DOES THE TYPE OF SURGERY IN BRAIN ABSCESS PATIENTS INFLUENCE THE OUTCOME? ANALYSIS BASED ON THE PROPENSITY SCORE METHOD.

There are different options for surgical treatment of brain abscess, mainly standard craniotomy and stereotactic aspiration. It has not yet been established which of these options is associated with a more favorable outcome under similar baseline conditions of patients. Demographic characteristics, microbiology, clinical presentation, and treatment outcome were analyzed for surgically treated adult patients with brain abscess over a 14-year period. A propensity score model was applied to account for baseline conditions that may determine the choice of neurosurgical method. The propensity score was included in the prediction of a favorable outcome, defined as a Glasgow Outcome Scale (GOS) score 4 or 5. We analyzed 91 adult surgically treated patients, of which 53 had standard craniotomy and 38 stereotactic aspiration of brain abscess. Focal neurological deficit was the most common symptom present in 60 (65.9%) patients on admission. Sixty-seven (73.6%) patients had GOS 4 or 5, and seven (7.7%) patients died. The choice of surgery did not influence the outcome (OR 1.181, 95% CI 0.349-3.995), neither did the time elapsed from diagnosis to surgery (OR 0.998, 95% CI 0.981-1.015). Propensity towards standard craniotomy procedure did not influence outcome in brain abscess patients (OR 1.181, 95% CI 0.349-3.995). Worse outcome (GOS below 4) was independently associated with Glasgow Coma Score (GCS) on admission (OR 0.787, CI 0.656-0.944). The choice of neurosurgical procedure did not influence the outcome in patients with brain abscess. Patients with brain abscess who had lower GCS on admission also had worse outcome.

Minimally invasive puncture and drainage versus craniotomy: basal ganglia intracerebral hemorrhage in elderly patients.

The two most common surgical interventions for spontaneous intracerebral hemorrhage in the basal ganglia of patients more than 65 years old are either minimally invasive puncture and drainage or craniotomy. This study aimed to compare the curative effects of these two procedures in such patients. A retrospective study of patients older than years with spontaneous intracerebral hemorrhage was conducted between January 2012 and December 2015. Of the 86 patients, 47 received minimally invasive puncture and drainage and 39 underwent craniotomy. One year after surgery no statistically significant difference was observed between the two groups with respect to: evacuation rate of the hematoma five days after the operation, volume of residual hematoma, occurrence of rebleeding, development of infectious meningitis, length of hospitalization, fatality, or Glasgow Outcome Scale and Barthel Index scores. However, the amount of blood loss during the procedure (P < 0.001), total cost of hospitalization (P = 0.004), and incidence of epilepsy (P = 0.045) were significantly higher for the craniotomy group than the minimally invasive puncture and drainage group. It was found that, in patients older than 65 years with basal ganglia hemorrhage, minimally invasive puncture and drainage is less invasive, more cost efficient and induces less bleeding during surgery than craniotomy.

Quality of life improves after palliative placement of percutaneous tunneled drainage catheter for refractory ascites in prospective study of patients with end-stage cancer.

