Incidence rate and risk factors for post-intensive care syndrome subtypes among critical care survivors three months after discharge: A prospective cohort study.

OBJECTIVES: To investigate the incidence of post-intensive care syndrome subtypes and their risk factors among intensive care unit survivors. RESEARCH METHODOLOGY/DESIGN: This prospective observational cohort study assessed post-intensive care syndrome at three months after discharge in 475 survivors (median age of 62 years, 59.4 % male) admitted for more than 24 hours to 19 intensive care units. SETTING: 19 intensive care units at four university hospitals in Korea. MAIN OUTCOME MEASURES: Three months after discharge, the Hospital Anxiety and Depression Scale, Posttraumatic Diagnosis Scale, Montreal Cognitive Assessment, and Activities of Daily Living were used to evaluate post-intensive care syndrome. RESULTS: Participants exhibited eight subtypes of post-intensive care syndrome: post-intensive care syndrome free (50.3 %), impaired in physical (3.4 %), mental (13.5 %), cognitive (12.4 %), physical and mental (7.8 %), physical and cognitive (2.3 %), mental and cognitive (4.0 %) and all three domains (6.3 %). Age, unemployment, education, comorbidities, unplanned admission, longer stay, and place of discharge were risk factors for each domain. Age ≥ 65 years (OR 9.234, p < .001), female gender (OR = 5.143, p = .002), two or more comorbidities (OR = 8.701, p = .002), and discharge to an extended care facility (OR = 36.040, p < .001) were associated with increased probability of impairment in all three domains. CONCLUSION: The type with impaired in both mental and physical domains was the most prevalent in cases of co-occurrence. Discharge to an extended care facility was one of the most significant risk factor for the occurrence of each domain and intensity of post-intensive care syndrome. IMPLICATIONS FOR CLINICAL PRACTICE: Nurses must promote prevention strategies by proactively evaluating intensive care unit survivors for post-intensive care syndrome risk factors. Additionally, it is necessary to raise healthcare providers' awareness of post-intensive care syndrome evaluation and management in extended care facilities.

Effectiveness of Simulation-Based Education for Caring Patients with COVID-19.

PURPOSE: The role of medical staff gained immense significance in the context of the prolonged coronavirus disease (COVID-19) pandemic. However, few studies had explored the impact of simulation-based education on the ability of nursing students to care for the patients of COVID-19. This study provided nursing students with simulation-based education in caring for the patients of COVID-19 and confirmed its effectiveness. METHODS: This study used a non-equivalent control group pretest-posttest design. The participants were recruited from the nursing departments of two universities in Korea through convenience sampling. A total of 79 participants were included: 37 in the intervention group and 42 in the control group. The intervention group received four sessions of simulation training based on the National League for Nursing Jeffries simulation theory. RESULTS: The intervention group showed an improvement compared to the control group in terms of knowledge related to coronavirus, confidence in performing infection control skills, and perception of preparedness for caring for the patients of COVID-19, with a high-level of satisfaction and self-confidence in learning. There was no significant difference between the two groups in terms of anxiety. CONCLUSION: This simulation is expected to be a significant strategy for alleviating the global burden in terms of staff safety and patient outcomes by improving the competencies of prospective medical staff in responding to pandemics.

Sources of meaning in life among older adults during the COVID-19 pandemic: A qualitative study.

AIM: This study aims to explore the sources of meaning in life (MIL) and its impact on South Korean older adults during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: This study had a qualitative descriptive study design. METHODS: The study participants included 18 older adults. Six focus group interviews were conducted. Data were analysed using content analysis. RESULTS: The subcategories 'Continued learning and growth', 'Self-transcending practices' and 'Efforts to maintain good health' were extracted under the category 'Sources of MIL for older adults'. Similarly, the subcategories 'Tremendous changes brought about by the virus' and 'Varying patterns of adjustment to the pandemic' were extracted under the category 'Changes in the sources of MIL since the COVID-19 outbreak'. PUBLIC CONTRIBUTION: Our study provides an in-depth understanding of the changed sources of MIL for older adults during the COVID-19 pandemic. The findings serve as useful guidance for planning interventions for older adults to lead meaningful lives during the COVID-19 pandemic and post-pandemic crises.

Highly Flexible and Durable Thermoelectric Power Generator Using CNT/PDMS Foam by Rapid Solvent Evaporation.

