2nd Attempt Research Articles

The Development and Impact the First Irish Nurse-Led Lumbar Puncture Clinic in a Regional Specialist Memory Clinic

Abstract Background A Regional Specialist Memory service assesses complex cases of cognitive impairment, requiring a comprehensive diagnostic assessment. Lumbar punctures (LP's) are the definitive procedure to identify Alzheimer's Disease. The highest limitation to LP access is shortage and availability of specially trained medical staff. Cognitive centres across Europe have been training nurses (Advanced Nurse Practitioner) to perform LPs since 2006. A nurse led service was established in April 2023 in a large Irish teaching hospital. Methods This analysis data represents a preliminary 5-month audit of an ANP Led LP service (ALLPS) compared to prior service provision (ALLPS n=40, pre-ALLPS n=20). Waiting time for LP prior to ALLPS averaged 25 weeks, which reduced by over 50% (12 weeks). Results CSF results were identified in half the time with ALLPS (3 weeks versus 6 weeks). The initiation of the ALLPS reduced the timeframe to diagnosis from 12 weeks to 5 weeks. This led to an average wait time reduction from date of CSF result to disclosure of diagnosis of 53% (15 weeks pre-ALLPS to 8 weeks). The ALLPS is pioneering the use of a seated upright LP procedural position, reported to be comfortable by this cohort. Analysis of the nurse led LP procedure is comparative with medical LP services. Almost 40% were achieved on 1st attempt, a further 28% on 2nd attempt, with 18% on 3rd attempt. The ANP successfully completed 75% of LPs in this initial cohort with 9 patients requiring supervisor LP performance. One case required x-ray guided LP. Conclusion Appointment of a dedicated ALLPS service has reduced waiting times for diagnostic intervention, leading to early diagnosis, accessing post diagnostic support, meeting best practice guidelines outlined by the National Dementia Office.

Treatment-free remission after a second TKI discontinuation attempt in patients with Chronic Myeloid Leukemia re-treated with dasatinib – interim results from the DAstop2 trial

Tyrosine kinase inhibitor (TKI) discontinuation in chronic myeloid leukemia (CML) has become part of routine care for patients with a sustained deep molecular response (DMR). Approximately 50% experience a molecular relapse upon TKI cessation. Most of them quickly regain DMR upon TKI resumption. Whether these patients can achieve a second treatment-free remission (TFR) remains unclear. DAstop2 (ClinicalTrials.gov ID: NCT03573596) is a prospective study including patients with a failed first TFR attempt re-treated with any TKI for ≥ one year. Upon entering the study, patients received the TKI dasatinib for additional two years. Patients with sustained DMR for ≥1 year qualified for a second TKI stop. Ninety-four patients were included between Oct 2017-Dec 2021. At the time of data analysis, 62 patients had attempted a 2nd stop. After a median follow-up of 27 months from 2nd stop, TFR rates were 61, 56 and 46% at 6, 12 and 24 months respectively. No progression to advanced stage disease was seen and 87% had re-achieved MR4 within a median of 3 months from TKI re-initiation. In summary, we show that a 2nd TFR attempt after dasatinib treatment is safe, feasible and TFR rates seem in the range of those reported in trials of a first TKI stop.

Ретестовая надежность кистевой динамометрии для измерения максимальной произвольной силы

Hand dynamometry is a technique frequently used in physiological and clinical studies. To determine maximum hand strength, several test attempts are made. Establishing the necessary and sufficient number of these attempts will help to avoid fatigue that can occur during the test and allow researchers to record other parameters as well. The purpose of this paper was to determine the number of hand dynamometry attempts sufficient to record maximum voluntary strength. Materials and methods. The study involved 24 male students aged 19.04 ± 1.37 years who made three hand dynamometry attempts before and after the experimental (modified Stroop test) or control (watching a neutral film) tasks. Differences between the attempts were assessed, as well as the relative reliability of repeated tests using the intraclass correlation coefficient (ICC). Results. No differences in dynamometry results between the experimental and control groups were observed; therefore, to determine reliability of repeated testing, the entire sample was considered, without division into groups. Statistically significant differences (p < 0.006) between the 1st and 2nd attempts before completing the tasks were detected; whereas between the 2nd and 3rd attempts before as well as between all attempts after completing the tasks, no significant differences were found. At the same time, retest reliability of this method was observed between all attempts (ICC = 0.852–0.930). Thus, we believe that in hand dynamometry it is necessary to either include a preliminary warm-up similar to the main physical task or choose the best attempt of the first two.

