Development and assessment of novel assist device for cardiac cannulation.

PURPOSE: Congenital heart defects are the most common birth defects in the USA and in 25% of cases need to be treated with cardiovascular interventions. One of such interventions is the postoperative use of an extracorporeal membrane oxygenation (ECMO) machine for the treatment of cardiorespiratory failure. The process of placing the patient on the ECMO is extremely time-critical and requires the use of cardiac cannulation. For the first time, our team developed and evaluated a new quick-connect cannulation system that allows for rapid, easy, and safe ECMO cannulation in the pediatric population. The design should eliminate the need for purse-string sutures that are currently used to secure cannulas, as the cannulas will be inserted through a port that is glued to the cardiovascular tissue. METHODS: The rapid cannulation assistance device was designed on the SolidWorks computer-aided design software using the dimensions of the commercially available arterial and venous catheters. These designs were then 3D printed, and tensile testing was performed. Then, a flow loop was developed, and cannulation was performed and analyzed on both 3D-printed hearts and porcine hearts. RESULTS: The rapid cannulation assistance device was designed and 3D printed. Tensile testing found that the parts were strong enough to withstand forces that may be introduced in studies. 3D-printed and porcine heart tests with a flow loop found no leakage with the 3D-printed hearts but minimal leaking with the porcine hearts. However, this leakage was observed at the junction between the device and the heart, leading us to believe that a glue better suited to attach the device to the heart would prevent leakage in the future. CONCLUSIONS: This project successfully demonstrated how a rapid cannulation assistance device could be developed and tested. Future studies will be conducted that address device adhesion to the cardiovascular tissue so that accurate pressure and flow rates can be measured. Future studies will also include testing the device in a fluid environment to more effectively analyze the device success and comparing the time required to cannulate using our device compared to the standard of care.

Avaliação da depuração de litíase ureteral até 7 mm em pacientes com cateter duplo-J / Assessment of ureteral lithiasis clearance up to 7 mm in patients with double-J catheter

A prevalência da nefrolitíase está em torno de 1-15% com estimativa crescente, sendo a ureterolítíase comum nos atendimentos de urgência. Custos elevados estão associados ao manejo da ureterolitíase em proporções que chegam ultrapassar 5 bilhões de dólares nos EUA. A cateterização com duplo-J por pielonefrite obstrutiva pode, em alguns casos, ser a única intervenção necessária. O objetivo foi analisar o impacto da retirada de cateteres duplo-J em pacientes com pielonefrite obstrutiva por ureterolitíase menor ou igual a 7 mm, sem intervenção cirúrgica prévia. Foi realizado um estudo clínico prospectivo, no período de Outubro de 2021 a Abril de 2023 em um hospital terciário da cidade de São Paulo. O estudo incluiu pacientes sem manipulação endourológica prévia, submetido à passagem de cateter duplo-J por pielonefrite obstrutiva secundária à ureterolitíase menor ou igual a 7mm. O cateter foi retirado a partir de 21 dias do evento inicial, e tomografia computadorizada foi realizada 14 dias após a extração do cateter. Durante o período, 36 pacientes foram incluídos no estudo, sendo 19 homens, e 61,1% com topografia em ureter distal. Desses, 29 pacientes (80,5%) apresentaram depuração do cálculo na tomografia de controle, apenas 7 (19,5%) desses pacientes foram submetidos ao retratamento. O diâmetro médio dos cálculos no grupo de pacientes que depuraram foi de 4,9mm (variação de 3 a 7 mm), com tempo médio de permanência do cateter de 39,5 dias. Em relação ao grupo que necessitou de retratamento, o diâmetro médio foi de 5,2 mm (variação de 4 a 7 mm), com tempo de permanência de 52,1 dias. Pacientes com ureterolitíase não infecciosa podem, inicialmente, serem tratados clinicamente. No tratamento da pielonefrite obstrutiva a utilização do cateter ureteral pode ser uma ferramenta única, devido à elevada depuração e incidência mínima de complicações, reduzindo a morbidade e os custos aos serviços de saúde. Palavras-chave: Ureterolitíase. Pielonefrite. Cateter duplo-J.

