Flexible low-profile external ventricular drain catheter for real-time brain monitoring.

External ventricular drainage is one of the most common neurosurgical procedures in the world for acute hydrocephalus, which must be performed carefully by a neurosurgeon. Although various neuromonitoring external ventricular drain (EVD) catheters have been utilized, they still suffer from rigidity and bulkiness to mitigate post-EVD placement trauma. Here, we introduce a flexible and low-profile smart EVD catheter using a class of technologies with sensitive electrical materials, seamless integration, and flexible mechanics, which serves as a highly soft and minimally invasive device to monitor electrical brain signals. This device reliably captures biopotentials in real time while exhibiting remarkable flexibility and reliability. The seamless integration of its sensory system promises a minimally invasive EVD placement on brain tissue. This work validates the device's distinct characteristics and performances through in vitro experiments and computational analysis. Collectively, this device's exceptional patient- and user-friendly attributes highlight its potential as one of the most practical EVD catheters.

Infections Associated with Medtronic Duet External Ventricular Drains - Rhode Island Hospital, Providence, Rhode Island, January 2023-January 2024.

External ventricular drains (EVDs) are medical devices that are inserted into the ventricles of the brain to drain excess fluid, manage intracranial hypertension, monitor intracranial pressure, and administer medications. Unintentional disconnections and breaks or fractures (breaks) of EVDs or associated drainage system components can result in cerebrospinal fluid (CSF) leakage and increased risk for EVD-associated infections. After replacement of Integra Life Sciences EVD systems with Medtronic Duet EVD systems at Rhode Island Hospital in mid-September 2023, a threefold increase was observed in the prevalence of positive CSF cultures, from 2.8 per 1,000 days with an EVD in place (EVD days) during January-September 2023 to 11.4 per 1,000 EVD days during October 2023-January 2024 (rate ratio [RR] = 5.7; 95% CI = 1.5-22.0; p = 0.01) and an eightfold increase in the prevalence of infections, from 0.7 to 6.5 per 1,000 EVD days (RR = 9.8; 95% CI = 1.1-87.3; p = 0.04). An investigation by Rhode Island Hospital Infection Control during December 2023-January 2024 identified frequent reports of disconnections and breaks of the Medtronic Duet EVD system. A search of the Food and Drug Administration Manufacturer and User Facility Device Experience database identified 326 reports nationwide of disconnection and breaks of components of the Duet EVD system, including 175 during 2023. A Medical Product Safety Network report was filed. The Duet EVD product was ultimately recalled in January 2024, citing disconnections of the EVD system and reports of CSF leakage and infection. Given the widespread use of EVD systems by neurosurgery centers and the risk for EVD-associated infections, a strategy for future consideration by hospital infection prevention and control programs might be inclusion of EVD-associated infections in hospital surveillance programs to rapidly identify increases in these events and determine factors related to such infections to prevent additional infections.

Divergent local and systemic antitumor response in primary uveal melanomas.

Uveal melanoma (UM) is the most common cancer of the eye. The loss of chromosome 3 (M3) is associated with a high risk of metastases. M3 tumors are more infiltrated by T-lymphocytes than low-risk disomic-3 (D3) tumors, contrasting with other tumor types in which T cell infiltration correlates with better prognosis. Whether these T cells represent an antitumor response and how these T cells would be primed in the eye are both unknown. Herein, we characterized the T cells infiltrating primary UMs. CD8+ and Treg cells were more abundant in M3 than in D3 tumors. CD39+PD-1+CD8+ T cells were enriched in M3 tumors, suggesting specific responses to tumor antigen (Ag) as confirmed using HLA-A2:Melan-A tetramers. scRNAseq-VDJ analysis of T cells evidenced high numbers of proliferating CD39+PD1+CD8+ clonal expansions, suggesting in situ antitumor Ag responses. TCRseq and tumor-Ag tetramer staining characterized the recirculation pattern of the antitumor responses in M3 and D3 tumors. Thus, tumor-Ag responses occur in localized UMs, raising the question of the priming mechanisms in the absence of known lymphatic drainage.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

"Curtain-fall" technique for cerebrospinal fluid leak prevention after removal of intradural drainage. Technical note: application in chronic subdural hematoma surgery.

