Time Of Insertion Research Articles

HPB SO30 - Evaluation of efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis

Abstract Background Acute cholecystitis is associated with considerable mortality. The risk of mortality ranges between 2.4% to 8.4% according to severity. The main line of managing patient presenting with grade II/ III acute cholecystitis is source control through insertion of cholecystostomy drain (if patient is not suitable for emergency cholecystectomy) and anti-microbial treatment. Tokyo 2018 guidelines recommends against use of Co-Amoxiclav as an empiric antimicrobial therapy for cases of acute cholecystitis as most common organism isolated is E. Coli. The aim of this study is to evaluate the efficiency of Co-amoxiclav as an empiric antimicrobial treatment for grade II/ III acute cholecystitis. Method The medical records were searched retrospectively for patient presented with acute severe cholecystitis grade II/ III who treated with cholecystostomy drain insertion as a temporary measure during 2020 and 2021. The culture and sensitivity (C&S) of cholecystostomy drain aspirate at time of insertion of the drains were reviewed to determine the type of appropriate antimicrobial therapy. The results were analysed using both best and worst case scenario to find about the efficacy of Co-Amoxiclav as an empiric antimicrobial treatment. Results 105 sample of cholecystostomy drain aspirate sent for culture and sensitivity, 27 samples were resistant to co-amoxiclav (25%), while 22 samples were sensitive to co-amoxiclav(20.9%) . 56 of samples (53.1%) showed no mention of testing of Co-Amoxiclav. On further analysis on best case scenario basis, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are sensitive to co-amoxiclav. While on worst case scenario, the sensitivity to co-amoxiclav will be 74% considering all the 56 non-tested samples are resistant to co-amoxiclav. Conclusion Use of co-amoxiclav as an empirical antimicrobial treatment for cases of grade II/ III acute cholecystitis is associated with considerable antimicrobial resistance ranges from 25% in the best case scenario and 79% in worst case scenario. The most common organism isolated from these samples was E.coli. These results are in complete agreement with Tokyo 2018 guidelines, which states that Co-amoxiclav is associated with more than 20% resistance.

A Prospective Randomised Comparative Study of Baska Mask and I-Gel for Airway Management in Elective Surgeries: Focus on Airway Sealing Pressure, Insertion Time, and Haemodynamic Response

Introduction: General anesthetic procedure requires a safe and open airway. Endotracheal intubation is the gold standard for airway management; it is being replaced by supraglottic airway devices because they are easy to introduce, better tolerated and results in a lesser haemodynamic response. As both the Baska mask and I-gel have a non-inflatable self-sealing mechanism, these two devices were compared in our study in terms of time taken for insertion, airway sealing pressure, the number of attempts, hemodynamic changes, and complications. Methods: A Prospective comparative study was conducted on 90 patients (45 in each group), aged 18-60 years, undergoing elective surgeries under general anesthesia at Tertiary care Hospital, Madurai. Patients were randomized into two groups using the computer generated statistical software STATA version14 (Texas, USA): Group B: Airway was secured by insertion of Baska mask. Group I: Airway was secured by insertion of I Gel. Following assessments were done to evaluate the SAD: Time taken to insert the device, airway sealing pressure, rate of successful insertion, number of attempts, Haemodynamic parameters, laryngopharyngeal morbidity. Data were analyzed using Student t-tests and chi-square tests, with p < 0.05 considered significant. Results: The mean airway sealing pressure of the Baska mask (26.1+6.1 cmH2O) was significantly higher than that of the I-gel (23.1± 5.9 cmH2O) with a P value of 0.019 which was statistically significant. In our study the time taken to insert the device, for Baska mask it was 18.9+4.1 seconds and for the I gel it was 17.2±5.1 seconds with a P value of 0.089 which was statistically insignificant. In our study there was no statistical difference between Baska mask and I-gel groups in regards to hemodynamic changes (Heart rate and Mean arterial pressure). This may be due to the same stress response produced by the both devices. Conclusion: Baska mask is superior to I-gel in positive pressure ventilation under general anaesthesia for short surgical procedures with statistically significant higher airway sealing pressure though it has comparable time of insertion, haemodynamic changes and laryngopharyngeal morbidity.