Efficacy Assessment of Phentolamine Accompanied by Lidocaine Subcutaneously under Ultrasound Guidance on Radial Artery Catheterization in Pediatric Patients.

Objective: Pediatric patients are facing greater difficulties in radial catheterization for anatomic variation and smaller diameter. This study is to investigate the efficacy of phentolamine accompanied by lidocaine subcutaneously under ultrasound guidance on radial catheterization in pediatric patients. Methods: 66 pediatric patients were enrolled and randomly divided into saline group, phentolamine group, and phentolamine+lidocaine group. Baseline characteristics and surgical types were collected. Relevant solutions were subcutaneously injected, and catheterization was subsequently conducted under ultrasound guidance. Radial artery diameter and depth were measured, the success rate of catheterization and procedure time were calculated, and the complications were evaluated with ultrasonography. Results: No significant differences were observed in age, sex, weight, American Society of Anesthesiologists' classification, systolic blood pressure, diastolic blood pressure, heart rate, hemoglobin, and surgical types among three groups. Subcutaneously, the diameter in phentolamine and phentolamine+lidocaine groups increased significantly compared with the saline group. Moreover, the diameter also increased significantly after injection compared with that before injection both in the phentolamine and phentolamine+lidocaine groups. The first-attempt success rates were significantly higher while the procedure times of cannulation were shorter in the phentolamine and phentolamine+lidocaine groups than that in the saline group. Kaplan-Meier analysis showed that the overall procedure time was shorter in the phentolamine and phentolamine+lidocaine groups than the saline group. Overall complications and vasospasm incidence were lower in the phentolamine and phentolamine+lidocaine groups than the saline group. Conclusion: Phentolamine accompanied by lidocaine subcutaneous injection under ultrasound guidance improved the first-attempt success rate and reduced the complication of radial artery catheterization in pediatric patients.

Cannulation Strategy for Extracorporeal Membrane Oxygenation Does Not Influence Total Hospital Cost.

BACKGROUND: The Center for Medicare and Medicaid Services decreased reimbursement rates for peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and venovenous (VV) ECMO procedures in October 2018. Limited data are available describing hospital costs and clinical resources required to support ECMO patients. METHODS: All patients supported on ECMO at our institution between March 2017 and October 2018 were identified. Exclusion criteria were cannulation at referring hospitals, organ transplant recipients, and temporary right ventricular support. The cohort was stratified by the initial cannulation strategy. Outcomes were total hospital cost and clinical resource utilization. RESULTS: There were 29 patients supported on central VA, 72 on peripheral VA, and 37 on VV ECMO. Survival at 30 days was 48% for central vs 37% for peripheral vs 51% for VV. Hospital costs were $187,848 for central vs $178,069 for peripheral vs $172,994 for VV (P = .91). Mean hospital stay was 25.8 days for central vs 21.5 days for peripheral vs 26.2 days for VV (P = .49). Mean intensive care unit stay was 14.1 days for central vs 12.8 days for peripheral vs 7.7 days for VV (P = .25). Mean length of ECMO support was 6.5 days for central vs 6.2 days for peripheral vs 7.8 days for VV (P = .38). Mean ventilator time was 13.0 days for central vs 8.2 days for peripheral vs 10.0 days for VV (P = .06). Hemodialysis was used in 41% central patients, 47% peripheral, and 41% VV (P = .75). Theoretical ECMO reimbursement losses ranged from $1,970,698 to $5,648,219 annually under 2018 Center for Medicare and Medicaid Services rates. CONCLUSIONS: ECMO cannulation strategy has minimal impact on resource utilization and hospital cost.

Rapid Development and Deployment of an Intensivist-Led Venovenous Extracorporeal Membrane Oxygenation Cannulation Program.

OBJECTIVES: To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN: A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING: An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS: Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS: Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS: Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS: There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.

Assessment of complications and short-term outcomes of percutaneous peritoneal dialysis catheter insertion by conventional or modified Seldinger technique.

