Significant Increase In Success Rate Research Articles

Effect of Anaesthesiologists’ Experience on Preferred Technique and Volume of Local Anaesthetic Administered for Brachial Plexus Nerve Block: A Retrospective Observational Analysis

Introduction: Faculty and Residents are trained in peripheral nerve blocks guided by blind technique, Peripheral Neuro Stimulator (PNS) or Ultrasound (USG) guided technique. But due to unavailability of USG machine in all institutes and requiring special training, techniques used for peripheral nerve blocks vary from institute to institute. Aim: To analyse the effect of anaesthesiologists’ experience on preferred technique and Local Anaesthetic (LA) volume used for brachial plexus nerve block retrospectively. Materials and Methods: In this retrospective observational study, 129 adults American Society of Anesthesiologists (ASA) grade I and II patients requiring brachial plexus nerve block for upper limb orthopaedic surgical anaesthesia for both elective and emergency surgery were divided into three groups for each year depending on technique for nerve block used. Group A: Received USG guided (Micromaxx Sonosite Inc, USA) brachial plexus nerve block. Group B: Received peripheral nerve stimulator (Inmed) guided brachial plexus nerve block. Group C: Received brachial plexus nerve block by traditional anatomical landmark based paraesthesia elicitation blind technique. Patients with inadequate surgical analgesia were given general anaesthesia and were categorised as failure rate. Year wise demographic data, type of technique used for giving brachial plexus nerve block, volume of drug used, failure rate, complications observed were collected and analysed by Student’s t-test and Chi-square test. Results: USG guided technique was the most prefered technique in both years (57.6%, n=38 in year 2018 and 49.2%, n=31 in year 2019). In remaining nearly half of the patients PNS and blind technique was used (PNS 24.2%, n=16 in year 2018 and 20.6%, n=13 in year 2019; blind technique 18.2%, n=12 in year 2018 and 30.2%, n=19 in year 2019). Significantly, less volume of LA drug (mL) was used in group A in year 2019 (16.43±6.07) than in year 2018 (22.34±4.75) (p<0.001). Failure rate in group A in year 2019 (3.2%) was significantly less than in year 2018 (5.2%), but the difference was insignificant in all three groups. In group A, no complications were observed in year 2019 while one incidence of hemidiaphragm paralysis was observed in year 2018, while in group B and C, complications were observed in both years. Conclusion: USG guided nerve block was the most preferred technique for nerve block in the study institute. In 24 months observation period, with increasing experience with USG there was significant increase in success rate and decrease in the volume of LA administered and complications.

Value of Ultrasonographic Guidance For Operative Hysteroscopy on the Safety and Outcome of the Procedure: Randomized Control Trial

Abstract Background Hysteroscopy is a minimally invasive intervention that can be used to diagnose and treat many intrauterine and endocervical problems. Hysteroscopic polypectomy, myomectomy are just a few of the commonly performed procedures. Hysteroscopy has nearly replaced standard D&C for the management of abnormal uterine bleeding (AUB), as it allows for direct visualization and diagnosis of intrauterine abnormalities, and it often offers an opportunity for simultaneous treatment. Operative hysteroscopy is a safe procedure resulting in complication in 0.95-3% of cases. The most frequently observed complications include hemorrhage (2.4%), uterine perforation (1.5%), and cervical laceration (1-11%). Another rare complication is excessive fluid absorption with or without resultant hyponatremia. Can use of ultrasound guidance during operative hysteroscopy decrease the rate of the operative complication? Objective To assess the value of ultrasound guidance for operative hysteroscopy on decreasing the complication and improving the success rate of the procedure. Patients and Methods It is estimated that a sample size of 88 patients that were divided to 44 patients in the Ultrasound guidance group and 44 patients in the group that didn’t perform ultrasound. The patients were encountered from those presented at the gynecology clinic of the Ain Shams university hospital or those presented at ECDU with the inclusion criteria in the period between December 2017 to November 2018. The patients were approached to participate on study and a written informed consent was taken from all the patients. Results Comparative study between the 2 groups revealed; highly significant increase in success rate in ultrasound guided hysteroscopy (USH) group; compared to conventional hysteroscopy (CH) group; with highly significant statistical difference (p < 0.01) and non-significant difference as regards failure and complications rates (p > 0.05). Conclusion Our study found that ultrasound assistance for difficult hysteroscopy reported that ultrasound appears to be a safe and reliable method of assistance.

Efficacy of chloral hydrate oral solution for sedation in pediatrics: a systematic review and meta-analysis.

