Aspiration Tube Research Articles

The Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic Evaluation of Swallowing) in Acute Respiratory Failure Survivors.

To determine whether a modifiable risk factor, endotracheal tube size, is associated with the diagnosis of postextubation aspiration in survivors of acute respiratory failure. Prospective cohort study. ICUs at four academic tertiary care medical centers. Two hundred ten patients who were at least 18 years old, admitted to an ICU, and mechanically ventilated with an endotracheal tube for longer than 48 hours were enrolled. Within 72 hours of extubation, all patients received a flexible endoscopic evaluation of swallowing examination that entailed administration of ice, thin liquid, thick liquid, puree, and cracker boluses. Patient demographics, treatment variables, and hospital outcomes were abstracted from the patient's medical records. Endotracheal tube size was independently selected by the patient's treating physicians. For each flexible endoscopic evaluation of swallowing examination, laryngeal pathology was evaluated, and for each bolus, a Penetration Aspiration Scale score was assigned. Aspiration (Penetration Aspiration Scale score ≥ 6) was further categorized into nonsilent aspiration (Penetration Aspiration Scale score = 6 or 7) and silent aspiration (Penetration Aspiration Scale score = 8). One third of patients (n = 68) aspirated (Penetration Aspiration Scale score ≥ 6) on at least one bolus, 13.6% (n = 29) exhibited silent aspiration, and 23.8% (n = 50) exhibited nonsilent aspiration. In a multivariable analysis, endotracheal tube size (≤ 7.5 vs ≥ 8.0) was significantly associated with patients exhibiting any aspiration (Penetration Aspiration Scale score ≥ 6) (p = 0.016; odds ratio = 2.17; 95% CI 1.14-4.13) and with risk of developing laryngeal granulation tissue (p = 0.02). Larger endotracheal tube size was associated with increased risk of aspiration and laryngeal granulation tissue. Using smaller endotracheal tubes may reduce the risk of postextubation aspiration.

Erratum: Nasogastric versus Orogastric Bolus Tube Feeding in Preterm Infants: Pilot Randomized Clinical Trial.

Objective According to the most recent metanalysis, the best way to establish safe enteral feeding in preterm babies using nasogastric or orogastric tubes is still not well understood. This study aimed to determine the effects of bolus nasal tubes versus bolus orogastric tubes on the time required to reach full enteral feeding in preterm infants, as well as to compare the incidence rates of adverse events including nonintentional removal or displacement of the feeding tube, aspiration pneumonia/pneumonitis, apnea, necrotizing enterocolitis, gastric residual, and growth parameters between the studied cohort of preterm infants. Study Design We conducted an unblinded pilot randomized clinical trial on hemodynamically stable preterm infants (>28 weeks) recruited from level 2 neonatal intensive care unit at Mansoura University Children's Hospital from June 2015 to May 2017. Results Our study included 98 stable preterm infants with mean gestational age (orogastric group: 33.27 ± 1.08, nasogastric group: 33.32 ± 1.57) and mean birthweight (orogastric group: 1,753.3 ± 414.51, nasogastric group: 1,859.6 ± 307.05). Preterm infants who were fed via bolus nasogastric tube achieved full enteral feeding in a significantly shorter duration compared with the infants fed via bolus orogastric tube. The incidence rates of aspiration and feeding tube displacement were significantly higher in the bolus orogastric tube group compared with the bolus nasogastric tube group. There was no difference in the incidence rates of apnea, necrotizing enterocolitis, bradycardia, oxygen desaturation, and gastric residual in both groups. Conclusion Preterm infants without any respiratory support receiving bolus nasogastric tube feeding achieved full enteral feeding significantly sooner than those receiving bolus orogastric tube feeding. Additionally, bolus nasogastric tube feeding had a lower incidence of aspiration, tube displacement, and the infants regained birthweight more quickly than those receiving orogastric tube feeding. Key Points

