULTS: Fifty patients underwent a permanent implant. The overall mean follow-up period was 55.52 ± 31.84 months. After 6 months, SNS significantly improved FI and positively impacted quality of life, as evidence by significant improvements in all 4 scales of the FIQLS. Anorectal manometry showed a trend towards an increase in maximum resting pressure and maximum pressure. After the first assessment at 6 months, Wexner score and FIQLS remained stable. Ability to defer defecation was also maintained. During follow-up, 3 patients (6 %) experienced implant site pain and episodes of extremity pain and paresthesias that were refractory to medical management and required device explantation. The implant site infection rate was 2 %. CONCLUSIONS: Analysis of our long-term results confirms the safety and effectiveness of SNS in the management of patients with FI.

Applicability, safety and efficiency of outpatient treatment in uncomplicated diverticulitis.

BACKGROUND: In most cases of diverticulitis, inflammation is mild, and the only treatment required is a clear liquid diet and antibiotics. Until recently, patients were given this treatment as inpatients with the consequent expenditure of resources. The aim of this study was to assess the safety and efficacy of an outpatient treatment protocol with oral antibiotics in selected patients with uncomplicated acute diverticulitis in comparison with inpatient intravenous treatment. METHODS: We conducted a prospective non-randomized study between January 2007 and December 2009. We included all patients diagnosed with uncomplicated acute diverticulitis, at the Emergency Department of the University General Hospital of Elche. We compared the efficacy, safety and costs of hospital treatment with intravenous antibiotics and outpatient treatment with oral antibiotics. Seventy-six patients were included in the study. Forty-four of them underwent intravenous treatment with Metronidazole 500 mg/8 h + Ciprofloxacin 400 mg/12 h (hospital treatment group) and 32 took oral antibiotics Metronidazole 500 mg/8 h and Ciprofloxacin 500 mg/12 h (outpatient group). RESULTS: Outpatient treatment is viable in almost 95 % of those patients suffering from uncomplicated acute diverticulitis. Treatment was effective in resolving inflammation, and there were no complications in the majority of cases (94 %). Only 2 patients (6 %) required admission after outpatient treatment. The results further reflect complications and relapse rates similar to those of patients admitted to hospital and treated with intravenous antibiotics. There are no significant statistical differences (p = 0.86) between inpatients and outpatients. It is possible to save approximately 1,600 € per patient with outpatient treatment (p < 0.05). CONCLUSIONS: Outpatient treatment has demonstrated a safety and efficiency similar to inpatient treatment, producing an important reduction in expenses and medical resources.

Plantar fascia evaluation with a dedicated magnetic resonance scanner in weight-bearing position: our experience in patients with plantar fasciitis and in healthy volunteers.

PURPOSE: This study assessed the usefulness of upright weight-bearing examination of the ankle/hind foot performed with a dedicated magnetic resonance (MR) imaging scanner in the evaluation of the plantar fascia in healthy volunteers and in patients with clinical evidence of plantar fasciitis. MATERIALS AND METHODS: Between January and March 2009, 20 patients with clinical evidence of plantar fasciitis (group A) and a similar number of healthy volunteers (group B) underwent MR imaging of the ankle/hind foot in the upright weight-bearing and conventional supine position. A 0.25-Tesla MR scanner (G-Scan, Esaote SpA, Genoa, Italy) was used with a dedicated receiving coil for the ankle/hind foot. Three radiologists, blinded to patients' history and clinical findings, assessed in consensus morphological and dimensional changes and signal intensity alterations on images acquired in both positions, in different sequences and in different planes. RESULTS: In group A, MR imaging confirmed the diagnosis in 15/20 cases; in 4/15 cases, a partial tear of the plantar fascia was identified in the upright weight-bearing position alone. In the remaining 5/20 cases in group A and in all cases in group B, the plantar fascia showed no abnormal signal intensity. Because of the increased stretching of the plantar fascia, in all cases in group A and B, thickness in the proximal third was significantly reduced (p<0.0001) under upright weight-bearing compared with the supine position. CONCLUSIONS: Imaging the ankle/hind foot in the upright weight-bearing position with a dedicated MR scanner and a dedicated coil might enable the identification of partial tears of the plantar fascia, which could be overlooked in the supine position.

