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.

Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis.

Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P < .001) and LOS by 1.5 days (P < .001). Bleeding complications increased cost by $19,066 (P < .0001) and LOS by 4.3 days (P < .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.

[Ultrasound-guided puncture : an inexpensive and effective learning model]. / Ultraschallgesteuerte Punktion : Ein kostengünstiges und effektives Lernmodell.

Ultrasound is present in almost any practice and hospital clinic today. In clinical practice, puncture of structures, injections of local anesthetics or glucocorticoids are frequently performed. However, unguided puncture into tissue may have deleterious side-effects if the target is not reached or the drug is not injected properly, such as bleeding, traumatization of delicate structures, glucocorticoid-induced tendon rupture and skin necrosis. Coordination of eye, probe and the manipulation hand needs practice before being used on patients.Therefore, we developed an inexpensive, easy to make and effective learning model for ultrasound-guided puncture and injections. We describe how the model is made and how it can be used to efficiently enhance learning success. It was found that a person unskilled in ultrasonography needs about 40-60 coached punctures in order to confidently hit the target.This model has already been used in our medical education program for rheumatologists, internists, surgeons, orthopedic specialists, anesthetists and general practitioners with great success.

Costs of bleeds relating to acute coronary syndrome therapies.

UNLABELLED: To estimate the costs to manage selected types of bleeding complications in patients with acute coronary syndrome (ACS) treated with antithrombotics, including antiplatelet, and fibrinolytic therapies: decrease in haemoglobin >3 g/dL, puncture site, and bleeding requiring transfusion of blood products. METHODS: Retrospective chart reviews of ACS patients experiencing decrease in Hb, puncture site, or bleeding requiring transfusion were conducted in hospitals in France, Germany, Italy, Spain and Sweden to determine the total length of stay (LOS), stay post-bleeding, procedures to identify the extent of bleeding, number and types of transfusion products, patient demographics, reason for hospital admission and disposition upon discharge. Country-specific costs were applied to estimate the average cost per patient by type of bleeding event. RESULTS: Records of 158 ACS patients with the bleeding complications were examined (26.9% decrease in Hb, 35.5% puncture site, and 37.8% transfusion). The average LOS was 10.6 days for decreasing Hb, 7.7 days for puncture site bleeding, and 11.3 days for patients receiving transfusions due to these bleeding events. The average costs per patient ranged between €3,986 and €10,252. The LOS ranged widely both within and across countries. LIMITATIONS: The study has a small sample size and costs are confounded by co-morbidities. CONCLUSIONS: The estimated costs for decreasing Hb, puncture site bleeding and bleeding resulting in transfusions provide a tool for researchers to conduct economic analyses of bleeding events associated with therapies for ACS.

Total percutaneous access for endovascular aortic aneurysm repair ("Preclose" technique).

OBJECTIVE: Percutaneous access during endovascular aneurysm repair has been difficult owing to the large size of the delivery catheters. This study reports a single-center experience of totally percutaneous access during endovascular abdominal and thoracic aortic repairs using the Preclose Proglide device (Abbott Vascular, Redwood City, Calif). METHODS: Between December 2004 and August 2006, 262 endovascular aortic aneurysm repairs were performed. Percutaneous access was used for the introduction of 12F to 24F sheaths (4.4-mm to 8.6-mm outer diameter). The technique involved deployment of two Proglide devices before insertion of the sheath ("Preclose" technique) with the sutures left extracorporeally for closure after conclusion of the procedure. A prospectively maintained endovascular database and medical records were retrospectively reviewed. Rates of technical success, failure modes, and the overall duration of the endovascular repair compared with a similar cohort using open femoral exposures were examined. RESULTS: A total of 559 Proglide devices were used to close 279 femoral arteries, and 175 (63%) required the insertion of 18F to 24F sheaths. There were 16 failures, mainly due to obesity, device malfunction, severe calcific disease, and faulty arterial punctures, for a technical success rate of 94.3%. The success rates for 12F to 16F size sheaths were significantly higher than for the larger 18F to 24F sheaths (99.0% vs 91.4%, P<.01). For both endovascular abdominal (EVAR) and thoracic (TEVAR) aortic repairs, the Preclose technique resulted in shorter overall procedure times compared with a similar cohort in which open femoral exposures were used (EVAR, 115 vs 128 min, P<.001; TEVAR, 80 vs 112, P=.019). Despite this reduction of procedure time, the savings on the cost of operating room time was negated by the cost of the Proglide devices ($295 per device). CONCLUSIONS: Percutaneous access for endovascular aortic repair is safe and feasible using the Proglide device. Although the success rates are higher for smaller size sheaths, successful closures may be obtained for up to 24F sheaths. Percutaneous access may result in shorter overall procedure times and potentially lower operating room costs, but this appears to be offset by the cost of the closure devices.

