Insertion Failure Research Articles

A Double-Blind, Randomized, Placebo-Controlled Study on the Evaluation of the Efficacy of Vaginal Misoprostol Plus Intramuscular Diclofenac Sodium in to Ease Insertion of Intra Uterine Contraceptive Device in Stenosis Cervix

Abstract Background: Intrauterine contraceptives (IUCs) are one of the most powerful contraceptives. The most popular versions used worldwide are the Cut 380A vice (Cu-IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS). Both forms are safe, cost-effective in the long run. Aim of Study: The aim of this study was to evaluate the efficacy of combination of vaginal misoprostol with intramus-cular diclofenac sodium in decreasing pain and facilitating IUD insertion in women with cervical stenosis. Patients and Methods: The patients were randomized to four groups (32 patient each) using simple randomization (closed envelop) and classified into: The first group (Misopr-ostol Group): Includes 32 patients who received two tablets (400mg) of misoprostol in the posterior fornix of the vagina 2 hours before IUD insertion. The second group (Diclofenac Group): Includes 32 patients who received diclofenac sodium 75mg ampule intramusculary 2 hours before IUD insertion. The third group (Misoprostol Diclofenac Group): Includes 32 patients who received two tablets (400mg) of misoprostol in the posterior fornix of the vagina and diclofenac sodium 75mg ampule intramusculary 2 hours before IUD insertion. The fourth group (placebo Group): Includes 32 patients who received placebo. Result: Misoprostol group and misoprostol diclofenac group showed a significant higher number of easy IUD inser-tion, and misoprostol diclofenac group showed a significant lower extremely difficult insertion in comparison to other groups. There was statistically significant difference between misoprostol diclofenac and placebo groups as regard pain. Conclusion: The administration of vaginal misoprostol and intramuscular diclofenac sodium before IUCD insertion in women with cervical stenosis facilitate the IUCD insertion, decrease failure of insertion and reduce pain sensation during IUCD insertion.

Laryngeal mask airway protector generates higher oropharyngeal leak pressures compared to the laryngeal mask airway supreme: A randomized clinical trial in the ambulatory surgery unit.

Background and Aims:The Laryngeal Mask Airway (LMA) Protector™ is one of the latest introduced supraglottic airway devices. It provides access and functional separation of the respiratory and digestive tracts. Compared to the LMA Supreme™, it has two digestive ports, one to provide suction in the pharyngeal region and one for gastric tube insertion. High oropharyngeal leak pressure is a marker for safe ventilation when using LMA devices. We hypothesized that oropharyngeal leak pressure of the LMA Protector™ is 5 cm H2O higher than the oropharyngeal leak pressure of the LMA Supreme™ at various cuff volumes. Secondary outcome measures were ease of insertion of both masks, fiberoptic confirmation of correct positioning, failures of insertion, presence of blood staining, sore throat, presence of air leak and insertion time.Material and Methods:American Society of Anesthesiologists (ASA) I-III patients aged >18 years, scheduled for elective minor ambulatory surgery under general anesthesia with a LMA were included. Patients were randomized in the LMA Protector™ or LMA Supreme™ group based on a computer-generated random sequence table. After general anesthesia induction, oropharyngeal leak pressures were measured.Results:Oropharyngeal leak pressures were significantly higher (P < 0.0001) for LMA Protector™ compared to LMA Supreme™ at different cuff volumes and a cuff pressure of 65 cm H2O. Insertion time was significantly higher for the LMA Protector™ (29 sec) [interquartile range (IQR) 23, 35] compared to the LMA Supreme™ (19 sec) (IQR 16, 22) (P < 0.0001). There were no statistically significant differences in ease of insertion (number of attempts for succesful positioning), failures of insertion, presence of blood staining, sore throat or presence of air leak.Conclusion:Oropharyngeal leak pressures were consistently higher (>5 cm H2O) for LMA Protector™ compared to LMA Supreme™. LMA Protector™, therefore, allows effective ventilation at higher airway pressures than LMA Supreme™.Trial Registration:http://clinicaltrials.gov.NCT03462550.

