Gauge Needle Research Articles

Unilateral conjunctival concretions associated with chronic inflammation and tear instability.

Conjunctival concretions are small yellow-white subconjunctival spots that can be asymptomatic for years and are an incidental finding on routine ophthalmic examination.[1,2] The etiologies are chronic vernal conjunctivitis, severe atopic keratoconjunctivitis, and post-trachomatous changes.[1–5] The concretions are located within the conjunctival recesses layered by epithelium and are made up of cell debris and phospholipids.[3,4] Case Report A 24-year-old-female presented with chronic irritation and redness in the right eye for 1 year. Systemic evaluation was unremarkable with no immunosuppressive disorders. Her symptoms were intermittently associated with discharge. Her vision was 20/20 in both eyes. Everted upper and lower eyelids of the right eye showed multiple concretions scattered beneath the tarsal conjunctiva, more in the upper eyelid, protruding through the conjunctiva at two focal points [Fig. 1]. There was diffuse congestion in the tarsal conjunctiva with a normal lid margin appearance. The left eyelid had neither congestion nor concretions. There was no ocular surface staining with fluorescein dye, but the exposed concretions showed fluorescein uptake. Dry eye workup revealed a tear break-up time of 7.8 s with normal tear secretion in the right eye, whereas tear breakup and secretion was normal in the left eye. She gave an antecedent history of a vegetative object falling into her right eye while driving a bike. The ocular symptoms developed 1 month after that trauma. She was using topical lubricants and antibiotic ointment over the eyelid margin for the meibomitis. Because of unilateral presentation and young age, two concretions were removed on slit lamp using a sterile 26-gauge needle under topical anesthesia and sent for tissue processing.Figure 1: (a) Everted right upper eyelid of the 24-year-old female shows scattered numerous concretions in the tarsal conjunctiva, fewer in the lower eyelid (d). (b) Gomori methenamine silver stain (100×) shows presence of fungal elements within the concretions (higher magnification in inset), which are also seen on gram stain (e, 400×) as empty round and vertical spaces. (c and f) Left upper and lower eyelids show normal tarsal conjunctivaThe histopathologic examination of concretions revealed eosinophilic homogenous amorphous material containing fungal elements, which were Gomori methenamine silver stain positive [Fig. 2]. The deepest sections (till the last tissue section) also contained numerous fungal hyphae, which ruled out contamination. Due to atypical histopathologic findings of concretions, a superficial conjunctival incision biopsy containing tarsal conjunctiva, concretions, and a thin sliver of tarsus was taken at 4 mm from the upper eyelid margin. The incision biopsy showed scattered amorphous, acellular eosinophilic hyaline-like material and diffuse lymphocytic infiltration in the substantia propria. The amorphous material had a rim of conjunctival epithelium suggestive of concretions embedded within the pseudoglands of Henle. The periphery of the concretions had a slight basophilic appearance. The concretions were negative for von Kossa stain, Alcian blue, and Congo red but were red on Masson trichrome stain, suggesting cell debris and keratin to be one of the constituents. Alcian blue was focally positive in the conjunctival epithelium at the location of goblet cells. She was started on tablet fluconazole 150 mg once a week for 3 weeks along with 1% itraconazole eye ointment into the eye twice a day. Her symptoms resolved with a reduction in the conjunctival concretions’ number and conjunctival congestion.Figure 2: (a) Everted right upper eyelid with highlighted biopsied part. (b and c) Incisional biopsy from the upper tarsal conjunctiva shows diffuse subepithelial lymphocytic infiltration along with eosinophilic hyaline-like material deposits (c, at 200×). Masson trichrome (d), Congo red (e), and Alcian blue (f) were negative for amyloid and mucopolysaccharide depositsTear film instability and reduced tear production have been reported in patients with conjunctival concretions, where 51% of asymptomatic patients with conjunctival concretions have reduced tear break-up time.[3] The current case had reduced tear break-up time in the eye with concretions. An interesting finding in the current case was the presence of fungal elements, which can be explained by the possible entrapment of organic body containing fungus 1 year back. The organic material dissolved away, but the fungal elements caused persistent chronic inflammation, which resulted in the formation of concretions. This case reports the possibility of having unilateral concretions secondary to chronic inflammation with degenerative changes. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Hyderabad Eye Research Foundation, Hyderabad. Conflicts of interest There are no conflicts of interest.