Chewing Screen and Interventions for Older Adults

Seeing older adults with nasogastric (NG) tubes in nursing homes is an unfortunately widespread phenomenon in Taiwan. NG tubes deprive the wearer of the tastes, smells, and joys of food and have been associated with malnutrition and increased susceptibility to aspiration pneumonia. In our studies, we found that 43% of nursing home residents in Taiwan are intubated with an NG tube and revealed a significant lower body mass index and hypoalbuminemia in these residents. In addition, the prevalence of dysphagia in residents of long-term care institutions was found to be greater than 60%. Older adults with dysphagia usually rely on liquid diets, which are frequently low in fiber, fruit, vegetable, and cereal contents. It is well known that diets low in fiber and vegetables increase the risks of constipation and cardiovascular events in older adults. A low intake of plant flavanols may also make older adults more susceptible to chronic inflammation. A high intake of red meats, eggs, or seafood may nurture gut microorganisms that catabolize carnitine and choline to trimethylamine-N oxide and which have been significantly linked to cardiovascular diseases and increased mortality. In contrast, eating plant vegetables and cereals is known to nurture better microbiota that produce short chain fatty acids, which, in turn, nurture enterocytes and improve immunity and brain health. Thus, the aims of this article are to demonstrate how to assess elders with chewing difficulty and dysphagia and to provide functional food scales for the classification, training, and care of active-aging nutrition. Through this article, we anticipate helping long-term care caregivers master key techniques for training and caring for elders with chewing difficulties and/or dysphagia. This article is also expected to 1) improve the nutrition of elders and satisfaction with feeding, 2) improve chewing and dysphagia care and training in long-term care institutions, and 3) avoid NG tube institution and aspiration pneumonia. The suggestions of this article may be used in the future to assist long-term care units across the interdisciplinary care providers teams to promote chewing instruction, swallowing care training, and active aging, appropriate nutrition, and health in older adult populations.

A Quasi Experimental Study to Evaluate the Effectiveness of Selected Nursing Interventions (Steam Inhalation, Deep Breathing Exercises and Ambulation) in Terms of Physiological Parameters and Selected Post-operative Outcomes among Patients Undergoing Abdominal Surgery in Selected Hospital of Delhi, India

Introduction & Background of the Study: Surgery is one of the unique experiences for the individual. There is an increased demand of oxygen to the cells of the body during this period. Patients may have some impairment of respiratory functions after surgery. If it is not treated earlier it may lead to development of respiratory complications such as hypostatic pneumonia, atelectasis, and respiratory failure. In post operative period patient has a greater risk of alteration in the physiological parameters. Postoperatively 30% patients experience alteration in physiological parameters. Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. Physiological parameters monitoring in the perioperative period for moderate- and high-risk surgical patients can improve postoperative outcome. Steam inhalation Deep breathing, coughing exercises and ambulation helps in oxygenation of the tissues However improvement in physiological parameters and post-operative outcomes delivered the overall quality of care. Aim: The study is to assess the effectiveness of selected nursing interventions (steam inhalation, deep breathing exercises and ambulation) regarding post-operative outcomes in terms of physiological parameters (temperature, pulse, respiration, blood pressure, pain) and selected post-operative outcomes (presence of cough, presence of bowel sounds, passage of flatus, passage of stool, amount of nasogastric tube aspiration, amount of abdominal drainage, activities of daily living, oral feeding, day of foleys catheter removal and days of hospital stay) among abdominal surgery patients. Material & Methods: A quasi-experimental pre-test post-test control group research design was adopted on 60 patients by using purposive sampling technique. 30 patients for control group and 30 patients for experimental group. A self-prepared observation checklist was used before and after implementation of nursing interventions to assess the physiological parameters and selected post-operative outcomes. Conclusion: It was concluded that physiological parameters were more stable and better results were observed in terms of post-operative outcomes in the experimental group than the control group.

Study of percutaneous endoscopic gastrostomy compared to nasogastric tube feeding in patients requiring prolong enteral nutritional support

Background: The aims and objectives of this article were to compare the advantages, disadvantages associated with percutaneous endoscopic gastrostomy (PEG) and nasogastric (NG) tube and also to compare complications, to measure the outcomes in terms of hospital stay, mortality and improvement in nutritional status.Methods: In this prospective and interventional study 25 patients were selected in each group on an alternate basis. Study was conducted on cases of traumatic brain injury and cerebrovascular accident patients admitted in Department of General Surgery, IGGMC for a period of November 2013- November 2015 with a need to provide prolonged enteral nutritional support. Each patient was assessed by a dietician and received a standard enteral feeding according to their body weight. The main outcome was measures at 4 weeks were complications (tube dislodgement, aspiration pneumonia, tube blockade and peristomal infections) and nutritional status.Results: The anthropometric parameters (mid arm circumference, biceps skin fold thickness and triceps skin fold thickness) and serum albumin showed a rise in PEG group at 4 weeks when compared to baseline (0 week) whereas they showed a decline in NG group at follow up (4 weeks). The NG group has got higher mortality 4 (17%) when compared to PEG group 2 (7%) due to aspiration pneumonia. Hence, PEG is better tolerated with lesser complications better nutritional support as assessed by the anthropometric parameters at 4 weeks.Conclusions: We conclude that whenever feasible percutaneous endoscopic gastrostomy (PEG) feeding is a choice over nasogastric (NG) feeding in patients requiring long term enteral support.

