Home About us Contact
|
Home About us Contact | ||
|
|
||
Puncture
Kinds of Puncture Terms modified by Puncture Selected AbstractsLUMBAR PUNCTURE IN OLDER ADULTS: WHICH APPROACH IS SAFER?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010A RETROSPECTIVE COHORT STUDY No abstract is available for this article. [source] MEASUREMENT OF FIRMNESS OF FRESH-CUT SLICED TOMATO USING PUNCTURE TESTS , STUDIES ON SAMPLE SIZE, PROBE SIZE AND DIRECTION OF PUNCTUREJOURNAL OF TEXTURE STUDIES, Issue 5 2007MILZA M. LANA ABSTRACT In order to investigate the firmness of tomato slices, two experiments were performed. In the first one, Monte Carlo simulation was used to study the variation in firmness within and between slices. Adding more slices and more measurements per slice reduced the SD, but in general, the efficiency of adding more slices was higher. In the second experiment, the firmness of tomato slices was measured by puncture test during storage, using one of three flat-tipped cylindrical probes (3.5-, 2.5- and 1.5-mm diameter) in two directions, along or perpendicular to the main axis of the fruit. Changes in firmness were studied by nonlinear regression analysis. The same model could be applied to all combinations of probe size and direction with the same correction for shear and compression. It suggests that shear and compression forces decay with storage time according to the same mechanism, irrespective of the measurement direction. PRACTICAL APPLICATIONS Methodologies for both firmness evaluation and data analysis were presented. Monte Carlo simulation was used to optimize the number of samples for firmness assays. After calculating the experimental SD from preliminary experimental results, simulations were performed with different numbers of replicates and measurements per replicate, to find an optimal experimental design where the SD is minimized. Using nonlinear regression, the effects on firmness of probe size, puncture direction in relation to the plant tissue and storage time can be analyzed simultaneously. The incorporation of a correction factor to account for differences in firmness due to probe size was proposed. The relative influence of shear (s) and compression force (c) on the observed force is estimated. Results of interest for the industry were presented, confirming previous findings that the firmness of ripened tomato slices measured by puncture analysis does not change significantly during short-term storage at low temperature. [source] PROBABILISTIC CHARACTERISTICS OF STRESS CHANGES DURING CEREAL SNACK PUNCTUREJOURNAL OF TEXTURE STUDIES, Issue 2 2007YOSHIKI TSUKAKOSHI ABSTRACT During puncture tests of Japanese cereal snacks, the force increases and decreases alternately. We herein compare the force,deformation curves recorded by two different testing machines and show that the number of changes in the curves depends on the testing machine. Thus, it is impossible to compare results obtained using different instruments. By removing the higher-frequency components of the force,deformation curves, small events are easily missed. The number of large events decreases when lower-frequency components are eliminated. This suggests the importance of providing the information on the frequency range of the testing machines. Nevertheless, the number of large force changes is similar between the examined machines. To model the size,frequency distribution, we selected a parametric probabilistic model from among the Weibull, exponential and Pareto distributions using Akaike information criterion and found that the Weibull or exponential distributions have a fit better than the Pareto distribution. PRACTICAL APPLICATIONS The methods developed in this work can be used to evaluate the quality of crisp snack food. By analyzing the samples obtained from a lot, samples with poor texture because of abnormal moisture levels and/or ingredients can be discerned and can be used to accept or reject the lot. [source] Incidence of Traumatic Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2 2003Kaushal H. Shah MD Abstract Objective: To determine the incidence of traumatic lumbar puncture (LP). Methods: A retrospective study was conducted at an urban, university tertiary care referral center with 50,000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1,000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. Results: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1,000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1,000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). Conclusions: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1,000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital. [source] Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute-onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?ACADEMIC EMERGENCY MEDICINE, Issue 4 2010Robert F. McCormack MD Abstract Objectives:, The primary goal of evaluation for acute-onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute-onset headache. Methods:, This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results:, SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions:, CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute-onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444,451 © 2010 by the Society for Academic Emergency Medicine [source] Iatrogenic Forearm Compartment Syndrome in a Cardiac Intensive Care Unit Induced by Brachial Artery Puncture and Acute AnticoagulationJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 2 2002M.H.A, SHAY SHABAT M.D. A