Use Of Adjunctive Techniques Research Articles

External Validation of the Percutaneous Renal Ablation Complexity Scoring System in Patients Undergoing Percutaneous Cryoablation or Microwave Ablation of Renal Tumors

PurposeTo assess the ability of the Percutaneous Renal Ablation Complexity (P-RAC) scoring system to predict procedural complexity or adverse events (AEs) in adult patients undergoing percutaneous thermal ablation of renal tumors. Materials and MethodsA retrospective review of 240 consecutive adult patients who underwent percutaneous thermal renal ablation from 2004 to 2018 was conducted. The P-RAC score was calculated for each renal tumor and procedural complexity recorded. A correlation coefficient was calculated for the P-RAC score and both the number of probes used and procedural duration. Receiver operating characteristic curves assessed the score’s ability to predict the use of adjunctive techniques and/or major AEs, classified according to the Society of Interventional Radiology guidelines. ResultsFor the entire cohort, there was a weak correlation between P-RAC scores and both the number of probes used (r = 0.31; P < .001) and procedural duration (r = 0.18; P = .03). When evaluating only patients treated with microwave ablation (MWA), no correlation between P-RAC scores and either the number of probes (P = .7) used or procedural duration (P = .4) was found. The area under the curve (AUC) for the P-RAC score to predict the use of adjunctive techniques was 0.55 and 0.53 for the entire cohort and MWA group, respectively. The AUC for the P-RAC score to predict major AEs was 0.70, 0.71, and 0.73 for the entire cohort, MWA group, and cryoablation group, respectively. ConclusionsThe P-RAC scoring system is limited in its ability to predict percutaneous thermal renal tumor ablation procedural complexity, especially in patients treated with MWA. The scoring system may have a role in identifying patients at risk of major AEs.

Postoperative Outcomes and Reinterventions Following Fenestrated/Branched Endovascular Aortic Repair in Post-Dissection and Complex Degenerative Abdominal and Thoraco-Abdominal Aortic Aneurysms.

Background: The outcome of FBEVAR in post-dissection thoracoabdominal aortic aneurysms has not been well established in the literature. The aim of this study was to compare midterm outcomes following FBEVAR in post-dissection aneurysms to degenerative aneurysms. (2) Methods: This was a retrospective review of all patients undergoing FBEVAR in a single center between 2017 and 2020. The baseline characteristics, intraoperative details, and postoperative outcomes of patients with post-dissection aneurysms were compared to those with degenerative outcomes. The primary end point was unplanned reinterventions. Cox regression analysis was performed to identify the determinants of worse outcomes. Results: A total of 137 subjects with a mean age of 70 ± 10 years were included in the study, out of which 30 presented post-dissection aneurysms (22%). Custom-made devices were employed in 119 patients, off-the-shelf devices in 13 and physician-modified endografts in 5, with incorporation in 505 target vessels. The technical success rate was comparable in both groups (97% vs. 98%, p = 0.21). However, the one-year freedom from unplanned reintervention was lower in the post-dissection group (67% vs. 89%, p = 0.011). Conclusion: FBEVAR in post-dissection aneurysms is associated with a favorable technical success rate, but reintervention rates remain high. Long procedural duration and the use of adjunctive techniques are associated with increased risk of reinterventions.

Impact of guidewire caliber on ERCP outcomes: Systematic review and meta-analysis comparing 0.025- and 0.035-inch guidewires.

Background and study aims The impact of guidewire caliber on endoscopic retrograde pancreatography (ERCP) outcomes are not clear. Recent studies have compared two guidewires, 0.035- and 0.025-inch, in randomized controlled trials (RCTs). We performed a systematic review and meta-analysis of available RCTs to assess if different caliber would change the outcomes in ERCP. Patients and methods A systematic search of PubMed/Medline, Embase, Cochrane, SciELO, Global Index Medicus and Web of Science was undertaken through November 23, 2021 to identify relevant RCTs comparing the two guidewires. Binary variables were compared using random effects model and DerSimonian-Laird approach. For each outcome, risk-ratio (RR), 95 % confidence interval (CI), and P values were generated. P < 0.05 was considered significant. Results Three RCTs with 1079 patients (556 in the 0.035-inch group and 523 in the 0.025-inch group) were included. The primary biliary cannulation was similar in both groups (RR: 1.02, CI: 0.96–1.08, P = 0.60). The overall rates of PEP were also similar between the two groups (RR: 1.15, CI: 0.73–1.81, P = 0.56). Other outcomes (overall cannulation rate, cholangitis, perforation, bleeding, use of adjunct techniques) were also comparable. Conclusions The results of our analysis did not demonstrate a clear benefit of using one guidewire over other. The endoscopist should consider using the guidewire based on his technical skills and convenience.