Perlindungan Hukum Bidan dalam Tindakan Pemasangan Alat Kontrasepsi dalam Rahim (AKDR) di Puskesmas

Increasing population growth can be suppressed through the Family Planning (Keluarga Berencana/KB) program, one of which is the installation of uterine contraceptive devices (IUDs) by midwives at the Puskesmas. Juridically, the midwife has the authority to install an IUD. However, contraceptive failure often occurs, in which midwives can face criminal or civil lawsuits regarding the IUD insertion case. The method in this study is a normative juridical approach to the law (statue approach) and conceptual approach (conceptual approach). Related to the problem of IUD insertion failure, midwives are only responsible for the installation actions according to their competency standards. While the results of failures that may occur can not be accounted for because the transactions that occur between midwives and patients emphasize the maximum effort of the midwife. Minister of Health Regulation No. 28 of 2017 related to the Licensing and Implementation of Midwife Practices that discusses the rights and authority of midwives regarding contraception. To ensure legal certainty, clear regulations regarding the profession of midwife are set out in the Midwifery Law.

Despite coronavirus, general practice is still the best job in the world.

<h3>Background</h3> Intrauterine contraception is a first-line option for young women, yet relatively few prospective studies have been performed in nulliparous women using currently available devices, and many providers are still reluctant to provide this option. <h3>Methods</h3> Between January 2012 and June 2014, 109 nulliparous women, aged 18–30 years, who had an intrauterine device (IUD) placed at a student health clinic [88 levonorgestrel-intrauterine system (LNG-IUS) users and 21 Cu T 380A (IUD) users] were surveyed at 1, 6, 12 and 18 months after insertion. <h3>Results</h3> Overall satisfaction was high; at follow-up survey 83% of 100 women (mean use 13.4 months) were ‘happy’ or ‘very happy’ with their IUD, and there were no differences in satisfaction between the two IUD types. Some 75% of participants stated that the insertion procedure went ‘very well’, despite 78% rating insertion pain as moderate to severe, and 46% experiencing vasovagal symptoms. The 12-month continuation rate was 89%, with discontinuations for expulsion (3%), side effects (6%), lack of anticipated benefit (1%) and pregnancy (1%). Users of the Cu T 380A were more likely to have heavy menses (74% vs 2%; <i>p</i>&lt;0.0001) or moderate to severe cramping (68% vs 20%; <i>p</i>=0.0002) compared with LNG-IUS users. There were no uterine perforations or diagnoses of pelvic inflammatory disease. The rate of failed insertions during the study period was 6.2%. <h3>Conclusions</h3> Despite significant symptoms with insertion, intrauterine contraception is safe, effective and ultimately well tolerated in nulliparous women and should be provided to this population in both university and community health settings.

LMA® Gastro™: A paediatric experience

The laryngeal mask airway, the LMA® Gastro™ (Teleflex Medical, Athlone, Ireland), is a novel airway device which permits upper gastrointestinal (GI) endoscopy to be performed via a dedicated large calibre oesophageal lumen. It has been validated in adult studies, but to our knowledge, there have been no data published regarding its use in a paediatric population. Following a brief education programme, the LMA Gastro was introduced on a trial basis at our institution and made freely available. Over a four-month period, our pre-existing endoscopy audit framework captured data on a total of 55 patients who had the LMA Gastro device chosen as the primary airway for elective upper GI endoscopy. These data were collected prospectively by the treating anaesthetist and included a range of airway and endoscopy outcomes. Of the 55 patients, the LMA Gastro provided an adequate airway in 52 (94.5%). Forty-six (88.5%) were sited on first attempt, and 50 (96.2%) insertions were rated 'easy' by the anaesthetist. Aside from three insertion failures, there were no airway events. The endoscopy success rate was 100% in the 52 patients who had an LMA Gastro airway successfully inserted. First-pass oesophageal access was achieved in 51 (98%) cases, and 100% of insertions were rated 'easy' by the gastroenterologist. Despite our relative inexperience with it, the device had a high success rate for airway maintenance and oesophageal access in our paediatric patient population. In our institution, the LMA Gastro provided a useful airway option in older children undergoing elective upper GI endoscopy.

Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial

Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure. We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143. 1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group. For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time. Becton Dickinson.

Perfecting temporary pacemakers in a developing country

ABSTRACT Introduction Transvenous pacemakers are used to temporarily pace heart in emergent situations. This study was conducted to analyze the current success rate of temporary pacemaker insertion in our institution and discover causes for failure to improve the technique. Methodology A retrospective cohort study was conducted of 263 patients from 2006 to 2016 who underwent TPM insertion at Aga Khan University Hospital, Karachi. Results The success rate for the procedure was 97.7%, with one mortality caused by the pacemaker. No significant risk factor was found for the failure of TPM. Conclusion There was no significant effect of anatomical site or technique on the failure of TPM insertion. However, with better training and higher experience of the residents, the complications and rate of failures can be reduced.

USING OF MISOPROSTOL VAGINALLY PRIOR TO INTRAUTERINE CONTRACEPTIVE DEVICE INSERTION FOLLOWING PREVIOUS INSERTION FAILURE: RANDOMIZED CLINICAL TRIAL

Background: Intrauterine devices (IUDs) are good contraceptive method for women as they have a long acting contraceptive effect compared to other hormonal methods. Misoprostol or prostaglandin El (PGE1) analogue is a synthetic prostaglandin that has been used to induce cervical ripening in vaginal delivery and in medical induction of abortion. Objective: To investigate the possible effect of vaginal administration of misoprostol to insertion of IUCDs in women with previous IUCD insertion failure. Subjects and methods: This study was done at Obstetrics and Gynecology Department of at El-Hussien hospital. It is a double blind randomized clinical trial. The study included 100 patients with previous failed attempt of IUD insertion, divided into two equal groups: Group I received misoprostol prior to IUD insertion and group II received placebo to IUD insertion. Results: There was high significant difference between the two groups regarding the degree of cervical softening and its effect on the success rate of IUCD insertion in each group. Conclusion: Vaginal misoprostol before IUD insertion in parous women with previous insertion failure increased the rate of successful insertion, particularly in women with previous cesarean delivery.

USING OF MISOPROSTOL VAGINALLY PRIOR TO INTRAUTERINE CONTRACEPTIVE DEVICE INSERTION FOLLOWING PREVIOUS INSERTION FAILURE: RANDOMIZED CLINICAL TRIAL

Background: Intrauterine devices (IUDs) are good contraceptive method for women as they have a long acting contraceptive effect compared to other hormonal methods. Misoprostol or prostaglandin El (PGE1) analogue is a synthetic prostaglandin that has been used to induce cervical ripening in vaginal delivery and in medical induction of abortion. Objective: To investigate the possible effect of vaginal administration of misoprostol to insertion of IUCDs in women with previous IUCD insertion failure. Subjects and methods: This study was done at Obstetrics and Gynecology Department of at El-Hussien hospital. It is a double blind randomized clinical trial. The study included 100 patients with previous failed attempt of IUD insertion, divided into two equal groups: Group I received misoprostol prior to IUD insertion and group II received placebo to IUD insertion. Results: There was high significant difference between the two groups regarding the degree of cervical softening and its effect on the success rate of IUCD insertion in each group. Conclusion: Vaginal misoprostol before IUD insertion in parous women with previous insertion failure increased the rate of successful insertion, particularly in women with previous cesarean delivery.