previously healthy patient developed late compartment syndrome in the cardiac intensive care unit after a brachial artery puncture due to acute heparinization after successful percutaneous transluminal coronary angioplasty (PTCA) and stent implantation. The cardiologists recognized the problem and immediately consulted an orthopedic surgeon, who promptly performed surgery. The latter consisted of decompression and fasciotomy. The patient recovered excellent hand function without any neurologic or muscular deficits. Knowledge and understanding of the clinical aspects of this complication are crucial in this devastating syndrome. [source] Percutaneous Suture Closure for Management of Large French Size Arterial and Venous PunctureJOURNAL OF INTERVENTIONAL CARDIOLOGY, Issue 4 2000TED FELDMAN M.D. Aortic valvuloplasty procedures have been limited principally by the occurrence of restenosis in this patient population. Once a decision has been made to proceed with aortic valvuloplasty, one of the next major concerns is management of the femoral artery puncture. For these procedures, 12Fr and 14Fr sheath introducers and prolonged compression with clamps or hemostatic devices have been necessary. Prolonged immobilization is painful for the elderly population in whom aortic valvuloplasty is used. The ability to use percutaneous suture closure to eliminate the need for manual compression, especially for clamp or hemostatic devices, has greatly improved patient tolerance for these procedures. A technique for preloading the suture closure device prior to insertion of a large bore sheath is the technique of choice to make this possible. Mitral valvuloplasty has faced fewer limitations and of course yields results equivalent to surgical commissurotomy in randomized trials. Improved management of the 14Fr femoral venous site has made outpatient treatment simpler. The technical approach necessary for success in the venous system uses contrast injections through the Perclose device marker port to insure that the device is properly positioned prior to deployment of the sutures. More rapid immobilization and simplified postprocedural management can be achieved using percutaneous suture closure for large caliber sheaths after mitral and aortic valvuloplasty. [source] Effect of Age and Abomasal Puncture on Peritoneal Fluid, Hematology, and Serum Biochemical Analyses in Young CalvesJOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 6 2005Luiz Claudio N. Mendes The goals of this study were to evaluate techniques for collection of peritoneal fluid from calves, establish reference ranges for fibrinogen in peritoneal fluid during the 1st month of life, and determine if abomasal puncture would alter peritoneal fluid or hematologic variables. Twenty-two healthy Holstein calves underwent 3 peritoneal fluid collections on day 1, day 15, and day 30 of age. Fibrinogen concentration in peritoneal fluid was 0.20 g/dL and 0.10 g/dL (P < .05) for day 1 and day 30, respectively, and 0.10 at day 15 (P > .05) for calves without abomasal puncture. Plasma fibrinogen concentration was 0.60 g/dL and 0.70 g/dL (P < .05) for days 15 and 30, respectively, in calves without abomasal puncture. There were no significant differences (P, .05) in peritoneal fluid and peripheral blood total protein and fibrinogen concentrations, specific gravity, total and differential cell count, or erythrocyte counts between calves with or without abomasal puncture. We concluded that the reference ranges established for fibrinogen and total protein concentration are important for accurate evaluation of peritoneal fluid in calves for further comparison with similar-aged animals with gastrointestinal-tract or abdominal-cavity disease. Additionally, accidental abomasal puncture does not alter values of fibrinogen, total protein, and nucleated cell count in peritoneal fluid and does not cause apparent clinical abnormalities. [source] Interatrial Septum Thickness and Difficulty with Transseptal Puncture during Redo Catheter Ablation of Atrial FibrillationPACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 12 2008DAVID R. TOMLINSON M.D. Background:Patients undergoing catheter ablation for atrial fibrillation (AF) frequently require redo procedures, but there are no data reporting interatrial septum thickness (IAS) and difficulty during repeat transseptal puncture (TSP). Methods:Patients undergoing two separate AF ablation procedures had preprocedural fossa ovalis (FO) thickness measured using transesophageal echocardiography (TEE). "Difficult" TSP was defined by two observers as requiring excessive force, or conversion to TEE guidance. Results:The study comprised 42 patients (37 male) with mean ± SD age 55 ± 9 years. Mean FO thickness was significantly greater at the time of redo TSP (2.2 ± 1.6 mm vs 2.6 ± 1.5 mm at redo, P = 0.03); however, this finding was limited to those who underwent initial dual transseptal sheath procedures, FO thickness 2.0 ± 1.5 mm and 2.5 ± 1.4 mm for TEE 1 and 2, respectively (P = 0.048). There was a trend for more frequent difficult redo TSP procedures, 7/42 (17%; 95% confidence interval [CI] 8,31) redo, versus 4/42 (10%; 95% CI 3,23) first TSP. On univariate analysis, FO thickness was not predictive of TSP difficulty; the only predictor of difficult redo TSP was diabetes. Conclusions:IAS thickness at the FO increased following catheter ablation of AF, yet on subgroup analysis this was limited to initial procedures utilizing dual transseptal sheaths. There was a trend toward more frequent difficulty