Single-puncture arthrocentesis - a technical review.

Microsurgical vasectomy reversal has progressed from bilateral scrotal incisions, through which the testes were delivered, to incisions delivering the vasa, and now to techniques using mini-incisions. We present our technique for microsurgical vasovasostomy via a single keyhole puncture using the no-scalpel vasectomy techniques.

Feasibility and safety of parallel Shockwave® balloon percutaneous mitral valvuloplasty for degenerative mitral stenosis.

Idiopathic syringomyelia represents a group of patients with a syrinx without an underlying pathological cause. Patients may present with back pain, leg pain and/or neurological dysfunction. We aim to examine the clinico-radiological outcomes of paediatric patients presenting with idiopathic syringomyelia managed with a therapeutic lumbar puncture. All paediatric patients with idiopathic syringomyelia who underwent a lumbar puncture over a 10-year time period were identified and included. Pre- and post-procedural clinico-radiological features were obtained from electronic patient records. Procedural details, including opening pressure and drainage volume, were obtained from electronic operative records. 31 patients underwent a therapeutic lumbar puncture. Median age at time of first lumbar puncture was 12years (range 2-17). 7/31 (23%) patients had significant long-term improvement or resolution in their symptoms following a single lumbar puncture. 13/31 (42%) patients had temporary improvement of their symptoms and underwent further lumbar punctures. 3/31 (10%) patients had resolution of their symptoms after more than one lumbar puncture. 8/31 (26%) patients did not experience any improvement in their symptoms. Symptomatic improvement was more likely in those with a high opening pressure of equal to or greater than 24cmH2O (OR 13 (1.3 - 126.3) P = 0.02). Median length of follow up was 3 yrs (range 6months - 9years). Complications occurred in 9/31 (29%) patients, with 8 of these experiencing a low pressure headache, and 1 patient experiencing temporary back pain following the lumbar puncture. Lumbar puncture may be a safe and effective treatment for symptomatic idiopathic syringomyelia in the paediatric population. It appears to be more effective in those with a higher opening pressure.

This study aims to compare the effectiveness of the modified concentric cannula and the conventional concentric cannula for single puncture arthrocentesis (SPA) in terms of irrigation efficiency, procedure duration, and clinician satisfaction. The study was conducted on 18 temporomandibular joints (TMJs) of 9 fresh cadavers between June and July 2022. After determining the entry points, 1 mL 10-μM methylene blue solution was injected into the upper joint cavities. For each cadaver, SPA was randomly conducted using a conventional concentric cannula (Group C) on one side and a modified concentric cannula (Group M) on the other side. The primary outcome variables were irrigation efficiency, procedure duration, and clinician satisfaction. All efflux solutions were analyzed using a spectrophotometer to determine irrigation efficiency based on the amount of methylene blue solution removed from the upper joint cavities. Both cannulas effectively washed the TMJ. However, there were no statistically significant differences in the median absorbance and concentration values between the groups (p = 0.144, p = 0.144). Procedure duration was significantly lower in Group M (p = 0.001). The clinician satisfaction scores were significantly higher in Group M (p = 0.001) than in Group C. Both cannulas could be used in SPA. However, the modified concentric cannula provides easier procedures, less procedure duration, and higher clinician satisfaction in SPA procedures than conventional concentric cannulas.

Concomitant pulsed field ablation (PFA) for atrial fibrillation (AF) with left atrial appendage closure (LAAC) offers a single-procedure approach for arrhythmia control and thromboembolic risk reduction. This study assessed the workflow, safety, and feasibility of combined PFA and LAAC in routine practice. We prospectively analysed patients undergoing zero-fluoroscopy PFA, with low fluoroscopy for LAAC. Pre-procedural planning used CT imaging and AI-based models for device selection and landing-zone assessment. A single transseptal puncture facilitated intracardiac echocardiography, PFA catheter, and LAAC sheath. A total of 209 patients were included (56% male; mean age 76.5 ± 7.8 years), with 59.3% paroxysmal AF, 40.7% persistent AF, and 50% de novo AF. The mean CHA2DS2-VASc score was 4.5. Mean procedure and left atrial dwell times were 57.3 ± 17 and 45.1 ± 13.6 min, respectively; fluoroscopy averaged 3.4 ± 0.8 min for LAAC. A single LAAC device was used in 94% of cases, achieving adequate seal in all. No pericardial effusion, phrenic nerve injury, kidney, or oesophageal injury occurred; two patients had minor groin bleeding. All were discharged same day on oral anticoagulation for 90 days. Follow-up CT (80%) or TEE (20%) at 111.6 ± 16.5 days showed no leaks >2 mm, a 4.7% small-leak rate, and two device-related thrombi without stroke, managed with extended anticoagulation. Combined PFA and LAAC is feasible and safe with favourable early outcomes. Multi-centre studies are warranted to confirm findings and standardize this workflow for broader clinical adoption.