OBJECTIVE: Percutaneous tunneled drainage catheter (PTDC) placement is a palliative alternative to serial paracenteses in patients with end-stage cancer and refractory ascites. The impact of PTDC on quality of life (QoL) and long-term outcomes has not been prospectively described. The objective was to evaluate changes in QoL after PTDC. METHOD: Eligible adult patients with end-stage cancer undergoing PTDC placement for refractory ascites completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire and McGill Quality of Life instruments before PTDC placement and at 2 to 7 days and 2 to 4 weeks after PTDC. Catheter function, complications, and laboratory values were assessed. Analysis of QoL data was evaluated with a stratified Wilcoxon signed-rank test. RESULT: Fifty patients enrolled. Survey completion ranged from 65% to 100% (median 88%) across timepoints. All patients had a Tenckhoff catheter, with 98% technical success. Median survival after PTDC was 38 days (95% confidence interval = 32, 57 days). European Organization for Research and Treatment of Cancer scores showed improvement in global QoL (p = 0.03) at 1 week postprocedure (PP). Significant symptom improvement was reported for fatigue, nausea/vomiting, pain, dyspnea, insomnia, and appetite at 1 week PP and was sustained at 3 weeks PP for dyspnea (p < 0.01), insomnia (p < 0.01), and appetite loss (p = 0.03). McGill Quality of Life demonstrated overall QoL improvement at 1 (p = 0.03) and 3 weeks (p = 0.04) PP. Decline in sodium and albumin values pre- and post-PTDC slowed significantly (albumin slope -0.43 to -0.26, p = 0.055; sodium slope -2.50 to 1.31, p = 0.04). Creatinine values increased at an accelerated pace post-PTDC (0.040 to 0.21, p < 0.01). Thirty-eight catheter-related complications occurred in 24 of 45 patients (53%). SIGNIFICANCE OF RESULTS: QoL and symptoms improved after PTDC placement for refractory ascites in patients with end-stage malignancy. Decline in sodium and albumin values slowed postplacement. This study supports the use of a PTDC for palliation of refractory ascites in cancer patients.

Abdominal paracentesis: use of a standardised procedure checklist and equipment kit improves procedural quality and reduces complications.

BACKGROUND: Paracentesis is a common invasive procedure performed by junior doctors. Audit of procedure conduct at two New Zealand hospitals in 2012 revealed poor performance across a range of quality measures, including documentation of informed consent, excessive catheter dwell times and inappropriate albumin prescription. Complication rates were 12.7%, compared with published rates of around 9%. A local procedure protocol did not exist. AIM: To evaluate the effect of a standardised procedure checklist (PC) and equipment kit (EK) on procedural quality and complication rates for abdominal paracentesis. METHODS: After presenting the 2012 audit results to resident doctors, we reviewed the paracentesis literature and developed a local procedure protocol (PC and EK). These tools were made readily available after an education campaign. Paracenteses performed after the intervention were studied to determine the impact on procedural quality and safety. RESULTS: Seventy-four paracenteses (14 diagnostic; 60 therapeutic) were performed in 10 months after the introduction of PC and EK. Significant improvements were observed with the use of PC including documentation of informed consent (97% vs 74%, P = <0.01) and aseptic technique (100% vs 62%, P = <0.01). Catheter dwell times <6 h improved (72% vs 48%, P = 0.02). Inappropriate albumin prescriptions were less frequent (21% vs 66%, P = <0.01). Complication rates decreased from 12.7% to 2.8% (P = <0.01). CONCLUSIONS: The PC and EK improved rates of informed consent, appropriate documentation and protocol adherence. Significantly fewer procedure-related complications occurred after introduction of these tools.

Clinical Observation of Treatment of Chronic Subdural Hematoma With Novel Double Needle Minimally Invasive Aspiration Technology.

OBJECTIVE: The aim of the present study was to explore the clinical effects, including the prevention of complications, of the treatment of chronic subdural hematoma with double needle aspiration. METHODS: The clinical data of 31 patients with chronic subdural hematoma treated by double YL-1 needle double skull drilling and 31 controls treated by traditional drilling and drainage were analyzed retrospectively. RESULTS: In the YL-1 needle group, only 1 patient was with hematoma recurrence, 1 patient was with intracranial pneumocephalus, and the remaining patients who were followed up for 3 months achieved a clinical cure. In the traditional drilling and drainage group, 13 patients were with hematoma recurrence within 3 months after the operation and 7 patients were with postoperative intracranial pneumocephalus. CONCLUSIONS: The method of double YL-1 needle is better than the traditional drilling and drainage method for the treatment of chronic subdural hematoma because it reduces the postoperative recurrence rate and complications.

