Pediatricians' focus of sight at pain assessment during a neonatal heel puncture.

OBJECTIVE: To evaluate the focus of pediatricians' gaze during the heel prick of neonates. METHODS: Prospective study in which pediatricians wearing eye tracker glasses evaluated neonatal pain before/after a heel prtick. Pediatricians scored the pain they perceived in the neonate in a verbal analogue numerical scale (0=no pain; 10=maximum pain). The outcomes measured were number and time of visual fixations in upper face, lower face, and hands, in two 10-second periods, before (pre) and after the puncture (post). These outcomes were compared between the periods, and according to pediatricians' pain perception: absent/mild (score: 0-5) and moderate/intense (score: 6-10). RESULTS: 24 pediatricians (31 years old, 92% female) evaluated 24 neonates. The median score attributed to neonatal pain during the heel prick was 7.0 (Interquartile range: 5-8). Compared to pre-, in the post-periods, more pediatricians fixed their gaze on the lower face (63 vs. 92%; p=0.036) and the number of visual fixations was greater on the lower face (2.0 vs. 5.0; p=0.018). There was no difference in the number and time of visual fixations according to the intensity of pain. CONCLUSIONS: At bedside, pediatricians change their focus of attention on the neonatal face after a painful procedure, focusing mainly on the lower part of the face.

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.

Epicardial access for VT ablation: analysis of two different puncture techniques, incidence of adhesions and complication management.

INTRODUCTION: Pericardial access for ablation of ventricular arrhythmias (VA) can be gained either by an anterior-oriented or inferior-oriented epicardial puncture under fluoroscopical guidance. We retrospectively sought to assess the safety of these two puncture techniques and the incidence of epicardial adhesions and introduce our algorithm for management of pericardial tamponade. METHODS AND RESULTS: In 211 patients (61.4 ± 15.6 years, 179 males; 84.8%) 271 epicardial ablation procedures of VA were performed using either an anterior- or inferior-oriented approach for epicardial access. Puncture-related complications were systematically analyzed. Furthermore, the incidence of adhesions was evaluated during first and repeated procedures. A total of 34/271 (12.5%) major complications occurred and 23/271 (8.5%) were directly related to epicardial puncture. The incidence of puncture-related major complications in the anterior and inferior group was 4/82 (4.9%) and 19/189 (10.1%), respectively. Pericardial tamponade was the most common major complication (15/271; 5.5%). Collateral damages of adjacent structures such as liver, colon, gastric vessels and coronary arteries occurred in 6/189 (3.2%) patients and only within the inferior epicardial access group. Adhesions were documented in 19/211 (9%) patients during the first procedure and in 47.1% if patients had 2 or more procedures involving epicardial access. CONCLUSION: Anterior-oriented epicardial puncture shows an observed association to a reduced incidence of pericardial tamponades and overall puncture-related complications in epicardial ablation of VA. In cases of repeated epicardial access adhesions increase significantly and may lead to ablation failure.

Air vs contrast pyelogram for initial puncture access in percutaneous nephrolithotomy: a randomized controlled trial.

Percutaneous nephrolithotomy (PCNL) is a standard procedure for large renal stones. Contrast (traditionally) as well as air is being used to delineate pelvi-calyceal system (PCS) to perform initial puncture. Contrast, when used has certain disadvantages including poor differentiation of anterior and posterior calyces. In this interim analysis of 122 patients of a prospective study subjects were stratified in two groups: in group 1, contrast was used while in group 2, air was used to delineate PCS. Out of 122,103 patients underwent puncture by contrast or air exclusively while 19 patients required mix of contrast and air (14 patients failed puncture using contrast while 5 using air). Mean dosage of radiation exposure (8.43 vs. 14.26 mGy), duration of radiation exposure (0.66 vs. 1.02 min), access time (3.72 vs. 5.84 min), were less in group 2 as compared to group 1. 84.5% of patients underwent puncture in single attempt in group 2 as compared to 56.25% in group 1. Five patients had post-operative fever and one had trans-pleural tract dilation. Complete stone clearance was seen in 94.8% of patients using air to only 75% of patients using contrast. Conclusion: Air pyelogram is a feasible, safe, cost effective and efficient access alternative to contrast pyelogram and in difficult situation a mixture of both is better than using one.

Thromboelastography testing in mice following blood collection from facial vein and cardiac puncture.

