Fluoroscopic Screening Research Articles

Biomechanical Motion Changes in Adjacent and Noncontiguous Segments Following Single-Level Anterior Cervical Discectomy and Fusion: A Computed Tomography-Based 3D Motion Capture Study.

Anterior cervical discectomy and fusion (ACDF) is known to elicit adverse biomechanical effects on immediately adjacent segments; however, its impact on the kinematics of the remaining nonadjacent cervical levels has not been understood. This study aimed to explore the biomechanical impact of ACDF on kinematics beyond the immediate fusion site. We hypothesized that compensatory motion following single-level ACDF is not predictably distributed to adjacent segments due to compensation from noncontiguous levels. Six fresh-frozen cervical spines (C2-T1) underwent fluoroscopic screening and sagittal and coronal reformats from computed tomography scans and were utilized to grade segmental degeneration. Each specimen was tested to 30° of flexion and extension intact and following single-level ACDF at the C5-C6 level. The motions of each vertebral body were tracked using 3-dimensional (3D) motion capture into an inverse kinematics model, facilitating correlations between the 3D reconstruction from computed tomography images and the 3D motion capture data. This model was used to calculate each level's flexion/extension range of motion (ROM). Single-level fusion at the C5-C6 level across all specimens resulted in a significant motion reduction of -6.8° (P = 0.002). No significant change in ROM occurred in the immediate adjacent segments C4-C5 (P = 0.07) or C6-C7 (P = 0.15). Hypermobility was observed in 2 specimens (33%) exclusively in adjacent segments. In contrast, the other 4 spines (66%) displayed hypermobility at noncontiguous segments. Hypermobility occurred in 42% (5/12) of the adjacent segments, 28% (5/18) of the noncontiguous segments, and 50% (3/6) of the cervicothoracic segments. Single-level ACDF impacts ROM beyond adjacent segments, extending to noncontiguous levels. Compensatory motion, not limited to adjacent levels, may be influenced by degenerative changes in noncontiguous segments. Surprisingly, hypermobility may not occur in adjacent segments after ACDF. Overall, the multifaceted biomechanical effects of ACDF underscore the need for a comprehensive understanding of cervical spine dynamics beyond immediate adjacency, and it needs to be taken into consideration when planning single-level ACDF.

THE TEN-YEAR RADIOLOGICAL RESULTS OF THE UNCEMENTED OXFORD MEDIAL COMPARTMENT KNEE ARTHROPLASTY

IntroductionThe Oxford Unicompartmental Knee Replacement (OUKA) is the most popular unicompartmental knee replacement (UKR) in the New Zealand Joint Registry with the majority utilising cementless fixation. We report the 10-year radiological outcomes.MethodsThis is a prospective observational study. All patients undergoing a cementless OUKA between May 2005 and April 2011 were enrolled. There were no exclusions due to age, gender, body mass index or reduced bone density.All knees underwent fluoroscopic screening achieving true anteroposterior (AP) and lateral images for radiographic assessment. AP assessment for the presence of radiolucent lines and coronal alignment of the tibial and femoral components used Inteliviewer radiographic software. The lateral view was assessed for lucencies as well as sagittal alignment.Results687 OUKAs were performed in 641 patients. Mean age at surgery was 66 years (39–90yrs), 382 in males and 194 right sided. 413 radiographs were available for analysis; 92 patients had died, 30 UKRs had been revised and 19 radiographs were too rotated to be analysed the remainder were lost to follow-up. Mean radiograph to surgery interval was 10.2 years (7.1–16.2yrs).RLLs were identified in zone 1 (3 knees), zone 2 (2 knees), zone 3 (3 knees), zone 5 (3 knees), zone 6 (2 knees) and zone 7 (42 knees). No RLL had progressed, and no case had any osteolysis or prosthesis subsidence.Alignment in the coronal plane: mean 2.90° varus (9.30° varus - 4.49° valgus) of the tibial component to the tibial anatomic axis and the femoral component in mean 4.57° varus (17.02° varus - 9.3° valgus). Sagittal plane posterior tibial slope was a mean 6.30° (0.44° -13.60° degrees) and mean femoral component flexion of 8.11° (23.70° flexion – 16.43° extension).ConclusionThe cementless OUKA demonstrates stable fixation with low revision rates at our centre supporting results earlier published by the design centre.