during redo TSP, yet this was not associated with FO thickening. Diabetes may predispose to difficulty during redo TSP; this finding requires confirmation in a larger study population. [source] Navigation by Parallax in Three-Dimensional Space During Fluoroscopy: Application in Guide Wire-Directed Axillary/Subclavian Vein PuncturePACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 9 2007ERNEST W. LAU M.D. Background:Fluoroscopy is range ambiguous,the relative positions in three-dimensional space of two structures with superimposed silhouettes cannot be ascertained. The parallax effect can be used to overcome this problem, and was used to develop a technique of axillary/subclavian vein puncture. Method:Patients requiring axillary/subclavian vein puncture were considered for the new technique. The vein was marked by a guide wire placed inside. In the postero-anterior (P-A) caudal projection, the needle was advanced dorsally from medial to the coracoid process at an arbitrary angle until its tip overlay the guide wire over the first intercostal space. Depending on whether the needle tip appeared caudad or cephalad of the guide wire in the P-A projection, the needle was advanced farther into or withdrawn back from the body, with its tip maintained over the guide wire in the P-A caudal projection at all times. Maneuvering of the needle stopped when the needle tip overlay the guide wire in both the P-A caudal and P-A projections or blood was aspirated. Result:Forty-one separate successful punctures were performed in 20 patients. No complications were recorded. Each puncture took no more than 1 minute, and the image intensifier needed to swing between the P-A caudal and the P-A projections only twice. Conclusions:The new technique was effective, efficient, and safe when implemented in clinical practice, justifying the parallax principles on which it is based. The parallax principles may be applied to other invasive medical procedures with due modifications. [source] Brief communication: Puncture and crushing resistance scores of Tana river mangabey (Cercocebus galeritus) diet itemsAMERICAN JOURNAL OF PHYSICAL ANTHROPOLOGY, Issue 3 2009Julie Wieczkowski Abstract Cercocebus mangabeys are characterized by dental traits that have been interpreted as adaptations to eat hard diet items. Although there are data that mangabeys include a large proportion of fruit and especially seeds in their diets, no hardness measurements have been done on mangabeys' food items. This study measured puncture and crushing resistance of food items in the diet of the Tana River mangabey (C. galeritus). Feeding data were collected by the use of scan samples from one mangabey group from August 2000 to July 2001 and from July 2005 to June 2006. Food items were collected during the latter period only, and from the same tree in or under which mangabeys had been observed eating. A portable agricultural fruit tester was used to measure the puncture resistance of fruit and a valve spring tester was used to measure the crushing resistance of seeds. The average puncture resistance of fruit was 1.7 kg/mm2, and the average crushing resistance of seeds was 12.8 kg. There were no correlations between puncture resistance, crushing resistance, or all resistance scores and frequency contribution to the diet. Resistance scores measured in this study were within the range of hardness scores of fruit and exceeded hardness scores of seeds eaten by other hard object feeders. Although this study supports the interpretation that Cercocebus dental traits are adaptations to hard object feeding, future research should investigate other material properties of food, as well as the role hard diet items play in niche separation and as fallback foods. Am J Phys Anthropol 2009. © 2009 Wiley-Liss, Inc. [source] Hunsaker Mon-Jet Tube for Secondary Tracheoesophageal PunctureTHE LARYNGOSCOPE, Issue 6 2007MRCSED, Muhammad Shakeel MBBS No abstract is available for this article. [source] Patterns of Innervation of the Anterior Maxilla: A Cadaver Study with Relevance to Canine Fossa Puncture of the Maxillary Sinus,THE LARYNGOSCOPE, Issue 10 2005Simon Robinson FRACS Abstract Objectives/Hypothesis: Complications from canine fossa puncture of the maxillary sinus are caused by damage to the anterior superior alveolar nerve (ASAN) and the middle superior alveolar nerve (MSAN). The aim of this study was to elucidate the pattern of ASAN and MSAN within the anterior maxilla and to secondly determine suitable surgical landmarks to aid in accurately localizing the area of the canine fossa least likely to produce complications when a trocar is passed into the maxillary sinus. Methods: Anatomic dissection of the anterior face of the maxilla from 20 cadaver heads was performed. The pattern and presence of the ASAN and MSAN was identified on each side and tabulated. Landmarks for the safest entry point for canine fossa puncture were determined, and each side had a puncture placed using these landmarks. Any disruption of nerves was noted. Results: Multiple differing patterns of ASAN were identified. The ASAN emerged from its foramen as a single trunk in 30 (75%) sides and in a double trunk in 10 (25%). In 24 (60%), single or multiple branches from the ASAN trunks were identified. A MSAN was identified in 9 (23%) maxillae. The safest entry point for a canine fossa puncture was where a vertical line drawn through the mid-pupillary line was bisected by a horizontal line drawn through the floor of the pyriform aperture. Conclusions: There is significant