Fine needle aspiration cytology of follicular dendritic cell sarcoma of the stomach masquerading as gastrointestinal stromal tumor: A case report of a unique entity with emphasis on cytomorphology.

Follicular dendritic cell sarcoma (FDCS) is a rare malignant neoplasm, postulated to arise from follicular dendritic cells, with approximately 343 reported cases. Less than 100 cases of FDCS were in the gastrointestinal tract, with only four cases described in the stomach, none of them diagnosed on fine needle aspiration (FNA) cytology. We report here the first case of FDCS of the stomach diagnosed on FNA. Our patient is a 31-year-old male who presented with several years history of intermittent abdominal pain prompting occasional emergency-room visits. Imaging showed a 10.6 cm mass arising from the stomach, concerning for gastrointestinal stromal tumor. FNA cytology was performed using five passes with a 22-gauge needle. The smears were moderately cellular consisting of sheets and large, loosely cohesive clusters of ovoid to spindle cells with indistinct cytoplasmic borders and abundant cytoplasm, peppered with numerous small mature lymphocytes. The nuclei of the tumor cells were oval with finely granular chromatin with frequent nuclear grooves, pseudoinclusions, and easily recognizable mitotic figures. The tumor cells were positive for FDCS markers (CD21, CD23, and CD35).

Seasonal Variations in Semen Quality, Testosterone Levels, and Scrotal Size following Dietary Flaxseed Oil and Ascorbic Acid in South African Indigenous Rams.

The purpose of this study was to determine the seasonal variations in semen quality, testosterone levels, and scrotal size, following dietary flaxseed oil and ascorbic acid in South African indigenous rams. A total of 22 South African indigenous rams were randomly distributed into five treatment diets from June 2021 to May 2022 (12 months). To allow for the spermatogenesis period, semen was collected after sixty days of dietary supplementation with treatment diets. Blood was collected twice a week using an 18-gauge needle and vacutainer tubes and sent to the laboratory for testosterone analysis. Semen and blood collection were repeated eight times each season. The scrotal size (circumference, length, and width) was measured using a flexible measuring tape. Data was subjected to the General Linear Model (GLM) in Minitab® 2017. Treatment means were separated using Fisher's t-test and considered significantly different when the p-value was less than 0.05. Seasons and diet had an effect on progression, total motility, and testosterone levels. For instance, NC during the spring season had the lowest progressive motility (42.84 ± 5.32), followed by the summer (49.38 ± 4.49), winter (62.46 ± 4.35), and autumn (63.26 ± 3.58). Notably, when treatment diets were introduced, improvements were realized, and there were significant differences (p < 0.05) among the seasons following supplementation of FLAX, ASCA, and FLAX + ASCA, except for FLAX in the autumn season (53.83 ± 4.16). Total motility did not differ significantly (p > 0.05) between the seasons when the NC and PC diets were supplemented; nevertheless, there was an improvement when FLAX, ASCA, and FLAX + ASCA were supplemented. Testosterone levels were significantly influenced by the seasons when negative and PC diets were supplemented. It is noteworthy that supplementing FLAX + ASCA can reverse the influence of the season on the testosterone levels (spring, 27.52 ± 4.42; summer, 20.23 ± 5.11; autumn, 25.24 ± 3.96; and winter, 25.92 ± 4.42). In conclusion, seasons do affect semen quality and testosterone levels of South African indigenous rams. However, flaxseed oil and ascorbic acid can reverse the seasonal variations in semen quality and testosterone levels.

Doxycycline sclerotherapy in patients with periorbital lymphatic malformation: A case series and literature review.

To describe and report the outcomes of doxycycline sclerotherapy in patients with periorbital lymphatic malformations(LMs). A retrospective review of consecutive patients diagnosed with periorbital LMs and who received doxycycline sclerotherapy at Hong Kong Eye Hospital and Queen Elizabeth Hospital, Hong Kong between January 2016 and June 2022. Doxycycline was prepared with a concentration of 100 mg diluted in 10 mL water for injection. A 23-gauge needle aiming at the center of the macrocyst was used to aspirate fluid from the lesion; this was then followed by an intralesional injection of 0.5 to 2 ml of doxycycline depending on the size of the cavity. A total of eight patients(six females) were included in this study. All of them received doxycycline sclerotherapy for periorbital LMs(five extraconal, three intraconal). The median age for receiving sclerotherapy was 29 years old. Seven patients had macrocystic LMs, and one had mixed macro- and microcystic LM. Two of the LMs had venous components radiologically. The average number of sclerotherapy treatment in one patient was 1.4 ± 0.7times. Seven of the eight patients had excellent response radiologically or clinically. One patient showed a satisfactory response after three cycles of sclerotherapy. No recurrence was experienced at median follow-up of 14 months. None of the patients experienced visual threatening or systemic complication. Our preliminary experience with doxycycline sclerotherapy has shown encouraging results for the treatment of macrocystic or mixed-type periorbital LMs, with a favourable safety profile. Further clinical trials with longer follow-ups are warranted on this topic.