Effects of Rapid Vaccine Injection Without Aspiration and Applying Manual Pressure Before Vaccination on Pain and Crying Time in Infants.

AIM: To compare effects of rapid injection without aspiration and 10-second manual pressure before injection on pain severity and crying time in 4- to 6-month-old infants given the vaccine DTaP/IPV/Hib. METHODS: This is a randomized double-blind controlled study. The study population included all the infants presenting for DTaP/IPV/Hib to two family health centers between April and August in 2015. The study sample included 128 infants based on confidence interval of 95% and statistical power of 80%. The sample was divided into four groups: manual pressure, rapid injection without aspiration, manual pressure combined with rapid injection without aspiration, and control groups. There were 32 infants in each group. Gender was adjusted in all groups. Stratified and block randomizations were used. RESULTS: Pain severity scores and crying time during and after the injections were significantly lower in the three intervention groups than in the control group (p = .001). The lowest increase in the mean heart rate during and after the injections occurred in the rapid injection without aspiration group (p < .05). In addition, the mean oxygen saturation before, during and after the injections was significantly lower in this group than in the other groups (p < .05). However, two infants in the rapid injection without aspiration group had low oxygen saturation levels starting before the injections. In fact, mean oxygen saturations did not change across time. This suggests that lower oxygen saturation in the rapid injection without aspiration group cannot be due to vaccines or the techniques used. LINKING EVIDENCE TO ACTION: Manual pressure and rapid injection without aspiration are effective and useful in relief of pain and reduction of crying time due to vaccine injections in 4- to 6-month-old infants.

Pleural procedures and patient safety: a national BTS audit of practice.

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service.

Hybrid simulation for knee arthrocentesis: improving fidelity in procedures training.

BACKGROUND: Procedures form a core competency for internists, yet many do not master these skills during residency. Simulation can help fill this gap, but many curricula focus on technical skills, and overlook communication skills necessary to perform procedures proficiently. Hybrid simulation (HS) is a novel way to teach and assess procedural skills in an integrated, contextually-based way. AIM: To create a HS model for teaching arthrocentesis to internal medicine residents. SETTING: Internal medicine residency program at the University of Toronto. PARTICIPANTS: Twenty four second-year internal medicine residents. PROGRAM DESCRIPTION: Residents were introduced to HS, given practice time with feedback from standardized patients (SPs) and faculty, and assessed individually using a different scenario and SP. Physicians scored overall performance using a 6-point procedural skills measure, and both physicians and SPs scored communication using a 5-point communication skills measure. PROGRAM EVALUATION: Realism was highly rated by residents (4.13/5.00), SPs (4.00) and physicians (4.33), and was perceived to enhance learning. Residents' procedural skills were rated as 4.21/6.00 (3.00 - 5.00; ICC = 0.77, [0.53 - 0.92]), comparable to an experienced post-graduate year (PGY) 2-3; and all but one resident was considered competent. DISCUSSION: HS facilitates simultaneous acquisition of technical and communication skills. Future research should examine whether HS improves transfer of skills to the clinical setting.

Conformity of behaviors among medical students: impact on performance of knee arthrocentesis in simulation.

Although the development of collaborative relationships is considered a requirement for medical education, the functioning of these relationships may be impaired by a well-documented social-psychological phenomenon known as group conformity. The authors hypothesized that students would insert a needle into an incorrect location relative to the patella when performing a knee arthrocentesis if they believed that their peers had also inserted a needle in the same incorrect location. This was a randomized controlled study conducted in 2011 with 60 medical students (24 male; 40.0 %) who were randomly assigned to either using a knee model that had a skin with holes left by peers inserting needles in the wrong location, or a knee with no marks in the skin. Each student's aspiration site was measured with a fibreglass ruler to determine whether it was correctly located within the superior third, 1 cm medial to the patella. The researchers determined that students who used the marked skin were more likely to insert the needle in the incorrect location compared to those who used the clean skin (n = 31, 86.11 vs. n = 14, 58.33 %), Fisher's exact test (1) = 5.93, p < 0.05, Cramer's ϕ = 0.31. This study demonstrates incorrect performance of the knee arthrocentesis procedure in simulation when students use a damaged model, which may be due to conformity. It suggests that further research on the impact of conformity in medical education is warranted.