Robotic Precision vs. Human Dexterity—Benchtop Comparative Study of Free-Hand vs. Robotic-Assisted Puncture in Fluoroscopy-Guided Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy (PCNL) is the standard procedure for treating large kidney stones, especially those measuring over 20 mm or staghorn stones. Accurate placement of the tract into the renal collecting system of interest is crucial. Objective: To compare the free-hand puncture technique with robotic-assisted puncture during fluoroscopy-guided PCNL on a phantom kidney model in terms of efficiency and safety. A self-assessment of confidence levels after each puncture was recorded. Study Design: This prospective single-center benchtop study was conducted at the University Malaya Medical Centre (UMMC). Four urological residents participated and performed phantom punctures using both the free-hand bull’s eye technique and the automated needle targeting system with X-ray (ANT-X). Each resident performed a total of 60 punctures on the renal phantom models, with 30 punctures using the free-hand technique and 30 punctures using the ANT-X robotic-assisted system. Results: A total of 240 needle insertions were conducted, with 120 in the ANT-X group and 120 in the free-hand group. The success rate of needle insertions was 100% in both groups. However, the study revealed that the ANT-X group required, on average, an additional 51 s for needle puncture compared to the free-hand group (p < 0.001). In terms of fluoroscopic exposure, the ANT-X group exhibited significantly lower radiation exposure compared to the free-hand group (p < 0.001). Sub-analysis showed that puncture time remained consistent regardless of the technique used, but fluoroscopic screening time decreased with increasing participant experience. The ANT-X group also resulted in significantly lower radiation exposure during initial sessions compared to the free-hand technique. Surgeons’ self-assessment of confidence levels indicated a high level of confidence in needle puncture. Conclusions: Our benchtop study comparing the efficacy and safety between free-hand and ANT-X phantom punctures revealed comparable results. The needle puncture technique facilitated by the ANT-X system showed promising results in terms of reducing fluoroscopic exposure, albeit at the cost of longer operative times. This technology holds promise for novice surgeons who are in the early stages of their learning curve and might be useful for experienced surgeons looking to reduce radiation exposure.

Decreasing exposure to thyroid radiation in an orthopaedic theatre setting: an educational intervention.

The use of personal protective equipment (PPE) can significantly reduce staff exposure to harmful radiation and infection. Fluoroscopic procedures in orthopaedic theatre can generate high levels of radiation and good adherence to PPE use is essential to reduce long term cancer risk, including thyroid cancer. To assess baseline compliance with PPE, availability of PPE in theatre and carry out an intervention to promote greater use of PPE. This was a closed-loop interventional study set in a level 1 trauma centre and an elective/rehabilitation unit. Data were collected in 40 cases pre and post-intervention from 26th May-7th July 2017. All health care practitioners present at fluoroscopic screening were observed. PPE availability was audited daily. A questionnaire was used to assess surgical and nursing knowledge/practices regarding radiation/infection safety. An educational presentation was delivered to the groups at highest risk of exposure. 39/41 questionnaires were completed (29 surgeons, 10 nurses). 41% of respondents had taken a radiation training course or felt they had adequate training. There was a significant increase in the use of thyroid guards by surgeons 13/115 (11.3%) pre-intervention to 54/117 (46.2%) post-intervention (p<0.001) and radiographers (p=0.019) post-intervention. Logistic regression showed an 89.7% increased likelihood of thyroid guard use post-intervention and a 12.7% increased chance of thyroid guard use for each extra guard available. A short educational, easily replicated session, significantly improved compliance with thyroid guards by orthopaedic surgeons.

Recurrent Valve Frame Infolding in the 34mm Self-Expanding Medtronic Evolut Pro+ Transcatheter Valve System: A Single Centre Experience

Valve frame infolding (VFI) is a rare complication (1-3%) of transcatheter aortic valve implantation (TAVI), which primarily occurs in large sized self-expanding valves. We report the incidence of VFI in a small group of patients with highly calcified and extra-large aortic annuli, who underwent implantation of the newer generation 34mm Medtronic Evolut Pro+ (EP+) valve system. A retrospective review was conducted on all patients presenting to a single centre experienced with TAVI in Sydney, NSW, Australia, between June and October 2022, for transfemoral TAVI using the Medtronic 34mm EP+ valve system. VFI was diagnosed using fluoroscopy, and pre-procedure computed tomography (CT) was analysed offline. VFI occurred in four of 10 patients who underwent TAVI using the 34mm EP+ system. Between VFI and non-VFI patients, the annular size, aortic angulation and total calcium volume was similar. Calcium distribution between the coronary cusps was symmetrical in non-VFI patients (37%, 33% and 30%), compared to 52% in the non-coronary cusp (NCC) in VFI patients. The mean ellipticity index was higher in VFI versus non-VFI patients (22% vs 14%). The 34mm Medtronic EP+ valve system is vital for safe and effective treatment of a niche subgroup of patients with extra-large annuli and extensive calcification, however operators should be aware of the increased incidence of VFI. Heavy eccentric calcification at the NCC, as well as using the cusp-overlap implant technique may exacerbate VFI, while multiplanar fluoroscopic screening may improve recognition.