: Blood collection is critical for mouse research studies particularly in hemostatic testing. Cardiac puncture; a standard effective method requires anesthesia and is a terminal procedure while facial vein technique allows multiple collections. Thromboelastography (TEG) is a global hemostasis test, provides a dynamic real-time picture of coagulation. However, TEG experiments in mice require large number of animals and may not allow pre/postinterventions assessment. In this study, we aimed to investigate the feasibility of facial vein sampling for TEG analysis as an alternative to cardiac puncture and examined the impact on coagulation results. Blood samples were obtained from a total of 10 C57BL/6 and CD-1 mice via cardiac puncture and a total of another eight mice of similar strains via facial vein sampling. We compared TEG parameters in both methods using descriptive statistics and the Student t test. Results show no significant difference in any of the TEG parameters between cardiac and facial vein blood indicating the two methods are comparable. Facial vein sampling provides a less costly alternative to cardiac puncture. It is a suitable blood collection method for pre/postinterventions or follow-up studies and it better addresses reduction and refinement goals in mouse studies. A larger study to evaluate the sex or strain and genetic background differences will be valuable.

Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers.

We have constructed simple and inexpensive models for ultrasound-guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.

An inexpensive, simple technique to improve the safety of femoral arterial puncture.

We describe a safe and inexpensive technique of avoiding femoral access site complications. Initial fluoroscopic screening of a fully inserted local anesthetic needle helps localize the anticipated arterial puncture site. Repeating fluoroscopy after guide wire insertion through the puncture needle confirms the exact puncture site in the artery.

First-in-man assessment of the InSeal VCD, a novel closure device for large puncture accesses.

AIMS: To demonstrate the feasibility and efficacy of the novel InSeal VCD for the closure of large puncture holes following percutaneous structural interventions. METHODS AND RESULTS: Prospective, non-randomised, single-arm, single-centre study with a series of patients submitted to endovascular treatment of abdominal and thoracic aortic aneurysm as well as transcatheter aortic valve implantation in whom the InSeal VCD was used to close the access site. These patients were followed up for one year with clinical examination, ankle-brachial index and Doppler ultrasound. The primary endpoint was the occurrence of major vascular complications at the puncture site. From a total of nine patients screened, seven were selected to receive the InSeal VCD. Technical and therapeutic successes were achieved in all cases. The sheath profiles used in these procedures ranged from 18 Fr to 25 Fr. No major vascular complications were observed during the follow-up period. Average ankle-brachial index pre-intervention and at one-month follow-up were 0.85 and 0.82, respectively. CONCLUSIONS: The InSeal VCD was shown to be effective in achieving acute and chronic haemostasis after usage of higher profile endovascular devices in this study. These results translated into no clinical complications up to one-year clinical follow-up.

Ovarian drilling for surgical treatment of polycystic ovarian syndrome: a comprehensive review.

This systematic literature review is intended to clarify and evaluate the results obtained by ovarian drilling as surgical treatment for polycystic ovarian syndrome (PCOS). Four databases were consulted (Medline at the National Library of Medicine, USA; Cochrane Library, UK; National Guideline Clearinghouse, USA; and the Health Technology Assessment Database, Sweden) and searched for 'polycystic ovary syndrome' plus 'drilling' in the title or abstract. The assessment criteria used to define the efficacy of the procedure were the rates of ovulation, clinical pregnancy and early miscarriage. Alternatives to surgical ovarian drilling were evaluated. This search produced 147 references, 81 of which met the selection criteria. This review of infertility management in women with PCOS indicates that ovarian drilling is a second-line treatment when treatment with clomiphene citrate fails to lead to conception. The benefits of ovarian drilling are that it does not induce either hyperstimulation syndrome or multiple pregnancies. It is concluded that ovarian drilling is an option in the management of female infertility associated with PCOS, especially as a second-line treatment after the failure of clomiphene citrate treatment.

Cost-efficient suturing simulation with pre-computed models.

Suturing is currently one of the most common procedures in minimally invasive surgery (MIS). We present a suturing simulation paradigm with pre-computed finite element models which include detailed needle-tissue and thread-tissue interaction. The interaction forces are derived through a reanalysis technique for haptic feedback. Besides providing deformation updates and high fidelity forces, our simulation is computationally less costly.

Direct puncture of the recanalized paraumbilical vein for portal vein targeting during transjugular intrahepatic portosystemic shunt procedures: assessment of technical success and safety.