Approach to Bartholin's abscesses and recurrences under office conditions.

OBJECTIVE: The aim of this study is to investigate the various treatment methods and recurrence rates regarding Bartholin's gland abscesses under office conditions in our clinic. METHODS: In our study, the data of 155 patients who applied to the gynaecology and obstetrics clinic of our hospital between January 2017 and November 2020 and had Bartholin's abscess that was treated with surgical methods under office conditions were analyzed retrospectively. RESULTS: Of the 155 patients included in the study, 111 underwent incision drainage, 22 underwent marsupialization, and 22 underwent incision drainage+ silver nitrate. Bartholin's abscess was localized on the right side in 48.4% of the patients and on the left side in 51.6% of the patients. Recurrence was detected in 53 of 155 patients included. Recurrence was detected in 39.6% of the patients who underwent incision drainage in the first treatment, 31.8% of those who underwent marsupialization, and 9.1% of those who underwent incision+silver nitrate. The difference in success, based on recurrence rates, was found to be statistically significantly in favour of silver nitrate (p<0.05). In secondary treatments for recurrent cases, marsupialization or incision+silver nitrate treatment was effective in over 90% of cases, while incision drainage was effective in 30% of patients. CONCLUSION: The findings of our study show that silver nitrate application led to a lower recurrence rate than the other two methods. In view of this, we recommend that marsupialization or silver nitrate be preferred, especially in the treatment of recurrent cases.

Safety of transvaginal aspiration of cysts in pregnancies complicated with ovarian endometrioma.

OBJECTIVES: Pregnancy complicated with ovarian endometrioma is a risk factor for preterm delivery and rupture or infection during pregnancy. This study aimed to clarify the effectiveness and safety of transvaginal aspiration during pregnancy for endometrioma diagnosed in the first trimester. DESIGN: This retrospective observational study included 8 pregnant women with endometrioma who underwent transvaginal cyst aspiration at 12-14 weeks (aspiration group) between March 2011-March 2018 and 23 pregnant women with endometrioma who refused aspiration during the same period (observation group). METHODS: Characteristics of patients were compared in both groups. Safety, feasability and complications of transvaginal cyst aspiration were reported. Complications and obstetrical outcomes were reported and compared in both groups. RESULTS: The maximum cyst diameter was 8.9 ± 1.5 cm (mean ± standard deviation) in the aspiration group, which was significantly larger than that in the observation group (4.7 ± 0.2 cm). Four preterm deliveries (17.3%) occurred in the observation group and none in the aspiration group. The emergency cesarean section rate during delivery was 14.2% in the aspiration group and 43.7% in the observation group. CONCLUSIONS: The aspiration group tended to have lower rate of preterm deliveries and emergency cesarean sections, suggesting that cyst aspiration could be an effective, minimally invasive, and safe management option for endometrioma during pregnancy.

The Surgical Treatment of Peritonsillar Abscess: A Retrospective Analysis in 584 Patients.