Role of transduodenal endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) for diagnosis of retroperitoneal fibrosis (Ormond's disease).

Retroperitoneal fibrosis (RPF), often referred to as Ormond's disease when it is of idiopathic origin, is a rare disease characterized by the presence of inflammatory infiltrates and periaortic masses in the retroperitoneum. For a definite diagnosis, a biopsy and subsequent pathological examination is required. Currently accepted methods for retroperitoneal biopsy include open, laparoscopic, or CT-guided approaches. However, transduodenal endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) for diagnosis of RPF has attracted only little attention in the literature. We report two male patient cases who presented with leukocytosis, elevated C-reactive protein, and a suspicious retroperitoneal mass of unknown origin on computed tomography. One patient also reported left lower quadrant pain, whereas the other patient suffered from back pain and weight loss. In both patients, idiopathic RPF was successfully diagnosed by using transduodenal EUS-FNA/FNB with 22- and 20-gauge aspiration needles. Histopathology revealed dense lymphocytic infiltrates and fibrosis. The procedures lasted approximately 25 and 20 minutes, respectively, and in both patients no serious adverse events occurred. Treatment included steroid therapy and administration of Azathioprine. We demonstrate that using EUS-FNA/FNB to diagnose RPF is a feasible, fast, and safe method, which should always be considered as a first-line diagnostic modality. Hence, this case report emphasizes that gastrointestinal endoscopists are likely to play an important role in the setting of suspected RPF.

Case report: Diagnosis and treatment of a chinchilla’s old radius and ulna fracture

The cortex of the limb bones of chinchillas is very thin and brittle, so it is prone to fractures of the limb bones, among which fractures of the tibia, radius and ulna are the most frequent types. When a chinchilla has a closed fracture, it can be immobilized with a splint, cast, or bandage. If the broken end of the fracture pierces the skin, it is best to choose internal fixation or external fixation brackets for treatment. In this report, a 0.661 kg, 2-year-old male uncastrated chinchilla was presented to the Veterinary Teaching Hospital of Huazhong Agricultural University due to an old fracture of the right forearm. With the consent of the owner, we decided to use a 25-gauge needle as an IM pin to fix the fracture. Ten days after surgery, the wound had healed well, and the limb could support body weight, but the palm did not show a grasping position. Twenty four days after the operation, the affected limb had not regained the ability to grasp. The X-ray showed a slight rotation of the IM pin and good callus growth in the ulna, but not in the radius. One month after the operation, it was found that the function of the affected limb of the chinchilla was normal and the grasping ability was restored through follow-up consultation and the return visit.

FOXO3-Activated circFGFBP1 Inhibits Extracellular Matrix Degradation and Nucleus Pulposus Cell Death via miR-9-5p/BMP2 Axis in Intervertebral Disc Degeneration In Vivo and In Vitro

(1) Background: intervertebral disc degeneration (IVDD) defined as the degenerative changes in intervertebral disc is characterized by extracellular matrix (ECM) degradation and death in nucleus pulposus (NP) cells. (2) Methods: The model of IVDD was established in male Sprague Dawley rats using a puncture of a 21-gauge needle at the endplates located in the L4/5 intervertebral disc. Primary NP cells were stimulated by 10 ng/mL IL-1β for 24 h to mimic IVDD impairment in vitro. (3) Results: circFGFBP1 was downregulated in the IVDD samples. circFGFBP1 upregulation inhibited apoptosis and extracellular matrix (ECM) degradation and promoted proliferation in IL-1β-stimulated NP cells. Additionally, circFGFBP1 upregulation mitigated the loss of NP tissue and the destruction of the intervertebral disc structure in vivo during IVDD. FOXO3 could bind to the circFGFBP1 promoter to enhance its expression. circFGFBP1 upregulated BMP2 expression in NP via sponging miR-9-5p. FOXO3 enhanced the protection of circFGFBP1 in IL-1β-stimulated NP cells, whereas a miR-9-5p increase partly reversed the protection. miR-9-5p downregulation contributed to the survival of IL-1β-stimulated NP cells, which was partially reversed by BMP2 silence. (4) Conclusions: FOXO3 could activate the transcription of circFGFBP1 via binding to its promoter, which resulted in the enhancement of BMP2 via sponging miR-9-5p and then inhibited apoptosis and ECM degradation in NP cells during IVDD.