Tattooing and body piercing. Body art practices among college students.

Tattooing and body piercing are increasing, especially among college students. A study of 766 tattooed and/or body-pierced college students in 18 universities across the United States and one in Australia was conducted to discover the demographic characteristics, motivational factors, and health concerns. The traditional college time of 18 to 22 years of age (69%) was when they obtained their tattoo (73%) and/or body piercing (63%). More frequent health problems and impulsive decision making were noted for those with body piercing when compared to those tattooed. Three cases of hepatitis were reported. Health professionals should openly discuss body art with students, convey a nonjudgmental attitude, and assist with informed decision-making information to either reduce risks or dissuade. Open communication and applicable health education will be very important.

[CT-guided punctures: diagnostic value, therapeutic consequences and economic aspects]. / CT-Punktionen: Diagnostische Bedeutung, therapeutische Konsequenzen und ökonomische Aspekte.

PURPOSE: To evaluate the diagnostic and clinical relevance and therapeutic consequences of CT-guided biopsy with regard to economic aspects. METHODS: 213 CT-guided biopsies in 190 patients were evaluated. All information regarding patient referral, reason for request, body region, underlying diagnosis, and clinical consequences were registered over a period of 22.2 +/- 9.4 month. RESULTS: Patient referral to biopsy was mainly from the departments of surgery, internal medicine, and radiotherapy with the question of tumor and metastasis. Less than 5% of biopsies were performed in outpatients. Main regions were the lung (39%), the abdomen (35%), and the skeleton (11%). Biopsy and surgical histology corresponded in 73%. Largest diagnosis groups were benign unspecific tissues or other benign lesions in 24%. As a result of CTP no further procedures were necessary in 22.5%. Follow-up studies or conservative treatment were indicated in 11.3%. Surgical procedures were needed in only 15.5%. There was only one complication requiring therapy. CONCLUSION: CT-guided biopsy is a safe procedure, which helps to avoid unneccessary cost-intensive diagnostics and surgical treatment. If CTP is performed early and in outpatients residence time in the hospital is reduced and thus money is saved.

[Preoperative breast PE marking: safe, simple, cost effective, dose-saving]. / Die präoperative Mamma-PE-Markierung: Sicher, einfach, kostengünstig, dosissparend.

Optimized technique permit the marking of non-palpable breast lesions in a manner equivalent to stereotactic methods. A marked wire-thread drawn through the breast is employed for adjustable localization in the depth.

Management of parapneumonic effusions. An analysis of physician practice patterns.

OBJECTIVE: To evaluate physician practices in managing patients with parapneumonic effusions and the impact of practice patterns on clinical outcome. DESIGN: Case series. SETTING: Private, tertiary care medical center. PATIENTS: Thirty-nine hospitalized patients with complicated parapneumonic effusions and a separate group of 191 patients admitted with community-acquired pneumonia. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Evaluation of physician practice patterns in managing complicated parapneumonic effusion and the impact of delaying thoracentesis (> or = 2 days after pleural fluid detection) or pleural drainage (> or = 2 days after pleural fluid criteria for drainage fulfilled) on duration of hospitalization, cost of hospitalization, and need for thoracotomy. RESULTS: Thirty-eight of the 39 patients with complicated parapneumonic effusions underwent thoracentesis that was "delayed" (5.7 +/- 3.1 days) in 16 patients. Delays in thoracentesis were associated with longer hospitalizations (P = .02). Laboratory tests ordered on nonpurulent pleural fluid were incomplete for 16 of 38 patients. Chest tube or surgical pleural drainage was delayed (4.2 +/- 3.5 days) in 10 of 38 patients who underwent thoracentesis. Delays in initiating drainage were associated with prolonged hospitalization (P = .04). Delaying interventions accounted for a mean cost increment per patient of $8462 for delayed thoracentesis and $9332 for delayed drainage. Of the 191 patients with community-acquired pneumonia, 99 (52%) had pleural effusions but only 15 (15%) underwent thoracentesis. CONCLUSIONS: Physicians commonly delay thoracentesis and chest tube drainage to observe parapneumonic effusions for improvement. This practice pattern is associated with longer and more costly hospitalizations.