Acute myocardial infarction in patient without cardiac risk factors during emergence from general anesthesia: a case report

BackgroundPerioperative myocardial infarction is a rare but highly fatal complication, which often occurs in patients with poor preoperative cardiac conditions undergoing high-risk surgery. We report a case of acute myocardial infarction in a patient without cardiac risk factors during emergence from general anesthesia for removal of spinal screws.Case presentationA 37-year-old, 60 kg, and 160 cm man, who had no history of cardiovascular diseases, underwent removal of loosen spinal plug screws at L4-L5. The preoperative investigations revealed no abnormality and the patient was ASA I. The surgery was uneventful. During aspiration of the endotracheal tube, the patient suddenly experienced paroxysmal atrial fibrillation and ST segment elevation in DII lead. He was treated with oxygenation, optimal hemodynamics, minimize cardiac work, antiarrhythmias, and anticoagulation. The clinical conditions improved. Sinus rhythm was regained after 24 h and discharged without complications.ConclusionsMyocardial infarction can occur suddenly and unexpectedly in patients without risk factors after a low-risk surgery in any period of general anesthesia. Close monitoring and prompt treatment with this condition is important for improving outcomes.

Standardizing education in interventional pulmonology in the midst of technological change.

Interventional pulmonology (IP) is a maturing subspecialty of pulmonary medicine. The robust innovation in technology demands standardization in IP training with both disease and technology driven training. Simulation based training should be considered a part of IP training as seen in other procedural and surgical subspecialties. Procedure volume is a component of training; however, this does not guarantee or translate into competency for learners. Basic competency skills can be assessed using standardized well validated assessment tools designed for various IP procedures including flexible bronchoscopy, endobronchial ultrasound guided transbronchial needle aspiration (EBUS TBNA), rigid bronchoscopy and chest tube placement; however, further work is needed to validate tools in all procedures as new technologies are introduced beyond fellowship training. Currently there are at least 39 IP fellowship programs in the United States (US) and Canada which has led to improved training by accreditation of programs who meet rigorous requirements of standardized curriculum and procedural volume. The challenge is to be innovative in how we teach globally with intention and how to best integrate new evolving technology training for those not only during fellowship training but also beyond fellowship training.

Methods of Estimating Nasogastric Tube Length: All, Including "NEX," Are Unsafe.

Predominance of blind feeding tube placement makes esophageal tube misplacement and aspiration risk commonplace. Accurate estimation of nose-to-stomach length could reduce this risk. Standards for estimating this length were audited against the length measured from guided tube placement. This prospective, single-center observational study used electromagnet-guided tube placement to measure the length from nose to gastric body flexure as part of routine care. This measurement was used to audit standard equations used to estimate this length from external measures: xiphisternum-ear-nose + 10cm (XEN+10), nose-ear-xiphisternum (NEX), and Hanson_A and Hanson_B. From April 23, 2015, to March 2, 2020, measurements were obtained from 200 primary tube placements. Median length to the gastric body flexure (61cm) was significantly different from that to the pre-gastroesophageal junction flexure (48cm) or lengths predicted by NEX (51cm) or Hanson_A (50.5cm) and Hanson_B (56.1cm) (all P < .00001) but similar to XEN+10 (61cm). Esophageal placement was a potential risk for all methods (NEX: 96.3%, Hanson_A: 99.5%, Hanson_B: 86.9%, XEN+10: 43.2%) and a definite risk for most (NEX and Hanson_A: 14.9%, Hanson_B: 1%, XEN+10: 0%). NEX and Hanson methods of predicting the length from nose to gastric body flexure are too short and risk esophageal misplacement. XEN+10 reduces but does not eliminate this risk. External measurement predictions are clinically unsafe as a guide blind tube placement. Guided placement is recommended.