Intracardiac migration of distal catheter—a rare complication of VP shunt insertion: case report and literature review

Intracardiac migration is a rare complication of ventriculoperitoneal shunt insertion. Only 15 cases have been reported, 7 of which were paediatric cases, treated with techniques including interventional radiography, open thoracotomies and direct extraction through the initial shunt incision. The authors report the youngest case of intracardiac shunt migration complicated by significant coiling and knotting within the cardiac chambers and pulmonary vasculature. Migration likely began when the SVC was pierced during initial shunt placement and progressed due to negative intrathoracic pressure. Extrusion was achieved combining thoracoscopic endoscopy, interventional fluoroscopy screening and a posterolateral neck incision with uncoiling of the shunt via a Seldinger guide wire. This offered a minimally invasive solution with rapid post-operative recovery.

Atraumatic versus cutting needles in fluoroscopic lumbar puncture.

Atraumatic needles are known to reduce complication rates of blind lumbar punctures (LP), however, their use in fluoroscopically guided LP is less studied. This study assessed the comparative difficulty of performing fluoroscopic lumbar puncture with atraumatic needles. Single-centre retrospective case-control study comparing atraumatic and conventional or "cutting" needles using fluoroscopic time and radiation dose (Dose Area Product or DAP) as surrogate markers. Patients were assessed from two comparable eight-month periods before and after a policy change to primary use of atraumatic needles. 105 procedures with a cutting needle were performed in the group prior to the policy change. Median fluoroscopy time was 48 sec and median DAP was 3.14. Of 102 procedures performed in the group after the policy change, 99 were performed with an atraumatic needle and three with a cutting needle after initial attempt with an atraumatic needle. Median fluoroscopy time was 41 sec and median DAP was 3.28. The mean number of attempts was 1.02 in the cutting needle group and 1.05 in the atraumatic needle group. There was no significant difference in median fluoroscopy time, median DAP, or mean number of attempts. Fluoroscopic screening time, DAP and mean number of attempts were not significantly increased with primary use of atraumatic needles for LP. Use of atraumatic needles should be considered in fluoroscopic LP given the lower complication rates. This study provides new data showing that the use of atraumatic needles does not increase the difficulty of fluoroscopically guided LP.

MP26-18 HOLMIUM VERSUS TRILOGY IN KIDNEY STONES GUY&amp;ACUTE;S 1-2 (TRIHOLMIUM) PRELIMINARY ANALYSIS

You have accessJournal of UrologyCME1 Apr 2023MP26-18 HOLMIUM VERSUS TRILOGY IN KIDNEY STONES GUY&ACUTE;S 1-2 (TRIHOLMIUM) PRELIMINARY ANALYSIS Braulio Manzo, Edgard Lozada, Pompeyo Alarcon, Edson Flores, Juan Galvan, Yonathan Gomez, Jonathan Jimenez, and Allan Casale Braulio ManzoBraulio Manzo More articles by this author , Edgard LozadaEdgard Lozada More articles by this author , Pompeyo AlarconPompeyo Alarcon More articles by this author , Edson FloresEdson Flores More articles by this author , Juan GalvanJuan Galvan More articles by this author , Yonathan GomezYonathan Gomez More articles by this author , Jonathan JimenezJonathan Jimenez More articles by this author , and Allan CasaleAllan Casale More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003254.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The desire to reduce complications related to percutaneous access and morbidity related to tract size has led researchers to evaluate PCNL using smaller-caliber instruments. In this context, mini-PCNL has emerged. Furthermore, its efficacy and safety have been demonstrated at the cost of a lower stone-free rate. Currently, mini-PCNL has been performed with High power laser lithotripsy; therefore, it is convenient to make a comparison between the results of lithotripsy with Ho:YAG laser energy and the new LithoClast Trilogy EMS; and thereby determine which is the most effective method in the resolution of kidney stones through a miniaturized percutaneous tract. METHODS: A total of 116 patients will be subjected to simple randomization with a table of random numbers; 58 patients will undergo a mini-PCNL with Trilogy EMS probe 1.5 mm (Group1), and the remaining will undergo mini-PCNL with 100 W laser lithotripsy (group 2). Comparing both groups will be made by evaluating lithotripsy rate, stone-free status, operation time, and complications. RESULTS: We present the preliminary results of 32 randomized patients (18 in group 1 and 14 in group 2). Demographic data were homogeneous between both groups, including age, the side affected, BMI, maximum stone diameter, and stone volume (p values: 0.362, 0.221, 0.441, 0.569, and 0.120, respectively). Total fluoroscopy screening time was 24.3 and 26.4 seconds for groups 1 and 2, respectively (p: 0.547). Endoscopic stone-free status at the end of the surgical procedure was not statistically different in both groups (p: 0.394). Lithotripsy rate (195.09 sd 82.9 group 1 vs 202.7 sd: 99.38 for group 2) and operative time (94.28 sd: 34 for group1 vs 81.2 sd: 28.8 for group 2) were not statistically different in both groups (p: 0.815 and p: 0.268, respectively). The overall mean stone-free rate was 78.9 % (80.9% and 76.9%, respectively, with a p-value: of 0.371). The complications rate was similar in both groups (5.6 vs. 7.1% for groups 1 and 2, respectively, with a p-value: of 0.854). CONCLUSIONS: Our preliminary data show that mini-PCNL with Trilogy lithotripsy (1.5 mm probe) shows similar results and efficacy to the current energy to perform mini-PCNL (high power holmium laser) by means of stone-free rate, lithotripsy rate, operative time, and complications rate. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e360 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Braulio Manzo More articles by this author Edgard Lozada More articles by this author Pompeyo Alarcon More articles by this author Edson Flores More articles by this author Juan Galvan More articles by this author Yonathan Gomez More articles by this author Jonathan Jimenez More articles by this author Allan Casale More articles by this author Expand All Advertisement PDF downloadLoading ...