Specifics of endovascular embolization for cerebral aneurysmsin the acute period of subarachnoid hemorrhage

Aim – to assess the benefits of modern methods for endovascular occlusion of ruptured cerebral aneurysms in the acute period of subarachnoid hemorrhage (SAН). Materials and methods. Medical records of patients undergoing treatment in the acute period of aneurysmal SAН between 2010–2021 were analyzed. 2 groups were formed: I – the use of standard surgical catheters, minimal use of adjunctive techniques for aneurysm embolization (2010–2016), II – routine use of triaxial access systems, intraarterial infusion of nimodipine, active use of adjunctive techniques for aneurysm embolization, intraoperative antiplatelet therapy immediately after aneurysm occlusion – 500 mg of solution Acelysin administrated intravenously (2017–2021). The severity of SAН according to the Hunt–Hess, Fisher scales, the treatment outcome according to the modified Rankin Scale (mSR), the location and size of aneurysms and intraoperative complications were analyzed. Results. There were 156 observations in group I, 91 – in group II. The median age was 48.26 years in group I, 51.44 years – in group II. On the basis of gender status, there was a majority of women in both groups. Aneurysms of the anterior cerebral-anterior communicating artery complex predominated in both groups; the internal carotid artery was the second most frequent localization. The severity of SAН according to the generally accepted scales (Hunt–Hess, Fisher) did not differ significantly. Coil embolization was used in 100 % of cases, balloon-assisted coiling was used in 6.48 % in group I and in 14.80 % – in group II, stent-assisted coiling – in 2.56 % and 9.30 %, respectively, distal access catheter with the triaxial system was not used in group I and it was performed in 57.4 % of cases in group II. Pharmacoangioplasty using nimodipine solution was used in 16.6 % in group I and in 22.2 % in group II. Intravenous drip infusion of 0.5 g Acelysin was performed immediately after aneurysm occlusion in 22.2 % of cases in group II. Intraoperative aneurysm rupture was observed in 5.1 % in group I and in 1.1 % in group II. Distal coil migration or into the maternal artery occurred in 6.41 % in group I and in 2.20 % in group II. Thromboembolic complications were noted in 7.69 % and in 2.20 %, respectively. The mean value of dysfunction degree on mSR amounted to 2.27 in group I and 1.45 – in group II. A good treatment outcome (mRS score 1–2) was defined in 71.2 % of observations in group I and in 87.9 % – in group II. The death rate was 12.82 % and 7.62 %, respectively. Conclusions. Routine use of triaxial access systems and intraarterial pharmacoplasty with nimodipine allow adequate prevention of mechanically induced vasospasm during catheterization of the aneurysm cavity. The triaxial access system stability provides better control of the microguidewire and microcatheters reducing the risk of aneurysmal wall perforation during catheterization. The use of adjunctive techniques for embolization of ruptured cerebral aneurysms in the acute period of SAH and prophylactic infusion of Acelysin solution after aneurysm occlusion significantly reduces the incidence of thromboembolic complications. The earliest possible occlusion of a ruptured cerebral aneurysm is not only the prevention of re-rupture, but also expands the possibilities of intensive care for preventing secondary complications of SAH.

Clinical adaptation of auxiliary methods and multidisciplinary approach to changing trends in parathyroid surgery.