Effect of Cooled Topical Anesthetic Gel on Pain Perception During Administration of Local Anesthesia: A Clinical Trial

Background: It is crucial to manage pain during both invasive and noninvasive dental procedures because discomfort may cause patients to refuse care or put off getting it altogether. As a result, it is imperative to develop techniques that lessen pain during injections in order to keep patients from skipping dental appointments. Pain is associated with both invasive and noninvasive dental operations, although it is more commonly associated with tooth extractions, surgeries, and other invasive procedures. The use of local anaesthetics is used to prevent and manage pain, and they are thought to be the safest and most effective medications available for these purposes. Aim: To evaluate the effect of cooled topical anesthetic gel on pain perception of pediatric dental patients during the administration of local anesthesia. Material and Method: In present split mouth clinical trail, 30 children between the ages of 6 and 10 year were enrolled. Uncooled topical anaesthetic was applied in one treatment session and cooled topical anaesthesia gel in the other session prior to the administration of local anesthesia. Lignocaine 2% gel was cooled and maintained at 40 C. A small sized topical anaesthetic gel was applied on tissue using a cotton pellet for 1 minute. Similarly in next treatment session uncooled anesthetic gel was applied on injection site. The procedure was followed by infiltration injection of 2% lidocaine with 1:80,000 adrenaline (LOX* 2% ADRENALINE) using a short 27-gauge needle (Dispovan). Visual analog scale (VAS) was used to evaluate the participants’ self-reports of injection pain. Children were asked to make a mark on the line that represented their level of perceived pain intensity, and the score was recorded after the treatment. Analysis of the data was carried out using SPSS version 20.0. In all the statistical tests used in this study the significant level was pre -set at P ≤ 0.05. Result: The mean visual analog score for uncooled anesthetic gel group were 63.12 ± 4.63 and statistically significant lower score in cooled anesthetic gel group 38.23 ± 5.53 group (p&lt; 0.001) Conclusion: The results of the present study showed application of cooled topical anesthetic gel on injection site prior to the injection of local anesthetic agent did significantly reduce the pain perceived during administration of local anesthesia for routine dental procedures.

Effects of needle puncturing on re-vascularization and follicle survival in xenotransplanted human ovarian tissue

BackgroundOvarian tissue transplantation can restore fertility in young cancer survivors, however the detrimental loss of follicles following transplantation of cryopreserved ovarian tissue is hampering the efficiency of the procedure. This study investigates whether needle puncturing prior to transplantation can enhance revascularization and improve follicle survival in xenotransplanted human ovarian cortex.MethodsCryopreserved human ovarian cortex pieces (N = 36) from 20 women aged 24–36 years were included. During the thawing process, each piece of tissue was cut in halves; one half serving as the untreated control and the other half was punctured approximately 150–200 times with a 29-gauge needle. The cortex pieces were transplanted subcutaneously to immunodeficient mice for 3, 6 and 10 days (N = 8 patients) and for 4 weeks (N = 12 patients). After 3, 6 and 10 days, revascularization of the ovarian xenografts were assessed using immunohistochemical detection of CD31 and gene expression of angiogenic factors (Vegfα, Angptl4, Ang1, and Ang2), and apoptotic factors (BCL2 and BAX) were performed by qPCR. Follicle density and morphology were evaluated in ovarian xenografts after 4 weeks.ResultsA significant increase in the CD31 positive area in human ovarian xenografts was evident from day 3 to 10, but no significant differences were observed between the needle and control group. The gene expression of Vegfα was consistently higher in the needle group compared to control at all three time points, but not statistically significant. The expression of Ang1 and Ang2 increased significantly from day 3 to day 10 in the control group (p < 0.001, p = 0.0023), however, in the needle group this increase was not observed from day 6 to 10 (Ang2 p = 0.027). The BAX/BCL2 ratio was similar in the needle and control groups. After 4-weeks xenografting, follicle density (follicles/mm3, mean ± SEM) was higher in the needle group (5.18 ± 2.24) compared to control (2.36 ± 0.67) (p = 0.208), and a significant lower percentage of necrotic follicles was found in the needle group (19%) compared to control (36%) (p = 0.045).ConclusionsNeedle puncturing of human ovarian cortex prior to transplantation had no effect on revascularization of ovarian grafts after 3, 6 and 10 days xenotransplantation. However, needle puncturing did affect angiogenic genes and improved follicle morphology.