variation in the pattern of ASAN and MSAN within the anterior face of the maxilla. By using the newly described landmarks when performing a canine fossa puncture, there is reduced risk of damage to these nerves and provides a reliable point to enter the maxillary sinus. [source] A Model for Ultrasound-Assisted Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2009Matthew Herron Clinicians may find traditional lumbar puncture (LP) attempts fail due to indistinct landmarks in morbidly obese patients necessitating ultrasound localization or fluoroscopy. We believe a readily available teaching model is needed because many emergency physicians may be unfamiliar with ultrasound-assisted LP. Review of current literature shows that there are few commercially available LP models suitable for use with ultrasound. Those on the market are expensive and have limited reusability. We have succeeded in creating a low-cost reusable model for training health care professionals to perform ultrasound-assisted LP. We believe there will be many benefits to using this model including: increase in emergency department (ED) LP success rates, decrease in number of radiology consults for fluoroscopy, increase in patient satisfaction, decreased waiting time in the ED, and fewer complications due to fewer needle passes. This model effectively reproduces the sonographic appearance of the lumbar spine and overlying soft tissue and aids in teaching bedside ultrasound-assisted LP. The model has an opaque "skin" overlying a gel wax mold containing a lumbar spine. A catheter containing water is imbedded in the spine to simulate the spinal canal and cerebrospinal fluid. The skin allows for a more realistic procedure and can be removed for visual confirmation of a successful LP. In addition, successful needle placement will result in return of clear fluid. Construction of the model requires a commercially available lumbar spine and items found in craft stores with a total cost of approximately $100. [source] Utility of fine-needle aspiration for diagnosis of carcinoma associated with multinodular goitreCLINICAL ENDOCRINOLOGY, Issue 6 2004Antonio Ríos Summary background, Fine-needle aspiration (FNA) is a useful method for evaluating a solitary thyroid nodule; however, this is not an agreed method for a multinodular goitre (MNG). The aim of this study was to assess the utility of preoperative FNA for detecting malignancy in MNG. patients and method, We analysed operated MNGs in which FNA had been performed. Puncture was carried out on the dominant nodule and any other nodules with features suggesting malignancy. The diagnosis was classed as colloid, follicular or Hürthle proliferation, suggestive of malignancy, haematic and inadequate. The thyroid FNA results, grouped into suggestive of malignancy (positive result) and other diagnoses (negative result), were compared to those of the final histological study in order to calculate the value of the test in diagnosing malignancy. results, FNA was performed in 432 MNGs, of which 42 (9·7%) were associated with carcinoma. Overall, the results of the test were poor, revealing a sensitivity of 17%, specificity of 96% and diagnostic accuracy of 88%, with a positive predictive value of 32% and negative predictive value of 88%. When the values were recalculated with the exclusion of microcarcinomas ,considering their minor clinical importance , there was a slight improvement in the results: the sensitivity increased to 26%, diagnostic accuracy to 93% and negative predictive value to 96%. However, the specificity remained at 96%, and the positive predictive value fell from 32% to 25%. The results of the test improved in multifocal carcinomas. conclusions, Thyroid fine needle aspiration is not useful for differentiating MNG with malignant degeneration from benign MNG, as more than 80% of carcinomas go unnoticed; it provides a sensitivity of 17% for detecting carcinomas, rising to 26% if microcarcinomas are excluded. We therefore suggest that clinical criteria should prevail over FNA. [source] Competence of New Emergency Medicine Residents in the Performance of Lumbar PuncturesACADEMIC EMERGENCY MEDICINE, Issue 7 2005Richard L. Lammers MD Abstract Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4,26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7,28) in 14.3 minutes (range: 3,22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0,10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance. [source] Fine Structure of Elytral Punctures and Diffraction Gratings in Korean Sericinae (Coleoptera, Melolonthidae)ENTOMOLOGICAL RESEARCH, Issue 2 2003Jin Ill KIM ABSTRACT The surface structures of the elytra in twenty two species belonging to the subfamily Sericinae (Coleoptera, Melolonthidae) were observed by scanning electron microscopy. For viewing specific characters, elytral punctures and diffraction gratings on interstitial surface were focused on. The elytral punctures of observed Sericid beetles have three representative forms: horseshoe, ocellus, and crease types. The diffraction gratings of the elytra show three distinctive patterns: regular and parallel, discontinued, and interconnected and curved. These patterns of elytral punctures and diffraction gratings considered to be useful for identification. [source] A Conservative Approach to Performing Transseptal Punctures Without the Use of Intracardiac Echocardiography: Stepwise Approach with Real-Time Video ClipsJOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 6 2007ALAN CHENG M.D. Atrial