To examine the effects of multidisciplinary approach and adjunct methods, on the surgical strategy, complications and treatment success of parathyroid surgery.Patients, who were operated for primary hyperparathyroidism (n = 411) at our institution between 2012 and 2019 were reviewed retrospectively. Preoperative imaging studies, surgical method, additional diagnostic methods used during surgery, frozen section results, and histopathology findings, complications, persistence, and recurrence were examined.Localization was determined by first-line examinations in 79.9% (n = 348). Four-dimensional computed tomography was used with an 83.3% success rate. Lateralization success for angiographic selective venous sampling was 80.3% and exact localization success was 65.1%. Bilateral neck exploration was performed in 10.6% (n = 37) of the patients, and in the remaining 89.4% (n = 311), minimally invasive parathyroidectomy (MIP) was performed. While the complication rate was higher in the bilateral neck exploration group (P = .019), persistence and recurrence rates were similar between 2 groups. During the study period, annual case volume increased from 9 cases to 103 cases (P < .001) and the rate of MIP increased from 44.4% to 92.8% over the years (P < .001).Effective use of adjunct techniques has increased the rates of MIP. The multidisciplinary approach has also provided low complication rates with the increasing number of cases.

A61 USE OF ADJUNCTIVE REMOVAL TECHNIQUES FOR ENDOSCOPIC MUCOSAL RESECTION OF LARGE NON-PEDUNCULATED COLONIC POLYPS IS PREDICTIVE OF POLYP RECURRENCE

Abstract Background Endoscopic mucosal resection (EMR) allows for safe and effective removal of large non-pedunculated colon polyps. However, prior studies have shown significant recurrence rates between 10–30% after EMR, which have led to recommendations for close endoscopic follow-up and the use of techniques such as snare tip soft coagulation (STSC) to EMR margins to prevent recurrence. Models such as the Size/Morphology/Site/Access score (SMSA) have been developed to aid in identifying polyp complexity and patients at high risk of recurrence. Numerous individual risk factors for recurrence have previously been reported, however the significance of these factors have varied between studies, with limited data from Canadian centres. Aims To evaluate predictors of recurrence for large non-pedunculated polyps following EMR. Methods Consecutive patients between April 1, 2017 to March 1, 2019 who underwent EMR were retrospectively identified from endoscopy unit administrative records. Patients with non-pedunculated colorectal polyps ≥ 2 cm that were removed by EMR were included if follow-up endoscopy data were available. Polyps found to contain invasive adenocarcinoma on histology and/or were referred for surgical resection were excluded. Patient demographic, pre-procedural, intra-procedural, and post-procedural data to time of first follow-up colonoscopy were extracted. Recurrence was defined as a positive pathology specimen from the EMR scar at follow-up. Adjunctive techniques were defined as the use of any non-snare resection or ablation technique for removal of visible adenoma at the time of the EMR. Chi-square and multivariate regression analyses were conducted for variables of interest. Results 517 patients underwent large polyp EMR during the study time period with 265 patients satisfying inclusion criteria. Median age of patients was 67 years (IQR 14); 48% were female. STSC was performed to EMR margins in 94% of cases. 30.9% and 69.1% of polyps were SMSA grade 3 and grade 4 respectively. Adjunctive removal techniques were utilized in 31% of patients, 95% of which was hot avulsion. 15% of patients had recurrence on follow-up endoscopy. Higher SMSA grade was associated with the use of adjunctive techniques (20% vs. 37%, p=0.006). The use of adjunctive removal techniques (OR 2.92, p=0.007) and male gender (OR 3.45, p=0.002) were the only factors found to be significantly predictive of recurrence on multivariate analysis. Conclusions Male gender and the use of adjunctive removal techniques, particularly hot avulsion, are independently predictive of recurrence after EMR of large complex colorectal polyps. Male patients and those who require hot avulsion may be considered high risk for recurrence and warrant closer follow-up. Funding Agencies None

Pledget Reinforcement and Tractional Compression as Adjunctive Techniques for Suture-Mediated Closure (SMC) in Percutaneous Endovascular Aneurysm Repair (pEVAR): A Retrospective Observational Cohort Study