Role of high-resolution ultrasonography without and with real-time spatial compound imaging in evaluating the injured posterior cruciate ligament: preliminary study.

PURPOSE: This study sought to compare high-resolution ultrasonography (HRUS) without and with compound imaging in evaluating the injured posterior cruciate ligament (PCL). MATERIALS AND METHODS: Thirteen patients with a magnetic resonance imaging (MRI) diagnosis of PCL lesions (ten acute and three chronic) and 20 healthy controls underwent conventional and compound HRUS performed by the same radiologist who was blinded to the subjects' case-control status. The PCL was scanned in a longitudinal direction in all cases. HRUS images were assessed for PCL thickness by two other radiologists blinded to the number and type of PCL injury. PCLs were classified as normal or injured, and the latter as having acute or chronic injuries. Inter-method reproducibility of measuring PCL thickness was assessed on conventional and compound HRUS images. RESULTS: Complete agreement in classifying normal or injured PCL and acute or chronic PCL injuries was achieved. PCL thickness in volunteers was 4.5+/-0.7 mm on conventional images and 4.6+/-0.7 mm on compound images. On conventional and compound HRUS images, the thickness of acutely injured PCL was 9.1+/-1.5 mm and 9.2+/-1.7 mm, respectively, and that of chronically injured PCL was 7+/-0.9 mm and 7+/-0.8 mm. Inter-method reproducibility of PCL thickness measurements on conventional vs. compound HRUS images was 98.6%. CONCLUSIONS: HRUS is a reliable technique for studying the PCL and detecting PCL injuries.

High-resolution ultrasonography (HRUS) of the meniscal cyst of the knee: our experience.

PURPOSE: This study was undertaken to assess the diagnostic accuracy of high-resolution ultrasonography (HRUS) in the detection of meniscal cysts. MATERIALS AND METHODS: Over a 2-year period, 1,857 patients underwent magnetic resonance imaging (MRI) of the knee for traumatic or degenerative disorders. All patients with MRI evidence of a meniscal cyst were studied by HRUS. HRUS was also performed on an equal number of patients without MRI evidence of meniscal cyst who were used as a control group. All HRUS examinations were conducted by a radiologist blinded to the MRI findings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of HRUS were assessed with reference to MRI. All patients underwent surgery, and the resected masses were studied by histological examination. RESULTS: MRI allowed identification of a meniscal cyst in 52 patients. HRUS enabled correct detection of the meniscal cyst in 49/52 cases. In the control group, HRUS excluded the presence of meniscal cysts in all cases. HRUS had a sensitivity, specificity, PPV and NPV of 94.23%, 100%, 100% and 94.54%, respectively, for the detection of meniscal cysts. CONCLUSIONS: HRUS is a fairly reliable technique in the detection, characterisation and differentiation of the different forms of meniscal cyst.

Is anal endosonography useful in the study of recurrent complex fistula-in-ano?

INTRODUCTION: performing anal endosonography in complex fistula-in-ano allows us to design a personalized surgical strategy in each case, thereby improving results. However, there are doubts in the literature as to its utility in recurrent complex fistulas. The aim of this study was to compare the utility of anal ultrasonography in the study of primary versus recurrent complex fistula-in-ano. PATIENTS AND METHOD: prospective study of patients diagnosed and treated for complex fistula-in-ano. Physical examination and anal ultrasonography provided data on primary track, internal opening, horseshoe extension and the presence of secondary tracks or cavities in a protocol designed specifically for the study. These assessments were subsequently contrasted with operative findings. RESULTS: we included 35 patients, 19 (54.3%) with primary complex anal fistulas and 16 (45.7%) with recurrent fistulas. According to the operative findings, fistulas were classified as high transsphincteric in 28 patients (80%), suprasphincteric in 6 (17.1%) and extrasphincteric in one patient (2.9%), with no differences between groups. Physical examination correctly classified 28 of the 35 fistulous tracks, in contrast to the 32 (91.4%) correctly described on ultrasonography (80%). We did not find any statistically significant differences between the primary and the recurrent fistula groups with regard to sensibility, positive predictive value and accuracy of the anal ultrasonography for any of the parameters studied. CONCLUSION: the accuracy of anal ultrasonography does not decrease in recurrent complex fistula-in-ano.