Case Series for Transradial Approach in Fistulograms for Arteriovenous Access.

Operating rooms (ORs), also known as surgical theatres, are the heart of surgical procedures, a unit within a hospital. They are designed to provide the patient with a sterile and infection-free environment. However, there is a risk of exposure to infectious agents, such as Staphylococcus aureus (including MRSA), Pseudomonas aeruginosa , and Streptococcus species. They affect the superficial skin, but in cases of severe infection, they lead the infection to deeper tissues, and the organs or contents (muscle layer, fascia, soft tissues, and blood vessels) that are exposed during the surgical procedure increase the risk of infection, eventually resulting in surgical site infection (SSI). There may be several postoperative complications, such as a delay in the healing of the wound or opening of the wound completely or partially due to SSI. To reduce contamination of pathogens, we practice preventive strategies with their advancements, like the practice of double gloving, which is used to reduce the risk of needle stick and other sharp injury traumas. The rate of single glove puncture during the surgical procedures was 90.2%, and with the combination of two gloves, it was 23%. In an OT, around 10,000 skin scales are shed per minute by the operating staff. However, about 10% of people have bacterial clumps that could lead to a postoperative complication. Control of contamination in airflow systems can be done using vertical laminar flow with high efficiency particulate air (HEPA) filters, which remove 0.3 mm particles with an efficiency of 99.9%. Installation of the ultra clean ventilation (UCV) system in the OT reduced the joint sepsis to 1 and 10 biological contaminant particles per cubic meter (BCP/m 3 ). Heating, ventilation, and air conditioning (HVAC), which controls the temperature, relative humidity, and air current. The study on the Efficacy of Nosocomial Infection Control (SENIC) showed that SSIs were reduced by 38% as a result of infection control teams, surveillance, and feedback of observed data. The surgical scrubs used in the OT were washed and reused, but the overall performance was affected due to contaminated stains and wear and tear. The number of washes affected the quality of the material, which increased the chances of exposure to pathogens. Polypropylene scrub suits are associated with lower bacterial contamination for single-use purposes, which reduces the risk of cross-contamination as compared to traditional scrubs. By using antibiotic combinations, a wide spectrum of pathogens can be treated. Nanotechnology carries the nanoparticles, which encapsulate the antibiotics, to release at localized surgical sites, which ultimately aims to enhance the efficiency and reduce the adverse effects of antibiotics. The implant is coated with an antimicrobial material that provides resistance towards the microorganisms within the blood during the surgical procedure. Further study shows that by analyzing the patient’s genetic makeup, the target genomic site is exposed to effective antibiotics. Knowledge and practice of health care workers (HCWs) also play a crucial role in the prevention of SSI. This paper aims to summarize the methods to minimize the SSI and focus on the prevention practice strategies with their advancement.