Does a New Modification of the Two-Step Injection Technique for Inferior Alveolar Nerve Block Reduce Pain Compared to the Conventional Technique? A Randomized Clinical Trial.

The ability to control pain is an essential part of dental procedures and the need for optimal pain control and reduction of discomfort is the primary concern of every dentist. This study aims to compare the pain and vital signs during inferior alveolar nerve block between conventional and a new modification of the two-step injection techniques. In this institutional single-blind randomized clinical trial, attendees of dental school at Mazandaran University of Medical Sciences from February to May 2022 were included. Inclusion criteria were 20-60 years old and healthy (ASA1) individuals who were willing to participate in this study. Individuals who were taking medications affecting their understanding of pain and patients with active infections at the injection site were excluded. These individuals were divided into two groups. First, superficial anesthesia was performed and afterward, conventional and two-step injection techniques were performed. For the two-step injection method, 6 mm of the needle was injected into the mucosa and one-third of the local anesthetic solution was released from the computer-controlled injection toolkit. Afterward, a 25 mm 30-gauge needle was reinserted into the previous hole delivering the remaining local anesthetic. The pain during injection was measured by a patient-reported numerical rating scale (NRS). Moreover, vital signs were monitored immediately before and after the injection. Kolmogorov-Smirnov test, Mann-Whitney U test, independent T-test, and Fisher's exact χ 2 test were performed for statistical analysis (α = 0.05). This study involved 32 adults aged between 20 and 50 years old with 1 : 1 female/male sex distribution. The pain score was significantly higher in the conventional injection technique compared to the two-step injection technique in all sex and age groups. There were no significant differences in vital signs between the conventional and two-step injection techniques. There was no significant difference in the mean pain scores of females and males, regardless of their injection techniques. Utilizing the two-step injection technique in patients for inferior alveolar block reduces pain during injection without altering patients' vital signs significantly. This trial is registered with IRCT20220106053646N1.

Needle caliber and design are associated with the risk of post-dural puncture headache after diagnostic lumbar puncture

Introduction Post-dural puncture headache (PDPH) is defined as an orthostatic headache that develops within the first few days after performing a spinal tap and it is related to extravasation of cerebrospinal fluid (CSF) into the epidural space, resulting in CSF hypovolemia and hypotension. The risk factors for PDPH are not yet fully understood. Objective To evaluate the risk of spontaneously reported PDPH according to the size and type of spinal tap needle. Methods A total of 4589 patients undergoing outpatient lumbar puncture (LP) were included. All CSF collections were performed at Senne Liquor Diagnostico, a laboratory specialized in CSF collection and analysis. Patients were instructed to report by telephone if they had orthostatic headache during the first 7 days after LP to the medical team of the laboratory. Patients with previous headache were instructed to report any change in the headache pattern during the same period. Needle gauge was classified into two groups: 1) 25G or less and 2) greater than 25G. Two types of needles were used and compared: 1) Pencil point and 2) Quincke. Comparisons of the percentages of spontaneous reports of PDPH were made using the chi-square test. Results 141 patients (3.07%) reported PDPH to the laboratory's medical team. Needles of 25G gauge or less were used in 31.8% of cases. The percentage of patients reporting PHD in the group of 25G or less needles was 1.9% versus 3.6% in the group of larger than 25G needles (P=0.003). Pencil point needles were used in 10.6% of cases. The percentage of PHD among pencil point group was 1.4% versus 3.2% in Quincke group (P=0.026). Conclusion 25G or finer gauge needles as well as pencil point type needles significantly reduced the risk of spontaneously reported PHD.