Clinical Outcomes of Percutaneous Endoscopic Gastrostomy in the Surgical Intensive Care Unit.

Background/AimsPercutaneous endoscopic gastrostomy (PEG) is usually performed on patients with chronic underlying diseases in the general ward (GW). This study evaluated the clinical outcomes of PEG performed on patients in the surgical intensive care unit (SICU) compared with those of PEG performed in the GW. MethodsThe medical records of 27 patients in the SICU and 263 in the GW, who underwent PEG between January 2013 and July 2017, were retrospectively reviewed. ResultsThe median age of the 27 SICU patients was 66 years, and their median body mass index was 21.1 kg/m2. In the SICU group, the median baseline Sequential Organ Failure Assessment (SOFA) score was 4, and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 16. The median interval between surgery and PEG in SICU patients was 30 days, with a PEG failure rate of 3.7%. Acute complications in SICU patients included bleeding (7.4%) and ileus (11.1%), while chronic complications included aspiration pneumonia (7.4%) and tube obstruction (3.7%). The rates of acute and chronic complications did not differ significantly between the SICU and GW groups. The 30-day mortality rate was 14.8% in SICU patients and 5.3% in GW patients (p=0.073). ConclusionsPEG is a safe and feasible method of enteral feeding for critically ill patients who require ICU care after surgery.

Ascaris lumbricoides-induced small bowel obstruction; Experience from a tertiary care center

Introduction: Ascaris lumbricoides induced intestinal obstruction is a sequel of this parasitic infestation. It presents as colic, vomiting (bilious or nonbilious), abdominal distention, and at times peritonitis. Management includes indoor admission, intravenous fluids, rectal enemas, and serial clinical and radiological assessment for detecting any indication of surgery. We, in our study, we analyzed the outcome of conservative management and the use of oral administration of 76% gastrograffin. Materials and Methods: Clinical parameters of all these patients were recorded and kept under close monitoring of the clinical parameters. Patients were initially subjected to conservative treatment whereby patients were advised nil per oral, nasogastric tube aspiration, intravenous fluid, rectal enemas, and antibiotics as indicated. In some patients, without signs of peritonitis and severe obstruction, contrast agent Gastrograffin was administered either per oral or vie6a nasogastric tube. Serial abdominal radiographs were taken. Surgical intervention was performed if worms were not expelled after 48–72 h of conservative treatment or contrast gets held up after 24–36 h in small intestines or clinical deterioration. Data were analyzed statistically. Results: A total of 240 patients were included in this study. The abdominal pain 156 (65%) was the most common symptom followed by distension in 168 (70%). Among patients, 65% were boys (n = 156) and 35% girls (n = 84). The clinical signs included abdominal distention in 168 (70%), tenderness in 28 (11%), rigidity 34 (14%), palpable worm masses in 115 (48%), and visible gut loops in 29 (23%). Most of the patients 204 (85%) responded to conservative management. Among 36 patients who needed surgery, 10 patients had received oral contrast. The peroperative findings included-impacted worms in 14 cases, impacted worm mass with gangrene 6 cases, intussusceptions without gangrene 7 cases, and gut volvulus with gangrene in 9 cases. The average hospital stay was 4.40 ± 2.25 days in cases managed conservatively, whereas about 10.35 ± 6.24 days in cases needing surgical intervention. There was no mortality in our series. Conclusions: Ascaris-induced worm obstruction should be managed conservatively; surgery is indicated if conservative management does not result in clinical improvement. The addition of Gastrograffin orally in some patients without complete obstruction significantly decreases the hospital stay and reduces the time period between admission to the expulsion of the worms.