Peripheral arterial catheterization (PAC) is widely used in pediatric intensive care units (PICUs) for continuous hemodynamic monitoring and arterial blood sampling. However, achieving successful arterial access in critically ill children remains technically challenging, and evidence regarding factors associated with first-attempt success is limited. A prospective observational cohort study was conducted in a tertiary PICU. Critically ill children who underwent PAC between April 2024 and May 2025 were included. Each catheterization procedure was treated as the unit of analysis, with clustering at the patient level. Patient-, disease-, procedure-, and peri-procedural variables were collected. The primary outcome was first-attempt success, defined as successful arterial catheterization within a single skin puncture at the intended site with limited needle redirection, resulting in a functional arterial line suitable for continuous blood pressure monitoring or arterial blood gas sampling. Factors associated with first-attempt success were evaluated using multivariable generalized estimating equation (GEE) logistic regression models. A total of 320 PAC procedures were analyzed, with an overall first-attempt success rate of 65% (208/320). In multivariable GEE logistic regression analysis, insertion site and catheterization technique were independently associated with first-attempt success. Compared with radial artery catheterization, cannulation at the dorsalis pedis artery (OR 0.41, 95% CI 0.20-0.83), and ulnar artery (OR 0.35, 95% CI 0.13-0.98) was associated with lower odds of success. Ultrasound-guided catheterization was associated with higher odds of first-attempt success compared with the blind technique (OR 2.10, 95% CI 1.08-4.08). Using early ultrasound rescue at the second attempt as the reference, ultrasound introduced after the fourth attempt was associated with a higher number of cannulation attempts (IRR 3.81, 95% CI 2.05-7.08). First-attempt success of PAC in critically ill children is influenced by both puncture site and catheterization technique. Preferential use of the radial artery and ultrasound guidance may improve cannulation success in the PICU. Early adoption of ultrasound guidance after failed landmark-guided attempts may help reduce repeated cannulation attempts.

Objective: To investigate the efficacy and safety of combined spinal-epidural (CSE) anesthesia using a 25G spinal fine needle via a single puncture for lower limb surgery in children. Methods: Sixty pediatric patients scheduled for surgery were randomly divided into two groups, with 30 patients in each. The control group received subarachnoid anesthesia with 2–2.5 mL of 0.33% ropivacaine. The experimental group received the same ropivacaine dose, followed by withdrawal of the needle to the epidural space and administration of 0.1 mg hydromorphone diluted to 5 mL. The anesthetic and analgesic effects, incidence of complications, and postoperative family satisfaction were observed in both groups. Results: Compared with the control group, the experimental group showed a higher anesthesia success rate, a shorter onset time, and a longer maintenance time of anesthesia (p < 0.05). Postoperative analgesia at various time points was significantly better in the experimental group (p < 0.05). The total incidence of complications was lower in the experimental group, though the difference was not statistically significant (p > 0.05). Family satisfaction was significantly higher in the experimental group (p < 0.05). Conclusion: CSE anesthesia using a 25G fine needle via a single puncture for pediatric lower limb surgery is safe and effective. It can significantly improve surgical outcomes and is worthy of clinical promotion.

Objetivo: Determinar la incidencia de punciones repetidas y analizar los factores que influyen en una punción exitosa. Material y Método: Estudio descriptivo, retrospectivo de corte transversal, realizado durante 2024. Variables analizadas: número repunciones, tipo y localización de fístula, posición de agujas, tiempo de uso y antigüedad del enfermero. Se empleó t de Student, U de Mann-Whitney y chi cuadrado. Resultados: Incluidas 81.968 sesiones de 1.167 pacientes, 69% varones y 31% mujeres, edad media 66,4±14,8 años eIMC 25,7(22,6-29,3). El 92% FAV autóloga y 8% protésica. Tipo de fístula: Humero-cefálica 45,8%, radio-cefálica 40,5%,humero-basílica 7,6% y otros 6,1%; 80% brazo derecho y 20% izquierdo. El 99% agujas canalizadas anterógradas. Antigüedad de los enfermeros mediana de 3,3 (RIQ 1,5-5,9) años. Incidencia de punciones repetidas en el 1% de las sesiones; 83,6% una única punción extra y el 70,3% aguja venosa. Variables asociadas a más punciones repetidas: fístula protésica (1,8 vs 0,9, p<0,001); tipo de fístula: Humero-humeral 2%, humero-axilar 2%, humero basílica 1,3%, radio-cefálica 1,1% y Humero-cefálica 0,7% (p<0,001); canulación retrógrada (2,2% vs 1%, p=0,002; menor tiempo de uso (mediana 29 meses, p<0,001) y mayor antigüedad del enfermero (mediana 3,3 años, p=0,003). Conclusión: La incidencia de punciones repetidas fue baja. Las fístulas protésicas, profundas y de reciente creación, asícomo la punción retrógrada, se asociaron a mayor número de punciones adicionales. Pese a lo esperado, los enfermeros con mayor antigüedad registraron mayor número de repunciones.