transseptal puncture as a means of accessing the left heart is a critical component of catheter ablation procedures for atrial fibrillation, left-sided accessory pathways, and access to the left ventricle in patients with certain types of prosthetic aortic valves. Although this technique has been performed successfully since the 1950s, severe and potentially life-threatening complications can still occur, including cardiac tamponade and/or death. Some have adopted the use of intracardiac echocardiography, but our laboratory and many others throughout the world have successfully relied on fluoroscopic imaging alone. The aim of this brief report is to describe in detail our technique for performing transseptal punctures during catheter ablation procedures for atrial fibrillation. We employ a similar approach when targeting left-sided accessory pathways, although only a single transseptal is performed in those cases. Utilizing a series of real-time video clips, we describe our technique of double transseptal puncture and illustrate in detail ways in which to avoid common pitfalls. [source] Evaluation of the Efficacy of Polidocanol in the Form of Foam Compared With Liquid Form in Sclerotherapy of the Greater Saphenous Vein: Initial ResultsDERMATOLOGIC SURGERY, Issue 12 2003Claudine Hamel-Desnos MD Background. Foamed sclerosing agents have been used with enthusiasm by phlebologists for more than 5 decades. Any type of varicose veins can and has been treated with this technique. Numerous publications have stressed the advantages of foamed sclerosing agents on the basis of empiric and experimental criteria and have described various individual techniques to prepare foams. Until now, however, no comparative study for the treatment of large varicose veins with foam or liquid exists. Objective. The purpose of this first randomized, prospective, multicenter trial was to study the elimination of reflux, the rate of recanalization, and possible side effects of foam sclerotherapy (FS) compared with conventional liquid sclerotherapy for the greater saphenous vein (GSV). Methods. Eighty-eight patients were randomized into two groups: One group was treated with sclerosing foam (45 patients) and the other with sclerosing liquid (43 cases). Sclerotherapy was performed with direct puncture of the vessel under duplex guidance. The reference sclerosing agent was polidocanol in a 3% solution. The foam was prepared using the Double Syringe System (DSS) method. Only one injection of 2.0 or 2.5 mL liquid or foam was allowed, depending on the diameter of the GSV. Results were assessed according to the protocol. Results. Follow-up after 3 weeks showed 84% elimination of reflux in the GSV with DSS foam versus 40% with liquid sclerosant (P < 0.01). At 6 months, six recanalizations were found in the liquid group versus two in the foam group. After 1 year, no additional recanalization was observed with either foam or liquid. Longer term studies are underway. Side effects did not differ between both groups. Conclusion. The efficacy of sclerosing foam (DSS) compared with sclerosing liquid in therapy of the GSV is superior, a finding that had already gained empirical recognition but for which there has not been any clinical evidence to date. [source] Diagnostic usefulness of laparoscopic fine-needle aspiration for intraductal papillary tumor of the pancreasDIGESTIVE ENDOSCOPY, Issue 4 2001Tomonori Akagi A 67-year-old man who was followed up for 20 years for a diagnosis of chronic pancreatitis developed a unilocular cystic lesion in the pancreatic body and a gallstone. The cystic lesion (3.0 cm in diameter) was considered to be a pseudocyst with suspicion of a mucinous cystic tumor. Laparoscopic ultrasonography and fine-needle aspiration (FNA) were performed following laparoscopic cholecystectomy. Under laparoscopic observation, the pinhole puncture was immediately closed. Analysis of the fluid revealed clusters of epithelial cells with mild atypia, remarkably elevated tumor markers (carcinoembryonic antigen and CA19-9) and a K- ras oncogene mutation. Distal pancreatectomy was performed 3 months after laparoscopic FNA and the pancreatic mass was diagnosed as an intraductal papillary tumor. The patient's postoperative course was uneventful and he continues to do well without signs of recurrence. Laparoscopic FNA appears useful and safe for the diagnosis of cystic masses in the pancreas. [source] Competence of New Emergency Medicine Residents in the Performance of Lumbar PuncturesACADEMIC EMERGENCY MEDICINE, Issue 7 2005Richard L. Lammers MD Abstract Background: Medical students are taught some procedural skills during medical school, but there is no uniform set of procedures that all students learn before residency. Objective: To determine the level of competence in the performance of a lumbar puncture (LP) by new postgraduate year 1 (PGY1) emergency medicine (EM) residents. Methods: An observational study was conducted at three EM residencies with 42 PGY1 residents who recently graduated from 26 various medical schools. The LP procedure was divided into 26 major and 44 minor steps to create a scoring protocol. The model, procedure, and scoring protocol were validated by experienced emergency physicians. Subjects performed the procedure without interruption or feedback on an LP training model using a standard LP kit. A step was scored as "performed correctly" if two of the three evaluators concurred. Pre- and poststudy questionnaires assessed subjects' prior instruction and clinical experience with