Conduction system pacing learning curve: Left bundle pacing compared to His bundle pacing.

Conduction system pacing (CSP), consisting of His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) is a rapidly developing field. These pacing techniques result in single lead left ventricular resynchronisation. Understanding of the associated learning curve of the two techniques is an important consideration for new implanters/implanting centres. We conducted a review of the first 30 cases of both HBP and LBBAP at The Royal Brompton Hospital. The procedural duration and fluoroscopy time were used as surrogates for the learning curve of each technique. Patient characteristics were similar in HBP and LBBAP groups; LV ejection fraction (46% vs 54%, p=0.08), pre-procedural QRS duration (119ms vs 128ms, p=0.32).Mean procedural duration was shorter for LBBAP than for HBP (87 vs 107mins, p=0.04) and the drop in procedural duration was more marked in LBBAP, plateauing and remaining low at 80mins after the initial 10 cases. Fluoroscopic screening time mirrored procedural duration (8min vs 16min, p<0.01). Our data suggest that the CSP learning curve was shorter for LBBAP than for HBP and appears to plateaux after the first 10 cases, however the HBP learning curve is longer with continued improvement over the first 30 cases. The shorter learning curve of LBBAP in conjunction with the superior electrical parameters and simplified programming mean the establishment of a CSP program is potentially easier with LBBAP compared to with HBP.

Fluoroscopy screening time and radiation dose during complete supine percutaneous nephrolithotomy.

Fluoroscopy-guided percutaneous nephrolithotomy (PCNL) is procedure of choice for treatment of large urinary tract calculi. This study aimed to investigate the affecting factors on fluoroscopy screening time (FST) and radiation dose (RD) of patients undergoing complete supine percutaneous nephrolithotomy (csPCNL). Analytic cross-sectional study was performed on 355 patients who underwent csPCNL. The correlation between the FST and RD and patients' demographics, stone characteristics, preoperative, intraoperative and postoperative parameters were assessed. Multivariate regression analysis was used to explore various parameters which affect FST and RD. Of all 355 patients, 191 (54.65%) were male and 161 were (45.35%) female with mean age of 48.29 ± 12.38 (16-82) years. BMI was 27.61 ± 4.53 (16.61-39.00) kg/m2. The mean operative time was 45.87 ± 18.29min with mean FST of 101.72 ± 62.00s. BMI, operative time, success rate, complications, stone number, and tract number had a significant relationship with FST and RD (P < 0.05). On multivariate analysis, BMI, tract number and success rate were found to be independent predictors for FST and RD. Age, gender, operation side, GFR, target calyx, lithotripsy history, stone opacity, size and site, stone configuration and distribution, and hydronephrosis did not have any correlation with FST and RD (P > 0.05). BMI, success rate and tract number can be significant predictor for FST and RD during csPCNL. Identifying the affecting factors on FST and RD can help the surgeon to minimize the danger of radiation exposure by predicting and preoperative planning.