OBJECTIVE: Chronic subdural hematoma (CSDH) is frequently met in neurosurgical practice and often need urgent surgical treatment in case of neurological deterioration. Different surgical approaches to evacuate CSDH are described in the literature. In our experience, an external drainage system is crucial in order to avoid recurrences. We recently encountered a case of subcutaneous CSF collection after drainage removal. Thus, we developed a simple surgical technique to prevent postoperative CSF leak after subdural drainage system removal. METHOD: We have developed a technique in which the periosteum is harvested during the surgery prior to the evacuation of the hemorrhage and fixed with sutures on the uncut dura mater opposite and laterally to the exit of the catheter exiting the dural hole caused by the passage of the Jackson-Pratt subdural drainage system. When the drainage catheter is removed, the flap, partially held by the sutures, falls over the hole avoiding CSF leakage. By using this technique, the small dural hole will be covered with the periosteum allowing for natural closure and wound healing hence preventing CSF leakage. RESULTS: This technique was successfully employed in 21 patients who didn't develop postoperative CSF leakage following CSDH evacuation and removal of subdural drainage system. CONCLUSION: In this technical note, we describe a safe dura closure technique that we developed to help reduce the risk of postoperative CSF leakage following subdural drainage removal, which can, however, also be applied in all surgeries in which a catheter is placed in the subdural space.

The Efficacy of Tranexamic Acid in Reducing Perioperative Drainage in Cardiac Surgery with Cardiopulmonary Bypass.

INTRODUCTION: Although cardiopulmonary bypass procedures remain a critical treatment option for heart disease, they come with risks, including hemorrhage. Tranexamic acid is known to reduce morbidity and mortality in surgical hemorrhage. OBJECTIVE: This study aimed to evaluate the efficacy of tranexamic acid, which is routinely used to treat hemorrhage, in decreasing the amount of intraoperative and postoperative drainage. METHOD: A total of 80 patients who underwent cardiac surgery with cardiopulmonary bypass were included in this retrospective study. Forty patients who received tranexamic acid during the operation were assigned to Group 1, while 40 patients who did not receive tranexamic acid were assigned to Group 2. Patient data were collected from the hospital computer system and/or archive records after applying exclusion criteria, and the data were recorded. Statistical analyses were then performed to compare the data. RESULTS: Age, sex, height, weight, body surface area, flow, and ejection fraction percentages, preoperative hematological parameters, and intraoperative variables (except tranexamic acid) were similar between the groups (P>0.05). However, there were statistically significant differences between the groups in terms of intraoperative (through the heart-lung machine) and postoperative red blood cell transfusion rates, intraoperative and postoperative bleeding drainage amounts, as well as postoperative hematocrit, hemoglobin, platelet, and red blood cell levels (P<0.05). CONCLUSION: We concluded that intraoperative and postoperative use of tranexamic acid in patients who underwent coronary artery bypass grafting with cardiopulmonary bypass has positive effects on hematological parameters, reducing blood product use, and bleeding drainage amount.

[Direct transfistulous ultrasound in minimally invasive surgical treatment of infected pancreatic necrosis]. / Pryamoe chresfistul'noe ul'trazvukovoe issledovanie pri minimal'no invazivnom khirurgicheskom lechenii patsientov s infitsirovannym pankreonekrozom.

OBJECTIVE: To develop a method for direct transfistulous ultrasound in minimally invasive treatment of infected pancreatic necrosis. MATERIAL AND METHODS: There were 148 patients with infected pancreatic necrosis between 2015 and 2019 at the Krasnodar City Clinical Hospital No. 2. Drainage with 28-32 Fr tubes was carried out at the first stage, endoscopic transfistulous sequestrectomy - at the second stage (19 (12.8%) patients). In 84 (56.8%) patients, we applied original diagnostic method (transfistulous ultrasonic assessment of inflammatory focus). RESULTS: There were 3 accesses to omental bursa in 93 (62.8%) patients and 2 in 43 (29.1%) patients. We also performed 2 access to retroperitoneal space in 63 (42.6%) patients and 1 access in 38 (25.8%) cases. Transfistulous ultrasound was used once in 19 (22.6%) patients, twice in 28 (33.3%) and 3 times in 37 (44.1%) patients. Examination was not performed in 18 (12.2%) patients due to the following reasons: migration of drainage catheters - 5, non-rectilinear fistulous tract - 13. No complications were observed. CONCLUSION: Transfistulous ultrasound makes it possible to diagnose pathological changes in the pancreas and parapancreatic tissue at various stages of surgical treatment.

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer - a monocenter retrospective study.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients. METHODS: Retrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010-2019). RESULTS: The median [interquartile range] age was 53 [45-64] years and 61% were female. On admission, Glasgow coma scale was 15 [13-15], World Federation of Neurological Surgeons (WFNS) grading scale was 1 [1-3] and Fisher scale was 4 [2-4]. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio [HR] 2.34, 95% confidence interval [CI] 0.98-5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16-2.02) and age (OR 1.03, 95% 1.00-1.07) were associated with one-year mortality. CONCLUSION: When necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.

Modern view on the problem of acute pleural empyema surgical treatment.