Unedited microneurosurgery of a falcotentorial meningioma

Background:Falcotentorial meningiomas are pineal region meningiomas that arise from the dura of the tentorium cerebelli and posterior part of the falx. These tumors are commonly supplied by branches of the internal carotid artery such as the meningohypophyseal trunk, inferolateral trunk, and anterior choroidal artery. Less frequently, branches of the ophthalmic artery, vertebral artery, or external carotid artery are also involved. Based on neuroimaging studies, falcotentorial meningiomas may be classified as anterior, superior, inferior, and posterior types. Here, we present an unedited microsurgical resection of a superior falcotentorial meningioma.Case Description:The patient with a meningioma of the posterior inferior falx and a minimal extension to the tentorium underwent sitting praying position and a right occipital interhemispheric approach. Strong retraction of the dura followed a superior sagittal sinus based opening. Careful microsurgical access between the medial surface of the occipital lobe and the falx toward the splenium of corpus callosum allowed us to recognize the lesion. Thus, a cottonoid placed over the cerebral surface avoiding direct contact with the bipolar forceps, and the constant separation of the falx cerebri with the aspiration tube along the access developed a proper surgical route preventing any cortical lesion. Along the approach, cerebrospinal fluid was continuously released from the pericallosal cistern as well. Once well recognized the meningioma, we proceeded with the internal decompression of the lesion using a thumb regulated suction tube and bipolar forceps. Tissue samples from the tumor were taken for the histological diagnosis, and under conventional microsurgical technique, the meningioma was completely removed by piecemeal technique. A small lateral tear on the falx required hemostatic reparation with Tachosil. Water dissection provided us a clear cleavage plane for the microsurgical dissection of the tumor and maintained a clean operative field along the procedure. Occipital arteries running over the lateral surface of the meningioma were carefully dissected and isolated from the lesion, while the deep venous system did not achieve any contact with the tumor. After the ipsilateral component of the meningioma was resected, we intent are dissecting the contralateral segments of the tumor with a curved dissector. At the last stage of the surgery, small incision at a tumor-free segment of the falx allowed us to remove the falcotentorial attachment of the lesion. Under high microscopic magnification, the remaining minimal portion of meningioma extending under the tentorium was coagulated. After complete microsurgical removal of the meningioma, careful homeostasis based on electrocoagulation surgical and Tachosil was achieved. Finally, we performed a surgical wound closure under standard technique.Conclusion:This unedited video offers all detailed aspects for an efficient and safe falcotentorial meningioma microneurosurgery.Videolink:http://surgicalneurologyint.com/videogallery/pineal-meningioma.

Pneumothorax-Time for New Guidelines?

Pneumothorax is a common pathology, but optimal management strategies are not yet defined. There are significant differences in international guidelines and therefore variation in clinical practice.There is increasing interest in pneumothorax research, particularly primary spontaneous pneumothorax (PSP), with evidence of lung abnormalities in this group without clinically apparent lung disease and recently completed clinical trials aiming to optimize management. The most robust evidence base is that of the equivalence of needle aspiration and chest tube insertion for initial management of PSP; although, patients with secondary spontaneous pneumothorax may also benefit. A convincing case for surgical intervention or thoracoscopy and talc poudrage to prevent recurrence at first episode in PSP has yet to be made. Clinicians should be vigilant for PSP being the first manifestation of a systemic disease, and should have a low threshold for onward referral. Time to change guidelines? First, chest tube drainage and hospitalization without recurrence prevention should no longer be standard treatment, as this has no advantage over the less invasive manual aspiration, which moreover can be performed on an outpatient basis in an important number of patients. The results of recent trials in conservative and ambulatory management are eagerly awaited. Second, shared decision-making should become more important with the well-informed patient, who may want to avoid a 1 in 3 recurrence rate and therefore will have the possibility to choose treatment including recurrence prevention even after the first episode of PSP. Third, surgical research should urgently make clear if the current practice of resection of emphysema-like changes is routinely necessary, alongside pleurodesis. Future studies should utilize risk stratification by clinical and radiological parameters (e.g., high-resolution computed tomography scanning and digital air leak monitoring) to predict short- and long-term outcomes, and hence personalize management.

Peranan Ultrasonografi Toraks dalam Menegakkan Diagnosis Beberapa Kelainan pada Paru

Ultrasound is useful in the diagnosis of cases in the field of lung disease, such as pleural effusion, pneumothorax, consolidation, atelectasis, pulmonary edema, and others. The advantages of thoracic ultrasound is a low cost, radiation is small, easy to carry, short examination time and has a dynamic aspect that can be seen at the time of examination. Thoracic ultrasound is an inexpensive tool and can be used to assist in intervention, especially in cases of peripheral lung, pleura and chest wall diseases, such as thoracocentesis, chest tube installation and aspiration lung abscess. Ultrasound can also replace aspiration and biopsy with CT-scan guidance in cases involving the pleura, chest wall, and lung tumors that invade the pleura and chest wall. With the ultrasound portable and compact form, in the future is possible if the ultrasound will be a routine part of the examination as well as a stethoscope. However, ultrasound also has limitations which in patients with subcutaneous emphysema, peripheral edema and obesity, lung ultrasound is hard to do. Ultrasound examination is also highly dependent on the experience and ability of the ultrasound operator.