LP, self-confidence, sense of relevance, motivation, and fatigue. Results: Subjects completed an average of 14.8 (57%; 95% confidence interval [95% CI] = 53% to 61%) of the major steps (range: 4,26) and 19.1 (43%; 95% CI = 42% to 45%) of the minor steps (range: 7,28) in 14.3 minutes (range: 3,22). Sixty-nine percent failed to obtain cerebrospinal fluid from the model. Subjects' levels of confidence changed slightly on a five-point scale from 2.8 ("little-to-some") before the test to 2.5 after the test. Eighty-three percent of the subjects previously performed LPs on patients during medical school (average attempts = 2.2; range: 0,10), but only 40% of those who did so were supervised by an attending during their first attempt. Conclusions: In the cohort studied, new PGY1 EM residents had not attained competence in performing LPs from training in medical school. Most new PGY1 residents probably require training, practice, and close, direct supervision of this procedure by attending physicians until the residents demonstrate competent performance. [source] Role of Echocardiography in Percutaneous Occlusion of the Left Atrial AppendageECHOCARDIOGRAPHY, Issue 4 2007Mráz M.D. Percutaneous occlusion of the left atrial appendage (LAA) is a modern alternative for the treatment of patients with atrial fibrillation (AF) and with a high risk of stroke who are not eligible for long-term anticoagulation therapy. Echocardiography plays a significant role in selecting patients, guiding the procedure, and in the postprocedural follow-up. Objectives and methods: To test the role of transesophagoeal echocardiography (TEE) and intracardiac echocardiography (ICE) in facilitating and shortening the procedure. Results: ICE represents a more convenient approach in patients who are not under generally anesthesia and helps to facilitate transseptal puncture. On the other hand, TEE, having the ability to rotate the image plane, helps to better determine the position of the occluder. Conclusions: Echocardiographic guidance of this procedure is essential. Which approach will be preferred will depend on the development of these two methods. [source] Witnessing invasive paediatric procedures, including resuscitation, in the emergency department: A parental perspectiveEMERGENCY MEDICINE AUSTRALASIA, Issue 3 2005Jonathon Isoardi Abstract Objective:, To determine whether parents prefer to be present during invasive procedures performed on their children in the ED. Methods:, A prospective study using a written survey was carried out in the ED of a secondary level regional hospital in south-east Queensland. The survey conducted between August 2003 and November 2003 consisted of parental demographics, seven theoretical paediatric procedural scenarios with increasing level of procedural invasiveness (including resuscitation) and reasons for the decisions of parents to either stay with the child or leave the room. Parents of children with Australasian Triage Scale (ATS) triage category 3, 4 and 5 were surveyed. Results:, Of 573 surveys collected, 553 (96.5%) were completed correctly. The number of parents expressing a desire to be present during a procedure performed on their child was 519 (93.9%) for phlebotomy or i.v. cannulation of an extremity, 485 (87.7%) for nasogastric tube insertion, 461 (83.4%) for lumbar puncture, 464 (83.9%) for urinary catheter insertion, 430 (77.8%) for suprapubic bladder aspiration, 519 (93.4%) during procedural sedation and 470 (85%) during a resuscitation where the possibility existed that their child may die. The most common reason for wanting to be present was to provide comfort to their child (542/98%). The most common reason for not wanting to be present was a parental concern of getting in the way (181/33%). Conclusion:, Most parents surveyed would want to be present when invasive procedures are performed on their children in the ED. With increasing invasiveness, parental desire to be present decreased. However, the overwhelming majority of parents would want to be in attendance during procedural sedation or resuscitation. [source] Analysis by DC,EPG of the resistance to Bemisia tabaci on an Mi -tomato lineENTOMOLOGIA EXPERIMENTALIS ET APPLICATA, Issue 3 2001Y.X. Jiang Abstract The tomato Mi gene confers resistance to nematodes, Meloidogyne spp., and to the potato aphid, Macrosiphum euphorbiae (Thomas). Previous greenhouse choice assays with Bemisia tabaci (Gennadius) showed that tomato commercial varieties carrying this gene had significantly lower values of host suitability and whitefly reproduction than varieties lacking Mi. This indicated that Mi, or another gene in its region, could regulate partial resistance. In order to characterise this resistance, probing and feeding behaviour of Bemisia tabaci B-biotype was studied with DC Electrical Penetration Graph (EPG) technique on the near-isogenic tomato lines Moneymaker (without Mi) and Motelle (carrying Mi). Significant differences (P < 0.05) between tomato lines were found in EPG parameters related to epidermis and/or mesophyll tissues. On Motelle, a lower percentage of whiteflies achieved phloem phase and they made more probes before attaining first phloem phase, had a higher ratio (number of probes before first phloem phase)/(total number of probes), had a longer total duration of non-probing time, and a longer time before making the first intracellular puncture and before making the first phloem phase. In contrast, most of the parameters related to phloem phase were found not to differ significantly between