Comparison of Macintosh laryngoscope and King Vision video laryngoscope for endotracheal intubation in adult patients

Background: Development of video laryngoscope has made management of airway easier. 0ur study was aimed to compare the efficacy of Macintosh laryngoscope and King Vision video laryngoscope for endotracheal intubation in adult patients under general anesthesia. Objectives: The primary objective of the study was to compare the glottic view obtained , the need for external manipulation, endotracheal tube insertion time and attempts taken for successful intubation with Macintosh laryngoscope and King Vision video laryngoscope. The secondary objective was to estimate the changes in hemodynamic parameters and to evaluate the occurrence of complications during intubation. Materials and Methods: The study included 136 patients posted for surgery under general anesthesia. Patients were randomly allocated in group C (N=68) and group V (N=68 ).Endotracheal intubation was done in group C by Macintosh and in group V by King Vision video laryngoscope. Laryngoscopy was assessed by Cormack Lehane grading and the need for any manipulation. The intubation time was calculated with each blade. Hemodynamic parameters were recorded and any complication during laryngoscopy and intubation were noted. The observations were analysed statistically by SPSS Program for windows version 28. Results: In group C, 61.8% of patients had Cormack and Lehane score I while in group V 76.5 % of patients had score I . Mean time of successful intubation was 34.90±8.35 sec in group C while in group V it was 32.82± 5.20 second . There was no statistical difference in distribution of patients according to number of attempts of intubation. In group C, 64.7% of patients needed external laryngeal pressure while in group V 97.1 % patients were intubated without external laryngeal pressure. Both the groups were comparable in relation to changes in hemodynamic parameters and any complications associated with laryngoscopy and intubation. Conclusion: We conclude that glottic view is better obtained with King Vision Video laryngoscope whereas optimisation of position and external laryngeal manipulation is often required with Macintosh laryngoscope to get similar glottic view. Introduction of King Vision video laryngoscope into the oral cavity takes time but intubation is easier with it. Hemodynamic variables and complications during the procedure are equally distributed between the two devices.

Traditional Versus Distal Radial Access for Coronary Diagnostic and Revascularization Procedures: Final Results of the TENDERA Multicenter, Randomized Controlled Study.

Traditional transradial access (TRA) is widely used for coronary and non-coronary interventions with significant improvements in procedural outcomes; however, it is associated with RAO that precludes repeat use of the same artery for possible future TRI and other purposes. Distal radial access (DRA) has been proposed as an effective alternative to decrease RAO rates. Published literature describing the RAO rate after DRA versus TRA from various RCT and clinical registries has shown conflicting results. This study compared the forearm radial artery occlusion (RAO) rate assessed by Doppler ultrasound between distal and conventional radial access at 1-year follow-up after the initial procedure. TENDERA was a multicenter, randomized controlled study comparing DRA versus TRA for coronary diagnostic and interventional procedures using 5 or 6F hydrophilic-coated sheaths. The primary endpoint was forearm RAO at 12 months after radial access. The secondary endpoints included puncture time, sheath insertion and total procedure time, radiation dose, and vascular access site-related complications. Eight hundred and fifty patients were randomized to either TRA (n = 418) and DRA (n = 432) groups. In the intention-to-treat analysis, the rate of forearm RAO at 12 months was observed in 39 patients (4.6%) and was significantly reduced in the DRA group compared with the TRA group (2.5% vs. 6.7%, RR 2.59 [95% CI 1.29-5.59], p = 0.010). Analysis in per protocol population has shown consistent results with forearm RAO rate 2.8% in the DRA group versus 6.5% in the TRA group (p = 0.008). The crossover rate was higher (4.6% vs. 1%, p = 0.013) and median hemostasis time was shorter (156.5 min vs. 180 min, p < 0.001) with DRA. Overall bleeding (BARC 1-2) and postprocedure hematoma > 5 cm occurred less frequently in the DRA group compared with the TRA group (3.2% vs. 20.5%, p < 0.001% and 9.0% vs. 27.0%, p < 0.001, respectively). No significant differences were observed in total procedure time and radiation dose between groups. DRA for coronary diagnostic and interventional procedures is associated with reduced forearm RAO rate and shorter hemostasis time, but a longer sheath insertion time and higher crossover rate compared with TRA. ClinicalTrials.gov: NCT04211584.