Percutaneous endovascular aneurysm repair (pEVAR) is commonly utilized and requires the use of suture-mediated closure (SMC) devices to ensure adequate femoral artery hemostasis. Despite the use of such devices, puncture-related complications remain relatively common. We introduced two new adjuncts (pledget reinforcement and tractional compression) along with SMC to reduce such puncture-related complications. The aim of the study was to assess the efficacy and safety of the new adjunct techniques. This retrospective observational cohort study examines the impact of two adjunctive techniques on puncture-related complications compared with the previous year data before this new introduction of adjunct techniques. Sixty-one percutaneous femoral punctures (in 31 patients) utilizing adjunct techniques for closure (the adjunct group) were retrospectively compared with 89 punctures (in 46 patients) closed with standard SMC technique (the standard group). The use of adjunctive techniques led to a significant reduction in overall puncture-related complications (3/61 (4.9%) vs. 20/89 (22.5%), P=0.0106) and the need for emergent surgical repair after failed hemostasis (2/61 (3.3%) vs. 13/89 (14.6%), P=0.037). These novel adjunctive techniques (pledget reinforcement and tractional compression) of SMC for pEVAR reduce puncture-related complications and increase the confidence to offer percutaneous techniques for more patients.

Delayed Intracranial Parenchymal Changes After Aneurysmal Coil Embolization Procedures for Unruptured Intracranial Aneurysms.

With the recent advances in endovascular treatment devices, it has become standard in wide-neck or large intracranial aneurysms to perform coil embolization with adjunctive techniques. However, device-related perioperative complications have been reported because of the use of more complex systems. To investigate patients who developed multiple parenchymal lesions after undergoing coil embolization for treating an unruptured intracranial aneurysm. This study investigated 305 consecutive patients who underwent coil embolization of unruptured intracranial aneurysms between 2015 and 2017. Delayed inflammatory changes referred to the delayed observation of multiple cerebral white matter lesions on follow-up magnetic resonance imaging at an area corresponding to the perfused area of the treatment target vessel. The timing and pattern of onset, device used, the combined use of adjunctive techniques, and the clinical course after steroid treatment were retrospectively investigated. The 7 patients (2.3%) who showed delayed inflammatory changes were all women with a mean age of 59 yr. A mean duration from treatment to onset was 28 d. Symptoms were convulsions in 3 patients, hemiplegia in 2 patients, and homonymous hemianopia in 1 patient. All 7 patients were treated with adjunctive technique including stents, double catheter method, and balloon assist. Response to steroid treatment was satisfactory both clinically and on imaging in all 7 patients. Skin patch test was positive for nickel allergy in 2 patients. Clinicians must be fully aware of symptomatic delayed inflammatory changes may occur after endovascular aneurysmal treatment with the use of various devices.

3:54 PM Abstract No. 253 Single transplant center’s experience with transjugular intrahepatic portosystemic shunt creation in patients with portal venous thrombosis

To characterize the creation of TIPS in patients with difficult anatomy due to portal venous thrombosis including indications for TIPS, technical feasibility, and adjunctive techniques. An internal database at a single transplant institution was queried for all patients with primary TIPS creation between January 2014 and June 2019. This patient list was then filtered for patients with presence of portal venous thrombosis demonstrated on cross-sectional imaging prior to TIPS creation. The charts of these patients were searched for preprocedural patient characteristics including etiology of portal venous thrombosis, indications for TIPS creation, procedural details including use of adjunct techniques, and technical success of TIPS creation. A total of 89 patients were identified in our retrospective review. Patients ranged in age from 12 years to 89 years. The top 3 locations for venous thrombosis in patients were the main portal vein (58%), superior mesenteric vein (52%), and splenic vein (21%). 25 patients had occlusive thrombosis of the portal system with cavernous transformation. Etiology of portal system thrombosis was most often secondary to NASH cirrhosis (25%), alcoholic cirrhosis (16%), and HCV cirrhosis (15%). The most common indications for TIPS placement were refractory thrombosis (37%), refractory ascites (33%), and recurrent upper GI bleeding (16%). 79 patients underwent technically successful TIPS creations (89%); of these 79 cases, 13 cases required splenic venous access via direct transsplenic needle puncture, 11 cases utilized the “Gunsight” technique for TIPS creation. Average fluoroscopic time for TIPS creation was 42.3 minutes. 19 patients in this study received liver transplantation following the successful placement of a TIPS. Portal venous thrombosis may present a technical anatomic challenge in patients presenting for TIPS creation. Use of intraprocedural adjunct techniques such as splenic access or gunsight technique can help increase technical success of TIPS creation in this patient population to treat a variety of symptoms secondary to portal hypertension and portal venous clot burden.