Endoscopic Ultrasonography-Guided Gallbladder Drainage as a Treatment Option for Acute Cholecystitis after Metal Stent Placement in Malignant Biliary Strictures.

Background/AimsIt is often difficult to manage acute cholecystitis after metal stent (MS) placement in unresectable malignant biliary strictures. The aim of this study was to evaluate the feasibility of endoscopic ultrasonography-guided gallbladder drainage (EUS-GBD) for acute cholecystitis.MethodsThe clinical outcomes of 10 patients who underwent EUS-GBD for acute cholecystitis after MS placement between January 2011 and August 2018 were retrospectively evaluated. The procedural outcomes of percutaneous transhepatic gallbladder drainage (PTGBD) with tube placement (n=11 cases) and aspiration (PTGBA) (n=27 cases) during the study period were evaluated as a reference.ResultsThe technical success and clinical effectiveness rates of EUS-GBD were 90% (9/10) and 89% (8/9), respectively. Severe bile leakage that required surgical treatment occurred in one case. Acute cholecystitis recurred after stent dislocation in 38% (3/8) of the cases. Both PTGBD and PTGBA were technically successful in all cases without severe adverse events and clinically effective in 91% and 63% of the cases, respectively.ConclusionsEUS-GBD after MS placement was a feasible option for treating acute cholecystitis. However, it was a rescue technique following the established percutaneous intervention in the current setting because of the immature technical methodology, including dedicated devices, which need further development.

The Utility of Indigo Carmine and Lipiodol Mixture for Preoperative Pulmonary Nodule Localization before Video-Assisted Thoracic Surgery

PurposeTo evaluate the safety and efficacy of a mixture of indigo carmine and lipiodol (MIL) as a marker of pulmonary nodule before video-assisted thoracic surgery (VATS). Materials and MethodsOne hundred sixty-eight sessions of pulmonary marking were performed using MIL before VATS for 184 nodules (mean size, 1.2 ± 0.6 cm; range, 0.3–3.6 cm) on 157 patients (83 men and 74 women; median age, 66 years). The mean distance between the lung surface and the nodule was 0.8 ± 0.7 cm (range, 0–3.9 cm). MIL was injected near the nodule using a 23-gauge needle. Mean number of 1.2 ± 0.4 (range, 1–3) punctures were performed in a session for the target nodules, with mean number of 1.1 ± 0.3 (range, 1–3). Successful targeting, localization, and VATS were defined as achievement of lipiodol accumulation at the target site on computed tomography, detection of the nodule in the operative field by fluoroscopy or visualization of dye pigmentation, and complete resection of the target nodule with sufficient margin, respectively. ResultsThe successful targeting rate was 100%, and the successful localization rate was 99.5%, with dye pigmentation for 160 nodules (87.0%) and intraoperative fluoroscopy for 23 nodules (12.5%). Successful VATS was achieved for 181 nodules (98.4%). Two nodules (1.1%) were not resectable, and surgical margin was positive in 1 nodule (0.5%). Complications requiring interventions occurred in 5 sessions (3.0%) and included pneumothorax with chest tube placement (n = 3) and aspiration (n = 2). No complication related to the injected MIL occurred. ConclusionsMIL was safe and useful for preoperative pulmonary nodule marking.

Needle aspiration versus intercostal tube drainage for pneumothorax in the newborn.