OBJECTIVES: There are three surgical treatment options for patients with peritonsillar abscess (PTA): needle aspiration, incision and drainage (ID), and abscess tonsillectomy (ATE). The updated German national guideline (2015) included changes in the treatment of PTA. The indication for tonsillectomy (TE) in patients became more stringent and preference was given to ID in certain cases. STUDY DESIGN: Retrospective analysis. METHODS: We performed a retrospective systematic analysis of patient data using the in-house electronic patient records and considered a 4-year period from 2014 to 2017. About 584 patients were identified. Our aim was to analyze the influence of the updated guideline on clinical practice. RESULTS: 236 of 584 patients (40.4%) underwent ATE with contralateral TE. In 225 patients (38.5%), unilateral ATE was performed. Mean surgery time was significantly shortened when only unilateral ATE was performed. Concerning postoperative bleeding, we noted a tendency toward a lower incidence after ATE in comparison to ATE with contralateral TE. Less than 1% of patients who underwent ATE had to be revised surgically due to postoperative hemorrhage. After the revision of the guideline, unilateral ATE and ID were conducted more frequently. CONCLUSION: These results support that ATE in an inpatient setting is a considerably safe and effective primary therapeutic option. ID represents a favorable treatment option for patients with PTA and comorbidities, nevertheless, patient compliance is required and insufficient drainage or recurrence of PTA may occur. The revision of the guideline had a significant impact on the choice of interventions (P < .001), which is reflected by the increased number of unilateral ATE. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2706-2712, 2021.

Lessons Learned Over More than 500 Stroke Thrombectomies Using ADAPT With Increasing Aspiration Catheter Size.

BACKGROUND: Endovascular thrombectomy is currently the standard of care for acute ischemic stroke (AIS). Although earlier trials on endovascular thrombectomy were performed using stent retrievers, recently completed the contact aspiration vs stent retriever for successful revascularization (ASTER) and a comparison of direct aspiration versus stent retriever as a first approach (COMPASS) trials have shown the noninferiority of direct aspiration. OBJECTIVE: To report the largest experience with ADAPT thrombectomy and compare the impact of advancement in reperfusion catheter technologies on outcomes. METHODS: We reviewed a retrospective database of AIS patients who underwent ADAPT thrombectomy between January 2013 and November 2017 at the Medical University of South Carolina. Demographics and baseline characteristics, technical variables, and radiological and clinical outcomes were reviewed. RESULTS: Among 510 patients (mean age: 67.7, 50.6% females), successful recanalization at first pass was achieved in 61.8%, and with aspiration only in 77.5%. Mean procedure time was 27.4 min, and the rate of good outcomes (mRS 0-2) at 90 d was 42.9%. The rate of recanalization with aspiration only was significantly higher, and procedure time was significantly lower in patients treated with larger catheters (ACE 064 and ACE 068) compared to smaller catheters (5 MAX and ACE, P < .05). There were no differences in complication rates or postoperative parenchymal hemorrhage across groups (P > .05); however, use of ACE 068 was an independent predictor of good outcomes at 90 d on multivariate regression analysis (odds ratio = 1.6, P < .05). CONCLUSION: Refinement of ADAPT thrombectomy by incorporating reperfusion catheters with higher inner diameters and thus higher aspiration forces is associated with better outcomes, shorter procedure times, and lower likelihood of using additional devices without impacting complication rates.

The safety and feasibility of large volume paracentesis performed by an experienced nurse practitioner.

Due to time constraints, fewer physicians are performing large volume paracentesis (LVP) resulting in a longer wait time and more emergency department (ED) and hospital admissions. At our institution, after initial supervision, a certified nurse practitioner (NP) has independently performed LVP in a dedicated cirrhosis clinic. The purpose of our study was to evaluate the feasibility and safety of LVP performed by a NP. A retrospective review of patients undergoing LVP between January 2003 and May 2007 was performed. Baseline patient information and the practitioner performing LVP (physician or NP) were recorded. Complications including post paracentesis hypotension, bleeding, local leakage of ascitic fluid, infection, perforation, and death were compared between the two groups. A total of 245 procedures in 41 patients were performed by a single NP, and 244 in 43 patients by physicians. Baseline characteristics of patients undergoing LVP were similar in two groups. Alcohol was the most common etiology of cirrhosis (46% in NP and 51% in physician group) followed by a combination of alcohol plus HCV (37% in NP and 28% in physician group). There was similar distribution of Childs class B and C patients in the two groups, as well as average MELD score. Total volume of ascites removed, number of needle attempts, and complications including post paracentesis hypotension, local leakage of ascitic fluid, bleeding, infection, and death were not statistically different between the two groups. Our study shows no difference between physician and NP performance of LVP and complication rates. LVP performed by a NP is feasible and has acceptable rate of complications.