Endovascular treatment with coil embolization of saccular celiac artery aneurysm: a case report

Objective: Aneurysms of the celiac artery and its visceral branches are more often an incidental finding and can lead to serious complications. Many difficulties arise in matters of their treatment due to the rarity of occurrence. Case presentation: This report describes the rare case of saccular celiac artery aneurysm in patient with severe cardiac comorbidities including history of cardiac surgeries. Celiac artery aneurysm was treated using the endovascular coiling procedure. We had coil dislocation during procedure, and 2nd attempt of coil embolization of aneurysm was successful. The dislocation into femoral artery was treated successfully. Immediate and 1st month follow-up data showed no evidence of recanalization and aneurysm enlargement and computed tomography angiography chowed correct position of coil. Conclusion: Coil embolization is a safe and effective method for the treatment of celiac artery aneurysm in patients with severe comorbid conditions. One should be also prepared for possible technical difficulties that were overcome successfully and thus making minimal invasive approach in such patients effective.

Repeat Microdissection Testicular Sperm Extraction in Azoospermic Men with Nonmosaic Klinefelter Syndrome

Introduction. To investigate the predictive factors for successful repeat microdissection testicular sperm extraction attempts in patients with Klinefelter syndrome. Methods. A total of 28 azoospermic men with nonmosaic Klinefelter syndrome who have received microdissection testicular sperm extraction twice with successful initial microdissection testicular sperm extraction attempts in our institute were studied. Outcome variables (age, serum follicle-stimulating hormone, luteinizing hormone, testosterone, prolactin, and estradiol) of azoospermic men with nonmosaic Klinefelter syndrome and a successful 2nd surgical sperm retrieval attempt (group A) were compared to those with an unsuccessful 2nd sperm retrieval attempt (group B). Results. Twenty-one patients (75%) had successful sperm recovery at the 2nd microdissection testicular sperm extraction attempt. The mean testosterone level at baseline and before the 1st microdissection testicular sperm extraction attempt was higher in group A than in group B (2.7 vs. 0.9 ng/mL, p < 0.01 , and 3.9 vs. 1.1 ng/mL, p = 0.02 ). Receiver operating characteristic curve analysis identified the threshold baseline testosterone concentration (1.5 ng/mL) of patients with Klinefelter syndrome in predicting successful 2nd sperm retrieval attempts and revealed positive and negative predictive values of 94.44% and 60%, respectively. Conclusion. Azoospermic men with Klinefelter syndrome presenting with low testosterone levels and successful sperm recovery during the first microdissection testicular sperm extraction procedure are unlikely to retrieve sperm on the 2nd microdissection testicular sperm extraction attempt. Hence, these patients should be properly counseled before sperm retrieval.

MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT

You have accessJournal of UrologyCME1 Apr 2023MP42-17 INCONTINENCE AFTER SUCCESSFUL ANATOMICAL CLOSURE OF VESICO-VAGINAL FISTULA; INCIDENCE AND MANAGEMENT Amaani Ahmad, Helena Gresty, Anthony Noah, Richard Nobrega, Mahreen Pakzad, Jeremy Ockrim, and Tamsin Greenwell Amaani AhmadAmaani Ahmad More articles by this author , Helena GrestyHelena Gresty More articles by this author , Anthony NoahAnthony Noah More articles by this author , Richard NobregaRichard Nobrega More articles by this author , Mahreen PakzadMahreen Pakzad More articles by this author , Jeremy OckrimJeremy Ockrim More articles by this author , and Tamsin GreenwellTamsin Greenwell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Vesicovaginal fistula (VVF) is a rare condition in high resource settings. Significant urinary incontinence (UI) rates have been reported following VVF closure in low resource setting. We have reviewed our VVF series for anatomical closure and post closure UI rates. METHODS: Retrospective review of 132 patients having 1st surgical management of their VVF between 2004-2022. Median age was 51 (16-88) with a median follow-up of 14 months (2-150). Data was collated on demographics, fistula aetiology and characteristics, previous surgery, outcome in terms of anatomical closure and urinary continence, and any requirement for further surgery. Statistical analysis was carried out using chi-squared test, fisher test or students t-test as appropriate. RESULTS: Of the 132 patients identified, 127 (96.2%) had surgery to close their VVF whilst 5 (3.8%) had a primary ileal conduit. Successful anatomical closure was achieved in 118 (93.9%) at 1st attempt. Of the 9 failures, 6 had a 2nd VVF closure attempt, 2 had ileal conduit formation and 1 had recurrent carcinoma and did not proceed to further surgery. Vaginal closure was successful in 95% (97/102) after 1st attempt whilst abdominal closure was successful in 88% (22/25). Of the 6 failures having a 2nd attempt at VVF closure, 3 had an abdominal and 3 had a vaginal approach, with 100% successfully closed. Anatomical closure was confirmed in all patients by cystogram and/or cystoscopy. Of those with successful VVF closure 19 (15.2%) (16 vaginal and 3 abdominal approach) had bothersome post repair UI. This was pre-existing stress urinary incontinence (SUI) in 5 (4%), new onset SUI in 8 (6.4%), pre-existing urgency urinary incontinence (UUI) in 1 (0.8%), new onset UUI in 3 (2.4%) and new onset mixed urinary incontinence (MUI) in 2 (1.6%). 5 (26.3%) (4 with pre-existing SUI) required surgical intervention for management of their SUI (2 colposuspensions and 3 rectus fascial slings) whilst the patient with pre-existing UUI progressed to sacral neuromodulation, with resolution or significant improvement. The remaining 13 (68%) patients experienced resolution or significant improvement of their UI with conservative measures. CONCLUSIONS: Successful anatomical closure of VVF in high resource health care settings can be achieved in 92.9% after 1st repair and 100% after 2nd repair. Post closure bothersome urinary incontinence occurs in 15.2% and resolves with conservative measures in 68%. Surgical interventions for SUI or UUI post closure in 4.8%, with excellent results. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e574 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amaani Ahmad More articles by this author Helena Gresty More articles by this author Anthony Noah More articles by this author Richard Nobrega More articles by this author Mahreen Pakzad More articles by this author Jeremy Ockrim More articles by this author Tamsin Greenwell More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of novel anteroposterior short-axis in-plane technique with conventional short-axis out-of-plane technique for ultrasound-guided internal jugular vein cannulation: A randomized-controlled trial.