Pneumothorax occurs more frequently in the neonatal period than at any other time of life and is associated with increased mortality and morbidity. It can be treated with either aspiration with a syringe (using a needle or an angiocatheter) or a chest tube inserted in the anterior pleural space and then connected to a Heimlich valve or an underwater seal with continuous suction. To compare the efficacy and safety of needle aspiration (either with immediate removal of the needle or with the needle left in situ) to intercostal tube drainage in the management of neonatal pneumothorax (PTX). We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2018, Issue 5), MEDLINE via PubMed (1966 to 4 June 2018), Embase (1980 to 4 June 2018), and CINAHL (1982 to 4 June 2018). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Randomised controlled trials, quasi-randomised controlled trials and cluster trials comparing needle aspiration (either with the needle or angiocatheter left in situ or removed immediately after aspiration) to intercostal tube drainage in newborn infants with pneumothorax. For each of the included trials, two authors independently extracted data (e.g. number of participants, birth weight, gestational age, kind of needle and chest tube, choice of intercostal space, pressure and device for drainage) and assessed the risk of bias (e.g. adequacy of randomisation, blinding, completeness of follow-up). The primary outcomes considered in this review are mortality during the neonatal period and during hospitalisation.We used the GRADE approach to assess the quality of evidence. Two randomised controlled trials (142 infants) met the inclusion criteria of this review. We found no differences in the rates of mortality when the needle was removed immediately after aspiration (risk ratio (RR) 3.92, 95% confidence interval (CI) 0.88 to 17.58; participants = 70; studies = 1) or left in situ (RR 1.50, 95% CI 0.27 to 8.45; participants = 72; studies = 1) or complications related to the procedure. With immediate removal of the needle following aspiration, 30% of the newborns did not require the placement of an intercostal tube drainage. None of the 36 newborns treated with needle aspiration with the angiocatheter left in situ required the placement of an intercostal tube drainage. Overall, the quality of the evidence supporting this finding is very low. There is insufficient evidence to establish the efficacy and safety of needle aspiration and intercostal tube drainage in the management of neonatal pneumothorax. The two included trials showed no differences in mortality; however the information size is low. Needle aspiration reduces the need for intercostal tube drainage placement. Limited or no evidence is available on other clinically relevant outcomes.

Manual aspiration versus chest tube drainage in primary spontaneous pneumothorax without underlying lung diseases: a meta-analysis of randomized controlled trials.

Although primary spontaneous pneumothorax (PSP) is an extremely frequent pathology, there is still no clear consensus on the treatment for these patients. We performed a strict meta-analysis on the effectiveness of manual aspiration (MA) compared to chest tube drainage (CTD) for the treatment of PSP. A literature search was performed on PubMed, EMBASE and the Cochrane Library to identify randomized controlled trials comparing MA with CTD for the treatment of PSP. Independent reviewers evaluated the methodological quality of the included randomized controlled trials. Statistical heterogeneity among studies was quantitatively evaluated using the I-squared index. Five randomized controlled trials were included, and a total of 358 subjects were reported on. We found that MA was related to significantly shorter hospital stays [in days; mean difference -1.70, 95% confidence interval (CI) -2.36 to -1.04; P < 0.00001, fixed effect model] compared with CTD. However, no significant differences were found between the 2 treatments for immediate success rate (risk ratio 1.15, 95% CI 0.73-1.81; P = 0.54), 1-year recurrence rate, 1-week success rate, time of recurrence, chest surgery rate or complication rate. Subgroup analysis showed that MA can provide a significantly lower hospitalization rate than CTD with a tube size of >12 Fr or a water seal drainage system. On the basis of the currently available literature, MA is advantageous in the treatment of PSP because of shorter hospital stays. The subgroup analysis also indicates that MA can provide a lower hospitalization rate than CTD with a tube size of >12 Fr or a water seal drainage system. However, there are no significant differences between the 2 interventions with respect to immediate success rate, 1-year recurrence rate, 1-week success rate, time of recurrence, chest surgery rate or complication rate.

The Next Step in In-Vivo Liver Engineering: Generation of an In vivo Liver Lobe Scaffold Which is Structurally Intact and Physiologically Reperfusable

In-vivo liver decellularization has become a promising strategy to study in-vivo liver engineering. However, long term survival after in vivo liver decellularization has not yet been achieved. This study aims to establish a survival model of in-vivo perfusion-decellularization of a selective liver lobe.We compared three decellularization protocols (1%Triton X100 followed by1%SDS, 1% SDS versus 1%Triton X100, n=6/group). Using the optimal one as judged by macroscopy, histology and DNA-content, we characterized the structural integrity and matrix-proteins using Histology, scanning electron microscopy (SEM), CT scanning and Immunohistochemistry. We prevented contamination of the abdominal cavity with the corrosive detergents by using polyvinylidene chloride (PVDC) film+dry gauze in comparison to PVDC-film+dry gauze+aspiration tube (n=6/group). Physiological reperfusion was assessed by histology. Survival rate was determined after a 7d observation period.Only perfusion with 1% SDS resulted in an a cellular scaffold (fully translucent without histologically detectable tissue remnants, DNA<50ng/mg) with remarkable structural and ultrastructural integrity as well as preservation of main matrix proteins (immunohistochemically positive for collagen I and IV, laminin, fibronectin and elastin). Upon reperfusion, the liver turned red within sec without any leakage from the surface of the liver. 12h after reperfusion, blood cells but also some clots were visible in the portal vein, sinusoidal matrix network and central vein, suggesting physiological perfusion. Complete abdominal protection was achieved by placing a suction tube in addition to the PDVC-film+dry gauze and allowed 7d-survival of all animals.In conclusion, we successfully completed a survival model of high quality in-vivo decellularization within 2h as next step towards in-vivo liver engineering.