[Italian Society of Rheumatology (SIR) recommendations for performing arthrocentesis]. / Raccomandazioni della Società Italiana di Reumatologia per l'esecuzione dell'artrocentesi.

Joint fluid aspiration, or arthrocentesis, is one of the most useful and commonly performed procedures for the diagnosis and treatment of rheumatic diseases, but to date no definite guidelines have been published. For this reason, a group of experts of the Italian Society of Rheumatology (SIR) produced evidence based recommendations for performing arthrocentesis. Among them, the most relevant are: a) arthrocentesis is necessary when synovial effusion of unknown origin is present, especially if septic or crystal arthritis is suspected; b) the patient should be clearly informed of the benefits and risks of the procedure in order to give an informed consent; c) ultrasonography should be used to facilitate arthrocentesis in difficult joints; d) fluid evacuation often has a therapeutic effect and facilitates the success of the following intraarticular injection; e) careful skin disinfection and the use of sterile, disposable material is mandatory for avoiding septic complications. Disposable, non sterile gloves should always be used by the operator, mainly for his own protection; f) contraindications are the presence of skin lesions or infections in the area of the puncture; g) the patient's anticoagulant treatment is not a contraindication, providing the therapeutic range is not exceeded; h) joint rest after arthrocentesis is not indicated. Several of these recommendations were based on experts' opinion rather than on published evidence which is scanty.

[Rumenocentesis: a suitable technique for analysis of rumen juice pH in cattle?]. / Rumenozentese: Eine geeignete Methode zur pH-Bestimmung im Pansensaft beim Rind?

In the United States, rumenocentesis has been recommended especially for early diagnosis of subacute rumen acidosis (SARA). The objective of the current study was to evaluate health risks due to the technique ofrumenocentesis and to measure pH in ruminal juice using a commercial indicator paper (Pehanon) and a pH electrode (reference method). After 11 dairy cows underwent rumenocentesis, the clinical status of those animals was evaluated daily, and cows were slaughtered as well as pathologically--anatomically examined on day 7. During the observation period, the following pathological clinical signs were evident: forced inspiration (3 cows), transient episode of hyperthermia (2 cows), increased tension of the abdominal wall (8 cows) and positive foreign body tests (3 cows). One cow had to be culled on day 7 because of severe generalised septic peritonitis spreading from the site of rumenocentesis. At slaughter, hematoma formation in the area of the puncture site was found in 9 out of 10 cows. It was concluded that the severe complications encountered with this technique do not legitimate rumenocentesis as a routine procedure for collection of rumen juice samples in cows under Swiss conditions. The correlation between the pH reference method and the commercial indicator paper was the high (r = 0.926).

An alternative treatment for iatrogenic right ventricular puncture in primary percutaneous intervention.

Right ventricle perforation is an uncommon, but potentially fatal, possible complication of pericardiocentesis. We presented a case of right ventricular perforation that developed during urgent pericardiocentesis due to tamponade. This case was successfully treated with the incremental removal of the drainage catheter, replacing it with a smaller catheter at 10-minute intervals. This may be an alternative option to treat iatrogenic right ventricle puncture occurring during pericardiocentesis without cardiac surgery or a vascular closure device.

Safety of paracentesis in inpatients.