Influence of timing of impella insertion on the prognosis of acute myocardial infarction complicated with cardiogenic shock requiring ECPELLA

Abstract Background/Introduction In patients with cardiogenic shock (CS), a combination of Impella-a percutaneous ventricular assist device with a catheter-type micro-axial heart pump-and venoarterial extracorporeal membrane oxygenation (ECPELLA) has been reported to have a better prognosis compared to venoarterial extracorporeal membrane oxygenation (VA-ECMO) alone, although it was associated with more complications. In contemporary clinical practice, ECPELLA has often been used in place of VA-ECMO alone. However, in many cases of acute myocardial infarction (AMI) with CS, there is controversy regarding the prioritization of Impella or VA-ECMO installation. Purpose The current study aims to clarify the factors of Impella use before VA-ECMO, the impact of the timing of Impella insertion (before or after VA-ECMO) for 30-day mortality, and major adverse events (MAEs) in the two groups. Methods The Japanese registry for Percutaneous Ventricular Assist Device (J-PVAD) Registry is a nationwide registry enrolling 5,718 consecutive Japanese patients treated with Impella between February 2020 and December 2022. The current study population consisted of 1,082 patients with AMI complicated by CS excluding cardiopulmonary arrest on arrival or using only Impella, who were divided into 2 groups; Impella use before and after VA-ECMO. Results Among the current study population, 323 patients (30%) used Impella before VA-ECMO, and 759 patients (70%) used Impella after VA-ECMO. Patients who used Impella before VA-ECMO were older (72 vs. 68 years old, P&amp;lt;0.0001) and had higher left ventricular ejection fraction (LVEF) (30 vs 20 %, P&amp;lt;0.0001), lower lactate level (5.6 vs 9.1 mmol/L, P&amp;lt;0.0001), and more often ST-elevation myocardial infarction (MI) (82% vs 76%, P&amp;lt;0.0001), whereas those patients had less often out-of-hospital cardiac arrest (OHCA) (13% vs 45%, P&amp;lt;0.0001), in-hospital cardiac arrest (IHCA) (27% vs 63%, P&amp;lt;0.0001), and prior heart failure (9.5% vs 16%, P=0.006). The factors of Impella use before VA-ECMO were 75 years or older, dyslipidemia, the absence of OHCA, the absence of IHCA, the absence of prior MI, and the absence of LVEF less than 30%. The cumulative 30-day incidence of all-cause death was 46.2% in patients with Impella use before VA-ECMO and 53.4% in those with Impella use after VA-ECMO (Log-rank P=0.02). After adjusting confounders, there was no excess risk of Impella use before VA-ECMO relative to Impella use after VA-ECMO (adjusted HR, 0.87; 95%CI, 0.55-1.37; P=0.55). Regarding major adverse events, hemolysis was significantly more frequent in patients with Impella use before VA-ECMO, while stroke was significantly more common in patients with Impella use after VA-ECMO. Conclusions The prognosis with AMI complicated by CS requiring ECPELLA remained poor. The 30-day mortality was lower in patients with Impella use before VA-ECMO compared to after VA-ECMO. However, after adjusting for confounders, there was no difference between the two groups.

A biologically transparent illumination device is more useful in children for detecting the position of the nasogastric tube in the stomach.

The study aimed to evaluate the efficacy of the Biologically Transparent Illumination (BTI) device for confirming the correct placement of nasogastric (NG) tubes in children, as an alternative to X-ray, which exposes patients to radiation. In this prospective observational study, 106 pediatric patients (ages 0-16) undergoing NG-tube insertion after general anesthesia were evaluated. The BTI catheter was used to emit bio-permeable red light from the NG tube, which was then visually confirmed in the cervical, thoracic, and epigastric regions. X-ray confirmed NG-tube placement in all patients. The ethics committee approved the study. The average patient age was 3.8years, with a male-to-female ratio of 72:34. BTI was successfully detected in the epigastric area in 105 of 106 patients, with one 9-year-old patient having unclear BTI visibility. X-ray confirmed NG-tube placement in the stomach for all patients, resulting in a BTI sensitivity of 99%. The mean NG-tube insertion time was 38s, and the mean abdominal thickness was 9.8mm. The BTI device proved to be a safe and effective method for NG-tube placement in children, offering a radiation-free alternative with 100% successful placement when BTI was detected in the epigastric area.

Outcomes in eyes with retained lens fragments undergoing pars plana lensectomy and scleral-fixated intraocular lens insertion.

