Limb spasticity and telemedicine consultation for reconstructive surgery: patient perspectives of surgical assessment.

CONTEXT: Spasticity is characterized by increased muscle tone and stretch reflexes, often caused by an upper motor neuron (UMN) syndrome. Many patients live with their dysfunction of their upper or lower limbs for many years and are managed by a multidisciplinary team including physical medicine and rehabilitation specialists, neurologists, and/or physical therapists in an attempt to decrease their spasticity and enhance their quality of life. Reconstructive surgery is a treatment option for many patients living with spasticity. The goal of surgery is to permanently decrease their spastic tone and improve their quality of life. Spastic hemiplegia or hemiparesis is an area of orthopedic surgery that is uniquely suited to telemedicine evaluation. Telemedicine visits can lower the threshold for patients to obtain consultation, receive second opinions, and determine whether traveling for an in-person assessment might be worthwhile, particular to larger medical centers. OBJECTIVES: The objective of our study was to characterize patient perceptions of telemedicine consultation for spasticity surgery and to determine its effectiveness for indicating reconstructive procedures. METHODS: An electronic survey consisting of 16 questions was distributed to all patients after the virtual consultation from April 2020 to September 2022 as part of a neuro-orthopedic evaluation. Domains of inquiry included patient demographic and diagnosis information, satisfaction with provider assessment, ease of use, appointment preference, and whether surgery was eventually performed. Identifying information was voluntarily provided by patients and allowed for survey data to be linked to the medical record. Patients were included in the study if they were diagnosed with upper and/or lower extremity spasticity, were evaluated by telemedicine visit, and were over the age of 18. They were excluded from the study if they were evaluated for any condition aside from spasticity or returned an incomplete survey. Patients who completed the survey were prospectively followed through December 2022 to determine whether a subsequent in-person visit was pursued and/or reconstructive surgery was performed. RESULTS: A total of 19 of 36 patients completed surveys, for a response rate of 52.7 %. Nearly all (94.7 %, n=18) patients felt that the provider expressed maximal concern for patient questions/worries, included them in decisions regarding care, and appropriately discussed treatment strategies. Similarly, the majority (89.5 %, n=17) were maximally satisfied with explanations about their condition and would recommend the care provider to others. Most patients (84.2 %, n=16) also felt that the ease of communication via the virtual platform was very good. All patients were eventually indicated for and subsequently underwent reconstructive surgery for spasticity. CONCLUSIONS: Spasticity patients were overwhelmingly satisfied with their initial virtual consultation as an alternative to face-to-face visits. Telemedicine provides a clinical opportunity for seeking information about spasticity surgery and offers a cost-effective and convenient option for patients who find travel to specialty centers prohibitive.

Does needle positioning with magnetic field induction improve central venous catheterization performance by novice learners?

OBJECTIVE: The novel ultrasound magnetic needle navigation technique can visualize the entire needle and identify its projected trajectory. We hypothesized that this technique increases the first-attempt success rate of central venous puncture by novice learners compared with the conventional needle navigation technique. METHODS: This prospective, randomized, controlled trial with a crossover design included 50 participants with limited prior experience in US-guided procedures. Participants were randomly assigned to novel or conventional technique groups and asked to perform central venous cannulation in a phantom task trainer. After the first successful attempt, participants were allocated to the other technique group. RESULTS: Although participants in the novel technique group had a higher first-attempt success rate than did those in the conventional technique group, this difference was not statistically significant (p = 0.17). The total number of attempts also did not significantly differ (p = 0.16). The conventional technique group had more needle redirections (p = 0.01) and a longer time to successful cannulation (p = 0.01). The number of adverse effects (p = 0.32) did not differ between groups. Participant confidence levels were higher in the novel technique group (p < 0.001). CONCLUSIONS: Magnetic needle navigation can reduce the number of needle redirections, shorten the time to successful cannulation, and increase confidence levels by novice learners for successful US-guided central venous access.

Evaluation of Soft-Tissue Hematomas With Real-Time, Contrast-Enhanced Ultrasound: A Pilot Study With Preliminary Findings.

ABSTRACT: In this study, we investigated the feasibility of using contrast-enhanced ultrasound (CEUS) to detect active hemorrhage in patients presenting with soft-tissue hematomas. Adult patients with clinically suspected, actively bleeding hematomas were prospectively enrolled. Contrast-enhanced ultrasound was used to assess for contrast extravasation. Ultrasound results were compared with those of multidetector computed tomographic (MDCT) imaging, operative findings, and clinical course. Sixteen patients (9 women, 7 men; mean age, 69 [SD, 13] years) were enrolled. Thirteen patients underwent MDCT imaging during their initial visit, and for 11, CEUS and computed tomography (CT) findings were concordant. The remaining patients had a negative CEUS study that was consistent with their clinical course. In 8 patients, CT imaging showed active extravasation (6 arterial, 1 indeterminate, 1 slow venous). Contrast-enhanced ultrasound and CT findings were concordant for all cases of arterial bleeding. For 1 patient, CEUS provided superior diagnostic information by identifying a pseudoaneurysm. The 2 discrepant patient cases had a ≥3-hour delay between CT and CEUS, and in 1 patient, CEUS was limited by body habitus. The second patient had no active bleeding identified in the operating room. Compared with CT, CEUS had a sensitivity and specificity of 75% and 100%, respectively, and positive and negative predictive values were 100% and 71%, respectively. Diagnostic accuracy was 85% in this limited study. Contrast-enhanced ultrasound is a promising alternative to MDCT in select patients and may sometimes provide superior clinical information. Limiting factors are large hematoma size, unfavorable anatomic location, and body habitus.

Ultrasound-Guided Great Saphenous Vein Access: Revisiting an Old Friend in a New Location.

BACKGROUND: Early recognition of difficult intravenous (i.v.) access and use of ultrasound-guided techniques prior to multiple attempts are important steps in improving patient care in the emergency department (ED). Success rates for ultrasound-guided peripheral i.v. (PIV) cannulation are affected by depth, size of target vessel, and predictability of anatomy. The great saphenous vein (GSV) in the medial distal thigh may provide an alternative site for ultrasound-guided cannulation in cases of difficult peripheral venous access. OBJECTIVES: Our objective was to determine the feasibility of ultrasound-guided GSV PIV placement as an alternative site for patients with difficult i.v. access. METHODS: Participants were prospectively enrolled from a convenience sample of patients presenting to the ED in June and July 2019. Inclusion criteria were age 18 years and older, and a history of difficult i.v. access or two unsuccessful nursing staff attempts. Ultrasound-guided access was conducted with an in-plane or out-of-plane approach on the basis of proceduralist preference. RESULTS: Twenty patients were enrolled; 1 patient withdrew consent prior to cannulation. GSV cannulation was successful in 14 (73.7%) of the 19 patients. Phlebotomy, blood transfusion, i.v. medications including norepinephrine, and i.v. computed tomography contrast medium were successfully performed via GSV access. No reported infection, thrombosis, or extravasation was identified throughout the cannulation dwell time, hospitalization, or for 72 h after discharge. CONCLUSION: Ultrasound-guided GSV PIV placement is a feasible alternative in situations of difficult i.v. access. No unforeseen complication or safety issue was identified. Blood products, medications, and contrast medium were successfully administered safely.