INTRODUCTION: Prior research has suggested that paracentesis is free from complications such as acute renal failure (ARF) providing albumin is administered. Actual safety of paracentesis > 1,000 ml was assessed at a tertiary care hospital. METHODS: 300 inpatient paracenteses performed between 12/99 and 4/04 were identified by coding records, of which 40 procedures were excluded due to lack of pre- or post-procedure lab values. Charts were reviewed for serum creatinine (Scr) before and after procedures, ascites volume, and clinical outcomes. RESULTS: 44 deaths occurred after 260 paracenteses (16.9%). Among 33 patients with ARF, 13 (39.4%) died. Only 31/227 patients without ARF (13.7%) died (p < 0.001). Serum creatinine (Scr) > 1.6 mg/dl prior to paracentesis predicted a 22.5% rate of ARF, compared to 8% for Scr < 1.0 (p = 0.002). ARF increased as volume increased (9.9%, 12.4%, and 14.9%, for volumes of < 2,300, 2,300 - 3,200, and > 3,200 ml) but this trend did not have statistical significance (p = 0.426). ARF occurred in 11/69 (15.9%) of patients receiving albumin, compared to 22/191 (11.5%) of patients who did not (p = 0.462). CONCLUSIONS: Paracentesis in inpatients has significant rates of ARF and death. Scr > 1.6 prior to paracentesis predicts an increased rate of ARF. Development of ARF is associated with an increased rate of death. No advantage was demonstrated with administration of albumin. Pre- and post-paracentesis labwork should be routine in inpatients.

Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media.

BACKGROUND: The distinction between acute suppurative otitis media (AOM) and otitis media with effusion (OME) is important for antibiotic treatment decisions. Tympanocentesis may be useful in the diagnosis of AOM in selected patients. OBJECTIVES: To assess physician accuracy in diagnosing AOM and OME from physical examination findings and technical competence in performing tympanocentesis. DESIGN AND SUBJECTS: Five hundred fourteen pediatricians and 188 otolaryngologists viewed 9 different videotaped pneumatic otoscopic examinations of tympanic membranes during a continuing medical education course. Diagnostic differentiation of AOM, OME, and a normal tympanic membrane was ascertained. An infant mannequin model was used to assess the technical proficiency of performing tympanocentesis on artificial tympanic membranes. RESULTS: Overall, the average correct diagnosis by pediatricians was 50% (range, 25%-73%) and by otolaryngologists was 73% (range, 48%-88%). Pediatricians and otolaryngologists correctly recognized the absence of normality 89% to 100% and 93% to 100% of the time, respectively, but overdiagnosed AOM in 7% to 53% (mean, 27%) and in 3% to 23% (mean, 10%) of examinations. Performance of tympanocentesis was optimally performed by 89% of otolaryngologists and by 83% of pediatricians. CONCLUSIONS: The use of video-presented examinations to assess diagnostic ability suggests that AOM and OME may be misdiagnosed often. Interactive continuing medical education courses with simulation technology may enhance skills and improve diagnostic accuracy and treatment paradigms.

Unilateral vulvar edema associated with paracentesis in patients with severe ovarian hyperstimulation syndrome. A report of nine cases.

BACKGROUND: Severe ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction. The clinical picture includes ovarian enlargement, accumulation of ascites and pleural effusion, increased coagulability and electrolyte disorders. Accumulation of ascites increases the intraabdominal pressure so that breathing difficulties ensue. Paracentesis is the only treatment that can immediately prevent respiratory deterioration. CASES: Nine women with severe ovarian hyperstimulation syndrome were treated by paracentesis for the drainage of massive ascites. Unilateral vulvar edema developed in all cases in which the lower abdomen was the puncturing site. This phenomenon was not observed when paracentesis was carried out through the upper abdomen. The edema resolved spontaneously over the subsequent 10 days. CONCLUSION: Apparently the puncturing needle created a fistulous tract through which the ascitic fluid was forced, by the increased intraabdominal pressure, into the subcutaneous tissues, presenting as unilateral vulvar edema. This can be prevented by using one of the abdominal hypochondriac regions as the puncturing site. This phenomenon is self-limited and causes only mild discomfort without late sequelae.