To report the visual outcomes and complications in eyes with retained lens fragments (RLF) following cataract surgery undergoing pars plana lensectomy (PPL) and scleral-fixated intraocular lens insertion (SFIOL). Patients with RLF who underwent pars plana vitrectomy (PPV), PPL, and SFIOL insertion from January 2015 to December 2022 were included. The visual acuity (VA) outcomes and complication rates were compared between those receiving sutured versus sutureless SFIOL insertion as well as those undergoing SFIOL insertion at the time of PPV and PPL versus those undergoing SFIOL insertion during a subsequent surgery. 65 eyes of 65 patients were included. Median (interquartile range) pre-operative logarithm of the minimum angle of resolution (logMAR) VA was 2.3 (2-2.3; Snellen: HM). The median logMAR VA improved to 0.14 (Snellen: 20/100), at the most-recent follow-up (p<0.001, Hodges-Lehmann estimator:1.56, 95% confidence interval -1.30 to -1.71). There was no statistically significant difference in VA outcomes and the complication rates, including cystoid macular edema, corneal edema, and retinal detachment, regardless of technique or timing of SFIOL insertion. In this retrospective study with small sample size, similar visual acuity outcomes and complication rates were observed regardless of the timing or technique of SFIOL insertion.

Comparing the Functional Analysis of Baska® Mask with I-gel in Short Surgeries - A Prospective Randomized Trial.

We have compared sealing pressure, usability, and complications of two second-generation supraglottic airway devices-Baska® mask and I-gel. The study design involves prospective randomized controlled trial. The study was undertaken involving 44 patients of the American Society of Anesthesiologists physical status I and II, aged 20-70 years, who underwent surgical procedures of short duration under general anesthesia. Patients were randomly categorized into two groups of 22 each: Group B (Baska® mask) and Group I (I-gel). The main objective was to compare oropharyngeal leak pressure (OLP). Continuous variables were compared between the two groups using an unpaired t-test. Categorical variables were compared using the Chi-square test and insertion attempts using Fisher's exact test. Group B had significantly higher mean OLP (32.22 ± 2.52 cmH2O vs. 26.18 ± 2.42 cmH2O, P < 0.001). In Group I, 97.1% of patients had very easy insertion (Grade 1), 2.9% had easy insertion (Grade 2) and Group B had very easy insertion in 50% of patients, easy in 36.4%, and difficult in 13.6% of patients (P = 0.009). Group B took a longer time for successful insertion than Group I (39.89 ± 7.15 s vs. 28.19 ± 3.29 s, P < 0.001). For positive pressure ventilation, both I-gel and Baska® masks proved to be successful, with I-gel being easier and quicker to insert. It is possible to employ the Baska® mask with superior seal pressures as an alternative to endotracheal intubation in elective surgeries if there are no patient contraindications.

Vaginal cytology during the estrous cycle and early pregnancy of ewes

Changes in vaginal epithelial cells and blood progesterone and estrogen concentrations were compared between estrous cycle and early pregnancy in multiparous Sanjabee ewes. Twenty non-pregnant ewes were synchronized with intravaginal insertion of a controlled internal drug release (CIDR) device which was in place for 7 days, intramuscular administration of a GnRH analog (Alarelin acetate; 12.5 µg) at the time of CIDR insertion (Day -7), a PGF2α analog (D-cloprostenol sodium; 125 µg) and 500 I.U. of human chorionic gonadotropin (hCG) at the time of CIDR removal (Day 0). At Day 0, all ewes were introduced to four fertile rams and observed for estrous signs. Ewes exhibiting estrous signs were divided into two groups: MATED (confirmed pregnant with transrectal ultrasound scanning at Day 35) and NOT-MATED (confirmed non-pregnant with transrectal ultrasound scanning at Day 35). Vaginal smears and blood samples were taken daily and every other day, respectively, from the beginning of estrus for 20 days for cytology and hormone assay. Based on the results, during days 0 and 1 of the estrous cycle, only the percentages of intermediate cells differed between the groups (P &lt; 0.05). During days 2 to 4, there was no difference in the cell populations between the groups (P ≥ 0.05). During days 5 to 16, the percentages of all cell types except the parabasal cells differed between the groups (P &lt; 0.05). During days 17 to 20, the percentages of all types of vaginal epithelial cells differed between the groups (P &lt; 0.05). Progesterone concentrations increased gradually from days 0 to 14 of the estrous cycle in both groups, however, they decreased significantly afterward in the NOT-MATED group. Estrogen concentrations changes showed an opposite pattern to that of progesterone in the study groups. Collectively, vaginal cytology can be used as a useful tool in assessing hormonal and physiological characteristics of the female reproductive system and thus provides a more accurate understanding of the physiology of estrous cycle and early pregnancy in ewes, which can be used to improve reproductive management.