OBJECTIVE: Aim: data study on the results of treatment of acute non-specific purulent-destructive pleura diseases with the purpose of further improvement of its results on the basis of improvement of diagnostics, identification of factors of disease prognosis and by implementing differential tactics of surgical treatment with the use of minimally invasive interventions. PATIENTS AND METHODS: Materials and Methods: We have studied modern literary sources on the topic of current trends in the treatment of acute pleural empyema and its complications. The studied material is summarized and presented in the form of a literature review in this article. CONCLUSION: Conclusions: These issues cannot be considered to be completely solved and require further study. Everything mentioned above dictates the search of new effective methods of the treatment of the mentioned pathology and proves the relevance of the theme. The outlined information highlights the necessity of improvement of surgical tactics in patients with pleural empyema.

Intraventricular haemorrhage treated by extra ventricular drainage with catheter mistakenly penetrating the cisterna ambiens: A case report.

Intraventricular haemorrhage (IVH) is a severe and acute type of stroke with a complex pathophysiology and is a therapeutic challenge. This case report described a man in his early 50's diagnosed with IVH by computed tomography (CT). Although bilateral extraventricular drainage (EVD) was undertaken, a postoperative CT scan showed that while the left catheter was correctly positioned, the right catheter had been wrongly inserted into the cisterna ambiens. The procedure was equivalent to simultaneous EVD combined with cisternostomy. As a consequence, the haematoma was rapidly removed, the risk of infection and long-term hydrocephalus was reduced, and prognosis was improved. Large case-control studies or prospective studies are needed to evaluate the safety and effectiveness of this treatment modality.

The Role of Upper Extremity Motor Function in the Choice of Bladder Management in Those Unable to Volitionally Void due to Neurologic Dysfunction.

It is estimated that 425,000 individuals with neurologic bladder dysfunction (spinal cordinjury, spina bifida and multiple sclerosis) are unable to volitionally void and must rely oncatheter drainage. Upper extremity (UE) motor function is one of the most important factors indetermining the type of bladder management chosen in individuals who cannot volitionally void. Novel bladder management solutions for those with impaired UE motor function and concurrent impairments involitional voiding continue to be an area of need. Those with poor UE motor function more often choose an indwelling catheter, whereas those with normal UE motor function more often choose clean intermittent catheterization.

Clinico-Pathological Profile and Outcome of Multiple Ultrasonogram Guided Aspiration of Breast Abscess in Outpatient Department Setup: A Prospective Study.

Treating breast abscess by conventional incision and drainage, followed by regular dressing with prolonged hospital stay, anesthesia, unsatisfactory scar and chances of developing milk fistula in lactating mother is unsatisfactory. Here we study the outcome of ultrasonogram guided multiple aspirations in non-admitted outpatient setup, for its effectiveness as a replacement of conventional surgery. This descriptive, prospective and observational study was carried out from July 2018 to December 2020 with purposive sampling of all cases of breast abscess in a secondary care hospital who underwent ultrasonogram guided aspiration and oral antibiotics, on multiple visits in outpatient department and followed up for three months to study outcome. Mean age of patient was 28.19 years. Fifteen (46.9%) were non-lactating women. The right breast 18(56.3%) and upper outer quadrant 8(25.0%) was affected slightly more. All cases had tender lump except one (3.1%) who had a non-tender lump, but 20(62.5%) had no maximum fluctuating point, usually found in abscesses of other parts of the body. Fever was not a common feature in 8(25.0%) patients and axillary lymph node was not palpable in 26(81.3%) patient. Eighteen (56.3%) patients had healthy nipple, 8(25%) patients had cracked and 5(15.6%) had retracted nipple 11(34.4%) with pus discharge from nipple. Mean duration of symptom was 7 days. Mean sonographic diameter was 5.53cm and volume was 21.09ml. Mean aspirated total volume was 28±10.5 ml. Fifteen (46.9%) patients required 3 aspirations, 10(31.3%) needed 4 aspirations. Success rate was 84.4%, while 25(78.1%) had no complications. Mean healing time in this study was 14 days. We conclude that multiple aspirations under ultrasonogram guidance in outpatient setup day care procedure, is equally effective as conventional surgery and also devoid of many avoidable complications, but meticulous evaluation and high suspicion of background pathology for non-responding case is crucial.

Utility of paired plasma and drainage fluid mNGS in diagnosing acute intra-abdominal infections with sepsis.