Estimation of patient doses from selected fluoroscopy guided examinations based on Monte Carlo calculations (PCXMC)

The aim of this work is to estimate organ and effective dose of patients during some selected fluoroscopy guided examinations using monte carlo based code PCXMC and propose conversion factors for dose estimation at the facility. Screening time, number of radiographs were recorded from the fluoroscopy console and the kerma area product (KAP) from a KAP meter for a total of one hundred and seventy-one (171) patients in two different facilities (A and B). Incident air kerma at reference point, organ and effective doses were estimated with PCXMC software. The mean KAP value was 11.0, 10.4 and 81.0 mGycm2 for hysterosalpingography (HSG), retrograde (RUG) and barium swallow (BaS) respectively. The estimated effective dose was 0.8, 1.1, 22.8 mSv for HSG, RUG and BaS respectively. The mean fluoroscopy screening time was 0.89, 1.26, 2.92 minutes for HSG, RUG and BaS respectively. The mean number of radiographs taken was 4.5, 7.0, 13.0 for HSG, RUG and BaS respectively. Bladder (7.96 mGy), testicles (21.89 mGy) and breast (76,77 mGy) received the highest dose for HSG, RUG and BaS respectively. The recorded mean KAP values of this study for BaS was high than that of HSG and RUG by a factor of 7.4 and 7.8 respectively. This was attributed to high number of radiographs taken and fluoroscopy screening time. The mean KAP of this study was more than that of other studies by a maximum factor of 22.0, 7.8 and 23.5 for HSG, RUG and BaS respectively. The fluoroscopy screening of this study was more than that of other studies by a maximum factor of 3.3, 4.7 and 10.3 for HSG, RUG and BaS respectively. Also, the mean number of radiographs taken for this study was more than that of other studies by a maximum factor of 2.0, 2.6 and 1.7 for HSG, RUG and BaS respectively. It was suggested that there are other contributing factors to patient doses in addition to the screening time and radiographs taken during fluoroscopy procedures. A dose conversion factor from measurable quantities to effective dose estimation has been proposed to aid patient dose optimization. Further studies aiming at reporting patient organ doses in fluoroscopy examination and investigate into other patient dose contributing factors has been recommended to strengthen patient dose optimization.

PO-621-06 SHORTER LEARNING CURVE OF LEFT BUNDLE PACING COMPARED TO HIS BUNDLE PACING

Conduction system pacing (CSP) with His bundle pacing (HBP) or left bundle branch pacing (LBP) is an elegant method to provide single ventricular lead cardiac resynchronisation. The implant procedure utilises specialised sheaths and techniques to achieve the desired electrical resynchronisation. Inevitably there is a learning curve in mastering the nuances of sheath manipulation and electrogram/QRS interpretation during the implant. We present the learning curve associated with establishing a conduction system pacing program with both HBP and LBP. The first 30 cases of HBP and the first 30 cases of LBP included in this study. At our institution HBP was commenced in 2017 and LBP implantation in 2021. All CSP implanters are experienced Electrophysiologists who regularly implant complex devices. All implants included in both cohorts were performed using the Medtronic 3830 lead and either the C315 or C304 sheath. Patient characteristics were similar in both HBP and LBP groups including male sex (73% vs 57%, p=0.16), LV ejection fraction (46% vs 54%, p=0.08) or pre-procedural QRS duration (119ms vs 128ms, p=0.32). The mean procedural duration was shorter for LBP than for HBP (87 vs 107mins, p=0.04) and the drop in procedural duration was more marked in LBP, after the first 10 cases, and remained low at 70mins for the subsequent 20 cases (Figure 1). Fluoroscopic screening time was significantly shorter for LBP compared to HBP (8min 21sec vs 15min 46sec, p<0.01), with both CSP modalities there was a reduction in screening time with increased experience (Figure 2). R-waves were higher with LBP (12.8 vs 3.2mV, p<0.01) and pacing thresholds were lower with LBP (0.7 @0.5ms vs 1.4 @1.0ms, p<0.01). The CSP learning curve, evidenced by procedural duration, was shorter for LBP than for HBP. The LBP learning curve appears to plateaux after the first 10 cases after which the procedural duration is consistent and short at 70mins. The HBP learning curve is longer with continued improvement over the first 30 cases. Electrical parameters and fluoroscopy time were also more favourable for LBP than for HBP.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Single Versus Multiple Mini-tract Percutaneous Nephrolithotomy for Staghorn Renal Stone