OBJECTIVE: To explore the efficacy and short-term complications of a modified technique to percutaneously insert a peritoneal dialysis catheter. METHODS: We reviewed the outcomes of 94 patients who underwent peritoneal dialysis catheterization between October 2017 and April 2020. Of these, 47 cases were placed by a conventional Seldinger technique, whereas 47 cases were placed by a modified technique based on the Seldinger method. The success rates of the catheter insertion and three-month postoperative complications were compared between these two groups. RESULTS: The catheter insertion success rates were comparable between the two groups: 93.6% in the conventional technique group and 97.9% in the modified technique group (p = 0.307). The incidence of postoperative catheter migration was lower using the modified technique (4.3%) than the conventional technique (18.3%) (p = 0.037). None of the patients in the modified technique group had postoperative dialysate leakage, whereas this occurred in 9.0% of patients in the conventional technique group (p = 0.036). There were no statistically significant differences in the incidence of postoperative bleeding, infection, or visceral damage between the two groups. CONCLUSIONS: The modified Seldinger technique for percutaneous peritoneal dialysis catheter insertion reduced the short-term postoperative complications of catheter migration and dialysate leakage, with a comparable successful catheter insertion rate compared with the conventional Seldinger technique.

Cost-Effectiveness Analysis of Transcatheter Arterial Embolization Techniques for the Treatment of Gastrointestinal Bleeding in the United States.

OBJECTIVES: Gastrointestinal (GI) bleeding is a common medical emergency associated with significant mortality. Transcatheter arterial embolization first was introduced by Rosch et al as an alternative to surgery for upper GI bleeding. The clinical success in patients with GI bleeding treated with transcatheter arterial embolization previously has been reported. However, there are no cost-effectiveness analyses reported to date. Here we report cost-effectiveness analysis of N-butyl 2-cyanoacrylate glue (NBCA) and ethylene-vinyl alcohol copolymer (Onyx) versus coil (gold standard) for treatment of GI bleeding from a healthcare payer perspective. METHODS: Fixed-effects modeling with a generalized linear mixed method was used in NBCA and coil intervention arms to determine the pooled probabilities of clinical success and mortality with complications with their confidence intervals, while the Clopper-Pearson model was used for Onyx to determine the same parameters. Models were provided by the "Meta-Analysis with R" software package. A decision tree was built for cost-effectiveness analysis, and Microsoft Excel was used for probabilistic sensitivity analysis. The cost-effective option was determined based on the incremental cost-effectiveness ratio and scatter plots of incremental cost versus incremental quality-adjusted life-years. RESULTS: Comparing scatter plots and incremental cost-effectiveness ratio results, -$1024 and -$1349 per quality-adjusted life-year for Onyx and N-butyl 2-cyanoacrylate glue, respectively, Onyx was the least expensive and most effective intervention. CONCLUSION: Onyx was the dominant strategy regardless of threshold values. Our analyses provide a framework for researchers to predict the target clinical effectiveness for early-stage TAE interventions and guide resource allocation decisions.

Comprehensive assessment of levodopa-carbidopa intestinal gel for Turkish advanced Parkinson's disease patients

Background/aim: Levodopa-carbidopa intestinal gel (LCIG) is an effective treatment modality in the management of advanced Parkinson's disease (PD) despite frequent adverse events and different rates of dropouts. Efficacy and safety data regarding Turkish patients on LCIG are limited. This study aims to report in detail the efficacy and adverse effect profile of LCIG among advanced PD patients from a Turkish center for movement disorders. Materials and methods: Twenty-two patients (50% male) who started receiving LCIG between December 2014 and March 2020 were recruited. The efficacy of LCIG was assessed with the Unified Parkinson's Disease Rating Scale (UPDRS III), Clinical Global Improvement (CGI) scale, and Quality of Life scale (PDQ8). Improvements in gait disorders and nonmotor features were also questioned. Adverse events (AE) were collated into 3 topics: related to percutaneous endoscopic gastrojejunostomy (PEG-J), device-related, and LCIG infusion-related. Results: Mean age and pre-LCIG disease duration were 66.7 (8.8) and 13.3 (8.0) years respectively. UPDRS III scores and H-Y scale assessments significantly improved. Better quality of life scores, clinical global improvements, and improvements in dysarthria, dysphagia, and gait were observed. None of our patients dropped out or died during a mean 17.5-month (12.3) period. Overall 20 (90.9%) patients experienced at least one AE. Twelve patients had PEG-J­related complications; three had acute abdomen. Eight (36.4%) patients had device-associated problems. Half of the patients required at least one additional endoscopic procedure and 7 had a device replaced. Mean body weight decreased from 69.5 to 62.5 kg and seven patients had newly onset PNP at a follow-up electromyography. Dyskinesia related to LCIG infusion was observed in 5 (22.7%) patients. There was no significant increase in hallucination among patients. Conclusion: LCIG is an efficient treatment modality in the management of Turkish patients with advanced Parkinson's disease. Although most of the patients had at least one AE, none of them dropped out. Patient selection, patient compliance, and collaborative management are important steps affecting the success of modality.