these near-isogenic lines. The behavioural data strongly suggest that the partial resistance in the variety Motelle is due to factors in the epidermis and/or mesophyll that inhibit the whiteflies from reaching phloem sieve elements. However, once the stylets reach a sieve element, whitefly behaviour did not differ between the two varieties. Thus, phloem sap of the two varieties appears to be equally acceptable to the whiteflies. Further studies are necessary to provide a better understanding of these mechanisms of resistance to whiteflies in tomatoes. [source] A cranial intercondylar arthroscopic approach to the caudal medial femorotibial joint of the horseEQUINE VETERINARY JOURNAL, Issue 1 2009T. Muurlink Summary Reason for performing study: Current noninvasive techniques for imaging the soft tissue structures of the stifle have limitations. Arthroscopy is commonly used for the investigation and treatment of stifle pain. Cranial and caudal arthroscopic approaches to the femorotibial joints are used. However, complete examination of the axial aspect of the medial femorotibial joint (MFTJ) is not possible currently. Objective: To develop a cranial approach to the caudal pouch of the MFTJ and to assess whether it would allow a more complete examination of the compartment and facilitate the caudomedial approach. Method: The regional anatomy was reviewed and the technique developed on cadavers. A series of nonrecovery surgeries were performed to evaluate the procedure, which was then used in 7 clinical cases. Advantages compared to existing techniques and complications encountered were recorded. Results: Successful entry into the caudal pouch of the MFTJ was achieved in 20 of 22 cadaver legs, 8 of 8 joints of nonrecovery surgery horses and 6 of 7 clinical cases operated. The caudal ligament of the medial meniscus could be visualised, along with other axial structures of the caudal joint pouch. The technique was used to facilitate a caudomedial approach and allowed better triangulation within the joint space. Complications were minor and included puncture of the caudal joint capsule and scoring of the axial medial femoral condyle. Conclusions and potential relevance: It is possible to access the caudal pouch of the MFTJ arthroscopically using a cranial intercondylar approach. The technique has advantages when compared to existing techniques and is associated with few significant complications. A cranial approach to the caudal pouch of the MFTJ could complement existing techniques and be useful clinically. [source] Incidence of Traumatic Lumbar PunctureACADEMIC EMERGENCY MEDICINE, Issue 2 2003Kaushal H. Shah MD Abstract Objective: To determine the incidence of traumatic lumbar puncture (LP). Methods: A retrospective study was conducted at an urban, university tertiary care referral center with 50,000 annual emergency department (ED) visits. The study population included all patients who had cerebrospinal fluid (CSF) samples sent to the laboratory between August 15, 2000, and August 14, 2001. The numbers of red blood cells (RBCs) recorded in the first and last CSF tubes, the location where the LP was performed, and the discharge summary and the discharge diagnoses from the particular visit were obtained. All patients with intracranial pathology and CSF obtained via neurosurgical procedure or fluoroscopic guidance were excluded from the study group. Given no clear definition of traumatic LP in the literature, the incidence of traumatic LP was calculated using a cutoff of greater than 400 RBCs (visual threshold for bloody fluid) and 1,000 RBCs (arbitrary threshold selected by other authors) in CSF tube 1. Proportions were compared using chi-square statistics. Results: Seven hundred eighty-six CSF samples were recorded over one year. Twenty-four samples were obtained from patients with intracranial pathology or were obtained via a neurosurgical procedure. Of the remaining 762 CSF samples in the study population, 119 (15.6%) were traumatic using a cutoff of 400 RBCs, and 80 (10.5%) were traumatic, using a cutoff of 1,000 RBCs in tube 1. Five hundred three LPs were done in the ED and 259 were attributed to all other locations in the hospital. Using a cutoff of 400 RBCs, the incidence of traumatic LP in the ED was 13.3%, compared with 20% in the rest of the hospital (p < 0.025). Similarly, using a cutoff of 1,000 RBCs, the incidence of traumatic LP in the ED was 8.9%, compared with 13.5% in the rest of the hospital (p = 0.1). The incidence of "champagne taps" (defined as zero RBCs in the first and last tubes) in the ED was 34.4%, compared with 24.3% in the rest of the hospital (p < 0.01). Conclusions: The incidence of traumatic lumbar puncture is approximately 15% using a cutoff of 400 RBCs and 10% using a cutoff of 1,000 RBCs. In this study, the rate of traumatic lumbar puncture was significantly less (with a cutoff of 400 RBCs) and the rate of champagne tap was significantly greater for LPs done in the ED compared with the rest of the hospital. [source] Impaired CD4+ T-cell proliferation and effector function correlates with repressive histone methylation events in a mouse model of severe sepsisEUROPEAN JOURNAL OF IMMUNOLOGY, Issue 4 2010William F. Carson Abstract Immunosuppression following severe sepsis remains a significant human health concern, as long-term morbidity and mortality rates of patients who have recovered from life-threatening septic shock remain poor. Mouse models of severe sepsis indicate this immunosuppression may be partly due to alterations in