Purpose: Percutaneous nephrolithotomy (PCNL) is the standard procedure used for large kidney stones, and multiple tracts of PCNL are applied to achieve better stone clearance. However, the creation of multiple tracts may have the potential risk of bleeding and higher complication rates compared with single-tract procedures. We reviewed our experience managing staghorn calculi with multiple tracts compared with a single tract. Materials and Methods: Records of 36 patients with staghorn calculi who underwent PCNL at our institution between January 2018 and April 2020 were reviewed retrospectively. Nineteen patients were managed by single-tract access (Group 1), and 17 patients underwent multiple-tract access (Group 2). Both groups were compared in terms of perioperative findings and postoperative outcomes. Results: The mean number of percutaneous accesses in the multiple-tract group was 2.88, with most patients requiring two tracts. The mean duration of fluoroscopy screening and operative time was longer in Group 2. Stone-free rates were 59% and 70.5% in Groups 1 and 2, respectively. The mean hospital stay was similar in both groups. Complications included blood transfusion, resulting from a hemoglobin drop of 2.15 ± 0.96 and 1.59 ± 0.69 g/dL in Groups 1 and 2, respectively. Mean pre- and post-operative creatinine concentrations were 1.212 and 1.211 mg/dL in Group 1 and 1.206 and 1.157 mg/dL in Group 2. Mean changes in creatinine values were not statistically significant between the groups. Clavien–Dindo Classification Grade II complications included urosepsis and blood transfusion, which occurred in five patients in Group 1 and three in Group 2. Pseudoaneurysm attributed to Grade III complications occurred in one patient in Group 1. Conclusion: Multiple-tract access during PCNL is a safe and efficient method to manipulate staghorn kidney stones. Mini PCNL with multiple-tract access is a successful alternative to deal with staghorn stones involving multiple calyces.

Novel assessment of the variation in cervical inter-vertebral motor control in a healthy pain-free population

Spinal control at intervertebral levels is dependent on interactions between the active, passive and neural control elements. However, this has never been quantifiable, and has therefore been outside the reach of clinical assessments and research. This study used fluoroscopy during repeated unconstrained flexion and return neck movements to calculate intersegmental motor control (MC), defined as the difference and variation in repeated continuous angular motion from its average path. The study aimed to determine control values for MC at individual levels and its variability. Twenty male volunteers aged 19–29 received fluoroscopic screening of their cervical spines during 4 repetitions of neutral to full flexion and return motion. Moving vertebral images from C0–C1 to C6–C7 were tracked using cross-correlation codes written in Matlab. MC for each level was defined as the mean of the absolute differences between each repetition’s angular path and their mean and its variability as represented by the SD. 1-way ANOVA and Tukey multiple comparisons were used to identify significant contrasts between levels. The mean MC differences and SDs were highest at C1-2, suggesting that this level has the least control and the most variability. Results at this level alone were highly significant (F-ratio 10.88 and 9.79 P < 0.0001). Significant contrasts were only found between C1-C2 and all other levels. The mean MC difference for summed C1-6 levels was 3.4° (0.7–6.1). This study is the first to quantify intervertebral MC in the cervical spine in asymptomatic people. Studies of neck pain patients are now merited.

Efficacy and safety of the EMS Swiss LithoClast® Trilogy for PCNL: results of the European multicentre prospective study on behalf of European Section of UroTechnology.

PurposePCNL requires a lithotrite to efficiently break stones, and some devices include active suction to remove the fragments. We set out to determine the efficacy and safety of the Swiss LithoClast® Trilogy, in a prospective European multicentre evaluation and compared it to published stone clearance rates for Trilogy based on surface area (68.9 mm2/min) and using the 3D calculated stone volume (526.7 mm3/min).MethodsTen European centres participated in this prospective non-randomized study of Trilogy for PCNL. Objective measures of stone clearance rate, device malfunction, complications and stone-free rates were assessed. Each surgeon subjectively evaluated ergonomic and device effectiveness, on a 1–10 scale (10 = extremely ergonomic/effective) and compared to their usual lithotrite on a 1–10 scale (10 = extremely effective).ResultsOne hundred and fifty seven PCNLs using Trilogy were included (53% male, 47% female; mean age 55 years, range 13–84 years). Mean stone clearance rate was 65.55 mm2/min or 945 mm3/min based on calculated 3D volume. Stone-free rate on fluoroscopy screening at the end of the procedure was 83%. Feedback for suction effectiveness was 9.0 with 9.1 for combination and 9.0 for overall effectiveness compared to lithotrite used previously. Ergonomic score was 8.1, the least satisfactory element. Complications included 13 (8.2%) Clavien–Dindo Grade II and 2 (1.3%) Grade III. Probe breakage was seen in 9 (5.7%), none required using a different lithotrite.ConclusionsWe have demonstrated that Trilogy is highly effective at stone removal. From a user perspective, the device was perceived by surgeons to be highly effective overall and compared to the most commonly used previous lithotrite, with an excellent safety profile.