Long-term results of botulinum toxin for the treatment of chronic anal fissure: prospective clinical and manometric study.

BACKGROUND: The aim of this prospective trial was to analyse the effectiveness and morbidity of chemical sphincterotomy in the treatment of chronic anal fissure after a 3-year follow-up. METHODS: One hundred consecutive patients with chronic anal fissures were treated by chemical sphincterotomy with 25 U botulinum toxin injected into the internal sphincter. Clinical and manometric results were recorded. RESULTS: No major complications were found; initial incontinence at the 2-month review (6%) spontaneously reversed at 6 months. There was a tendency of progressive recurrence over time, with an overall healing after 3 years of 47%. We found a group of patients with clinical (symptoms longer than 12 months and presence of a sentinel pile before treatment) and manometric factors (persistently elevated mean resting pressure, percentage of time with slow waves, and number of patients or percentage of time with ultra slow waves after treatment) associated with a higher recurrence of anal fissures. CONCLUSION: Since it avoids the greater risk of incontinence associated with surgical sphincterotomy, we recommend the use of botulinum toxin as the first therapeutic approach for patients with chronic anal fissure and risk factors for incontinence; despite the higher rate of recurrence associated with this treatment. In patients with factors related to recurrence, re-injection with higher doses of botulinum toxin or complementary medical-surgical treatment should be considered.

Open versus closed day-case haemorrhoidectomy: is there any difference? Results of a prospective randomised study.

BACKGROUND AND AIMS: Nowadays there is still controversy as to whether open or closed haemorrhoidectomy is the surgical treatment of choice for haemorrhoidal pathology. PATIENTS AND METHODS: We carried out a randomised prospective study in the Day Surgery Unit comparing 100 patients undergoing Milligan-Morgan haemorrhoidectomy (group A) versus 100 patients undergoing Ferguson haemorrhoidectomy (group B) for symptomatic haemorrhoids, in whom medical treatment or rubber band ligation had failed. RESULTS: Characteristics of the population were: mean age 43.5 years, with predominance of males, 123 vs. 77; 88% ASA I-II. CLINICAL PRESENTATION: 95% rectal bleeding; 87.5% third-fourth degree. The anaesthetic technique of choice was local anaesthesia plus sedation in 180 patients (90%). Length of surgery: 24 min (group A) and 30 min (group B) (p=n.s.). Resection of three haemorrhoidal cushions was done in 87.5% of cases. There were no re-operations or re-admissions after discharge. Symptomatic recurrence, stenosis and incontinence were not found during the follow-up of the first year. Postoperative pain during the first postoperative week was greater in the open haemorrhoidectomy group, but the difference was statistically significant (p<0.05) only during bowel movements. There was complete healing in 40% of the patients in group A and 90% of those in group B (p<0.05) after 1 month. After 1 year, the results and complications were similar in both groups (p=n.s.). CONCLUSIONS: Closed haemorrhoidectomy gives better results in terms of pain and healing than open haemorrhoidectomy, whereas recurrence and complications are similar after 1 year.

Pigmented villonodular synovitis of the foot: MR findings.