Various ultrasound (US)-guided probe positioning and needle procedures have been described in the literature for cannulation of the internal jugular vein (IJV). In the present study, we compared the conventional short-axis out-of-plane (SAX-OOP) method with a novel anteroposterior short-axis in-plane (APSAX-IP) technique for IJV cannulation under US guidance. The APSAX-IP method of IJV cannulation has not been compared to other IJV cannulation techniques. A total of 104 patients above 18-year-old were randomly allocated to one of two groups - APSAX-IP or SAX-OOP and evaluated for US-guided IJV cannulation in either the operating room or critical care unit. The primary outcome of this research was the access time for IJV cannulation using both approaches. The secondary outcomes were the number of attempts of needle insertion, success rate, and complications of IJV cannulation. The access time for IJV cannulation was 13.0 (12.0-15.0) sec in the APSAX-IP group and 13.0 (12.0-14.0) sec in the SAX-OOP group; P = 0.947. The number of successful 1st attempts was 90.91%, and the 2nd attempts were 9.09% in the APSAX-IP group and 85.19% and 14.81% in the SAX-OOP group, respectively. Both techniques did not have any complications. We conclude that the US-guided APSAX-IP IJV cannulation method has comparable access time to the SAX-OOP technique.

Elective egg freezing patients may benefit from increasing the maximal daily gonadotropin dose above 300IU

ObjectiveNowadays, patients attempting social/elective egg freezing has spread globally. Ovarian stimulation (OS) with high daily gonatotropin doses, are commonly offered to this group of patients, aiming to achieve the maximal oocytes cohort with minimum IVF cycle attempts. We aim to assess the IVF-ET outcome, and specifically the oocyte yield, of patients undergoing two successive IVF cycle attempts for elective egg freezing (EEF), and whether changing the daily gonadotropin dose in the second IVF cycle attempt, affect the outcome.Patients and methodsAll women admitted to our IVF unit for social/EEF, who underwent 2 consecutive IVF cycle attempts, with only those who used in the first attempt a starting daily gonadotropin dose of 300 IU were included. Ovarian stimulation characteristics, duration of OS, number of retrieved oocytes, number of mature oocytes were assessed and compared between the 1st and the 2nd IVF cycle attempts, and between the different daily gonadotropin doses and the oocyte yields in the 2nd cycle attempt (increase, decrease or no change).Main outcome measuresOocytes and mature oocytes yield in the 2nd as compared to the 1st IVF cycle attempt.ResultsA reduced oocyte yield in the 2nd cycle attempt was observed in those who highly responded in the 1st attempt, regardless the daily dose in the 2nd cycle attempt (whether it was increased, no change and decreased). Moreover, the proportion of patients with same or more oocytes in the 2nd IVF cycle attempt was significantly lower in patients with high peak E2 levels, compared to those with peak E2 levels < 9175 pmol/L. Among patients with high peak E2 (> 9175 pmol/L), those who achieved a lower oocytes yield in the 2nd IVF cycle attempt had lower basal Day-3 FSH/LH ratio (1.5 + 0.5 vs 1.8 + 0.8, p < 0.03) and higher oocyte (range: 7–28, median:10; vs range: 2–15, median:7) and mature oocytes yields. With a cut-off of 9 oocytes, 78.8% of those with > 9 oocytes and 61.8% of those with < 9 oocytes will achieve lower/higher oocytes yield in the 2nd IVF cycle attempt, respectively.ConclusionsOvarian stimulation with high daily gonatotropin doses (300 IU) should be offered to patients attempting social/EEF. Moreover, in their 2nd IVF cycle attempt, those with high peak E2 (> 9175 pmol/L) in the 1st attempt, and basal Day-3 FSH/LH ratio < 1.5 and/or more than 9 oocytes retrieved, should receive same OS protocol with no change in the daily gonadotropin dose.