A cadaveric study on the rate of strain-dependent behavior of human anterior cruciate ligament

Purpose: Failure of anterior cruciate ligament often occurs in young sports personnel hampering their career. Such ACL ruptures are quite prevalent in sports such as soccer during dynamic loading which occurs at more than one rate of loading. In this work, a structural constitutive equation has been used to predict the forces acting on ACL for different rates of loading. Methods: Ligaments with distal femur and proximal tibia were subjected to tensile loading to avoid crushing of tissue ends and slipping at higher rates of strain. Custom designed cylindrical grippers were fabricated to clamp the distal femur and proximal tibial bony sections. To estimate parameters for the model, eighteen fresh cadaveric femur-ACL-tibia complex (FATC) samples were experimented on by pure tensile loading at three orders of rates of strain viz., 0.003, 0.03, and 0.3 s–1. The experimental force-elongation data was used to obtain parameters for De-Vita and Slaughter’s equation. The model was validated with additional tensile experiments. Results: Statistical analysis demonstrated failure stress, Young’s modulus and volumetric strain energy to vary significantly as a function of rate of strain. Midsection failure was observed only in samples tested at 0.03 s–1. Femoral or tibial insertion failure were observed in all other experiments irrespective of rate of strain. Conclusion: Human FATC samples were tensile tested to failure at three rates of strain using custom-designed cylindrical grippers. A structural model was used to model the data for the ACL behaviour in the linear region of loading to predict ligament behaviour during dynamic activities in live subjects.

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Posterior Humeral Avulsion of the Glenohumeral Ligament: A Rare and Nonspecific Injury

Improvement of impact resistance of plain-woven composite by embedding superelastic shape memory alloy wires

Carbon fiber reinforced polymer (CFRP) composites have excellent mechanical properties, specifically, high specific stiffness and strength. However, most CFRP composites exhibit poor impact resistance. To overcome this limitation, this study presents a new plain-woven CFRP composite embedded with superelastic shape memory alloy (SMA) wires. Composite specimens are fabricated using the vacuum-assisted resin injection method. Drop-weight impact tests are conducted on composite specimens with and without SMA wires to evaluate the improvement of impact resistance. The material models of the CFRP composite and superelastic SMA wire are introduced and implemented into a finite element (FE) software by the explicit user-defined material subroutine. FE simulations of the drop-weight impact tests are performed to reveal the superelastic deformation and debonding failure of the SMA inserts. Improvement of the energy absorption capacity and toughness of the SMA-CFRP composite is confirmed by the comparison results.

Efficacy and safety of misoprostol for intrauterine device insertion in women with no previous vaginal delivery

Introduction: The efficacy of misoprostol use for cervical priming before intrauterine device insertion (IUD) is controversial. This review aims to evaluate the evidence from published randomized controlled trials about the efficacy and safety of misoprostol before IUD insertion for pain relief in women with no previous vaginal delivery. Materials and methods: We searched the following electronic databases: Web of Science, Cochrane CENTRAL, SCOPUS, and PubMed for relevant studies using the following Mesh terms: (misoprostol) AND (intrauterine device OR IUD). The primary outcome was the mean pain score during insertion. Secondary outcomes included the ease of insertion score, the rate of successful IUD insertion, the rate of IUD insertion failure, and the adverse effects. Results: Ten randomized controlled trials (RCTs) (misoprostol: n=698 and placebo: n=689) were pooled in the analysis. The overall Standardized Mean Difference (SMD) of pain score did not favor either of the two groups (SMD= -0.09, 95%CI [-0.50, 0.33], p=0.007). Pooled results were highly heterogeneous (I2=93%, P<0.001). The total MD of the ease of insertion score favored the misoprostol group (MD= -1.36, 95% CI [-2.20, -0.52], p =0.002). The overall risk ratio (RR) of the number of failed insertions showed that misoprostol is associated with less IUD insertion failures compared to placebo (RR=0.55, 95% CI [0.38, 0.81], p=0.002). Finally, the overall risk showed that misoprostol is associated with more shivering, diarrhea and pelvic pain. Conclusions: Misoprostol facilitates IUD insertion in women with no previous vaginal delivery, and is associated with 50% less chance for IUD insertion failure despite inducing mild adverse effects

Percutaneous nephrostomy versus JJ ureteric stent as the initial drainage method in kidney stone patients presenting with acute kidney injury: A prospective randomized study.