Minimally invasive and inexpensive percutaneous abscess drainage using an indwelling needle cannula.

PURPOSE: Abscess is still a formidable disease and requires adequate drainage. Moreover, drainage in the head and neck area needs cosmetic care, especially in the pediatric population. In this report, we introduce our method of percutaneous abscess drainage using an indwelling needle cannula. PATIENTS AND METHODS: Ten pediatric and five adult patients with cervical and/or facial abscess treated with this drainage method were retrospectively reviewed. Using an indwelling needle cannula (18-14 G Surflow®, Terumo, Tokyo, Japan), abscesses were penetrated under ultrasonic examination. Once purulent retention was identified, the inner metal needle was removed and the outer elastic needle was left and fixed. The outer needle was connected to the tube for continuous suction drainage for large abscess. RESULTS: The primary diseases of these abscesses were cervical abscess of dental origin (5), purulent lymphadenitis (3), pyriform sinus fistula (2) and subperiosteal abscess due to mastoiditis (2), circumorbital cellulitis (1), infection of Warthin's tumor (1), and unknown origin (1). The median (range) duration of drainage was 4 days (3-9 days). Abscesses were successfully treated, and no patients required additional incision for abscess drainage. No apparent scars after drainage were observed. CONCLUSION: This technique resembles the usual venous placement of an indwelling needle cannula and is thought to be familiar to physicians. Although simple and inexpensive, this drainage is safe, effective, and minimally invasive for the treatment of abscess.

Feasibility of a customizable training environment for neurointerventional skills assessment.

OBJECTIVE: To meet increasing demands to train neuroendovascular techniques, we developed a dedicated simulator applying individualized three-dimensional intracranial aneurysm models ('HANNES'; Hamburg Anatomic Neurointerventional Endovascular Simulator). We hypothesized that HANNES provides a realistic and reproducible training environment to practice coil embolization and to exemplify disparities between neurointerventionalists, thus objectively benchmarking operators at different levels of experience. METHODS: Six physicians with different degrees of neurointerventional procedural experience were recruited into a standardized training protocol comprising catheterization of two internal carotid artery (ICA) aneurysms and one basilar tip aneurysm, followed by introduction of one framing coil into each aneurysm and finally complete coil embolization of one determined ICA aneurysm. The level of difficulty increased with every aneurysm. Fluoroscopy was recorded and assessed for procedural characteristics and adverse events. RESULTS: Physicians were divided into inexperienced and experienced operators, depending on their experience with microcatheter handling. Mean overall catheterization times increased with difficulty of the aneurysm model. Inexperienced operators showed longer catheterization times (median; IQR: 47; 30-84s) than experienced operators (21; 13-58s, p = 0.011) and became significantly faster during the course of the attempts (rho = -0.493, p = 0.009) than the experienced physicians (rho = -0.318, p = 0.106). Number of dangerous maneuvers throughout all attempts was significantly higher for inexperienced operators (median; IQR: 1.0; 0.0-1.5) as compared to experienced operators (0.0; 0.0-1.0, p = 0.014). CONCLUSION: HANNES represents a modular neurointerventional training environment for practicing aneurysm coil embolization in vitro. Objective procedural metrics correlate with operator experience, suggesting that the system could be useful for assessing operator proficiency.

A simple and cost-effective model for ventricular catheter placement training: technical note.