ObjectiveChloral hydrate (CH), as a sedation agent, is widely used in children for diagnostic or therapeutic procedures. However, it has not come into the market and is currently only used as hospital preparation in China. This review aims to systematically evaluate the efficacy of CH in children of all age groups for sedation before medical procedures.Materials and methodsSeven electronic databases and three clinical trial registry platforms were searched and the deadline was September 2018. Randomized controlled trials (RCTs) evaluating the efficacy of CH for sedation in children were included by two reviewers. The extracted information included success rate of sedation, sedation latency and sedation duration. The Cochrane risk of bias tool was applied to assess the risk of bias. The outcomes were analyzed by Review Manager 5.3 software and expressed as relative risks (RR) or Mean Difference (MD) with 95% confidence interval (CI). Heterogeneity was assessed with I-squared (I2) statistics.ResultsA total of 24 RCTs involving 3564 children of CH for sedation were included in the meta-analysis. Compared to placebo group, CH group had a significant increase in success rate of sedation when used for painless and painful procedure (RR=4.15, 95% CI [1.21, 14.24], P=0.02; RR=1.28, 95% CI [1.17, 1.40], P<0.01), which included 22 and 455 children for this analysis, respectively. Compared to midazolam group, CH group had a significant increase in success rate of sedation (RR=1.63, 95% CI [1.48, 1.79], I2=0%, P<0.00001), sedation latency (MD=13.29, 95% CI [11.42, 15.16], I2=0%, P<0.00001) and sedation duration (MD=17.52, 95% CI [10.3, 24.71], I2=0%, P<0.05), which included 1052, 710 and 727 children for this analysis, respectively. Compared to diazepam, there was no significant difference in success rate of sedation (RR=0.93, 95% CI [0.80, 1.08], I2=52%, P=0.32), which included 230 children for this analysis. Compared to dexmedetomidine, there was no significant difference in the success rate of sedation (RR=0.92, 95% CI [0.80, 1.06], I2=48%, P=0.27) and sedation latency (RR=−1.09, 95% CI [−2.45, 0.26], I2=26%, P=0.11), which included 512 and 371 children for this analysis, respectively. Compared to barbiturates, there was no significant difference in the success rate of sedation (RR=1.03, 95% CI [0.94, 1.13], I2=50%, P=0.58) and sedation duration (MD=−0.72, 95% CI [−1.78, 0.34], I2=38%, P=0.18), which included 749 and 210 children for this analysis, respectively.ConclusionsFrom the extrapolation of the existing literature, CH oral solution is an appropriate effective alternative for sedation in pediatrics.

Intermittent exotropia: relation between age and surgical outcome: a change-point analysis

To study the relationship between age and response to surgery in patients with intermittent exotropia and to identify change points in response to surgery. A retrospective analysis was conducted on 311 patients with intermittent exotropia who had bilateral lateral rectus recession using standard tables with minimum follow-up of 6 months. Data were analyzed using the change-point analysis software to identify cutoff points. A prospective pilot study was then performed on 171 consecutive patients with intermittent exotropia with the same clinical characteristics, in whom amount of recession was modified according to the identified cutoff points. In angles with two change points, 1-mm recession was reduced from patients younger than the lower change point and 1.5-mm recession was added to those older than the upper change point. In angles with one change point, 1.5-mm recession was added to those older than the change point. Satisfactory alignment was defined as esophoria/tropia ≤ 5Δ to exophoria/tropia ≤ 8Δ. There was a negative correlation (P<0.01) between response to surgery and age at surgery for all angles. In younger patients (<7 years) in whom surgical dose was reduced, there was no significant change in success rate (77%), compared with those who had surgery using standard tables (75%). In older patients (>12 years) in whom surgical dose was increased, there was a statistically significant increase in success rate (80% vs 41%). Modifying the surgical dose according to age can improve the success in patients with intermittent exotropia.

Enhanced Prediction of Intrinsically Disordered Regions with the Optimized Data

 Abstract—A protein that lacks a three-dimensional (3-D) structure in its intrinsic state has been called natively unfolded or intrinsically disordered. The observation that many intrinsically disordered protein regions play a key role in many essential functions has promoted increased interest in studies on the structural identification of intrinsically disordered proteins in the field of bioinformatics. Since amino acid sequence have been widely used for the determination of protein structure, it has been theorized that the sequence could also determine disorder. To improve the quality of prediction, recent studies have focused on finding more useful features and developing more robust predictors. Machine learning techniques are ideally used for extracting the complex relationships and correlations hidden in large data sets. In the study, several features of the chosen proteins were combined together in different ways to obtain an optimized dataset and prediction was accomplished by using the most common method, SVM, resulting in significant increase in success rate with the modeled data. Besides, the feature selection method, ERGS, was used to explore the optimum features that have the adequate information on finding disorder. In the research, 37 attributes were found to be the most influential features in predicting disordered regions.