To compare percutaneous nephrostomy tube versus JJ stent as an initial urinary drainage procedure in kidney stone patients presenting with acute kidney injury. Between January 2017 and January 2019, 143 patients with acute kidney injury secondary to obstructive kidney stone were prospectively randomized into the percutaneous nephrostomy tube group (71 patients) and JJ stent group (72 patients) at Beni-Suef University Hospital, Beni-Suef, Egypt. Exclusion criteria included candidates for acute dialysis, fever (>38°C), pyonephrosis, pregnancy and uncontrolled coagulopathy. The period required for serum creatinine normalization, failure of insertion, operative and fluoroscopy time were recorded. Definitive stone management for proximal ureteral stones >1.5cm consisted of percutaneous nephrolithotomy for the percutaneous nephrostomy group and ureteroscopic laser lithotripsy for the JJ stent group. For stone size <1.5cm, ureteroscopy or shockwave lithotripsy was carried out for both groups. Percutaneous nephrolithotomy was carried out for renal stones >2cm, and shockwave lithotripsy for stones <2cm. Distal and mid ureteral stones were treated by ureteroscopy. The percutaneous nephrostomy group had shorter operative time (P=0.001). There was no significant difference in the recovery period for normalization of serum creatinine between both groups (P=0.120). Procedural failure, ureteric mucosal injury and perforations increased in the case of male sex, stone size >1.5cm and upper ureteric stones in the JJ stent group. Procedural failure, pelvic perforations and intraoperative bleeding increased in case of male sex, mild hydronephrosis and stone size >2.5cm in the percutaneous nephrostomy group. Suprapubic pain, urethral pain and lower urinary tract symptoms were significant in the JJ stent group. The presence of a JJ stent directed us toward ureteroscopy (P=0.002) and the presence of a percutaneous nephrostomy directed us toward percutaneous nephrolithotomy (P=0.001). Percutaneous nephrostomy facilitates subsequent percutaneous nephrolithotomy, especially when carried out by a urologist, and it has a higher insertion success rate, a shorter operative time and a lesser incidence of postoperative urinary tract infection than a JJ stent. A JJ stent facilitates subsequent ureteroscopy, but operative complications can increase in the case of proximal ureteral stones >1.5cm.

The effects of labor on airway outcomes with Supreme\u2122 laryngeal mask in women undergoing cesarean delivery under general anesthesia: a cohort study

BackgroundPregnancy is associated with higher incidence of failed endotracheal intubation and is exacerbated by labor. However, the influence of labor on airway outcomes with laryngeal mask airway (LMA) for cesarean delivery is unknown.MethodsThis is a secondary analysis of a prospective cohort study on LMA use during cesarean delivery. Healthy parturients who fasted > 4 h undergoing Category 2 or 3 cesarean delivery with Supreme™ LMA (sLMA) under general anesthesia were included. We excluded parturients with BMI > 35 kg/m2, gastroesophageal reflux disease, or potentially difficult airway (Mallampati score of 4, upper respiratory tract or neck pathology). Anesthesia and airway management reflected clinical standard at the study center. After rapid sequence induction and cricoid pressure, sLMA was inserted as per manufacturer’s recommendations. Our primary outcome was time to effective ventilation (time from when sLMA was picked up until appearance of end-tidal carbon dioxide capnography), and secondary outcomes include first-attempt insertion failure, oxygen saturation, ventilation parameters, mucosal trauma, pulmonary aspiration, and Apgar scores. Differences between labor status were tested using Student’s t-test, Mann-Whitney U test, or Fisher’s exact test, as appropriate. Quantitative associations between labor status and outcomes were determined using univariate logistic regression analysis.ResultsData from 584 parturients were analyzed, with 37.8% in labor. Labor did not significantly affect time to effective ventilation (mean (SD) for labor: 16.0 (5.75) seconds; no labor: 15.3 (3.35); mean difference: -0.65 (95%CI: − 1.49 to 0.18); p = 0.1262). However, labor was associated with increased first-attempt insertion failure and blood on sLMA surface. No reduction in oxygen saturation or pulmonary aspiration was noted.ConclusionsAlthough no significant increase in time to effective ventilation was noted, labor may increase the number of insertion attempts and oropharyngeal trauma with sLMA use for cesarean delivery in parturients at low risk of difficult airway. Future studies should investigate the effects of labor on LMA use in high risk parturients.Trial registrationThe study was prospectively registered at clinicaltrials.gov (NCT02026882) on 3 January 2014.