Using a simple, rapid solvent evaporation process, the authors produced 3D carbon nanotube (CNT)/polydimethylsiloxane (PDMS) foams with both high thermoelectric (TE) and good mechanical performance and used them to fabricate highly flexible and durable TE generators. The numerous pores and interfaces in the CNT/PDMS foams, which have porosities exceeding 87%, afford very low thermal conductivity of 0.13 W m-1 K-1 . The foam has a zT value of 6.6 × 10-3 , which is twice as high as that of pristine CNT foam. Importantly, the CNT/PDMS foam exhibits good tensile strength of 0.78 MPa, elongation greater than 20%, and excellent resilience even at compressive strain of 80%. This foam is used to fabricate a highly flexible TE foam generator that exhibits a moderate output power of 1.9 µW generated from the large temperature gradient of 18.1 K produced by applied heat. The authors also demonstrate a practical TE foam generator that produces sustainable output power of 3.1 µW under a compressive strain of 80% and 38.2 nW under the continuous vibrational stress produced by a car engine. The TE foam generator also exhibits excellent stability and durability under cyclic bending and harsh vibrational stress.

Correlations between Changes in Medical Opioid Dispensing and Contributions of Fentanyl to Opioid-Related Overdose Fatalities: Exploratory Analyses from Canada.

Canada is experiencing an epidemic of opioid-related mortality, with increasing yet heterogeneous fatality patterns from illicit/synthetic (e.g., fentanyl) opioids. The present study examined whether differential provincial reductions in medical opioid dispensing following restrictive regulations (post-2010) were associated with differential contributions of fentanyl to opioid mortality. Annual provincial opioid dispensing totals in defined daily doses/1000 population/day, and change rates in opioid dispensing for the 10 provinces for (1) 2011-2018 and (2) "peak-year" to 2018 were derived from a pan-Canadian pharmacy-based dispensing panel. Provincial contribution rates of fentanyl to opioid-related mortality (2016-2019) were averaged. Correlation values (Pearson's R) between provincial changes in opioid dispensing and the relative fentanyl contributions to mortality were computed for the two scenarios. The correlation between province-based changes in opioid dispensing (2011-2018) and the relative contribution of fentanyl to total opioid deaths (2016-2019) was -0.70 (t = 2.75; df = 8; p = 0.03); the corresponding correlation for opioid dispensing changes ("peak-year" to 2018) was -0.59 (t = -2.06; df = 8; p = 0.07). Provincial reductions in medical opioid dispensing indicated (near-)significant correlations with fentanyl contribution rates to opioid-related death totals. Differential reductions in pharmaceutical opioid availability may have created supply voids for nonmedical use, substituted with synthetic/toxic (e.g., fentanyl) opioids and leading to accelerated opioid mortality. Implications of these possible unintended adverse consequences warrant consideration for public health policy.

ABCA1 69C>T Polymorphism and the Risk of Type 2 Diabetes Mellitus: A Systematic Review and Updated Meta-Analysis.

Background: The ATP-binding cassette transporter A1 (ABCA1) is likely associated with the risk of type 2 diabetes mellitus (T2DM) via ß cell function modification, but the evidence on the association remains unclear. This study aimed to investigate the relationship between the ABCA1 69C>T polymorphism and the risk of T2DM through a systematic review and meta-analysis. Materials and Methods: The PubMed, Web of Science, and Embase databases were searched for qualified studies published until August 2020. Studies that included the association between the ABCA1 69C>T polymorphism and the risk of T2DM were reviewed. The odds ratios (ORs) and 95% confidence intervals (CIs) were evaluated. Results: We analyzed data from a total of 10 studies involving 17,742 patients. We found that the CC or CT genotype was associated with increased risk of T2DM than the TT genotype (OR, 1.41; 95% CI, 1.02-1.93). In the Asian population, the C allele carriers had a higher risk of T2DM than those with the TT genotype; the ORs of the CC and CT genotypes were 1.80 (95% CI, 1.21-2.68) and 1.61 (95% CI, and 1.29-2.01), respectively. Conclusions: This meta-analysis confirmed that the ABCA1 69C>T genotype showed a decrease risk of T2DM compared to the CC or CT genotypes.

Implementation of a multimodal infection control strategy in the nursing home.