A COMPARATIVE STUDY OF ATRACURIUM AND CIS- ATRACURIUM FOR INTUBATING CONDITIONS UNDER GENERAL ANAESTHESIA

Background: Atracurium and Cisatracurium are intermediate-acting nondepolarizing neuromuscular drugs. They both are promising drugs offering a predictable recovery due to non-organ dependent elimination. However, due to the variability in metabolism and narrow therapeutic window, monitoring of neuromuscular functions has signicant importance. Cisatracurium is approximately four times as potent as atracurium. In contrast to Atracurium, Cisatracurium is devoid of chemically mediated histamine release. Routinely atracurium is used for the neuromuscular blockade in most pediatric surgeries. On the other hand, 2 ED95 doses of Cisatracurium do not create satisfactory intubating conditions such as those seen with equipotent doses of atracurium. Aim: Ÿ To compare the intubating conditions of Atracurium(0.5mg/kg) and Cisatracurium 0.15mg/kg). Ÿ To compare the hemodynamic parameters (MAP, PR, SPO2,) between atracurium and Cisatracurium Ÿ To compare the signs of histamine release potential between atracurium and Cisatracurium. Materials and Methods : A Prospective, observational study was conducted at SRI SIDDHARTHA MEDICAL COLLEGE AND RESEARCH INSTITUTE,TUMKUR. from 1st Jan 2021 to 30th June 2022 on 74 patients. In Atracurium group, there were 15 patients Results: with ASA grade of 1 and 17 patients with ASA grade of II. In Cis-Atracurium group, there were 15 patients with ASA grade of 1 and 22 patients with ASA grade of II. Chi square test was performed between the 2 groups and p value was observed to be &gt; 0.05 indicating no statistically signicant difference between the groups. Average onset time for Atracurium group was 177 ± 22.4 seconds and same was 184 ± 17.3 seconds in Cis Atracurium group. In Atracurium group, intubation was successful at 1st attempt in 33 subjects, 2nd attempt in 2 subjects, 3rd attempt in 2 subjects. In Cis Atracurium group, intubation was successful at 1st attempt in 35 subjects and 2nd attempt in 2 subjects. In Atracurium group, duration of action of the muscle relaxant was 46 ± 4.9 minutes, Duration of 25% recovery was 33 ± 4.2 minutes, Time of recovery from reversal was 1.7 ± 0.8 minutes. In Cis Atracurium group, duration of action of the muscle relaxant was 68 ± 7.1 minutes, Duration of 25% recovery was 48 ±5.6 minutes, Time of recovery from reversal was 2.2 ± 1.1 minutes. Cis atracurium had longer recovery time and duration of action. Atracurium c Conclusion: aused signicant hemodynamic impact than Cis atracurium. Adverse effects were comparable in both.

Duration of ≥MR4 Is the Best Predictor for a Successful 1st Treatment-Free Remission (TRF1) Attempt in CML Patients Treated with Tyrosine Kinase Inhibitors (TKI); Long-Term Follow-up of a Large Cohort of Patients Including a Cohort Undergoing a 2nd Tfr (TFR2) Attempt