Polyethylene glycol-based hydrogel rectal spacers for prostate brachytherapy: a systematic review with a focus on technique

IntroductionRadiation dose to the rectum in prostate brachytherapy (PBT) can be reduced by the use of polyethylene glycol (PEG) hydrogel spacers. This reduces the rate of rectal toxicity and allows dose escalation to the prostate. Our objectives were to provide an overview of technique for injection of a PEG hydrogel spacer, reduction in rectal dosimetry, gastrointestinal toxicity and potential complications.MethodsWe systematically reviewed the role of PEG hydrogel spacers in PBT using the Cochrane and PRISMA methodology for all English-language articles from January 2013 to December 2019. Data was extracted for type of radiotherapy, number of patients, type of PEG-hydrogel used, mean prostate-rectum separation, rectal dosimetry, acute and late GI toxicity, procedure-related complications and the technique used for hydrogel insertion.ResultsNine studies (671 patients and 537 controls) met our inclusion criteria. Of these 4 used DuraSeal® and 5 used SpaceOAR®. The rectal spacing achieved varied between 7.7-16 mm. Failure of hydrogel insertion was seen only in 12 patients, mostly related to failure of hydrodissection in patients undergoing salvage PBT. Where reported, the rectal D2 cc was reduced by between 21.6 and 52.6% and the median rectal V75% cc was reduced by between 91.8–100%. Acute GI complications were mostly limited to grade 1 or 2 toxicity (n = 153, 33.7%) with low levels of grade 3 or 4 toxicity (n = 1, 0.22%). Procedure-related complications were limited to tenesmus (0.14%), rectal discomfort (1.19%), and bacterial prostatitis (0.44%).ConclusionsPEG hydrogel spacers are safe to insert. Gel insertion is easy, fast and has a low rate of failure. These studies convincingly demonstrate a significant reduction in rectal dosimetry. Although the results of spacers in reducing rectal toxicity is promising, these need to be confirmed in prospective randomised trial.

Effect of echoendoscope angle on success of guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy.

With endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS), guidewire manipulation might be a critically limiting step for nonexperts. However, the causes of difficult guidewire manipulation remain unclear. The aim of this study was to evaluate factors associated with successful guidewire manipulation. This retrospective cohort study included consecutive patients who underwent EUS-HGS between October 2018 and October 2019. We measured scope angle between the long and needle axes of the echoendoscope using still fluoroscopic imaging immediately after puncturing the intrahepatic bile duct. Factors associated with successful guidewire insertion were assessed by multivariable analysis using logistic regression. The influence of the angle between the fine-needle aspiration (FNA) needle and echoendoscope on failed guidewire insertion was assessed using receiver operating characteristic (ROC) curves. Area under the ROC curve was 0.86 (95 % confidence interval [CI] 0.00 - 0.76), and an angle of 135° offered 88.0 % sensitivity and 82.9 % specificity for predicting successful guidewire insertion. According to multivariable analysis, only angle between the FNA needle and echoendoscope > 135° was independently associated with successful guidewire insertion (odd ratio 0.03, 95 %CI 0.01 - 0.14; P < 0.05), whereas sex, puncture site, and diameter of puncture site were not significant factors. After multivariable analysis, all variables were adjusted using age ≥ 70 or < 70 years, yielding the same results. The angle between the FNA needle and echoendoscope might be associated with successful guidewire manipulation during EUS-HGS. Adjusting this angle to 135° before puncturing the intrahepatic bile duct might be helpful in achieving successful guidewire manipulation during EUS-HGS.