Is Hypoglycemia Caused by G6PD Deficiency?

Background: Individuals with G6PD deficiency are mostly asymptomatic but develop hemolytic anemia with the use of certain medications, chemicals, or food. Hemolytic anemia episodes in patients with G6PD deficiency have been observed to occur following hypoglycemia. Case: An 18-year-old, vigorously exercising African American male was referred to the endocrine clinic for post-prandial hypoglycemia (Blood glucose (BG) of 47 mg/dl) accompanied by palpitations, lightheadedness, dyspnea, diaphoresis, and tremulousness. He admitted to having short symptomatic episodes, almost daily over four years. His mother has sickle cell trait, and due to the need for blood typing, a qualitative direct fluoroscopic screening test was positive for G6PD deficiency. Physical examination revealed a height of 5’2” with a weight of 126 lbs. (BMI: 22.7 kg/m2), blood pressure of 97/55 mmHg, and heart rate of 62/minute. The patient was a normal male with low set ears, and no other abnormalities, except for questionable non-genetic short stature. Fingerstick BG was 62 mg/dl. Lab tests showed a fasting BG of 90 mg with concomitant proinsulin of 8.2 pmol/l (≤ 18.8 pmol/l), fasting insulin of 8.98 mIU/l (≤ 25 mIU/l), 2-hour post-prandial insulin of 33.4 µIU/ml (5.0–55.0 µIU/ml), and a c-peptide 1.24 ng/ml (0.81–3.85 ng/ml). Uric acid, TSH, Free T4, LH, FSH, Prolactin, IGF-1, PTH, free and total testosterone were all normal. Fasting cortisol level was normal with an elevated ACTH of 72 pg/ml (0–47 pg/ml), low 25-hydroxyvitamin D at 18.5 ng/ml (30–100 ng/ml), and a flat oral glucose tolerance test. A continuous glucose monitor revealed average daily glucose of 85 mg/dl with 34% of the time spent < 80 mg/dl. A high carbohydrate diet with frequent meals improved symptoms with normal fingerstick BG. However, due to the concern that hypoglycemia can be related to G6PD deficiency, hemoglobin electrophoresis, and gene testing for G6PD were done to confirm this diagnosis, and they were both normal. In addition, a bone density scan was done, which revealed osteopenia. He was started on vitamin D supplementation. Conclusion: Case reports exist of G6PD deficient hospitalized patients with type 1 diabetes mellitus and DKA in recovery, who have had new onset hemolytic anemia, proposing that relative hypoglycemia can be responsible for this effect. Multiple screening tests have been developed for the detection of G6PD deficiency, which assay the normal function of the enzyme and reduction of NADP to NADPH. However, confirmatory testing needs to be conducted if the screening test is positive. Although this adds to the burden of testing, screening tests can result in false positives and lead to a misdiagnosis, as in our case.

Has the introduction of an advanced practitioner led service had an impact on radiation dose for fluoroscopy guided lumbar punctures? A service review

IntroductionHistorically, procedures requiring fluoroscopic guidance such as myelography; barium and video swallows; and fluoroscopy guided lumbar punctures (LP) have been performed by radiologists with the assistance of radiographers. As the National Health Service (NHS) evolves, more responsibilities are being disseminated to specifically trained radiographers to relieve workload due to a national shortage of radiologists. One step taken by the trust was to train an Advanced Practitioner (AP) in fluoroscopy to perform fluoroscopy guided LPs. Clinical audit and service evaluations are required to ensure there is no impact on patient care as a result of changes in practice. Regardless of occupation, healthcare workers undertaking procedures must ensure the same standards of care for patients. Minimising radiation dose is a duty of all radiological professionals. MethodsThis retrospective review evaluated and compared examinations performed by a group of radiologists and an AP in terms of dose area product (DAP) and fluoroscopy screening time. A total of 300 X-ray guided LPs doses were reviewed and comparison between the radiation exposure data sets was performed to determine whether there was a significant difference between the two operator groups. ResultsThe study revealed that AP-performed LPs had a statistically significant lower DAP and fluoroscopy time (a mean of 4.21Gycm2 and 0.74min) compared to the radiologist-performed LPs (a mean of 5.72Gycm2 and 0.94min). ConclusionThe review demonstrates that patient dose is not detrimentally affected by the introduction of an advanced practitioner. It establishes that dose and screening time was significantly lower. It also highlights the effectiveness of APs in an evolving radiology department. Implications for practiceThese outcomes propose advanced practitioners in this area of expertise can expand their role from neuroradiographer with no detriment to patient dose. Despite the results, it is recognised that continuous appraisal is required to ensure that competencies are maintained, and high levels of care are sustained.