Prolonged Umbilical Port Insertion Time Increases the Incidence of Umbilical Surgical Site Infection in Laparoscopic Percutaneous Extraperitoneal Closure for Inguinal Hernia in Children.

Introduction: Umbilical surgical site infection (U-SSI) is the most common complication of laparoscopic percutaneous extraperitoneal closure (LPEC) for the treatment of inguinal hernia in children. Prolonged operative time is known to increase the risk of SSI in general pediatric surgery; however, the association between prolonged operative time and post-LPEC U-SSI is unclear. The present study aimed to elucidate the association between umbilical port insertion time and the incidence of U-SSI. Materials and Methods: The present study included all patients <16 years of age who underwent LPEC for the treatment of inguinal hernia between June 2018 and May 2023 at our institution. Those who underwent umbilical hernia repair or other procedures were excluded. We retrospectively collected and analyzed the following: patient demographics; operative data; and U-SSI data. The cutoff value for the umbilical port insertion time was determined using receiver operating characteristic analysis, and the incidence of U-SSI was compared based on the cutoff value, determined to be 8 minutes. Results: A total of 232 patients (133 boys; mean age, 4.6 ± 3.3 years) were eligible for the present study, 7 (3.0%) of which developed superficial incisional post-LPEC U-SSI within a median of 7.5 [4-19] days. The incidence of U-SSI was 20.0% in the long (≥8 minutes) versus 2.3% in the short (<8 minutes) umbilical port insertion time group (P = .03). Conclusion: Prolonged umbilical port insertion time (≥8 minutes) increases the incidence of post-LPEC U-SSI during the treatment of inguinal hernia in children.

The efficacy of acupuncture-assisted blind insertion of bullet nasointestinal tube method in patients with ischemic stroke: A retrospective study

Objective: To explore the efficacy of Traditional Chinese Medicine (TCM) acupuncture-assisted blind insertion of bullet nasointestinal tube method in patients with ischemic stroke. Methods: This is a retrospective study using clinical records of 180 patients with ischemic stroke, hospitalized in the Department of Neurology of the Zhejiang Province Tertiary Class A Hospital, Huzhou, China from July 2022 to June 2023. The patients were divided into two groups on the basis of the nasogastric tube insertion method. We selected 90 patients for each group from the database of records by using a random list method. Patients in the observation group underwent TCM acupuncture-assisted blind insertion of nasointestinal tube and those in the control group underwent the traditional bedside blind insertion of bullet nasointestinal tube. Success rate of tube insertion, average tube insertion time, intragastric insertion time, stomach time to jejunal insertion, patient comfort, and patient satisfaction in both groups were compared. Results: The success rate of nasointestinal tube insertion was significantly higher in the observation group compared to the control group (96.6% and 88.9%, p&lt;0.05). There was no statistically significant difference in the time of nasoenteral tube insertion into the stomach (p&gt;0.05). The insertion time from stomach to jejunum in the observation group was significantly shorter than in the control group (p&lt;0.05). The patient comfort and satisfaction levels were significantly higher in the observation group compared to the control group (p&lt;0.05). Conclusion: TCM acupuncture-assisted blind insertion of bullet nasointestinal tube method improves the success rate of tube insertion, shortens the average catheterization time from the stomach to the jejunum and improves patient’s comfort and satisfaction. doi: https://doi.org/10.12669/pjms.40.10.9936 How to cite this: Zhao H, Chen J, Chen H, Lv X, Lu Z, Sun Y. The efficacy of acupuncture-assisted blind insertion of bullet nasointestinal tube method in patients with ischemic stroke: A retrospective study. Pak J Med Sci. 2024;40(10):2208-2212. doi: https://doi.org/10.12669/pjms.40.10.9936 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

A More Efficient and Safer Improved Percutaneous Pedicle Screw Insertion Technique-Trajectory DynamicAdjustment Technique, Technical Note, and Clinical Efficacy.