PURPOSE: To assess the success of direct percutaneous puncture of the recanalized paraumbilical vein (RPUV) for access and visualization of the portal vein (PV) to guide transhepatic puncture during transjugular intrahepatic portosystemic shunt (TIPS) creation. The predictive value of successful catheterization based on preprocedural vein diameter was analyzed. MATERIALS AND METHODS: A retrospective review of all TIPS procedures from 2002 to 2008 performed at a single institution was conducted, and a subset of procedures in which portal venography was attempted via the paraumbilical vein were identified. In this subset, TIPS outcomes and diameters of the RPUV near the skin puncture site and left PV junction were measured and analyzed with a two-tailed Student t test. RESULTS: During the study period, 114 TIPSs were created. RPUV punctures were found in 22 patients (19.3%) and portal venography was successful in 14 of the 22 patients (64%), all without complications. In the remainder (n = 8), access via the RPUV failed secondary to a small vein diameter (< 0.3 cm; n = 3), moderate to severe vessel tortuosity (n = 4), and distal thrombosis (n = 1). Puncture, catheterization, and portal venography was successful when the paraumbilical vein measured a mean of 0.75 cm at the skin and a mean of 0.84 cm at the junction with the left PV when analyzed against the failed attempts. CONCLUSIONS: Portal venography via the RPUV is a feasible and probably safe alternative to other methods of PV opacification during TIPS procedures.

Citología tiroidea: métodos complementarios / Thyroid cytology: complementary methods

Describir nuestra experiencia en la punción aspiración con aguja fina de tiroides utilizando ultrasonido tiroideo y/o control citológico inmediato para así evaluar la sensibilidad de los mismos en apoyo a este procedimiento. Se revisaron historias clínicas de 242 pacientes entre enero 2005 y abril 2007 en los cuales se realizaron 130 punciones guiadas por ultrasonido, 126 con control citológico inmediato y ambos en 26 pacientes; evaluando el número, tamaño y distribución de los nódulos, caraterísticas ecográficas, número de láminas, diagnóstico citológico y correlación con el diagnóstico definitivo. Se encontró mayor prevalencia de nódulos únicos entre 1 y 4 cm; ubicándose principalmente en el lóbulo derecho siendo más frecuentes las lesiones complejas. Para valorar los diagnósticos citológicos, fueron agrupados como maligno, hipercelular o hipocelular, consiguiendo porcentajes de 12 por ciento, 81 por ciento respectivamente. De las muestras hipocelulares 15 fueron guiadas por ultrasonido y 5 con control citológico inmediatos, en 3 casos se utilizaron ambos métodos. La sensibilidad de las punciones guiadas por ultrasonido fue de 88 por ciento y de los casos en los que se utilizó control citológico inmediato del 96 por ciento. El 20 por ciento de los pacientes fueron llevados a cirugía, siendo compatible el diagnóstico citológico con el definitivo en 88 por ciento de los mismos. La punción aspiración con aguja fina de tiroides es un método adecuado para suministrar información de los nódulos tiroideos, cuya sensibilidad aumenta al utilizar soporte citológico y ultrasonográfico. Estudios posteriores deben realizarse con el objetivo de valorar la relación costo beneficio en cada caso.

[Maxillary puncture: endoscopic assessment].

Frequency of the injury of the nasolacrimal duct ostium during maxillary puncture through the lower nasal passage was estimated endoscopically. Changes in the maxillary medial wall during the puncture were also studied. Anatomic features of the ostiomeatal complex which may contribute to development of chronic inflammation were determined. Forty one sinuses of 27 deceased middle-aged patients were examined within 24 hours after death. One third of patients in a random population had chronic maxillary inflammation caused by structural anomalies in the ostiomeatal complex. Half of the punctures were made with severe traumas of the nasolacrimal duct ostium. Natural anastomosis of the sinus did not function in about 20% cases. Accessory anastomosis in the posterior fontanelle was registered in 12.2% cases. The posterior fontanelle broke during sinus lavage in 3 cases. Indications for maxillary puncture in acute and chronic maxillary sinusitis should be considered much more carefully in the presence of stable alterations in the ostiomeatal complex and block of the natural anastomosis.

[Immediate hemostasis of the femoral artery after heart catheterization: the present situation of closure systems]. / Sofortige Blutstillung der Arteria femoralis nach Herzkatheter: aktueller Stand der Verschlusssysteme.