myeloid cell function; however, the effect of severe sepsis on subsequent CD4+ T-cell responses remains unclear. In the present study, CD4+ T cells from mice subjected to an experimental model of severe sepsis (cecal ligation and puncture (CLP)) were analyzed in vitro. CD4+CD62L+ T cells from CLP mice exhibited reduced proliferative capacity and altered gene expression. Additionally, CD4+CD62L+ T cells from CLP mice exhibit dysregulated cytokine production after in vitro skewing with exogenous cytokines, indicating a decreased capability of these cells to commit to either the TH1 or TH2 lineage. Repressive histone methylation marks were also evident at promoter regions for the TH1 cytokine IFN-, and the TH2 transcription factor GATA-3 in naïve CD4+ T cells from CLP mice. These results provide evidence that CD4+ T-cell subsets from post-septic mice exhibit defects in activation and effector function, possibly due to chromatin remodeling proximal to genes involved in cytokine production or gene transcription. [source] Complement C5a regulates IL-17 by affecting the crosstalk between DC and ,, T cells in CLP-induced sepsisEUROPEAN JOURNAL OF IMMUNOLOGY, Issue 4 2010Ruonan Xu Abstract Complement 5a (C5a) and Interleukin-17 (IL-17) are two important inflammatory mediators in sepsis. Here we studied the mechanisms underlying regulation of IL-17 by anaphylatoxin C5a. We found that C5a blockade increased the survival rate of mice following cecal ligation and puncture (CLP)-induced sepsis and decreased IL-17 expression in vivo. IL-17 was secreted mainly by ,, T cells in this model. Importantly, our data suggest that C5a participates in the regulation of IL-17 secretion by ,, T cells. Dendritic cells (DC) were found to act as a "bridge" between C5a and ,, T cells in a mechanism involving IL-6 and transforming growth factor , (TGF-,). These results imply that C5a affects the crosstalk between DC and ,, T cells during sepsis development, and this may result in a large production of inflammatory mediators such as IL-17. [source] The chemokine receptor CCR6 is an important component of the innate immune responseEUROPEAN JOURNAL OF IMMUNOLOGY, Issue 9 2007Haitao Wen Abstract In our initial studies we found that naïve CCR6-deficient (CCR6,/,) C57BL/6 mice possessed significantly lower number of both F4/80+ macrophages and dendritic cells (DC), but higher number of B cells in the peritoneal cavity, as compared to naïve wild type (WT) controls. Furthermore, peritoneal macrophages isolated from CCR6,/, mice expressed significantly lower levels of inflammatory cytokines and nitric oxide following lipopolysaccharide (LPS)stimulation, as compared to WT macrophages. In a severe experimental peritonitis model induced by cecal ligation and puncture (CLP), CCR6,/, mice were protected when compared with WT controls. At 24,h following the induction of peritonitis, CCR6,/, mice exhibited significantly lower levels of inflammatory cytokines/chemokines in both the peritoneal cavity and blood. Interestingly, DC recruitment into the peritoneal cavity was impaired in CCR6,/, mice during the evolution of CLP-induced peritonitis. Peritoneal macrophages isolated from surviving CCR6,/, mice 3,days after CLP-induced peritonitis exhibited an enhanced LPS response compared with similarly treated WT peritoneal macrophages. These data illustrate that CCR6 deficiency alters the innate response via attenuating the hyperactive local and systemic inflammatory response during CLP-induced peritonitis. [source] Viral meningoencephalitis: a review of diagnostic methods and guidelines for managementEUROPEAN JOURNAL OF NEUROLOGY, Issue 8 2010I. Steiner Background:, Viral encephalitis is a medical emergency. The prognosis depends mainly on the pathogen and host immunologic state. Correct immediate diagnosis and introduction of symptomatic and specific therapy has a dramatic influence upon survival and reduces the extent of permanent brain injury. Methods:, We searched the literature from 1966 to 2009. Recommendations were reached by consensus. Where there was lack of evidence but consensus was clear, we have stated our opinion as good practice points. Recommendations:, Diagnosis should be based on medical history and examination followed by CSF analysis for protein and glucose levels, cellular analysis, and identification of the pathogen by polymerase chain reaction amplification (recommendation level A) and serology (level B). Neuroimaging, preferably by MRI, is essential (level B). Lumbar puncture can follow neuroimaging when immediately available, but if this cannot be performed immediately, LP should be delayed only under unusual circumstances. Brain biopsy should be reserved only for unusual and diagnostically difficult cases. Patients must be hospitalized with easy access to intensive care units. Specific, evidence-based, antiviral therapy, acyclovir, is available for herpes encephalitis (level A) and may also be effective for varicella-zoster virus encephalitis. Ganciclovir and foscarnet can be given to treat cytomegalovirus encephalitis, and pleconaril for enterovirus encephalitis (IV class evidence). Corticosteroids as an adjunct treatment for acute viral encephalitis are not generally considered to be effective, and their use is controversial, but this important issue is currently being evaluated in a large clinical trial. Surgical decompression is indicated for impending uncal herniation or increased intracranial pressure refractory to medical management. [source] | ||||||||||||||||||||||||||||||||||||||||