Background: Prior to TKIs, CML was uniformly fatal unless the patient underwent allogeneic-HSCT. With TKIs, some patients achieve deep molecular responses with bcr-abl <0.01% (MR4); a portion of such patients can achieve long-term TFR, possibly cure, after TKI cessation. This approach is now considered the goal for every newly diagnosed CML patient. We present a single centre experience, with long-term follow up, of a cohort of CML patients undergoing TFR1 and TFR2 attempts. Method: Our database of 173 patients diagnosed with CML from 1994 to 2022 was searched for patients who had the potential to be eligible for a TFR attempt (pending adequate response to TKI): CML diagnosed in 1st chronic phase (CP1); no allogeneic HSCT in CP1; >3 yrs treatment with TKI; adequate follow-up. 120 patients fulfilled these criteria. Results: 70/120 (58%) achieved accepted criteria to attempt TFR: >3 years of TKI treatment; a deep molecular response (≥MR4) and underwent TFR attempt. Median age at diagnosis was 49.5 (20-81) yrs; 42% were female. Sokal score was low in 38%; intermediate in 29%; high in 33%. 66% of patients received multiple TKIs; 23% had received interferon. TKI at time of TFR1 attempt was imatinib (40%), nilotinib (30%), dasatinib (27%), and ponatinib (3%). Median time from diagnosis to TFR was 8.5 (4-23) yrs and median time on TKI was 7.5 (3.4-17.9) yrs. 36/70 (51%) remain in TFR with median follow-up of 46 (1-180) mths including; 16 patients now >5 yrs and 2 now >10 yrs in ongoing TFR; the cohort includes 2 patients with historically acquired bcr-abl mutations and 1 with a historically acquired additional cytogenetic abnormalities (no longer present at TFR1 attempt). All 3 are long-term TFR successes. Median time to relapse was 5 (2-36) mths, 25/34 (73.5%) relapsed within 6 mths of TKI withdrawal and 28/34 (82.4%) within 12 mths. Time of relapse for 1 patient is unknown. The remaining 5 patients relapsed at 13, 14, 18, 20, and 36 mths. All patients with CML recurrence (bcr-abl >0.1%) restarted TKI with a rapid return to major molecular response (MMR) or better (2 are too early for assessment) with median time to MMR of 3 (1-12) mths. No patient developed CML with high-risk features or blast phase. The strongest predictors for TFR success were duration of MR4 prior to attempting TFR1 (Table 1) - 60% (25/42) of patients with >5 yrs of ≥MR4 prior to cessation remain in TFR, compared to 55% (11/20) with 3-5 yrs and 0% (0/7) of patients with <3 yrs (p<0.03 for <3 vs 3-5 yrs and <3 vs >5 yrs, p=0.79 for 3-5 vs >5 yrs) ; prior treatment with interferon (81% - 13/16 - of patients who received interferon remain in TFR compared to 37% - 20/54 - who had not received interferon, p=0.0035), and a Sokal score <0.8 (64% of patients with low Sokal score remain in TFR compared to 45% with a score 0.8-1.2 and 45% with a score >1.2, p=0.35 for <0.8 vs 0.8-1.2, p=0.16 for <0.8 vs >1.2, p=1 for 0.8-1.2 vs >1.2). 6 patients had transient rises in their bcr-abl (>0.01%), ranging from 0.012 - 0.033, but these 6 returned to MR4 or better and remain in TFR for 8-77 mths. 13 (38%) of the 34 failed TFR1 patients attempted TFR2. Median time on TKI between 1st and 2nd attempts was 5.7 (4.8-8.9) yrs and had a median time ≥MR4 of 5.4 (4.6-8.8) yrs. Median follow up was 12 (1-27) mths. Currently, 9 (69%) patients remain in TFR2. Of the 4 patients who relapsed, all did so in the first 6 months after TKI withdrawal. 17 patients (25%) developed a withdrawal syndrome. Symptoms included fatigue, myalgias, and arthralgias. All but 4 patients had resolution over a median of 11 (1-25) mths. 3 patients benefited from a course of prednisolone. 4 patients have had persistent symptoms for median 12.5 (10-19) mths. Conclusion: Of 120 patients with adequate duration of TKI, 58% were eligible for TFR1 attempt which, to date, is successful in 51%. Prior interferon treatment, longer period in ≥MR4 and a Sokal score <0.8 predicted a successful TFR. For those that fail TFR1, TFR2 appears safe, and with short follow-up, currently 9/13 (69%) patients remain off treatment. In our cohort, overall 64% (45/70; 36 TFR1 + 9 TFR2) of patients eligible for TFR attempts remain off TKI giving an actual or functional cure rate of 38% (45/120). Historically acquired bcr-abl mutations or additional cytogenetic abnormalities are not necessarily contraindications to a TFR attempt - with 3 long-term TFR successes in our cohort. TFR is safe with no cases of disease progression, and all patients with TFR failure and adequate duration of follow-up regaining MMR. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

ODP586 Analysis of Adrenal Vein Sampling (AVS) Success: A Retrospective Study of Primary Aldosteronism Patients at the National University of Malaysia (UKM) Medical Center

Abstract Currently, the gold standard for identifying a unilateral Primary Aldosteronism (PA) is adrenal vein sampling (AVS), an invasive and technically challenging procedure. In this study, we aim to identify the clinical-laboratory characteristics associated with successful AVS, and clinical parameters associated with PA patients that had successful AVS (on 1st, 2nd, or 3rd attempt), or had rejected further attempts after a failed AVS attempt.100 records of AVS from eighty-three AVS patients conducted between 2015 and 2020 at the National University of Malaysia (UKM) Medical Centre, Kuala Lumpur, Malaysia were analysed retrospectively. Of the 83 PA patients studied, 47 were performed on men and 36 were on women. Variables significantly associated with patients who booked for a further attempt of AVS was having a serum aldosterone of &amp;lt;300pg/ml compared to those who rejected further attempts. There was also a trend for those who rejected further attempts to have a shorter duration of hypertension. Over one third of patient's have a failed AVS on 1st attempt and more than half do not wish to reattempt this invasive procedure. A biomarker for those that achieve complete cure should be identified to give incentives to the PA patients to proceed with AVS. Presentation: No date and time listed

S3117 Partial Splenic Artery Embolization for Patients With Portal Hypertension Undergoing Organ Transplant Evaluation: A Case Series