BACKGROUND: Metagenomic next-generation sequencing (mNGS) has been increasingly applied in sepsis. We aimed to evaluate the diagnostic and therapeutic utility of mNGS of paired plasma and peritoneal drainage (PD) fluid samples in comparison to culture-based microbiological tests (CMTs) among critically ill patients with suspected acute intra-abdominal infections (IAIs). METHODS: We conducted a prospective study from October 2021 to December 2022 enrolling septic patients with suspected IAIs (n = 111). Pairwise CMTs and mNGS of plasma and PD fluid were sent for pathogen detection. The mNGS group underwent therapeutic regimen adjustment based on mNGS results for better treatment. The microbial community structure, clinical features, antibiotic use and prognoses of the patients were analyzed. RESULTS: Higher positivity rates were observed with mNGS versus CMTs for both PD fluid (90.0% vs. 48.3%, p < 0.005) and plasma (76.7% vs. 1.6%, p < 0.005). 90% of enrolled patients had clues of suspected pathogens combining mNGS and CMT methods. Gram-negative pathogens consist of most intra-abdominal pathogens, including a great variety of anaerobes represented by Bacteroides and Clostridium. Patients with matched plasma- and PD-mNGS results had higher mortality and sepsis severity. Reduced usage of carbapenem (30.0% vs. 49.4%, p < 0.05) and duration of anti-MRSA treatment (5.1 ± 3.3 vs. 7.0 ± 8.4 days, p < 0.05) was shown in the mNGS group in our study. CONCLUSIONS: Pairwise plasma and PD fluid mNGS improves microbiological diagnosis compared to CMTs for acute IAI. Combining plasma and PD mNGS could predict poor prognosis. mNGS may enable optimize empirical antibiotic use.

Comparison between use of a pleural drainage system with flutter valve and a conventional water-seal drainage system after lung resection: a randomized prospective study.

BACKGROUND: There is still a debate regarding the most appropriate pleural collector model to ensure a short hospital stay and minimum complications. OBJECTIVES: To study aimed to compare the time of air leak, time to drain removal, and length of hospital stay between a standard water-seal drainage system and a pleural collector system with a unidirectional flutter valve and rigid chamber. DESIGN AND SETTING: A randomized prospective clinical trial was conducted at a high-complexity hospital in São Paulo, Brazil. METHODS: Sixty-three patients who underwent open or video-assisted thoracoscopic lung wedge resection or lobectomy were randomized into two groups, according to the drainage system used: the control group (WS), which used a conventional water-seal pleural collector, and the study group (V), which used a flutter valve device (Sinapi® Model XL1000®). Variables related to the drainage system, time of air leak, time to drain removal, and time spent in hospital were compared between the groups. RESULTS: Most patients (63%) had lung cancer. No differences were observed between the groups in the time of air leak or time spent hospitalized. The time to drain removal was slightly shorter in the V group; however, the difference was not statistically significant. Seven patients presented with surgery-related complications: five and two in the WS and V groups, respectively. CONCLUSIONS: Air leak, time to drain removal, and time spent in the hospital were similar between the groups. The system used in the V group resulted in no adverse events and was safe. REGISTRATION: RBR-85qq6jc (https://ensaiosclinicos.gov.br/rg/RBR-85qq6jc).

Acute diverticulitis with extraluminal air: is conservative treatment sufficient? A single-center retrospective study.

BACKGROUND: Acute diverticulitis with extraluminal air constitutes a heterogeneous condition whose management is controversial. The aims of this study are to report the failure rate of conservative treatment for diverticulitis with extraluminal air and to report risk factors of conservative treatment failure. METHODS: A retrospective study was performed from an institutional review board-approved database of patients admitted with acute diverticulitis with extraluminal air from 2015 to 2021 at a tertiary referral center. All patients managed for acute diverticulitis with covered perforation (without intraabdominal abscess) were included. The primary endpoint was failure of medical treatment, defined as a need for unplanned surgery or percutaneous drainage within 30 days after admission. RESULTS: Ninety-three patients (61% male, mean age 57 ± 17 years) were retrospectively included. Ten patients had failure of conservative treatment (11%). These patients were significantly older than 50 years (n = 9/10, 90% versus n = 47/83, 57%, p = 0.007), associated with cardiovascular disease (n = 6/10, 60% versus n = 10/83, 12%, p = 0.002), American Society of Anesthesiologists (ASA) score of 3-4 (n = 4/7, 57% versus 6/33, 18%, p = 0.05), under anticoagulant and antiplatelet (n = 6/10, 60% versus n = 11/83, 13%, p = 0.04) and steroid or immunosuppressive therapy (n = 3/10, 30% versus 5/83, 6%, p = 0.04), and with distant pneumoperitoneum location (n = 7/10, 70% versus n = 14/83, 17%, p = 0.001) compared with those with successful conservative treatment. On multivariate analysis, only distant pneumoperitoneum was an independent risk factor of failure (odds ratio (OR) 6.5, 95% confidence interval (CI) [2-21], p = 0.002). CONCLUSIONS: Conservative treatment with antibiotics for acute diverticulitis with extraluminal air is safe with a success rate of 89%. Patients with distant pneumoperitoneum should be carefully monitored.