Percutaneous pedicle screw fixation (PPSF) technique requires a very precise entry point of the Jamshidi needle, which leads to repeated adjustments, damaging the pedicle and increasing radiation exposure. This study was designed to propose an improved percutaneous pedicle screw fixation technique-trajectory dynamic adjustment (TDA) technique, and evaluate its feasibility and assess the clinical outcomes. A total of 445 patients with lumbar spondylolisthesis or lumbar spinal stenosis associated with instability from June 2017 to May 2022 were included in the retrospective study. They were randomly separated into two groups. Two hundred thirty-one patients underwent TDA technique (TDA group). Two hundred fourteen patients underwent traditional PPSF technique (PPSF group). All patients underwent postoperative CT to assess the accuracy of screw placement, superior facet joint violation (FJV). The evaluated clinical outcomes were needle insertion time, radiation exposure, blood loss, hospital stay, the Japanese Orthopedic Association (JOA) score, the Visual Analogue Scale (VAS) scores for lower back pain (LBP), and leg pain, lumbar interbody fusion rate, and postoperative complications. The independent-sample t test and paired t-test were used for continuous data. The contingency table and Mann-Whitney U test were used for categorical data. The time of the insertion in TDA group was significantly lower than that in PPSF group (p < 0.05). Similarly, the fluoroscopy frequency in TDA group was significantly lower than that in PPSF group (p < 0.05). There was no difference in intraoperative blood loss and hospital stay between the two groups (p > 0.05). Overall, there was no significant difference in the proportion of clinically acceptable screws between the two groups (p > 0.05). In addition, the lateral screw misplacement in TDA group was higher. Moreover, FJV rate was significantly lower than that in PPSF group (p < 0.05). In both TDA group and PPSF group, postoperative back and leg pain and the JOA score were significantly improved (p < 0.05). However, there were no significant differences in the pre- and postoperative VAS score for back and leg pain and the JOA score, JOA recovery rate, intervertebral fusion rate, and complications rate between the two groups (p > 0.05). Compared to traditional PPSF technique, TDA technique is a safer and more effective procedure which has shorter surgical time, lower radiation exposure, and lower facet joint violation rate.

Impact of advanced endoscopy training on colonoscopy quality and efficiency.

Few reports have detailed improvements in the quality of colonoscopies with continuous training post-fellowship completion. We examined the changes in colonoscopy performance among trainees during our advanced endoscopy training program. Screening or surveillance colonoscopies performed by 11 trainees who participated in our 3-year advanced endoscopy training program between April 2015 and March 2020 were retrospectively analyzed. Quality and efficiency metrics of colonoscopies were evaluated annually. Altogether, 297, 385, and 438 colonoscopies were enrolled in the first, second, and third training years, respectively. The mean insertion times were 8.6, 7.6, and 6.9 min in the first, second, and third training years, respectively, with significant improvement from the first to second year (p = 0.03) and from the first to third year (p < 0.01). The adenoma detection rate, proximal adenoma detection rate, and mean number of adenomas per patient exhibited a tendency to improve annually; however, the difference was not significant. Polypectomy efficiency was 10.5%, 11.2%, and 13.0%, with significant improvements from the first to third year (p < 0.01) and from the second to third year (p = 0.02). Insertion time and polypectomy efficiency showed significant improvements, especially among trainees experienced with <500 colonoscopies. Through our advanced endoscopy training program, there has been an improvement in the quality and efficiency of colonoscopy for trainees who have completed their fellowships, particularly those with <500 colonoscopies.

Recent advances in peritoneal dialysis catheter placement: the association between method of insertion, operator, and prior abdominal surgery and outcomes.

Peritoneal dialysis (PD) is associated with comparable outcomes to hemodialysis and is much less expensive to provide in most parts of the world. A well functioning PD catheter is required, but complications are frequent, and while there are guidelines for the placement and care of a PD access, they are based on low-quality evidence. Data reporting the outcomes of percutaneous, as compared to surgical pathways for placement of catheters and the role of operator type in determining outcomes are examined. The impact of prior abdominal procedures on patient selection and the prognostic importance of the presence of adhesions at the time of catheter insertion are reviewed. There are conflicting data about the relative merits of percutaneous as compared to surgical placement of catheters that may relate to differences in patient selection, operator experience, or operator volume. Prior abdominal procedures are not associated with worse PD catheter outcomes and likely should not influence patient selection, except in exceptional circumstances. Finally, the presence of adhesions is associated with a higher risk of complications. However, even in the presence of adhesions, the termination of PD therapy and need for re-intervention occurs in <20% of patients.