Introduction: Partial splenic artery embolization (PSAE) is an infrequently utilized approach to reduce portal hypertension (PHT) by reducing splenic arterial inflow and thereby splenic vein flow into the portal vein. We describe three patients who underwent PSAE to address diverse manifestations of PHT due to contraindications to transjugular intrahepatic portosystemic shunts (TIPS). Case Description/Methods: Case 1: A 50-year-old male with CKD stage 4 and idiopathic PHT had diuretic-refractory ascites and thrombocytopenia, precluding surgery for an arteriovenous fistula (AVF) and kidney transplantation. He was not a candidate for TIPS due to extensive portal vein thrombosis but underwent PSAE leading to resolution of ascites and marked improvement in thrombocytopenia (Figure 1). The patient ultimately received an AVF and was placed on the kidney transplant waitlist. He has been followed for 30 months with sustained clinical improvement. Case 2: A 60-year-old male with prior hepatocellular carcinoma (HCC) status post right partial hepatectomy and hepatitis C cirrhosis complicated by severe thrombocytopenia and refractory ascites, had two previously aborted TIPS procedures due to unusual hepatic vein anatomy. He underwent PSAE that led to a reduction in frequency of therapeutic paracenteses and improvement of thrombocytopenia (Figure 1). Eight months later, TIPS was reattempted and resulted in complete ascites control for over six years. He is currently on the waitlist for liver transplantation. Case 3: A 60-year-old male had cryptogenic cirrhosis complicated by mild ascites, significant thrombocytopenia, and massive splenomegaly with mass effects. He underwent successful PSAE to alleviate splenic compression of the bladder. One year later, he had a repeat PSAE for diaphragmatic compression secondary to splenic hypertrophy. His thrombocytopenia also mildly improved (Figure 1). The patient was declined for liver transplant due to lack of social support. He expired from advanced HCC after two years of follow-up. Discussion: We report three cases of PSAE in patients with PHT awaiting organ transplantation. All three cases had improvement in ascites, splenomegaly, and thrombocytopenia. Although PSAE is not the primary treatment for PHT, it may have a therapeutic role in advanced cases, particularly in transplant candidates when other interventions like TIPS are not possible. Future studies should be conducted to further evaluate the role of PSAE in patients with PHT awaiting organ transplantation.Figure 1.: *2nd PSAE attempt in case 3 represented at time 0.

Pilot Study to Evaluate a New Method for Endotracheal Administration of Surfactant in Neonatal Respiratory Distress Syndrome: Fiberscope Assisted Surfactant Therapy (FAST)

Introduction: Currently, INSURE (Intubation-Surfactant-Extubation) and LISA (Less Invasive Surfactant Administration) are two recommended techniques for surfactant delivery to newborns with respiratory distress syndrome. The aim of this study was to evaluate the feasibility, safety, tolerability of a new technique of surfactant administration in newborns without anesthesia or laryngoscopy: Fiberscope Assisted Surfactant Therapy (FAST). Methods: This monocentric, prospective, nonrandomized, pilot feasibility study was conducted from January to December 2021. Spontaneously breathing infants born ≥28 weeks gestational age with respiratory distress syndrome received surfactant by a 1.5 French catheter inserted in the trachea using a flexible endoscope without anesthesia, while maintaining a continuous positive expiratory pressure. The learning curve of this new technique by caregivers was studied during training sessions on high fidelity mannequins. Results: Eight infants born ≥28 weeks of gestation with a birth weight of 1,000 g–2,685 g were included in the study. FAST was successfully performed in each case without anesthesia, second dose of surfactant or mechanical ventilation. One hour after FAST, a decrease of FiO₂ and PCO₂ and an increase of arterial pressure and pH were recorded with medians of individual differences of −0.9, −4 mm Hg, 6.5 mm Hg, and 0.06, respectively. The learning curves of 13 physicians showed a rapid mastery of FAST from the third attempt onwards (mean duration of 113, 66, and 50 s for 1st, 2nd, and 3rd attempts, respectively, 29–37 s for further attempts). Conclusion: FAST may be considered as a possible new minimally invasive surfactant therapy technique for neonates ≥28 weeks with mild respiratory distress syndrome.