OBJECTIVE: External ventricular drain (EVD) placement is one of first cranial procedures neurosurgery residents are expected to perform independently. While proper training improves patient outcomes, there are few options for practicing EVD placement prior to placing the EVD in patients in a clinical setting. Proposed solutions to this include using cadaveric models and virtual simulations, but barriers exist with these as well in regard to authenticity. EVD simulators using virtual reality technologies are a promising new technique for training, but the cost of these devices poses a barrier to general/widespread accessibility among smaller programs or underserved hospitals. The authors desribe a novel, yet simple, and cost-effective technique (less than $5 per mold) for developing a brain model constructed of homemade ballistics gelatin that can be used for teaching and practicing the placement of EVD. METHODS: A brain model is made with ballistics gelatin using an anatomically correct skull model as a mold. A 3D-printed ventricular system model is used to create a mold of an anatomically correct ventricular system in the brain model. A group of medical students (n = 10) were given a basic presentation about EVD placement, including standard landmarks and placement techniques, and were also shown a demonstration of EVD placement on the brain model. They were then allowed to perform an EVD placement using the brain model. The students were surveyed on their experience with using the brain model, including usability and practicality of the model. Accuracy of EVD placement by each student was also assessed, with adequate position of catheter tip being in the ipsilateral frontal horn. RESULTS: The final product is fairly inexpensive and easy to make. It is soft enough to pass a catheter through, but it is also firm enough to maintain its shape, including a cavity representing the lateral ventricles. The dense gelatin holds the catheter in its final resting position, while the two halves are separated and inspected. All participants in the test group of medical students reported that the brain model was easy to use, helped them understand the steps and technique of EVD placement, and provided good feedback on the ideal position of ventricular catheters. All of the participants in the group had adequate positioning of their ventricular catheters after one attempt. CONCLUSIONS: The presented brain model is easy to replicate, inexpensive, anatomically accurate, and provides a medium for neurosurgeons to teach and practice ventricular catheter placement in a risk-free environment.

Predicting cannulation difficulty in endoscopic retrograde cholangiopancreatography using CT image findings: a decision-tree analysis.

BACKGROUND: Difficult cannulation during endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased complications; therefore, its prediction is important. PURPOSE: To identify radiologic risk factors of difficult cannulation during ERCP based on computed tomography (CT) findings and to develop a predictive model for a difficult cannulation. MATERIAL AND METHODS: A total of 171 patients with native papilla who underwent both enhanced CT and ERCP were recruited. Two radiologists independently measured the distal common bile duct (CBD) diameter and choledochoduodenal (CD) angle and analyzed CT images for presence of CBD stone and papilla bulging, size and type of periampullary diverticulum (PAD), and duodenal segment in which major papilla was located. Multivariate logistic regression analysis and decision-tree analysis were performed to identify risk factors for difficult cannulation. RESULTS: Thirty-nine patients underwent a difficult cannulation. The multivariate logistic regression analysis revealed that a smaller CBD diameter, presence of papilla bulging, location of the major papilla other than the descending duodenum, a smaller CD angle, and a higher worrisome PAD score were statistically relevant factors for difficult cannulation (P < 0.049). In the decision-tree analysis, a higher worrisome PAD score was the strongest predictor of difficult cannulation, followed by the presence of papilla bulging, smaller CD angle, and a smaller CBD diameter. The predictive model had an 82.5% overall predictive accuracy. CONCLUSION: The CT findings-based decision-tree analysis model showed a high accuracy in predicting cannulation difficulty and may be helpful for making pre-ERCP strategy.

Feasibility of a circulation model for the assessment of endovascular recanalization procedures and periprocedural thromboembolism in-vitro.