Injectable Devices for Delivery of Liquid or Solid Protein Formulations

Sustained delivery of protein therapeutics remains a largely unsolved problem across anatomic locations. Miniaturized devices that can provide sustained delivery of protein formulations have the potential to address this challenge via minimally invasive administration. In particular, methodologies that can optimize protein formulation independent of device manufacture have the greatest potential to provide a platform suitable for wide applications. The techniques developed here demonstrate the fabrication of tubular devices for sustained release of protein therapeutics. Utilizing a dip-casting process, fine-scale tubes can be reliably produced with wall thickness down to 30 μm. Techniques were developed that enabled effective loading of either solid or liquid formulations, while maintaining a cylindrical form-factor compatible with placement in a 22-gauge needle. Further, highly compacted protein pellets that approach the expected density of the raw materials were produced with a diameter (∼300 μm) suitable for miniaturized devices. Release from a solid-loaded device was capable of sustaining release of a model protein in excess of 400 days. Given significant interest in ocular applications, intravitreal injection was demonstrated in a rabbit model with these devices. In addition, to simulate repeated injections in ocular applications, serial intravitreal injection of two devices in a rabbit model demonstrated acceptable ocular safety without significant intraocular inflammation from clinical exam and histology.

Comparison of the harvest volume between maneuvers of endobronchial ultrasound-guided transbronchial needle aspiration including the "cross-fanning technique".

Recently, a certain volume of biopsy specimens has been required for genetic testing of tumors using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). This study aimed to verify the superiority of our newly devised EBUS-TBNA biopsy technique, the "cross-fanning technique," which combines rotation and up-down maneuvers, by comparing its harvest volume with that of other maneuvers. Using a bronchoscope simulator, ultrasonic bronchoscope, and 21-gauge puncture needle, we compared the weight of silicone biopsy specimens obtained by the following 4 procedures: Conventional maneuver; Up-down maneuver; Rotation maneuver, and; Cross-fanning technique. Each procedure was repeated 24 times in total, rotating the sequences of the maneuvers, and the operator/assistant pair to align the conditions. The means ± standard deviations of the sample volumes for each puncture technique were as follows: 2.8 ± 1.2 mg; 3.1 ± 1.6 mg; 3.7 ± 1.2 mg, and; 3.9 ± 1.2 mg. There was a significant difference between the 4 groups (P = .024). The post hoc test showed a statistically significant difference between techniques A and D (P = .019). This study showed that the cross-fanning technique might contribute to the increased volume of tissue samples obtained by EBUS-TBNA biopsy.

SIMPLE REFIXATION OF A DISLOCATED HAPTIC OF FLANGED INTRAOCULAR LENS USING A 25-GAUGE NEEDLE.

To report the development of a novel, simple-to-use technique for the salvage of a haptic of dislocated flanged intraocular lens during a retinal detachment surgery. A 25-gauge regular-wall needle was prepared and threaded by the dislocated flanged haptic before the flanged haptic was heated and enlarged by low-temperature cautery. The dislocated flanged haptic was probably the result of too small of a diameter of the previously flanged haptic and was triggered by scleral indentation. The rescue technique required only a 25-gauge regular-wall needle to conduct the conventional procedure of flanged haptic intraocular lens fixation before being enlarged by low-temperature cautery. The intraocular lens remained centered and stable at a 3-month postoperative follow-up examination. The application of a 25-gauge needle in the salvage of a haptic of dislocated flanged intraocular lens is simple and effective without the need for trimming the flanged tip.

Troubleshooting the migration of a double-pigtail plastic stent into a pelvic abscess (with videos).