Comparison between the standard method and the 30° curved tongue depressor-aided technique for insertion of a laryngeal mask airway: a randomized controlled trial

BackgroundLaryngeal mask airway (LMA) has been increasingly used for airway management; however, LMA insertion can be difficult and cause adverse effects. Therefore, the rapid, safe, and effective insertion of LMA is necessary. This study aimed to compare the efficacy of the standard method with that of the 30° curved tongue depressor-aided technique for LMA insertion to determine the superior technique.MethodsThis study included 154 patients aged 18–70 years (American Society of Anesthesiologists class I or II) scheduled for general anesthesia. The patients were randomly assigned to the standard LMA insertion group (Group C, n = 77) or the 30° curved tongue depressor-aided LMA insertion group (Group T, n = 77). The primary outcome evaluated was the first-attempt success rate. The secondary outcomes were the second-attempt success rate, insertion time, fiberoptic position grade, oropharyngeal leak pressure (OPLP), and adverse events.ResultsThe first-attempt success rate was significantly higher in Group T than in Group C (97.40% vs. 88.31%, P = 0.029). The second-attempt success rate (P = 0.209), insertion time (P = 0.340), fiberoptic position grade (P = 0.872), and OPLP (P = 0.203) were slightly improved in Group T; however, there was no statistical significance. Bleeding events were reduced in Group T than in Group C (6.49% vs. 14.29%); however, there was no statistical significance. The incidence of sore throat symptoms was significantly reduced in Group T than in Group C (5.19% vs. 15.58%, P = 0.035).ConclusionsThe curved tongue depressor-aided technique significantly improved the first-attempt success rate of LMA insertion and reduced the incidence of sore throat symptoms.Trial registrationKCT0004964; Registered at https://cris.nih.go.kr on April 27, 2020.

Algorithm for Key Transparency with Transparent Logs

Background Cryptography plays a crucial role in securing digital communications and data storage. This study evaluates the Transparent Key Management Algorithm utilizing Merkle trees, focusing on its performance and security effectiveness in cryptographic key handling. Methods The research employs simulated experiments to systematically measure and analyze key operational metrics such as insertion and verification times. Synthetic datasets are used to mimic diverse operational conditions, ensuring rigorous evaluation under varying workloads and security threats. Implementation is carried out using R programming, integrating cryptographic functions and Merkle tree structures for integrity verification. Results Performance analysis reveals efficient insertion and verification times under normal conditions, essential for operational workflows. Security evaluations demonstrate the algorithm's robustness against tampering, with approximately 95% of keys verified successfully and effective detection of unauthorized modifications. Simulated attack scenarios underscore its resilience in mitigating security threats. Conclusions The Transparent Key Management Algorithm, enhanced by Merkle trees and cryptographic hashing techniques, proves effective in ensuring data integrity, security, and operational efficiency. Recommendations include continuous monitoring and adaptive algorithms to bolster resilience against evolving cybersecurity challenges, promoting trust and reliability in cryptographic operations.

Comparative analysis of LMA Blockbuster® clinical performance: Blind versus Miller laryngoscope-guided insertion in paediatric general anaesthesia - A double-blinded, randomised controlled trial.

The second-generation supraglottic airway device is conventionally inserted blindly, which might result in suboptimal placement. Limited literature exists on under-vision insertion techniques, particularly in paediatric patients. The primary objective of this study was to compare the oropharyngeal leak pressure (OPLP) between the blind insertion of the LMA Blockbuster® and the Miller laryngoscope-guided insertion in children. Secondary outcomes included the number of insertion attempts, haemodynamic disturbances, insertion time and airway complications. This randomised controlled trial study enroled 100 patients aged 1-4 years undergoing elective surgery. Patients were randomised into blind insertion (Group A) or Miller laryngoscope-guided insertion (Group B) of the LMA Blockbuster®. The primary outcome measure was OPLP. Insertion time, haemodynamic changes and postoperative complications were also assessed. The Chi-square, Fisher's exact and t-test were applied appropriately, with the significance level set at P < 0.05. Significantly higher mean OPLP was observed in Group B compared to Group A - 27.9 [standard deviation (SD): 1.58] cmH2O versus 25.94 (SD: 0.63) cmH2O [mean difference (MD): 1.96 (95% confidence interval {CI}: 1.48, 2.44; P < 0.001)]. Mean insertion time was longer in Group B, that is, 11.9 (SD: 1.91) s versus 8.7 (SD: 0.6) s [MD: 3.2 s; (95% CI: 2.63, 3.76; P < 0.001)]; however, the difference was not clinically relevant. First-attempt insertion, haemodynamic stability and postoperative complications were comparable (P > 0.05). Miller laryngoscope-guided under-vision insertion of LMA Blockbuster® improves alignment with epiglottic structures compared to blind insertion.