Aim of this study was to establish a simple and highly reproducible physiological circulation model to investigate endovascular device performance. The developed circulation model included a pneumatically driven pulsatile pump to generate a flow rate of 2.7 L/min at 70 beats per minute. Sections from the superficial femoral arteries were used in order to simulate device/tissue interaction and a filter was integrated to analyze periinterventional thromboembolism of white, red and mixed thrombi. The working fluid (3 L) was a crystalloid solution constantly tempered at 36.5 °C. To evaluate the model, aspiration thrombectomy, stent-implantation and thrombectomy with the Fogarty catheter were performed. Usability of the model was measured by the System Usability Scale (SUS) - Score. Histological specimens were prepared and analyzed postinterventional to quantify tissue/device interaction. Moreover, micro- and macroembolism were evaluated for each thrombus entity and each device. Results were tested for normality using the D'Agostino-Pearson test. Statistical comparisons of two groups were performed using the Student's t-test. All devices were able to remove the occlusions after a maximum of 2 attempts. First-pass-recanalization was not fully achieved for aspiration thrombectomy of mixed thrombi (90.6%), aspiration thrombectomy of red thrombi (84.4%) and stent-implantation in occlusions of red thrombi (92.2%). Most micro- and macroembolism were observed using the Fogarty catheter and after stent-implantation in occlusions of white thrombi. Histological examinations revealed a significant reduction of the vascular layers suggesting vascular damage after use of the Fogarty catheter (327.3 ± 3.5 µm vs. 440.6 ± 3.9 µm; p = 0.026). Analysis of SUS rendered a mean SUS-Score of 80.4 which corresponds to an excellent user acceptability of the model. In conclusion, we describe a stable, easy to handle and reproducible physiological circulation model for the simulation of endovascular thrombectomy including device performance and thromboembolism.

Assessment of Intermittent Self-Catheterization Procedures in Patients with Neurogenic Lower Urinary Tract Dysfunction: Dutch Translation and Validation of the Intermittent Catheterization Satisfaction Questionnaire, Intermittent Catheterization Acceptance Test, Intermittent Self Catheterization Questionnaire and Intermittent Catheterization Difficulty Questionnaire.

BACKGROUND: Intermittent self-catheterization (ISC) is by far the most appealing therapy to achieve a complete bladder emptying in patients with neurogenic lower urinary tract dysfunction (NLUTD). Four questionnaires have been developed in French in order to assess patient's satisfaction, difficulties and acceptance of this technique. OBJECTIVES: The aim of this study was to translate, culturally adapt and validate Dutch versions of the Intermittent Catheterization Satisfaction Questionnaire (InCaSaQ), the Intermittent Catheterization Acceptance Test (ICAT), the Intermittent Self Catheterization Questionnaire (ISCQ) and the Intermittent Catheterization Difficulty Questionnaire (ICDQ). METHODS: (1) Translation and cross-cultural adaptation of the questionnaires were performed according to the standardized guidelines. (2) The test of the pre-final version was performed by a group of bilingual lay people by comparing the original version of the questionnaires and the back translated one, assessing the comparability of language and comparability of interpretation. (3) Problematic issues were reviewed for correction. (4) Reliability was examined by intra-class correlation coefficients (ICC) statistics and Cronbach alpha analysis. RESULTS: Pre-test by 45 raters who are fluent in the source language led to an adapted and improved version of the translated questionnaires. Fifty native Dutch-speaking patients performing ISC (>6 months) due to an NLUTD were prospectively included. InCaSaQ, ICAT, ISCQ and ICDQ showed good internal consistency (α respectively (test and re-test): 0.79-0.88, 0.88-0.92, 0.85-0.88, and 0.88-0.86) and reproducibility (ICC respectively 0.77, 0.84, 0.84, and 0.87). CONCLUSION: The translated versions of InCaSaQ, ICAT, ISCQ and ICDQ are reliable and valid, allowing self-reported assessment of satisfaction, acceptance, difficulties and quality of life related to ISC in Dutch-speaking patients with NLUTD.

Selective Epidurography for the Assessment of Epidural Catheter Placement After Esophagectomy.

BACKGROUND: Adequate pain control immediately after esophagostomy is critical to patient recovery and may be compromised by uncertainty regarding correct epidural catheter placement. The aim of the current study was to determine the role of performing an epidurogram in selective patients to assess epidural placement after esophagectomy. METHODS: Patients undergoing esophagectomy in a high-volume center were retrospectively reviewed to identify those in whom an epidurogram was performed less than 24 hours after surgery. Since 2012 epidurograms have been selectively performed in patients and have demonstrated features concerning for incorrect epidural catheter placement, including difficult/complicated insertion, negative sensory test, nonreassuring intraoperative hemodyamic response, and inadequate postoperative pain control. RESULTS: Fifty-two of 192 patients (27%; 43 men; age 65 ± 11 years) who underwent esophagostomy since 2012 had an epidurogram. Epidurograms were not associated with any adverse events. In 21 patients (40%) epidurogram findings led to a direct change in patient management, prompting either removal/replacement of an incorrectly sited catheter (n = 9), partial withdrawal of a catheter associated with unilateral contrast distribution (n = 2), or by endorsing a clinical decision to modify the analgesic regimen in a patient with a correctly sited epidural catheter (n = 10). Identifying and rescuing incorrect epidural catheter placement was not associated with longer intensive care unit/hospital stay or postoperative morbidity (p > 0.05) CONCLUSIONS: We reviewed selective epidurogram use in esophagectomy patients to determine its role in "rescuing" inadequate pain control through expediting clinical decision-making. Findings confirm that in selected patients epidurography is feasible and has the potential to directly contribute to patient care.