The femoral approach is the most commonly used route for diagnostic cardiac catheterization and coronary interventions today. Manual compression and pressure bandages usually lead to immobilisation of the patient for several hours and may result in significant discomfort. Since the introduction of the first femoral closure device in 1991, many devices have proven their efficacy in significantly reducing time to hemostasis while simultaneously improving patient comfort. Twenty four closure device systems with different concepts are on the market, e. g. pure collagen, collagen + thrombin, collagen + anchor, vascular suture, hemostatic patches and pads, staples and more. The four predominantly used are Angio-Seal (46 %), Perclose (32 %), VasoSeal (14 %) and Duett (3 %). The effectiveness of all four systems has been proven in a prospective, randomized, controlled multicenter trial each. Efficacy and safety were analyzed using data from ten comparative studies in 8832 predominantly or exclusively interventional patients, however none of the closure systems proved to be superior. Fortunately, recent years have shown a trend toward a reduction in local complications by vascular closure devices compared to manual compression. Closure devices are thus becoming increasingly cost effective. Vascular closure systems should be preferred when the prolonged supine position is not tolerated, a protein IIb/IIIa-inhibitor was used during the procedure, or early discharge of patient is anticipated. In the presence of peripheral vascular disease, small diameter of the femoral vessels or stenotic lesions in the femoral artery, closure devices should be used with caution. Closure systems for immediate femoral puncture site hemostasis are now an important tool of invasive cardiology today.

Renal aluminium handling in the rat: a micropuncture assessment.

Uncertainties exist over the glomerular filtration of aluminium and virtually nothing is known about its segmental handling along the nephron. The present study has used micropuncture, combined with electrothermal atomic absorption spectroscopy, to determine directly the aluminium content of glomerular filtrate and of late PCTs (proximal convoluted tubules) and early distal tubules in anaesthetized Munich-Wistar rats infused with three different doses of aluminium citrate (plasma aluminium concentrations, 2.9+/-0.1, 5.2+/-0.4 and 10.0+/-0.9 microg.ml(-1) respectively). Aluminium filtration into Bowman's space was found to be considerably greater than that predicted by an in vitro filtration system: in all three groups it was essentially filtered freely. No significant aluminium reabsorption took place along the PCT, but with every dose the FD(Al) (fractional delivery of aluminium; tubular fluid:plasma aluminium/inulin concentration ratio) was lower at the early distal site than at the late PCT (P<0.001 in each case), indicating net aluminium reabsorption in the loop of Henle. This reabsorption amounted to 19-26% of the filtered aluminium load. In the low- and medium-dose groups, there was no significant difference between FD(Al) at the early distal site and that in the final urine; however, in the high-dose group, FD(Al) in the urine (1.02+/-0.06) exceeded that at the early distal tubule (0.75+/-0.04; P<0.001), suggesting aluminium secretion in the distal nephron. The results indicate that aluminium loads, when complexed with citrate, are excreted efficiently owing to a combination of glomerular filtration and minimal reabsorption.

Assessment of multiple cardiocentesis in ball pythons (Python regius).

This study evaluated the gross and microscopic effects of serial blood collection from six ball pythons (Python regius) by using cardiocentesis. We collected 39 blood samples from each snake over a 120-day period. Cardiocentesis was performed on manually restrained snakes, with each sample requiring approximately 15 sec to collect. No clinically apparent complications were noted in any of the snakes after the cardiocentesis procedures, and all snakes survived until they were euthanized 73 days after the last blood sample. Minimal gross lesions were noted at necropsy; faint brown pigmentation of the pericardium was present in five of six snakes, and three snakes had approximately 0.5 ml dark pigmented fluid in the pericardial space. One snake had a small, organized hematoma in the pericardial space. Microscopic findings were limited to moderate and regularly arranged collagen fibrosis and focal thickening of the epicardium. The pericardial sac in all snakes had a mild infiltrate of hemosiderin-laden macrophages and small numbers of heterophils. The results suggest that serial cardiocentesis is well tolerated in ball pythons.

A new system for rapid large-caliber percutaneous transhepatic drainage in patients with obstructive jaundice: a prospective randomized trial.