Indications, Clinical Outcomes, and Survival Rate of Pediatric Penetrating Keratoplasty in Suburban Malaysia: A 10-year Experience.

PurposeTo describe the demographics, indications, clinical outcomes and survival rate of penetrating keratoplasty in Malaysian children living in a suburban area, and discuss the literature on paediatric penetrating keratoplasty.MethodologyA retrospective review of medical records was performed on children younger than 17 years of age who had undergone penetrating keratoplasty in Hospital Universiti Sains Malaysia from January 2008 to December 2017. We recorded demographic data, presenting visual acuity, indications, final visual acuity, and graft survival at 12 months into the postoperative period.ResultsSixteen eyes of 14 children had penetrating keratoplasty. Mean age was 7.8 ± 5.9 years. Both genders were equally affected. The main indications were infective keratitis (56.25%), congenital corneal opacity (18.75%) and trauma (12.50%). There were 62.50% of patients who had a preoperative visual acuity worse than 6/60. Fifty percent had other combined procedures during the surgery, including lens aspiration, peripheral iridectomy, pupilloplasty and glaucoma tube implant. Best corrected visual acuity of 6/12 or better was achieved in 18.75% of patients. A hazy graft was noted in 68.75% of patients, and was attributed to graft rejection, glaucoma and graft failure. There was a statistically significant association between the presence of vascularized cornea, intraocular inflammation and combined surgery with survival rate of the graft at one-year postoperative period (p < 0.05).ConclusionsInfective keratitis is the main indication for penetrating keratoplasty in our pediatric patients. Good visual outcome was documented in a small percentage of the patients. Amblyopia and hazy graft were the main barriers to success in this group of patients. Vascularized cornea, inflammation and combined surgery had significantly affected the survival rate of the grafts in our series.

Establishment of a novel and effective reflux laryngitis model in rabbits: a preliminary study.

To establish a novel and effective reflux model with a modified nasogastric aspiration tube and to investigate the association between different types of nasogastric aspiration tubes and reflux laryngitis, we conducted this study. Thirty-eight healthy New Zealand albino rabbits (2.5-3.5kg) were divided into three groups: control (CTR, n = 6)-non-intubated; normal nasogastric intubation (NNI, n = 16)-intubated with 4#, 6#, 8#, and 10# normal nasogastric aspiration tubes; and modified nasogastric intubation (MNI, n = 16)-intubated with 4#, 6#, 8#, and 10# modified nasogastric aspiration tubes. The laryngoscopy, body weight, and pH values at the esophageal entrance were recorded before and 1, 2, and 4 weeks after intubation. After the final laryngoscopy, the animals in groups with a pH below 4 were sacrificed to obtain histological and gene expression analysis results. The reflux finding score (RFS) after 4 weeks showed that there was a statistically significant difference in the 8# NNI group (7 ± 0.816, P < 0.001), the 8# MNI group (11.5 ± 2.517, P < 0.001) and the 10# MNI (12.75 ± 1.893, P < 0.001) group compared with the control group (1.83 ± 1.602). The pH values of these three groups were lower than 4. However, the weight loss of the rabbits in the 10# NNI and 10# MNI groups was more obvious. Submucous gland hyperplasia and inflammation were significantly increased in the 8# NNI group, 8# MNI group and the 10# MNI group, but in the level of some pro-inflammatory cytokines and COX-2, the MNI group was significantly higher than the NNI group (8# NNI × 8# MNI, P < 0.01; 8# MNI × 10# MNI, P < 0.01). This study showed that 8# modified nasogastric intubation (MNI) produces effective reflux laryngitis in the rabbits.