The main cause of morbidity and mortality among residents of nursing homes (NHs) is healthcare-associated infections (HAIs). We conducted infection control intervention by applying the WHO multimodal strategy for one year from January to December 2018 in the one NH in South Korea. Healthcare workers (HCWs) in NH were observed by infection control nurse from February to December 2018. Hand hygiene (HH) compliance according WHO 5 moments and type of HH, glove use were measured as main outcomes. During the intervention period, a total of 1,461 cases were observed. HH compliance among HCWs increased from 12.6% to 55.2% after the intervention. According to WHO 5 moments, HH before touching a patient and after touching a patient saw significant improvements. Further, glove misuse decreased significantly from 45.9% to 25.4%. The multifaceted infection control program in the NH group significantly improved the HH compliance of HCWs.

The effectiveness of the information-motivation-behavioral skills model-based intervention on preventive behaviors against respiratory infection among community-dwelling older adults.

OBJECTIVE: To evaluate the effectiveness of an information-motivation-behavioral skills (IMB) model-based multi-component intervention on engagement and the quality of preventive behaviors against respiratory infections among community-dwelling older adults. METHODS: This study was a controlled pretest-posttest study in which 91 community-dwelling older adults aged above 65 years were included. The intervention group (n = 42) received the six-week intervention theoretically based on the IMB model that comprised weekly group education and 5-10 min of tele-counseling per week. RESULTS: The results showed that, after the intervention, the improvement in the level of knowledge, self-efficacy, self-reported engagement, and the quality of respiratory infection preventive behaviors was significantly greater in the intervention group compared to the control group. There was no significant difference between the two groups for the perceived threat of respiratory infection. CONCLUSION: The IMB model-based intervention improved the engagement and quality of preventive behaviors by increasing the level of knowledge and self-efficacy in community-dwelling older adults. PRACTICE IMPLICATIONS: The IMB model-based multi-component intervention can be an effective approach to improve preventive behaviors and will contribute to the preparation of communities for outbreaks of respiratory infections.

A systematic review on the causes of the transmission and control measures of outbreaks in long-term care facilities: Back to basics of infection control.

BACKGROUND: The unique characteristics of long-term care facilities (LTCFs) including host factors and living conditions contribute to the spread of contagious pathogens. Control measures are essential to interrupt the transmission and to manage outbreaks effectively. AIM: The aim of this systematic review was to verify the causes and problems contributing to transmission and to identify control measures during outbreaks in LTCFs. METHODS: Four electronic databases were searched for articles published from 2007 to 2018. Articles written in English reporting outbreaks in LTCFs were included. The quality of the studies was assessed using the risk-of-bias assessment tool for nonrandomized studies. FINDINGS: A total of 37 studies were included in the qualitative synthesis. The most commonly reported single pathogen was influenza virus, followed by group A streptococcus (GAS). Of the studies that identified the cause, about half of them noted outbreaks transmitted via person-to-person. Suboptimal infection control practice including inadequate decontamination and poor hand hygiene was the most frequently raised issue propagating transmission. Especially, lapses in specific care procedures were linked with outbreaks of GAS and hepatitis B and C viruses. About 60% of the included studies reported affected cases among staff, but only a few studies implemented work restriction during outbreaks. CONCLUSIONS: This review indicates that the violation of basic infection control practice could be a major role in introducing and facilitating the spread of contagious diseases in LTCFs. It shows the need to promote compliance with basic practices of infection control to prevent outbreaks in LTCFs.

Community-dwelling older adults' needs and acceptance regarding the use of robot technology to assist with daily living performance.

BACKGROUND: The rate of aging in Korea is extremely fast compared to major countries. We examined the key demands of community-dwelling older adults with regard to Connected Active Space technology, which provides tailored assistance with daily living performance through robotic services. METHODS: This study is based on a mixed-method design, through a quantitative survey (n = 234) first phase, followed by a qualitative study with focus group interviews (n = 23) to explore the needs and acceptance of community-dwelling aged people concerning the application of robot technology in their daily lives. RESULTS: The scores concerning the need for and acceptance of robot services to assist daily living performance were high, at 7.2 and 7.9 out of 10 points, respectively. Further, for both needs and acceptance, timely reaction to emergency situations, early detection of emergency situations, help to locate objects, assistance with mobility, and assistance in memory recall were prioritized (in that order). In a thematic analysis of qualitative data from three focus-group interviews, a 'mismatch between desires and functional capacity' was the core characteristic of living as an older person and 'being a friend and helper' was the most desired trait of a robot service. CONCLUSION: Although most of the participants lived independently, they regularly experienced difficulties regarding buying products, transportation, using phones, and preparing meals. If appropriate assistance technology is developed, this population can maintain its independence. Thus, it is necessary to address main needs, including detecting and addressing emergency situations, locating objects, assisting mobility and memory recall, and assisting with daily living performance. New robot services that can be tailored to the functions or abilities of the elderly must be developed based on individually collected information.