The transeptal puncture (TSP) is an obligatory step during catheter ablation (CA) for atrial fibrillation (AF). There is no consensus regarding the utility for a single or double transeptal (TSP) access for CA of AF. To evaluate procedural outcomes and in-hospital complications (death, cardiovascular, neurological, peripheral vascular and pulmonary events) associated with CA of AF in patients undergoing single versus double TSP puncture using the National Cardiovascular Data Registry (NCDR). Clinical characteristics and procedural outcomes of patients undergoing CA for AF between 2016 and 2024 were evaluated. Inverse probability of Treatment Weighting (IPTW) analysis was developed to adjust for confounding variables between TSP groups. A total of 212,345 patients were identified. Among patients with paroxysmal AF (PAF) and non-paroxysmal AF (NPAF), single TSP was associated with comparable but lower risk of total procedural complications (PAF: 1.47% vs. 1.73%, OR:0.91, 0.88–0.93), (NPAF: 2.09% vs. 2.58%, OR:0.77 0.72–0.82), hospitalization > 1 day (PAF: 7.15% vs. 7.92%, OR:0.90, 0.87- 0.93), (NPAF: 10.41% vs. 12.13%, OR:0.84, 0.81–0.86) and a similar but higher likelihood of discharge in sinus rhythm (PAF: 95.55% vs. 95.17%, OR:1.09, 1.05–1.14) (NPAF: 93.37% vs. 92.31%, OR:1.17, 1.13–1.22) compared to double TSP technique. The incidence of stroke or TIA was not different between TSP groups. In a large AF ablation registry, single and double TSP use had similar procedural safety, and comparable likelihood of discharge in sinus rhythm. Single TSP use was not associated with embolism or cerebrovascular events. Operator preference and patient characteristics should be taken into consideration to define optimal TSP strategy.

Ankle and foot conditions with muscle overactivity often require botulinum neurotoxin (BoNT) injections into the flexor digitorum longus (FDL), tibialis posterior (TP), and flexor hallucis longus (FHL) muscles. This manuscript introduces a novel ultrasound (US) window for simultaneous BoNT injections into these muscles to improve efficiency and patient comfort in treating ankle and foot spasticity. A novel posterior approach using a transverse US probe placement on the distal leg was developed in patients requiring BoNT injections for lower limb muscle overactivity. This technique modifies traditional probe handling to achieve a horizontal alignment of TP, FDL, and FHL within the US window, facilitating simultaneous visualization and a single skin puncture three-muscle in-plane injection. This single US window allows concurrent visualization of the TP, FDL, and FHL. It may facilitate more precise needle and injectate placement. The approach reduces the number of skin punctures. It may also improve procedural efficiency and patient comfort. This technique offers a practical option for BoNT injections into deep posterior leg muscles. It could be considered for routine clinical use in managing ankle and foot muscle overactivity.

BackgroundInstitutional characteristics can affect atrial fibrillation (AF) catheter ablation procedural outcomes. Although hospital teaching status may affect patient care in other settings, its effect on AF ablation is unknown. We sought to determine variations in procedural characteristics and complications according to hospital teaching status.MethodsWe included all adult patients in the prospective National Cardiovascular Data Registry AFib Ablation Registry. Hospitals were categorized as university hospitals, nonuniversity teaching hospitals, and nonteaching hospitals. Associations were analyzed using adjusted logistic regression models.ResultsA total of 212 327 AF ablations (mean age of patients, 67.0±10.3 years, 35.5% female) were performed between January 2016 and June 2024. University hospitals performed the fewest cryoablations (unadjusted proportions: 14.4% versus 29.9% at nonuniversity teaching hospitals and 16.9% at nonteaching hospitals, P<0.001), adjunctive lesions (59.0% versus 63.3% versus 66.9%, P<0.001), and empiric linear lesions (27.4% versus 30.2% versus 38.1%, P<0.001). Single transseptal punctures were most common at nonuniversity teaching hospitals and least common at nonteaching hospitals (68.9% versus 47.9%, P<0.001). Procedural differences persisted after adjusting for patient characteristics and procedural volume. Same‐day discharge rates were lower at university hospitals compared with nonuniversity teaching hospitals and nonteaching hospitals (34.1% versus 44.5% versus 44.0%, P<0.001). Overall complication rates (2.3% versus 2.2% versus 2.1%, P=0.179) and major complication rates (0.8% versus 0.7% versus 0.7%, P=0.064) were similar based on teaching status.ConclusionsAfter adjustment for patient characteristics and procedural data, AF ablation procedural approaches differ by hospital teaching status. Overall complication rates are low with no differences between hospitals by teaching status.