UNLABELLED: BACKGROUND AND STUDY, AIMS: Percutaneous access to the biliary tract is an important diagnostic and therapeutic tool in the management of biliary diseases. It is usually chosen when the endoscopic approach via endoscopic retrograde cholangiopancreatography (ERCP) fails, or is not possible. Once established, the percutaneous tract is then used for the treatment of biliary stones and strictures. To establish a percutaneous tract with a caliber large enough for cholangioscopy to be performed, or for a large-bore permanent drainage tube to be inserted, stepwise dilation up to 14 Fr or 16 Fr is usually required. We present here a new method of rapid dilation using specially designed materials, including a stiffenable guide wire and specially adapted bougies. PATIENTS AND METHODS: Consecutive patients undergoing percutaneous drainage for biliary diseases were included in this prospective study, over a 19-month period. After establishment of a 10-Fr transpapillary drain, the patients were randomly assigned to either conventional percutaneous transhepatic biliary drainage (PTBD) or stepwise dilation using the new method, aiming at a need for only one further session, using a specially designed stiffenable metal guide wire of 6.6 Fr and plastic bougies. The details of the procedure (duration, materials used, technical ease), initial and later complications, assessment by the patients, and procedural costs were compared between the two groups. RESULTS: Of the 60 patients included, 29 were randomly assigned to group I (the new method) and 31 to group II (the conventional approach); there were no significant differences between the two groups in terms of clinical data or biliary pathology. The clinical efficacy of PTBD was similar in the two groups, although three patients in group II were switched to the new procedure because of failure of dilation using the conventional approach. The rates of major complications (four of 29 in group I, five of 31 in group II) and patient tolerance were also similar. However, the new procedure led to a significant reduction in the cumulative procedure duration (20.1 minutes vs 30.1 minutes), mean number of sessions (1.1 vs. 1.7), and mean number of hospital days (2.0 vs 5.5), and was therefore also cost-effective, reducing costs from a mean of 5813 to 2581 German marks (DM) per patient. CONCLUSIONS: The new system for rapid establishment of large-caliber PTBD offers significant advantages in terms of saving hospital resources while maintaining clinical efficacy.

Direct percutaneous approach to the upper pole of the kidney: MRI anatomy with assessment of the visceral risk.

PURPOSE: In an attempt to determine the visceral risk secondary to a direct percutaneous puncture of the upper renal calix, the anatomic relations of the upper pole of the kidney were studied by magnetic resonance imaging. METHODS: Examination was performed on 25 normal volunteers placed successively in the right and left prone oblique position. The kidney axis and minimal distances from the cutaneous plane at the level of the upper and lower poles were measured. Axial and tangential simulated percutaneous approaches to the upper renal calix were compared in term of risk of damage to the pulmonary, splenic, and hepatic parenchyma. RESULTS: The transversal anteversion angle was statistically comparable for right and left kidneys, but the sagittal anteversion angle was significantly higher for right kidneys (p = 0.05). The minimal distance from the cutaneous plane was statistically comparable for the upper and lower poles. The lower pole was significantly deeper for left than right kidneys (p = 0.01). The visceral risk was statistically comparable for left and right kidneys and was significantly higher in case of an approach in the axis of the upper renal calix or through the 10th intercostal space compared to a puncture via the l1th space (p = 0.0001). CONCLUSION: A percutaneous puncture of the upper pole of the kidney above the 11th rib increases the risk of visceral damage. Preoperative evaluation, with the aid of CT scan or MRI, of the risk of pulmonary, splenic, or hepatic injury could be carried out in these cases.

[Treatment of hepatic hydatid cysts by percutaneous aspiration and hypertonic saline injection: results of a cooperative work]. / Tratamiento de quistes hidatídicos hepáticos por aspiración percutánea e inyección de solución salina hipertónica: resultados de un trabajo cooperativo.

Percutaneous puncture-aspiration-injection-reaspiration (PAIR) of hydatid liver cysts, was performed in 38 patients 14-80 years old, with a total of 60 liver hydatid cysts. After aspiration under computed tomography guidance, hypertonic saline was injected into the cystic cavities of patients as a scolecidal agent. No major complications were associated with the procedures. In the follow-up period of 18 months, control CT scans of 35 cysts revealed a gradual decrease in cyst size with a mean volume reduction of 66%. Complications included two cases of urticaria, one case of anaphylaxis and one subcapsular hematoma. No mortality occurred. It is concluded that percutaneous aspiration and hypertonic saline injection for liver hydatid cysts appears to be an effective form of treatment and may eventually prove to be an alternative to surgical intervention.