Buttonhole versus Stepladder Cannulation for Home Hemodialysis: A Multicenter, Randomized, Pilot Trial.

BACKGROUND AND OBJECTIVES: Canadian home hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for home hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: All patients training for home hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for home hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. RESULTS: Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for home hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete home hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. CONCLUSIONS: We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on home hemodialysis to be able to draw meaningful conclusions.

Assessment and recency drive skill acquisition.

BACKGROUND: The assessment of medical students' clinical skill acquisition is variable and is driven by differences in curricula and health services requirements. This project aimed to ascertain whether different assessment models impact on students' performance of as intravenous (i.v.) cannulation. Recency of practice was also explored as a factor influencing performance. METHODS: A total of 137 students in the first clinical year (years 2 or 3 of a 4-year course) of their medical degree, from four regional clinical schools, participated in a multiple-station mock objective structured clinical examination (MOSCE). Intravenous cannulation was one of the stations examined. Fifty-nine students came from a model that required the assessment of i.v. proficiency during their clinical year (model 1). Seventy-eight students came from a model that required no assessment of i.v. proficiency (model 2). Students reported their most recent clinical i.v. cannulation experience relative to the MOSCE. RESULTS: The MOSCE pass rate of 73% for students in model 1 was significantly higher than the corresponding MOSCE pass rate of 45% for students in model 2. There was a highly significant association between assessment model and MOSCE pass/fail rate. The assessment model was also highly associated with recency of practice. The assessment of medical students' clinical skill acquisition is variable CONCLUSIONS: The results support an assessment model that promotes the continuing clinical practice of i.v. cannulation. Integration of this model will require innovative approaches by staff and collaboration with affiliated organisations.

Assessment of an ultrasound-guided technique for catheterization of the caudal thoracic paravertebral space in dog cadavers.

Background: The caudal thoracic paravertebral (CTPV) block is a regional anesthesia technique currently used in human medicine to provide analgesia in abdominal surgical procedures. Aim: The objectives of this study are to describe an ultrasound-guided technique to place catheters in CTPV space in canine cadavers and evaluate the distribution of a 50:50 contrast-dye solution administered through them. Methods: Eight thawed adult beagle cadavers (9.2 ± 2.0 kg body total weight) were used. Thirteen catheters were placed. In the first phase, a volume of 0.3 ml kg-1 of the contrast-dye was administered in all cases. After the injections, computed tomography (CT) scans were carried out to assess the distribution of the contrast-dye. In the second phase, an extra 0.2 ml kg-1 of the contrast-dye was administered through eight catheters, followed by a second CT scan. Two cadavers were dissected to assess the distribution of the contrast-dye. The injection site varied between T8-9 and T12-13. Results: The evaluation of the CT scans showed contrast-dye within the paravertebral space in 92% (12/13) of the injections. The distribution pattern observed after the injections performed within the TPV space was linear and intercostal in all cases. The median (range) linear spread of the contrast was 7 (5-10) spinal nerves and involved 3 (2-8) intercostal spaces. The contrast-dye reached lumbar regions in 42% of the injections (5/12). A larger spread of the contrast-dye was not observed after the administration of a second dose of the injectate. No signs of epidural, intrapleural/intrapulmonary, intravascular, or intraabdominal spread were observed. The dissection of the two cadavers confirmed the spread of the contrast-dye along the sympathetic trunk and intercostal spaces. Conclusion: The administration of 0.3 ml kg-1 of the contrast-dye in the CTPV space resulted in a distribution compatible with the block of nerves responsible for the innervation of the majority of the abdominal viscera and cranial abdominal wall.