Abstract Building on work of Harer, we construct a spine for the decorated Teichmüller space of a non‐orientable surface with at least one puncture and negative Euler characteristic. We compute its dimension, and show that the deformation retraction onto this spine is equivariant with respect to the pure mapping class group of the non‐orientable surface. As a consequence, we obtain a model for the classifying space for proper actions of the pure mapping class group of a punctured non‐orientable surface, which is of minimal dimension in the case there is a single puncture.

Single-puncture ultrasound-guided sciatic, femoral, and obturator injection (SP-SFO): Spread of dye in cadavers.

Thyroid nodules are frequently encountered clinically and the prevalence has surged to 68% as cited (1). Many guidelines in the literature recommend USG guided FNAC in differentiating malignant from benign thyroid nodules (2). Fine needle aspiration (FNA) biopsy of thyroid nodules is one of the minimally invasive, safe and frequently performed procedure on outpatient basis. FNA can be performed under palpation guidance or ultrasound guidance. In addition to knowing the optimum technical skills, one must know the limitations of procedure, its indication and factors affecting the adequacy. Local site pain and ecchymosis are two main commonly seen complications by the IR operators however serious events are rarely reported till date (3). FNA is a well-tolerated procedure but pain is one of the few drawbacks of FNA, however pain score may vary in different people. Some reports have suggested that FNA can be done without local anesthesia when single puncture is used, however multiple punctures are required for adequacy of the sample and in this case, pain is the limitation. Literature review suggest use of 22 to 27 G needles for FNA but blood contamination is frequently seen with the use of larger needles (4). In our setting, oral paracetamol is administered pre-procedurally to alleviate any discomfort caused by minor bruising and the needling process. Techniques used to minimize the pain felt during the procedure include the following: 1) of the smallest needle size available. We use the needle from a 1 cc syringe which has a detachable 26 gauge needle (commonly used for Insulin injectons). For patients with increased skin to gland distance a longer needle in 23 gauge is used in addition. 2) Mixing of the local anesthesia with bicarbonate to neutralize the stinging effect of the acidic local anaesthetic. We perform infiltration of the skin and in addition the thyroid capsule so that all subsequent needle entries are painless. In our setup, almost 10 mL of local anesthesia is used comprising of 9 mL of 2% xylocaine and 1 mL of sodium bicarbonate (8.4% w/v) in a ratio of 9:1. Since adopting this protocol and technique in our setup at Shifa International Hospital the patients have given excellent feedback especially those who had a FNA performed in the past.

Recently, a transbronchial needle biopsy (TBNB) method using a three-plane symmetric Acquire needle with Franseen geometry was developed to improve diagnostic yield. This study describes our experience with Endobronchial ultrasound (EBUS)-TBNB for pulmonary and mediastinal diseases. A retrospective review was conducted involving 37 patients who underwent EBUS-TBNB with an Acquire 22G needle between July 2021 and September 2024. Enlarged lymph nodes were sampled, and medical records were analyzed to evaluate diagnostic outcomes, including histological core tissue acquisition, programmed death-ligand 1 (PD-L1) expression testing, and next-generation sequencing (NGS). We sampled a total of 48 lymph nodes (26 subcarinal [#7], 12 right lower paratracheal [#4R], and 10 right hilar [#11]) with a median longest diameter of 23.1mm (range, 9.3-44.6mm). Definitive diagnoses were achieved in 36 patients, including 25 cases of lung cancer, one large-cell neuroendocrine carcinoma, one renal cell carcinoma, five cases of sarcoidosis, and four cases of unspecified lymphadenopathy. The overall diagnostic yield was 97.3% (95% confidence interval: 85.8%-99.5%). Both PD-L1 expression testing and NGS were successfully performed in all lung adenocarcinoma cases (nine using the Oncomine Dx Target Test and four using the AmoyDx Pan Lung Cancer polymerase chain reaction (PCR) Panel). Histological samples were successfully obtained from 35 patients, whereas only two cases of lung squamous cell carcinoma were cytologically diagnosed due to necrotic and calcified samples. The nucleic acid yield from a single puncture was sufficient for analysis using the Lung Cancer Compact Panel. EBUS-TBNB demonstrated high efficacy for diagnosing lung cancer, including PD-L1 testing and NGS, and for obtaining histological core tissue.