The usefulness of EUS pelvic abscess drainage (EUS-PAD) for treating pelvic abscesses (PA) has recently been reported;[1] however, the procedure is often difficult to perform due to limited working space and field of view of that particular anatomical location. During EUS-related drainage, stent placement must be confirmed by both endoscopic and fluoroscopic images, to avoid risk of occurrence of misplacement.[2] A 70-year-old Japanese female with morbid obesity presented with PA secondary to a perforated appendicitis. Abdominal computed tomography revealed size of the PA to be125.3 mm that had originated from the appendix through the retroperitoneum [Figure 1a-c]. EUS-PAD was performed using a convex EUS scope. The abscess was punctured through the rectum using a 19-gauge needle [Figure 1d]. Two guidewires were inserted and coiled in the cavity, and the puncture tract was dilated using an 8-mm balloon dilator. Since the endoscope was inserted through a narrow and short space, it could easily shift position and slip out of the body. Due to the patient’s high obesity, the radiographic permeability was low, which made placing the double-pigtail plastic stent (DPPS) difficult. The DPPSs placement was finally performed, but under poor both endoscopic and fluoroscopy image. During placement of the second DPPS, it was observed that the first DPPS had strayed into the PA cavity [Figure 1e and Video 1]. After two DPPSs were placed incompletely, we proceeded to reposition the first DPPS that had migrated to the wrong position. After we dilated the puncture site using an 8-mm balloon dilator, a 5.8-mm endoscope was inserted into the cavity. The position of the migrated DPPS could be confirmed and its pigtail edge was re-inserted into the rectum using a 1.8-mm-diameter retrieval net [Figure 2]. No complications with the EUS-PAD procedures were encountered, and the patient’s symptoms improved gradually thereafter [Video 2]. Here, we present a procedure for dealing with an erroneously migrated DPPS during EUS-PAD. Additionally, the technique of direct insertion and drainage using a thin endoscope into the PA cavity, which was performed to retrieve the stray DPPS, may be useful in aggressive treatments of PA.Figure 1: Abdominal computed tomography revealed a pelvic abscess (a) with an air bubble of 125.3 mm that originated from an appendiceal perforation (b) and traversing the retroperitoneum (c; arrowhead). Endoscopic-ultrasound pelvic abscess drainage using a convex endoscopic-ultrasound scope. The abscess (outlined with asterisks) was punctured using a 19-gauge needle through the rectum (d). The first DPPS strayed into the pelvic cavity during the placement of the second DPPS (e; arrowhead). DPPS: Double-pigtail plastic stentFigure 2: Replacement of the migrated DPPSs following incomplete placement of two DPPSs. An esophagogastroduodenoscopy scope was inserted to place a guidewire into the PA cavity, and the puncture tract dilated using an 8-mm balloon dilator (a). Subsequent insertion of a 5.8-mm endoscope into the abscess cavity (b). A large amount of purulent fluid in the PA cavity, and the surface of the cavity with effusion, erythema, and purulent fluid (c). After aspiration of sufficient purulent fluid, the migrated DPPS was identified (d; arrow). DPPS: Double-pigtail plastic stent, PA: Pelvic abscesses {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 1","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8datqvv1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video Clip 2","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_hvyt4t8t"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

OFFICE MANAGEMENT OF OZURDEX IMPLANT DISLOCATION INTO THE ANTERIOR CHAMBER.

To describe a novel office procedure that permits the repositioning of an Ozurdex implant from the anterior chamber back into the vitreous cavity. Description of an office technique for Ozurdex repositioning using a 30-gauge needle. In both cases, the Ozurdex implant was successfully returned to the vitreous cavity. In Case 1, the patient's visual acuities 1 and 2 weeks after this were 20/70 and 20/40, respectively, and had no further complications. In Case 2, the patient returned 1 week later, with the implant remaining posterior and a visual acuity of 20/40. The success of this novel technique in these cases demonstrates the potential to avoid a surgical procedure in the event of Ozurdex implant migration to the anterior chamber, while at the same time allowing the Ozurdex implant to remain effective in the eye.

The Roth Net at 40 years: celebrating the spirit of innovation

The Roth Net at 40 years: celebrating the spirit of innovation

Rotator Cuff Repair With a Novel Interpositional Allograft Augmentation

Background: Nearly half a million rotator cuff repairs are performed annually in the United States. Rotator cuff healing occurs at the interface between the tendon and greater tuberosity, known as the enthesis. Given that a significant number of rotator cuff tears do not heal following surgical repair, multiple adjunctive strategies have been devised to improve the structural integrity of the repaired construct. Recently, a biphasic, demineralized allograft bone implant has been developed to improve enthesis healing. Indications: Relative indications for use of tissue augmentation include greater tuberosity osteopenia, revision rotator cuff surgery, attenuated rotator cuff tissue quality, and massive rotator cuff tears. Relative contraindications include a history of infection and recent immunosuppression. Technique Description: Following preparation of the footprint with an arthroscopic burr, two triple-loaded PEEK suture anchors were placed along the medial aspect of the greater tuberosity. Sutures were then passed through the rotator cuff tendon in a horizontal mattress configuration, and each pair of suture limbs were tied along the medial row. To aid in arthroscopic passage, the biphasic graft is folded longitudinally and clamped with a curved hemostat. The graft is loaded into an arthroscopic cannula and both are delivered simultaneously through a lateral arthroscopic portal. Two 18-gauge spinal needles are placed percutaneously to fix the allograft in the desired position. Subsequently, double-row transosseous-equivalent rotator cuff repair with standard techniques is done, which provides sufficient stability to the graft. Discussion: In a series of 192 patients who underwent arthroscopic rotator cuff repair augmented with a similar bioinductive collagen implant, patients demonstrated significant improvement in patient-reported outcomes at 1 year postoperatively. Moreover, a meta analysis published in 2022 demonstrated a significantly reduced retear rate among patch-augmented rotator cuff repairs as compared to isolated rotator cuff repairs. Conclusion: Tissue augmentation can be performed efficiently and reproducibly to promote biologic healing of arthroscopic rotator cuff repairs. The specific biphasic cancellous allograft presented in this video may be a viable treatment adjunct in the setting of deficient greater tuberosity bone stock, revision cases, or impaired native enthesis healing; however, further research is needed to assess clinical outcomes associated with its use. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