Effect of Semi-Fluorinated Alkyl Side Chains on Conjugated Polymers with Planar Backbone in Organic Field-Effect Transistors.

Newly synthesized donor-acceptor (D-A) type of conjugated copolymer (PCTV-BTzF) with semi-fluorinated alkyl side chains, which has good solubility in common organic solvents, is described. Unlike polymers with hydrocarbon-based alkyl side chains, semi-fluorocabonated polymer leads to intriguing results. First, the self-organization behavior of the semi-fluoroalkyl side chains by the self-aggregate propensity between hydrocarbon and fluorocarbon induces patterned microstructural morphology in polymer films; second, it dominates the molecular orientation of polymers with planar back structure. Such unusual properties of the polymer with semi-fluoroalkyl side chains compared to that with the hydrocarbon ones are verified and characterized though various systematic characterizations, including temperature-dependent UV-Vis absorption spectroscopy, atomic force microscopy, and 2D-grazing incident X-ray diffraction measurement. As a result, PCTV-BTzF-based OFETs show the maximum p-type field-effect mobility of 1.02 cm2  V-1  s-1 in the 200 °C annealed films.

The long-term effects of the health coaching self-management program for nursing-home residents.

BACKGROUND AND AIMS: Little is known about whether a self-management program for nursing-home residents (NHR) with cognitive impairment is likely to have an impact on the care of this growing population. This study aimed to evaluate the effects of the health-coaching self-management program for NHR (HCSMP-NHR) on 1) self-efficacy and goal attainment scaling (GAS), 2) health status and quality of life (QoL) among older people, including those with cognitive impairment, in Korean nursing homes. METHODS: This was a cluster-randomized controlled trial. Participants in the intervention group (n=43, mean age =80.91±7.65 years) received the HCSMP-NHR intervention, composed of group health education and individual coaching, for 8 weeks. Conventional care was provided to the conventional group (n=47, mean age =80.19±7.53 years) during the same period. The effects of the HCSMP-NHR were measured three times: at baseline, week 9, and week 20. RESULTS: The intervention group showed better results for self-efficacy (P=0.007), health distress (P=0.007), depression (P<0.001), and QoL (P=0.04) at week 9. Mean GAS score of the intervention group gradually increased from -0.38 to 0.74. The time × group interaction showed that the intervention group had significant improvements in QoL (P=0.047), and significant reductions in health distress (P=0.016) and depression (P<0.001), while showing no deterioration in shortness of breath (P<0.001). CONCLUSION: Our study findings indicate that the HCSMP-NHR improved self-efficacy and GAS and enhanced the health status and QoL of NHR with chronic conditions who also had mild-to-moderate cognitive impairment. Moreover, these effects were successfully maintained over the 5 months of the trial. Further research is needed to establish the optimum intervention period and to assess the possibility of nationwide implementation of the HCSMP-NHR.

Comparative transcriptome analysis of isogenic cell line models and primary cancers links capicua (CIC) loss to activation of the MAPK signalling cascade.