Abstract Specific binding sites for non‐circulative viruses within the mouthparts of aphid vectors have been investigated with limited success. Such sites have been described more precisely for cauliflower mosaic virus (CaMV, Caulimovirus ), and shown to be restricted to the acrostyle, a specific anatomical structure located in the common duct of the aphid stylets. However, the nature and precise location of binding sites of other non‐circulative viruses (e.g., cucumoviruses and potyviruses), and whether distinct viral species compete for the same sites remains unknown. In this study, competition between non‐circulative viruses for binding sites was assessed for viruses that differ in their transmission mode: cucumber mosaic virus (CMV, Cucumovirus ), transmitted by the capsid strategy, and three viruses using the helper strategy for their transmission—turnip mosaic virus (TuMV, Potyvirus ), zucchini yellow mosaic virus (ZYMV, Potyvirus ), and CaMV. In this work, we performed competition and sequential acquisition experiments, with contrasting results obtained depending on the virus species used and the sequence of acquisition/inoculation of the potentially competing viruses. Our results showed that potyviruses and caulimoviruses do not appear to compete for the same binding sites and/or receptors within aphid stylets, as no modifications in their transmission rates were observed regardless of their acquisition sequence. However, a decrease of CMV transmission rate when ZYMV was previously acquired, suggests that potyviruses and cucumoviruses might compete for binding sites in their aphid vectors. Moreover, we observed that potyviruses and cucumoviruses can be co‐acquired and co‐inoculated in the same plant cell during a single intracellular puncture, demonstrating co‐infection of individual cells by more than a single virus species.

We aims to evaluate the effects and complications associated with mid-line catheters inserted via different puncture veins in neonates, ultimately providing a foundation for selecting the most suitable puncture site for catheterization in clinical neonatal practice. A retrospective data analysis was conducted, involving 244 neonates with indwelling mid-line catheters who were admitted to a Class III Grade A general hospital in Anhui Province between August 2020 and December 2023. The study compared catheter indwelling duration, the incidence of catheter-related complications, and the first puncture success among neonates with catheterization through various veins. The analysis revealed a statistically significant difference in indwelling duration across different puncture veins (H = 28.65, P < 0.001). Specifically, significant differences were observed in the indwelling duration between the median cubital vein, axillary vein, and superficial temporal vein (adj. P < 0.05), whereas no significant differences were found among the other puncture sites (adj. P > 0.05). A statistically significant variation in catheter complications was observed among different puncture veins (P < 0.001). Specifically, the incidence of complications was lower in the median cubital and axillary veins compared to other puncture sites, with these differences reaching statistical significance (P < 0.05). Furthermore, the basilic vein exhibited a lower incidence of complications than the cephalic vein, superficial temporal vein, and great saphenous vein, with the difference being statistically significant only when compared to the great saphenous vein (P < 0.05). Additionally, no statistically significant difference was found in the success rate of single puncture among the various puncture veins (P > 0.05). However, the one-time successful catheter insertion rate was significantly higher for the median cubital and axillary veins compared to other veins (P < 0.05), while no statistically significant differences were observed among the remaining veins. The insertion of mid-line catheters into the axillary vein and the median cubital vein has been shown to extend catheter indwelling time, enhance the ease of catheter insertion, and decrease the incidence of complications. Consequently, it is advisable to prioritize the axillary vein and median cubital vein for the insertion of mid-to-long catheters in neonates.