The use of ultrasound to guide time-critical cannula tracheotomy when anterior neck airway anatomy is unidentifiable

Transtracheal or transcricothyroid placement of a cannula is a practice used in a number of aspects of airway management in anaesthesia and intensive care. In this study, we aimed to investigate whether the use of ultrasound will facilitate cannula placement in a time-critical situation in patients with difficult anterior neck airway anatomy. Fifty anaesthetists were randomised to either ultrasound-guided or conventional unguided attempts, at cannula insertion into a model simulating a patient with unidentifiable anterior neck anatomy. Endpoints were the success, and time to success, of cannula placement. There was a significant increase in success rate (83 vs. 43%, P = 0.011) and a significant decrease in time to successful placement (median time to successful cannulation 57 vs. 110 s, P = 0.008) using ultrasound guided compared to unguided cannula placement. If a 'can't intubate, can't oxygenate' scenario occurs in a patient with unidentifiable anterior neck airway anatomy in a location where an ultrasound machine is immediately available, we recommend that consideration is given to the use of ultrasound-guided cannula tracheotomy as the first-line rescue technique.

Ultrasonic Guided Insertion of Central Venous Catheter in Infants and Children

Background/Purpose: ultrasound is licensed for application of regional blocks and insertion of vascular access. We aimed to compare ultrasonic guided (USG) and anatomical landmark technique (ALT) for insertion of central venous catheter (CVC) as regard success rate and rate of complications in infants and children. Materials & Methods: eighty childen (age ranged from 1-5 y) were classified into 2 groups, anatomical landmark technique was used to insert CVC in group I and ultrasonic guided technique was used in group II. Number of trials, duration of the procedure, and rate of complications were recorded. Results: There was a significant increase in success rate of insertion in group II as compared to group I (p = 0.001). Number of trials showed significant decrease in group II as compared to group I (p<0.0001). Incidence of arterial puncture was significantly decreased in group II (p = 0.028). Duration of the procedure was 21.3 ± 0.05 min in group I, and 12.5 ± 0.3 min in group II, ( p<0.0001). Conclusion: Insertion of central venous catheter in children should be guided with ultrasonography to avoid complications and failure of the procedure. Index Word: CV line insertion, ultrasonography.

Clinical aspects and therapeutic outcome in thyrotropin-secreting pituitary adenomas: A single center experience

The management of pituitary adenomas secreting TSH has evolved considerably over the last decades.We report the clinical features, management, and outcome of a large monocentric series. A monocentric retrospective cohort of 26 patients admitted to our Department of Endocrinology between 1983 and 2007, followed for a period up to 204 months. The diagnosis of TSH-secreting adenoma was based on clinical and biochemical findings of central hyperthyroidism. Evaluation of basal and dynamic pituitary function, magnetic resonance imaging or computerized tomography scan were performed in all patients. Twenty-two patients, of whom 15 pre-treated by somatostatin analogs (SSA), underwent trans-sphenoidal surgery and were regularly re-evaluated. The number of cases increased over the years. Age at diagnosis, micro- to macroadenoma ratio, and mean estimated latency between first symptoms and diagnosis did not appreciably change over time. Latency was significantly shorter in macroadenomas. Following surgery, 55% of patients obtained remission (success rate of 40 and 67% in macro- and microadenomas, respectively). SSA pre-treatment led to an apparent although not statistically- significant increase in success rate in micro- but not in macroadenomas. In a monocentric group of 26 TSH-secreting adenomas the high ratio between micro- and macroadenomas remained stable over time with a significantly shorter diagnosis latency in macroadenomas. A more precocious recognition of the tumors and possibly the use of presurgical SSA allowed a high remission rate. A varied combination of neurosurgery, SSA, radiotherapy, and thyroid ablation led to the control of the disease in all the patients studied.

Structured training in intraosseous infusion to improve potentially life saving skills in pediatric emergencies – Results of an open prospective national quality development project over 3 years

Children in emergencies need peripheral intravenous (IV) access in order to receive drugs or fluids. The success of IV access is associated with the age of patients and fails in up to 50% of children younger than 6 years. In such situations, it is essential that physicians and paramedics have a tool and easily learnable skills with a high chance of success. According to international guidelines intraosseous (IO) access would be the next step after failed IV access. Our hypothesis was that the success rate in IO puncturing can be improved by standardizing the training; so we developed an IO workshop. Twenty-eight hospitals and ambulance services participated in an evaluation process over 3 years. IO workshops and the distribution of standardized IO sets were coordinated by the study group of the University Hospital of Berne. Any attempted or successful IO punctures were evaluated with a standardized interview. We investigated 35 applications in 30 patients (a total of 49 punctures) between November 2001 and December 2004. IO puncture was not successful in 5 patients. The success rate depended neither on the occupation nor the experience of users. Attendance at a standardized IO workshop increased the overall success rate from 77% to 100%, which was statistically not significant (P = 0.074). Standardized training in IO puncturing seems to improve success more than previous experience and occupation of providers. However, we could not show a significant increase in success rate after this training. Larger supranational studies are needed to show a significant impact of teaching on rarely used emergency skills.