PURPOSE: To evaluate the MRI findings in the various forms of pigmented villonodular synovitis (PVNS) of the foot. MATERIALS AND METHODS: Seven hundred and fifty-three MR studies of the foot performed at our institute between June 1994 and April 2000 were retrospectively reviewed for the presence of PVNS. Spin echo (SE) T1W, Gradient echo (GE) T2*W, and fat suppression (Short Time Inversion Recovery: STIR) images were acquired with a 0.5 T superconductive unit (Vectra, GE Medical System, Milwaukee, WI, USA) provided with a dedicated transmitter/receiver coil. The site and type of lesions, the signal intensity patterns, and the presence of associated changes were evaluated. RESULTS: On the basis of the MR images and the above parameters, six patients (3 men, 3 women, age range: 35-48 years) with PVNS were selected. Three out of six PVNS were nodular, whereas the remaining three were diffuse. Of the three nodular forms, one was found in the sub-talar joint and the remaining two antero-medially to the talus. Instead, all of the diffuse lesions were located on the metatarsus. Perilesional oedema was seen in all cases, although more obvious in the nodular forms, whereas bone involvement (osteochondral erosion) was observed only in the diffuse metatarsal PVNS. Intra-articular bloody effusion was never observed. The MRI findings were confirmed by surgery in all cases. DISCUSSION: The high contrast resolution and multiplanar capabilities of MRI allow the complete evaluation of the structures of the foot affected by PVNS, and of the extent of soft tissue (bursae, synovial or nervous structures), bone and articular involvement. Although not specific, the presence of haemosiderin results in characteristic MR findings, due to the shortening of both T1 and T2 relaxation times. GET2* images are particularly well suited to this PURPOSE: Furthermore, in our experience, FIR images added better depiction of associated swelling. CONCLUSIONS: According to our results, MRI is now the most reliable technique for identifying and classifying PVNS, and allows correct treatment planning and effective monitoring.

[Stapedotomy, stapedectomy and revision surgery performed with laser techniques. Revision of literature]. / Estapedotomía, estapedectomía y cirugía de revisión realizados con técnica láser. Análisis de la evolución de los sistemas.

The usefulness of laser in otologic surgery, and specifically the suitability of its use in stapes surgery, is still under discussion. We intend to support the use of this method in the surgical treatment of otosclerosis, as well as to elucidate which type of laser is the most advisable one, establishing also in which stages of surgery it should be used. For this, we carry out a revision of the main opinions published in this regard in the international literature, commenting on the results and observations gathered in it. We end by setting out a number of conclusions which are the result of the analysis of the criteria put forward in the bibliography.

Randomized clinical trial comparing simple drainage of anorectal abscess with and without fistula track treatment.

BACKGROUND AND AIMS: Anal abscess is a frequent acute proctological disorder and whether the underlying fistula should be treated at the same time when the abscess is drained remains controversial. We examined indications for drainage alone versus drainage plus fistulotomy in terms of recurrence and continence. PATIENTS AND METHODS: We carried out a randomized prospective study of 200 consecutive patients with anal abscess. One group received drainage alone, while in the other group drainage plus fistulotomy was performed when a subcutaneous-mucosa, low transsphincteral, or intersphincteral fistula was found. Delayed progressive fistulotomy with suture threads was performed in cases of high transsphincteric or suprasphincteric fistula. RESULTS: The internal opening of the fistula track was found in 83% of the patients. The recurrence rate was related to the surgical technique employed: 29% in the group with drainage alone and 5% in the group for which treatment of the fistula track was attempted. The incontinence rate was also related to the surgical option. In those receiving drainage and treatment of the fistula track incontinence was restricted mostly to patients with delayed fistulotomy (36.7%), compared to 2.8% of patients when simple fistulotomy was performed. There was no incontinence in the drainage alone group. CONCLUSION: Drainage of anal abscess with fistulotomy can be safely performed in cases of subcutaneous, intersphincteral, or low transsphincteral fistulae with a minimal recurrence rate. However, drainage alone and posterior treatment of the fistula track is recommended for high transsphincteral or suprasphincteral fistulae.