In vitro and in vivo applications of a universal and synthetic thermo-responsive drug delivery hydrogel platform

A synthetic and thermo-responsive polymer, poly(N-isopropylacrylamide)-co-(polylactide/2-hydroxy methacrylate)-co-(oligo (ethylene glycol)), is used to formulate a universal carrier platform for sustained drug release. The enabling carrier, denoted as TP, is prepared by dissolving the polymer in an aqueous solution at a relatively neutral pH. A wide range of therapeutic moieties can be incorporated without the need for the addition of surfactants, organic solvents, and other reagents to the carrier system. The resulting solution is flowable through fine gauge needle, allowing accurate administration of TP to the target site. After injection, TP carrier undergoes a coil to globe phase transition to form a hydrogel matrix at the site. The benign nature of the polymer carrier and its physical gelation process are essential to preserve the biological activity of the encapsulated compounds while the adhesive hydrogel nature of the matrix allows sustained elusion and controlled delivery of the incorporated therapeutics. The TP carrier system has been shown to be non-toxic and elicits a minimal inflammatory response in multiple in vitro studies. These findings suggest the suitability of TP as an enabling carrier of therapeutics for localized and sustained drug delivery. To confirm this hypothesis, the capabilities of TP to encapsulate and effectively deliver multiple therapeutics of different physicochemical characteristics was evaluated. Specifically, a broad range of compounds were tested, including ciprofloxacin HCl, tumor necrosis factor-alpha (TNF-α), transforming growth factor beta 1 (TGF-β1), and recombinant human bone morphogenetic protein 2 (BMP2). In vitro studies confirmed that TP carrier is able to control the release of the encapsulated drugs over an extended period of time and mitigate their burst release regardless of the compounds’ physiochemical properties for the majority of the loaded therapeutics. Importantly, in vitro and in vivo animal studies showed that the released drugs from the TP hydrogel matrix remained potent and bioactive, confirming the high potential of the TP polymer system as an enabling carrier.

Effect of combined intervention of exercise and autologous bone marrow stromal cell transplantation on neurotrophic factors and pain-related cascades over time after sciatic nerve injury.

The purpose of this study was to determine whether combined inter-vention of treadmill exercise and bone marrow stromal cell (BMSC) transplantation would affect the expression of neurotrophic factors in the sciatic nerve injury (SNI) and neuropathic pain-related cascades in ipsilateral lumbar 4-5 dorsal root ganglion (DRG) during the early or late stage of sciatic nerve regeneration. The rats were randomly divided into the normal control group (CONT, n=6), sedentary group (SS, n=24), exercise group (SE, n=24), BMSC transplantation group (SB, n=24), BMSC transplantation+exercise group (SBE, n=24) 1, 2, 3, and 5 weeks after SNI. Single dose of 5×106 harvested BMSC was injected into the injury area sing by a 30 gauge needle. Treadmill exercise was performed at a speed of 8 m/min for 30 min once a day. Tropomyosin-receptor kinase B, brain-derived neurotrophic factor and ciliary neurotrophic fac-tor were significantly upregulated in the SE and SBE groups at 1- and 2-week postinjury than those in the CONT and SS groups, and SB and SBE groups continuously kept up proinflammatory cytokines until the late stage of regeneration. Nuclear factor kappa-light-chain-enhancer of activated B cells, interleukin and tumor necrosis factor alpha in ipsi-lateral DRG were progressively decreased by exercise alone application and/or BMSC transplantation at early and late stage of regeneration. Present results provide reliable information that combined intervention of treadmill exercise and BMSC transplantation might be one of the effective treatment strategies for recovering sciatic nerve injury-induced neuropathic pain over time.