Prevalence of and factors associated with difficult peripheral venipuncture in adult surgical patients.

To determine the prevalence of difficult venous access in adult patients admitted to a surgical unit. This observational prospective cohort study included 235 patients from a Brazilian hospital. Clinical data were collected by direct observation and analyzed by descriptive, inferential statistics, and multiple binomial logistic regressions. Odds ratios were also calculated. Most of the patients (66.4%) were men and self-reported as white (59.2%). The prevalence of difficult intravenous access was 32.8%. Predictors of peripheral intravenous cannula insertion failure were history of difficult intravenous access and nonvisibility of the vein. History of difficult intravenous access and a nonvisible venous network were significant predictors of peripheral cannula insertion failure in adults undergoing clinical surgery. The prevalence of difficult intravenous access was 32.8%.

The value of ultrasound guidance during IUD insertion in women with RVF uterus: A randomized controlled trial

ObjectiveThe study objective is to evaluate the benefits of using ultrasound guidance during insertion of Intrauterine device IUD in women with retroverted flexed RVF uteri. Study designA randomized controlled trial conducted on 400 women with RVF uteri eligible for IUD insertion. They were randomly divided into 2 groups. Group 1 underwent IUD insertion under ultrasound guidance while in group 2 no ultrasound guidance was used. The primary outcome measure was the(Visual Analogue Scale) VAS pain score reported by the women during insertion. Other outcome included easiness of insertion, the procedure time and occurrence of complications as nausea, vomiting, abdominal cramps, failure of insertion, uterine perforation and bleeding. ResultsThe VAS pain score was significantly lower (2.36 ± 1.77 vs. 4.74 ± 2.35, p < 0.001), the insertion was much easier (score 4.0 ± 0.9 vs. 2.5 ± 1.27, p < 0.001) and the time needed for the procedure was significantly shorter (5.82 ± 2.56 vs. 9.4 ± 4.99 min, p < 0.001) in women within the ultrasound guided group when compared to control group.The total rate of complications was significantly lower (6 vs. 16 %, p 0.001) especially bleeding (2 vs. 9%, p = 0.002), abdominal cramps (10.5 vs. 28 %, p 0.012) and failure of the procedure (0 vs. 3%, p = 005) in ultrasound guided group women when compared to control. ConclusionInsertion of Intrauterine device IUD under ultrasound guidance in women with Retroverted flexed RVF uterus easier and less painful than the blind standard technique.

Denial of Service Attack on Cuckoo Filter Based Networking Systems

Approximate membership check structures, such as Bloom filters or cuckoo filters, are widely used in Networking systems to speed up processing. Filters are beneficial as packets can be quickly examined to determine if further processing has to be done. This enables faster and more efficient processing that is needed to cope with the ever increasing traffic. Security is also becoming a critical issue for networked systems as we increasingly depend on them for most of our daily life tasks. Recently, the security of Bloom filters has been studied showing that depending on their implementation they may be vulnerable to attacks that degrade the false positive rate or that create false positives for certain elements. In this letter, the vulnerability of cuckoo filters is considered by first showing that an attacker can collapse the filter effectively disabling it by forcing insertion failures. This can be done with no knowledge of the implementation details. Then, in the second part of the letter, several techniques that could be used to mitigate such attacks are discussed.