CIC encodes a transcriptional repressor, capicua (CIC), whose disrupted activity appears to be involved in several cancer types, including type I low-grade gliomas (LGGs) and stomach adenocarcinomas (STADs). To explore human CIC's transcriptional network in an isogenic background, we developed novel isogenic CIC knockout cell lines as model systems, and used these in transcriptome analyses to study the consequences of CIC loss. We also compared our results with analyses of transcriptome data from TCGA for type I LGGs and STADs. We identified 39 candidate targets of CIC transcriptional regulation, and confirmed seven of these as direct targets. We showed that, although many CIC targets appear to be context-specific, the effects of CIC loss converge on the dysregulation of similar biological processes in different cancer types. For example, we found that CIC deficiency was associated with disruptions in the expression of genes involved in cell-cell adhesion, and in the development of several cell and tissue types. We also showed that loss of CIC leads to overexpression of downstream members of the mitogen-activated protein kinase (MAPK) signalling cascade, indicating that CIC deficiency may present a novel mechanism for activation of this oncogenic pathway. © 2017 The Authors. Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Precise Side-Chain Engineering of Thienylenevinylene-Benzotriazole-Based Conjugated Polymers with Coplanar Backbone for Organic Field Effect Transistors and CMOS-like Inverters.

Two donor-acceptor (D-A) alternating conjugated polymers based on thienylenevinylene-benzotriazole (TV-BTz), PTV6B with a linear side chain and PTVEhB with a branched side chain, were synthesized and characterized for organic field effect transistors (OFETs) and complementary metal-oxide-semiconductor (CMOS)-like inverters. According to density functional theory (DFT), polymers based on TV-BTz exhibit a coplanar and rigid structure with no significant twists, which could cause to an increase in charge-carrier mobility in OFETs. Alternating alkyl side chains of the polymers impacted neither the band gap nor the energy level. However, it significantly affected the morphology and crystallinity when the polymer films were thermally annealed. To investigate the effect of thermal annealing on the morphology and crystallinity, we characterized the polymer films using atomic force microscopy (AFM) and 2D-grazing incidence X-ray diffraction (2D-GIWAXD). Fibrillary morphologies with larger domains and increased crystallinity were observed in the polymer films after thermal annealing. These polymers exhibited improved charge-carrier mobilities in annealed films at 200 °C and demonstrated optimal OFET device performance with p-type transport characteristics with charge-carrier mobilities of 1.51 cm2/(V s) (PTV6B) and 2.58 cm2/(V s) (PTVEhB). Furthermore, CMOS-like inorganic (ZnO)-organic (PTVEhB) hybrid bilayer inverter showed that the inverting voltage (Vinv) was positioned near the ideal switching point at half (1/2) of supplied voltage (VDD) due to fairly balanced p- and n-channels.

[Efficacy of Lactose-free Milk in Korean Adults with Lactose Intolerance].

BACKGROUND/AIMS: Lactose-free milk (LFM) is available for nutrient supply for those with lactose intolerance (LI). However, there are no consistent results of the efficacy of LFM in LI subjects. We aimed to examine the changes of gastrointestinal (GI) symptoms and hydrogen breath test (HBT) values after ingestion of lactose contained milk (LCM) vs. LFM. METHODS: From May 2015 to September 2015, thirty-five healthy adults with history of LCM-induced GI symptoms were recruited at a tertiary hospital. For the diagnosis of LI, HBT with LCM 550 mL (lactose 25 g) was performed every 20 minutes for 3 hours. The test was defined as "positive" when H2 peak exceeded 20 ppm above baseline values (ΔH2>20 ppm). When the subjects are diagnosed as LI, the second HBT using LFM 550 mL (lactose 0 g) was performed 7 days later. Subjects were asked to complete a questionnaire about the occurrence and severity of GI symptoms. RESULTS: Among a total of 35 subjects, 31 were diagnosed with LI at first visit, and their LCM-related symptoms were abdominal pain (98.6%), borborygmus (96.8%), diarrhea (90.3%), and flatus (87.1%). The ΔH2 value in subjects taking LCM (103.7±66.3ppm) significantly decreased to 6.3±4.9 ppm after ingesting LFM (p<0.0001). There were also significant reduction in total symptom scores and the severity of each symptom when LCM was changed to LFM (p<0.0001). CONCLUSIONS: This is the first report that LFM reduce LCM-related GI symptoms and H2 production in Korean adults. LFM can be an effective alternative for LCM in adults with LI.

A PHF8 homolog in C. elegans promotes DNA repair via homologous recombination.