Same procedure as Video 3 but real-time fluoroscopy screening is also shown. During unsheathing of ablation catheter, the operator avoids any unintentional forward or backward shifting of the whole system.

Same procedure as Video 3 but real-time fluoroscopy screening is also shown. During unsheathing of ablation catheter, the operator avoids any unintentional forward or backward shifting of the whole system.

Simplified biplanar (0-90°) fluoroscopic puncture technique for percutaneous nephrolithotomy: the learning curve.

To evaluate the learning curve of the simplified fluoroscopic biplanar (0-90º) puncture technique for percutaneous nephrolithotomy. We prospectively evaluated patients with renal stones treated with percutaneous nephrolithotomy by a single institution's fellows employing the simplified bi-planar (0-90º) fluoroscopic puncture technique for renal access. The learning curve was assessed with the fluoroscopic screening time and the percutaneous renal puncture time. Data obtained were compared to a subset of patients operated by a senior surgeon. Eighty-nine patients were included in the study. Forty patients were operated by fellow-1, 39 by fellow-2, and 10 patients by the senior surgeon. Demographic data of all patients between groups were homogeneous, with no difference in gender (p = 0.432), age (p = 0.92), stone volume (p = 0.78), puncture laterality (p = 0.755), and body mass index (p = 0.365). The mean puncture time was 7.5, 4, and 3.1min for fellow-1, fellow-2, and expert, respectively. The mean fluoroscopic screening time for the puncture was 10, 11, and 5.1s for fellow-1, fellow-2, and the expert, respectively. Stone cases, both fellows needed to complete 10 procedures to match the senior surgeon in the mean puncture time (p = 0.046); meanwhile, the fluoroscopic screening time was equal even before to complete 10 procedures. This study suggests that with the simplified biplanar (0-90º) puncture technique, the fluoroscopic screening time used in the learning process is brief. A novice fellow could require to complete ten cases to flatten the learning curve treating complex stone cases, and a flat learning curve is seen since the beginning when treating simple renal stones.

Early outcomes of Jotec inner-branched endografts in complex endovascular aortic aneurysm repair

ObjectiveComplex aortic endografts have evolved to include inner branches to overcome specific challenges with existing technologies. We have reported the early outcomes of endovascular aortic aneurysm repair (EVAR) using a Jotec inner branched endograft (iBEVAR). MethodsAll patients who had undergone complex EVARs using extra-design engineering iBEVAR (Jotec GmbH, Hechingen, Germany) from 2018 to 2020 at a single center were reviewed. The patient demographics, cardiovascular risk factors, anatomic features of the aneurysms, and target vessels were recorded. The reasons for using inner branches instead of fenestrated and standard branched endografts and the procedural details, outcomes, and reintervention during follow-up were examined. ResultsA total of 110 patients were treated with branched and fenestrated endografts during the study period, of whom 18 patients had had a patient-specific custom-made iBEVAR endograft with downward inner branches. The technical success rate was 100%. A total of 68 target vessels were cannulated, and bridging stent-grafts were placed successfully in all. The reasons for choosing the iBEVAR design included unfavorable target vessel trajectory for fenestrated repair (n = 15), excessive infrarenal aortic angulation and/or adverse iliac access vessels for fenestrated repair (n = 11), the presence of a narrow aortic lumen (n = 14), and/or to reduce aortic coverage compared with that with standard outer branched repair (n = 14). We also used iBEVAR to treat type Ia endoleaks after failed EVAR with a short main body (n = 5). The median contrast volume used was 120 mL (range, 48-200 mL), with a median fluoroscopy screening time of 66 minutes (range, 35-136 minutes) and a median dose-area product of 17,832 dGy∙cm2 (range, 8260-55,070 dGycm2). No 30-day mortality and no major complications occurred. One early intervention was required for a suspected type Ib endoleak from an iliac limb and one late intervention for in-stent stenosis in a renal bridging stent-graft. One patient had died of non–aortic-related causes at 3 months. All other patients continued with follow-up with their aneurysms excluded, patent target vessels, and no type I or III endoleak identified at a median follow-up of 12 months (range, 1-26 months). ConclusionsThe use of Jotec extra-design engineering endografts incorporating downward inner branches resulted in satisfactory early outcomes with a low reintervention rate. The technology has the potential to be a useful addition to our armamentarium for treating complex aortic endografts; however, long-term outcomes data are needed.