Dynamic pickup-and-delivery for collaborative platforms with time-dependent travel and crowdshipping

We study a pickup-and-delivery problem that arises when customers randomly submit requests over the course of a day from a choice of vendors on a collaborative e-commerce portal. Based on the attributes of a customer request, a dispatcher dynamically schedules the delivery service on either a dedicated vehicle or a crowdshipper, both of whom experience time-dependent travel times. While dedicated vehicles are available throughout the day, the availability of crowdshippers is unknown a priori and they appear randomly for only portions of the day. With an objective of minimizing the sum of routing costs, piece-rate crowdshipper payments, and lateness charges, we model the uncertainty in request arrivals and crowdshipper appearances as a Markov decision process. To determine an action at each decision epoch, we employ a heuristic that partially destroys the existing routes and repairs them under the guidance of a parameterized cost function approximation that accounts for the remaining temporal capacity of delivery vehicles. We benchmark our real-time heuristic with an adaptive large neighborhood search and demonstrate the effectiveness of our method with several performance metrics. In addition, we conduct computational experiments to demonstrate the impact of inserting wait time in the route scheduling and the benefit of explicitly modeling time-dependent travel times. Through our computational testing, we also investigate the potential of demand management mechanisms that facilitate many-to-one request bundles or one-to-many request bundles to reduce the cost to service requests.

An observational study on the modulation of anxiety, depression, and adverse event incidence in painless colonoscopy patients through venous access nursing.

To investigate the clinical significance of venous access nursing in modulating anxiety, depression, and adverse event incidence among patients undergoing painless colonoscopy. Sixty patients who underwent painless colonoscopy in our hospital from September 2021 to September 2022 were selected as the control group (CG, receiving routine perioperative nursing). Sixty patients who underwent painless colonoscopy in our hospital from October 2022 to August 2023 were taken as the study group (SG, receiving venous access nursing modulation). After nursing, patients in the SG exhibited lower scores of the Self-Rating Anxiety Scale and the Self-Rating Depression Scale than those in the CG (P < .05). The SG showed significantly lower mean Ottawa Bowel Preparation Score, but exhibited higher adequacy of bowel preparation compared with the CG (P < .05). The colonoscopy insertion time was (7.18 ± 1.02) minutes in the SG and (8.69 ± 1.00) minutes in the CG, and the colonoscopy withdrawal time was (4.66 ± 1.66) minutes in the SG and (5.64 ± 1.06) minutes in the CG, which showed statistically significant differences between the 2 groups (P < .05). The total incidence of adverse events did not have statistical significance between the 2 groups (P > .05). Application of venous access nursing in patients undergoing painless colonoscopy may help alleviate adverse emotions and shorten colonoscopy insertion time and colonoscopy withdrawal time, thus warranting recognition for its safety and efficacy.

Usefulness and safety of new ultrasmall-diameter colonoscope for cases with difficult insertion: a retrospective study

Colonoscopies are widely available, but there are cases where insertion can be difficult, even for experienced endoscopists. EC-760XP/L, a new ultrasmall-diameter long scope, may be useful in such cases. This single-center retrospective study included 39 cases where colonoscope insertion was difficult even when previously conducted by an experienced endoscopist. The primary outcome was the cecal intubation time using EC-760XP/L compared to the time used in a previous examination with a standard scope. The secondary outcomes were the cecum intubation rate, intestinal cleanliness level, adenoma detection rate, polyp detection rate, sedative use rate, occurrence of adverse events, and pain experience. A comparison of cecal intubation times between EC-760XP/L and the standard scope showed that insertion times were significantly lower with EC-760XP/L (9.5 min) compared to the standard scope (19 min) (p < 0.01). The standard scope achieved cecal intubation in 30 cases (76.9%), whereas EC-760XP/L reached the cecum in all cases (p < 0.01). Pain was observed in 3 cases (8.3%) with the EC-760XP/L, which was significantly lower than the 22 cases (56.4%) with the standard scope (p < 0.01). In conclusion, EC-760XP/L proved to be useful in cases where colonoscope insertion was difficult.