PHF8 is a JmjC domain-containing histone demethylase, defects in which are associated with X-linked mental retardation. In this study, we examined the roles of two PHF8 homologs, JMJD-1.1 and JMJD-1.2, in the model organism C. elegans in response to DNA damage. A deletion mutation in either of the genes led to hypersensitivity to interstrand DNA crosslinks (ICLs), while only mutation of jmjd-1.1 resulted in hypersensitivity to double-strand DNA breaks (DSBs). In response to ICLs, JMJD-1.1 did not affect the focus formation of FCD-2, a homolog of FANCD2, a key protein in the Fanconi anemia pathway. However, the dynamic behavior of RPA-1 and RAD-51 was affected by the mutation: the accumulations of both proteins at ICLs appeared normal, but their subsequent disappearance was retarded, suggesting that later steps of homologous recombination were defective. Similar changes in the dynamic behavior of RPA-1 and RAD-51 were seen in response to DSBs, supporting a role of JMJD-1.1 in homologous recombination. Such a role was also supported by our finding that the hypersensitivity of jmjd-1.1 worms to ICLs was rescued by knockdown of lig-4, a homolog of Ligase 4 active in nonhomologous end-joining. The hypersensitivity of jmjd-1.1 worms to ICLs was increased by rad-54 knockdown, suggesting that JMJD-1.1 acts in parallel with RAD-54 in modulating chromatin structure. Indeed, the level of histone H3 Lys9 tri-methylation, a marker of heterochromatin, was higher in jmjd-1.1 cells than in wild-type cells. We conclude that the histone demethylase JMJD-1.1 influences homologous recombination either by relaxing heterochromatin structure or by indirectly regulating the expression of multiple genes affecting DNA repair.

Disseminated gonococcal infection presenting as bacteremia and liver abscesses in a healthy adult.

Herein, we describe a bacteremia caused by Neisseria gonorrhoeae that presented as liver abscesses. The patient had no risk factors for disseminated gonococcal infection. Periodic fever, skin rashes, and papules were present and the results of an abdominal computed tomography scan indicated the presence of small liver abscesses. The results of blood culture and 16S rRNA sequencing of the bacterial isolates confirmed the presence of N. gonorrhoeae. The patient improved with antibiotic therapy.

Preparation of quercetin and rutin-loaded ceramide liposomes and drug-releasing effect in liposome-in-hydrogel complex system.

In this study, we developed a 2-step delivery system to enhance transdermal permeation of quercetin and its glycoside rutin, an antioxidant. Liposome-in-hydrogel complex systems were prepared by incorporating ceramide liposomes, which consist of biocompatible lipid membranes, into cellulose hydrogel. We evaluated the encapsulation efficiency, in vitro release behavior, and skin permeability of formulations that remained stable for over 3 weeks. Rutin had greater encapsulation efficiency and better in vitro release properties than quercetin. However, quercetin demonstrated greater skin permeability than rutin. We also found that liposome-in-hydrogel complex systems (quercetin, 67.42%; rutin 59.82%) improved skin permeability of quercetin and rutin compared to control (phosphate buffer, pH 7.4) (quercetin, 2.48%; rutin, 1.89%) or single systems of hydrogel (quercetin, 31.77%; rutin, 26.35%) or liposome (quercetin, 48.35%; rutin, 37.41%). These results indicate that liposome-in-hydrogel systems can function as potential drug delivery systems to enhance transdermal permeation of the water-insoluble antioxidants quercetin and rutin.

Meta-analysis identifies a MECOM gene as a novel predisposing factor of osteoporotic fracture.

BACKGROUND: Osteoporotic fracture (OF) as a clinical endpoint is a major complication of osteoporosis. To screen for OF susceptibility genes, we performed a genome-wide association study and carried out de novo replication analysis of an East Asian population. METHODS: Association was tested using a logistic regression analysis. A meta-analysis was performed on the combined results using effect size and standard errors estimated for each study. RESULTS: In a combined meta-analysis of a discovery cohort (288 cases and 1139 controls), three hospital based sets in replication stage I (462 cases and 1745 controls), and an independent ethnic group in replication stage II (369 cases and 560 for controls), we identified a new locus associated with OF (rs784288 in the MECOM gene) that showed genome-wide significance (p=3.59×10(-8); OR 1.39). RNA interference revealed that a MECOM knockdown suppresses osteoclastogenesis. CONCLUSIONS: Our findings provide new insights into the genetic architecture underlying OF in East Asians.

Accuracy of live fluoroscopy to detect intravascular injection during lumbar transforaminal epidural injections.

BACKGROUND: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. METHODS: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. RESULTS: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). CONCLUSIONS: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.