[Menière's disease: diagnostic criteria, criteria to establish stages, and standards for treatment evaluation. Bibliographic review and update]. / Enfermedad de menière: criterios diagnósticos, criterios para establecer estadios y normas para la evaluación de tratamientos. Revisión bibliográfica y actualización.

If all doctors would use the same concepts to define Meniere's Disease (MD) and the same scale to either establish the different steps of the disease or to evaluate a specific treatment, it would be easy to compare our results. This would be beneficial for patients because of the possibility of giving them a more accurate information about the follow-up of their disease and the advantages of the different possibilities of treatment. Since the introduction of informatic systems a new goal appeared: large databases could be achieved, as a result of being able to gather the different database that are independently used in each hospital, provided that rules to establish data would be previously standardized. The purpose of this paper is to evaluate the proposal of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology and those proposed by other authors according to the stated courses of action.

Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults.

BACKGROUND: Prosthetic repair has become the standard method for inguinal hernia and has excellent results. The question remains of whether the mesh technique could also improve results for umbilical defects. METHODS: The study was a randomized clinical trial comparing herniorrhaphy (primary suture) with hernioplasty (polypropylene mesh or plug) in 200 adult patients with a primary umbilical hernia. Patients at high anaesthetic risk (American Society of Anesthesiologists (ASA) grade IV) or those who needed emergency surgery were excluded. The mean postoperative follow-up was 64 months. The population studied included 118 women and 82 men with a mean age at presentation of 57 years. Some 173 patients were ASA grade I-II and 27 were ASA III. The anaesthetic technique of choice was local anaesthetic infiltration plus sedation (98 per cent). RESULTS: There were no significant anaesthetic complications or surgical deaths. The mean duration of surgery was greater for mesh than for suture repair (45 versus 38 min). Rates of early complications such as seroma, haematoma or wound infection were similar in the two groups. The hernia recurrence rate was higher after suture repair (11 per cent) than after mesh repair (1 per cent) (P = 0.0015). CONCLUSION: Prosthetic repair could become the standard treatment for primary umbilical hernia in adults.

[Sportsman hindfoot pain: role of magnetic resonance imaging]. / Tallodinia dello sportivo: ruolo della risonanza magnetica.

PURPOSE: To assess the outcome of Magnetic Resonance Imaging (MRI) in the diagnosis of sportsman hindfoot pain. MATERIALS AND METHODS: Fortythree professional athletes (31 men, 12 women, age range: 17-37 years) affected by hindfoot pain underwent MRI. Spin echo (SE) T1W, Gradient echo (GE) T2*W, and fat suppression (Short Time Inversion Recovery: STIR) images were acquired with a 0.5 T superconductive unit (Vectra, GE Medical System, Milwaukee, WI, USA). A dedicated extremities transmitter/receiver coil was used. The lesion site, the presence of anatomic variants (os trigonum, Haglund's deformity), and signal intensity changes were evaluated. RESULTS: In all cases MRI allowed the identification of the cause of the hindfoot pain, in relation to soft tissue (bursae, synovial or nervous structures), bone and articular diseases. Particularly, as regards soft tissue diseases, tendinous abnormalities and inflammatory bursal involvement were frequently found (77% of cases). Bone diseases (22% of cases with posterior talalgia alone), mostly involved the heel (60%), whereas cartilagineous diseases were present in 9% of cases. In 60% of cases an intra-articular osseous or cartilagineous displaced fragment coexisted, determinating joint locking during foot flexo-extension movements. In 38% of cases contemporary involvement of different articular structures was observed. DISCUSSION: Both MRI high contrast resolution and multiplanar capabilities allow the complete evaluation of hindfoot region. In our experience sagittal and axial planes were particularly well suited for the diagnosis and the assessment of disease extension. Furthermore, T2W (GET2*) and fat suppression (STIR) images allow high sensitivity even in early disease detection, when hyperemia or fluid collection occur. CONCLUSIONS: According to our results, it seems possible to state that nowadays MRI is the most reliable technique for identifying the causes of hindfoot pain, in order to provide a correct and effective pre-therapeutic planning.