Trans-illumination Devices: Improving IV Insertion Accuracy and Success Rates

<h3>Background Information</h3> Difficult Venous Access (DVA) patients are a frequent cause of increased preoperative pain scores, increased delays in Preop to OR times, and decreased patient satisfaction with their perioperative experience. Expert vascular access nurses (EVANs) have had little effect changing these key issues. Use of Trans-Illumination Devices (<b>TID</b>s) has demonstrated promising results in alieving some of these issues without increased risk to the patient. <h3>Objectives of Project</h3> The TID pilot was designed to improve patient safety, comfort and satisfaction while decreasing delays in the preoperative area relating to DVA patients. Staff satisfaction with TIDs data was measured through feedback on ease of use, procedure type, and success rates. <h3>Process of Implementation</h3> Staff education was required for the use of the ACCU VEIN red light LED TID. Training included a review of the equipment, proper distancing, settings, and cleaning for patient safety. Real time training was performed on live patients with verbal consent in the Prep and PACU. Data collection included patient Vascular Access Difficulty Level (VADL), number of insertion attempts, and the procedure performed. Post training satisfaction surveys were sent to nursing and clinical technicians to provide feedback on use of the TID. <h3>Statement of Successful Practice</h3> The ACCU VEIN TID was used on 70 patients. VADL A (55) and VADL B (15). It successfully reduced the number of insertion attempts in the DVA population (1^st attempt=62, 2nd attempt=8). Calls for Anesthesia or EVANs were zero. The device gave real time information regarding the location and quality of veins being accessed. Reduction in number of insertion attempts decreased pain and improved patient satisfaction with IV starts. Staff graded the ACCU Vein ease of use (100%), being helpful (90%), and that they would use the device again (99%). <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> Use of TIDs in areas where venous access is frequent will improve the quality of patient care and reduce the wait times associated with IV insertion of the DVA patient. Prep/PACUs, Infusion Centers, Emergency Departments, Phlebotomy, and IV therapy would all benefit having TIDs as standard equipment.

ULTRA-SONOGRAPHIC ESTIMATION OF ENDOTRACHEAL TUBE SIZE IN PAEDIATRIC PATIENTS UNDERGOING SURGERY IN PRONE POSITION: A PROSPECTIVE OBSERVATIONAL CLINICAL STUDY

Background: ETT is important in securing paediatric airway and its right size plays crucial role in paediatric patients. The airway anatomy in paediatric patients is different from adults hence requires precise ETT size. The subglottic diameter being the narrowest portion of upper airway, determines the ETT size. USG is safe, reliable, non-invasive tool used to estimate the narrowest subglottic diameter to estimate the correct ETT size. Conventional formulae included age and height. Concerns in prone position include accidental extubation,secretions, difficult airway access, increased abdominal pressure, increased FRC. Methods: Sixty patients in the age group 1-4 years posted for PSARP under GA were included in the study. USG guided ETT size was estimated and compared with conventionally estimated size. Results:The size of ETT predicted by USG was more appropriate than that estimated by physical indices(p&lt;0.005). ETT size estimated by age-based formula was 2nd nearest to best fit tube. 65% patients were intubated in 1st attempt while 31.6% required 2nd attempt and 3.33% needed 3 attempts to get intubated with the best fit ETT. Conclusion:USG is useful and reliable screening modality in estimating appropriate ETT size especially in paediatric patients undergoing surgery even in prone position such as PSARP.

Assessment of failed spinal anesthesia for cesarean section during COVID-19 pandemic

Objective: 1490 pregnant women with confirmed COVID 19 were admitted to the hospital between April 2020 and February 2021. In Ankara City Hospital, Ankara, Turkey, 416 pregnant women gave birth spontaneously and 251 underwent cesarian section. We attempted spinal anesthesia for cesarian sections because all regional anesthesia organizations advised regional anesthesia for obstetric surgery. However, spinal anesthesia for cesarean delivery is not a foolproof method. Material and Method: We used a retrospective analysis of 251 COVID 19 cesarean section anesthesia to determine the incidence of failed spinal anesthesia, management strategies, and risk variables that contribute to failure. Results: The total number of failed spinal anesthesia instances was 14 (5.58%), with 1% of complete failures and 4% of partial failures. One patient was given spinal anesthesia for the 2nd attempt (0.4%), while the other two were given general anesthesia (0.79%). In failed spinal cases, sedation was utilized. Patients received varied dosages of midazolam, fentanyl, ketamine, and propofol. Conclusion: The rate of failed spinal anesthesia among COVID 19 pregnant women was similar to, even lower than, the rate of failed spinal anesthesia in the general population. Despite all the negative consequences, such as wearing PPE and moving around, vision and hearing problems due to PPE, anesthesiologist fear about being infected by the patient or patient anxiety about infection, the future and babies’ health is the reason for this result.

Comparison between Standard Technique versus Reverse Manoeuvre of Airtraq Insertion for Tracheal Intubation in Lean versus Obese Patients undergoing Surgery under General Anaesthesia: A Randomised Clinical Study