Detection and measurement of retinal vessels in fundus images using amplitude modified second-order Gaussian filter

In this paper, the fitness of estimating vessel profiles with Gaussian function is evaluated and an amplitude-modified second-order Gaussian filter is proposed for the detection and measurement of vessels. Mathematical analysis is given and supported by a simulation and experiments to demonstrate that the vessel width can be measured in linear relationship with the "spreading factor" of the matched filter when the magnitude coefficient of the filter is suitably assigned. The absolute value of vessel diameter can be determined simply by using a precalibrated line, which is typically required since images are always system dependent. The experiment shows that the inclusion of the width measurement in the detection process can improve the performance of matched filter and result in a significant increase in success rate of detection.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY AS A GUIDE TO CENTRAL VENOUS CATHETER PLACEMENT IN CONGENITAL CARDIAC SURGERY

Introduction: Transesophageal echocardiography (TEE) has become an essential monitor for the management of most patients undergoing surgery for congenital heart disease. Central venous access for monitoring and drug infusion is used in many centers, despite a recognized incidence of complications from malposition, most significantly cardiac perforation from right atrial positioning [1,2]. This study assesses the effect of TEE on correct catheter placement and complications. Methods: After informed consent, 143 patients age 1 day-29 years undergoing surgery for congenital heart disease were enrolled. Patients were randomized to the TEE group or the control group, and further randomized to receive an internal jugular or subclavian vein catheter. The TEE group had a TEE probe inserted, and a transverse plane four-chamber view obtained. Then the vein was entered and a guidewire advanced into the right atrium under direct TEE visualization. The catheter was advanced over the guidewire until its full length was inserted, and a longitudinal plane TEE view of the junction of the superior vena cava (SVC) and right atrium (RA) was obtained. Catheter position was adjusted until the tip was in the SVC at the superior edge of the crista terminalis. Control group patients had the central venous catheter (CVC) placed by standard methods, which included observing the electrocardiogram for premature atrial contractions to confirm atrial guidewire position. Catheter insertion length to the distal SVC was estimated to place the tip midway between the sternal notch and the nipples. The location of the CVC was assessed by TEE after placement. Both groups had catheter location assessed radiographically, with desired location in the SVC, parallel to the vessel wall. Results were compared using a paired T test or Chi square analysis. Results: 76 catheters were placed in the right subclavian vein, 2 in the left subclavian vein, 62 in the right internal jugular vein, and 1 each in the left internal jugular and right external jugular. There was no difference in rate of successful placement if the chest radiograph was used to determine correct placement. There was, however, a significant increase in success rate if the TEE was used to determine correct placement. The SVC/RA junction was an average of 15 mm lower by TEE than by CXR, explaining the difference in success rate. The complication rate, or number of attempts required between the two groups was not different. The time to placement was significantly shorter in the control group. (Table 1)Table 1All catheters inserted via the internal jugular vein were in the SVC or RA. 4 of 77 subclavian catheters were located in the contralateral innominate vein. There was one significant complication: an SVC perforation from a subclavian catheter in the control group necessitating surgical reexploration. Discussion: TEE can be reliably used to assist in the placement of CVC in pediatric cardiac surgical patients. Catheters located high in the RA by CXR are probably in the SVC and pose little risk of atrial perforation.

The relationship of time-dose fractionation factors to complications in the treatment of pituitary tumors by irradiation

The records of the Radiotherapy Division of the Radiology Department of Vanderbilt University Hospital were reviewed for the years 1952-71. During that period of time, 122 patients with diagnosis of pituitary adenomas were treated by external irradiation. A variety of techniques (2 or 3 stationary fields, 180° rotational fields), equipment ( 60Co, 6 MeV Linac) and fractionation schedules (treating 4, 5 or 6 days per week, doses ranging between 150 and 280 rad per fraction), were used. Five patients developed severe complications: 1 with brain necrosis and 4 with blindness related radiation damage to optic pathways. From analysis of time-dose factors (TDF), it is evident that the risk of complications increases from 0% to 25% as the dose exceeds a TDF of 80. Although a significant increase in success rate has resulted from doses in excess of 3500 rad, there is little support for believing that doses in excess of 5000 rad (TDF 80) achieve improved results.