Introduction: Obese patients pose challenge to anaesthesiologist in terms of securing airway due to large tongue and anatomical variations, need a novel tracheal intubation technique to quickly secure airway in obese individuals. The airtraq laryngoscope with reverse technique of insertion is used to secure airway without classical sniffing position. Aim: To compare the two techniques of airtraq insertion, standard and reverse manoeuvre, in lean versus obese patients undergoing surgery under general anaesthesia. Materials and Methods: This randomised clinical study was conducted from July 2012 to January 2014 at Seth GS Medical College and KEM Hospital, Mumbai, Maharasthra, India in a total of 200 American Society of Anaesthesiologists (ASA) I-III undergoing surgery under general anaesthesia. Both lean and obese patients were randomly allocated to each technique. After induction of anaesthesia intubation was performed by an expert anaesthesiologist with each technique (three attempts) were used to intubate trachea. If there was a failure, switch over technique was applied. All the groups were analysed for intubation time, number of attempts, ease of intubation Visual Analogue Scale (VAS), haemodynamics, and complications. Results: Both lean and obese groups were comparable in the airway and demographic characteristics. In lean patients there was no significant difference between intubation time with both standard and reverse manoeuvre. While in obese patients reverse manoeuvre (11.84±1.99 seconds) significantly reduced exposure time by 13 seconds as compared to standard technique (24.02±6.94 seconds), thereby reducing total duration of intubation (26.08±1.16 seconds) as compared to total duration of intubation with standard technique (39.62±8.95 seconds). Lean group were comparable in number of attempts with standard technique (47 1st /3 2nd attempt) and reverse manoeuvre (49 1st /1 2nd attempt). Obese group with reverse manoeuvre all were intubated with first attempt (50 1st) with standard technique (46 1st /1 2nd attempt) and there was switch over from standard to reverse technique in three patients. Both lean and obese groups were comparable in complications with both technique. Conclusion: Reverse manoeuvre proved beneficial in obese patients as it reduced intubation time as compared to standard technique, while lean patients showed no difference.

Effectiveness of combined neurometabolic therapy in complex treatment of patients with hemorrhagic hemispheric stroke in recovery period

Objective. The aim of this work was to estimate the effectiveness of combination neurometabolic therapy that includes 5 mg of ipidacrine hydrochloride and 300 mg of phenibut in complex therapy of patients with hemisphere hemorrhagic stroke in the early rehabilitation period. Material and methods. Open comparative randomized study and treatment of 46 patients (31 men and 15 women) with hemisphere hemorrhagic stroke in the early rehabilitation period was performed. The mean age of patients was 57.17 ±7.09 years. All patients were divided into two groups - the main group included 20 patients with hemorrhagic stroke, who took neurometabolic combination therapy (5 mg of ipidacrine hydrochloride and 300 mg of phenibut three times per day) in addition to complex recovery treatment during 30 days (start from 30th day after stroke) and control group, that included 26 patients with hemorrhagic stroke, who received standard complex recovery treatment without additional neurometabolic therapy. Outcomes. The median MoCA score of the main group of patients was 21.0 (19; 24), while the second group had 20.5 (18; 23.75) MoCA score, but without any intergroup difference. It was also identified reliable improvement of cognitive values on the MoCA scale after treatment (р ˂ 0.05). Besides, statistical difference was reached between groups in these measures. Also, we showed that statistical improvement in memory was observed in both groups at 1st and 2nd attempts using Luriya’s method “memorizing 10 words”. But subsequent such an effect took place only in the main group. The present study showed the absence of improvement “memorizing of 10 words” at 3rd, 4th and 5th attempts in control group. At the same time, patients of the main group had improved results at 4th and 5th ones (р ˂ 0.05). Conclusion. The combined drug of neurometabolic nature, consisting of 5 mg ipidacrinum and phenibut 300 mg, improved rehabilitation effectiveness rates for account of cognitive functions in patients with hemorrhagic hemispheric stroke during recovery period during comprehensive rehabilitation.

Simulation of tracheal intubation for medical students. The effects of anticipatory study

Clinical simulation allows the acquisition of procedural skills among medical students. The anticipatory study of these skills may improve the efficiency of simulation sessions. To Compare two anticipatory study guides in the simulation of airway management, in a cohort of medical students from Chile. Fifth year medical students were randomly assigned to prepare the simulation of tracheal intubation with a theoretical guide, an audiovisual guide, and a control group without study. The skills acquired were evaluated in a simulated scenario. All groups increased their successful orotracheal intubation (OTI) rate and decreased the time to achieve a successful OTI after each attempt. The study group with a theoretical guide had the higher rate of success in the 1st OTI attempt without feedback. In contrast, the group without any anticipatory study had more failed attempts (1st and 2nd attempt), achieving their first successful OTI in the 3rd attempt after feedback. Study guides improve practice effectiveness. Our results indicate that the best results are obtained by simulation accompanied with immediate directed feedback and opportunities to repeat the procedures, independent of the type of anticipatory study.

Interim Results of the Canadian Tyrosine Kinase Inhibitor Discontinuation Trial for 2nd Attempt of Treatment Free Remission: Treatment Free Remission Accomplished By Dasatinib (TRAD)

Interim Results of the Canadian Tyrosine Kinase Inhibitor Discontinuation Trial for 2nd Attempt of Treatment Free Remission: Treatment Free Remission Accomplished By Dasatinib (TRAD)