Intramedullary Nailing of Lower-Extremity Periarticular Fractures.

Intramedullary nailing is used to stabilize distal femoral, proximal tibial, and distal tibial periarticular fractures with short proximal or distal segments, as well as some intra-articular fractures in which a stable articular block can be created. Intramedullary nailing may be beneficial in complex fracture patterns with diaphyseal extension, segmental injuries, or patients who might benefit from a decreased incision burden. Step 1: Preoperative planning. Review imaging and make sure there is a nail with adequate interlocks. Consider the use of adjunctive techniques to obtain and maintain alignment, and how intra-articular fracture lines will be stabilized. Step 2: Position and prepare the patient. Step 3: Exposure for nailing via suprapatellar, infrapatellar, or knee arthrotomy approaches. Limited exposure of fracture planes may also be necessary for adjunctive techniques. Step 4: Convert an OTA/AO C-type fracture to an A-type fracture if needed. Step 5: Obtain appropriate starting point and trajectory with the nail starting wire and use the opening reamer. Step 6: Obtain reduction, if not yet done, and pass the ball-tipped reaming wire across the fracture. Step 7: Ream while holding reduction. Step 8: Pass nail. Step 9: Verify reduction is maintained and correct if needed. Step 10: Place interlocks, preferably multiplanar, in the short segment. Create a fixed angle construct if desired and convert adjunctive techniques/provisional fixation to definitive fixation as needed. Step 11: Perform final checks. Step 12: Closure. Step 13: Postoperative plan. For extra-articular fractures, one may expect healing with maintained alignment from what was present at the case end intraoperatively in the vast majority of cases. For intra-articular fractures, development of posttraumatic arthritis is an additional concern.

Localisation of the cricothyroid membrane by digital palpation in the emergency department

IntroductionA surgical approach to airway management may be essential in situations of difficult or failed airway, where immediate airway access is needed to provide oxygenation. However, the procedure is uncommonly...

Changing Paradigms in the Endovascular Management of Ruptured Anterior Communicating Artery Aneurysms.

Approximately 17% of ruptured anterior communicating artery (ACoA) aneurysms were deemed unsuitable for coil embolization during the Barrow Ruptured Aneurysm Trial (BRAT), most commonly due to unfavorable dome-to-neck ratio or small size. To compare patients treated by coil embolization for ruptured ACoA aneurysms during the trial to those treated after the trial to determine whether advances in endovascular techniques have allowed for effective treatment of these lesions. All cases of ruptured ACoA aneurysms treated by endovascular modalities during BRAT (2003-2007) and post-BRAT (2007-2012) were reviewed for patient and aneurysm characteristics, treatment types, and clinical and angiographic outcomes at 3-yr or last follow-up. The BRAT ACoA cohort included 39 patients treated with coiling (excluding those crossed over to clipping). The post-BRAT cohort included 93 patients who were significantly older (mean age, 59.5 vs 52.8 yr, P = .005) than the BRAT cohort; there were no significant cohort differences in sex, Hunt and Hess grade, or mean aneurysm size. The use of balloon remodeling was significantly higher in the post-BRAT cohort (31.2% [29/93] vs 5.1% [2/39], P = .001), as was the proportion of wide-necked aneurysms treated (66.7% [62/93] vs 30.8% [12/39], P < .001). There was no significant difference in clinical outcome or retreatment rate between the 2 cohorts (P = .90 and P = .48, respectively). ACoA lesions thought unamenable to endovascular therapy in an earlier randomized trial are now successfully coiled with increased use of adjunctive techniques, without sacrificing patient outcome or treatment durability.

Minimally Invasive Surgery for Complicated Diverticulitis

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann’s (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

A comparison of formalin and GEWF in fixation of colorectal carcinoma specimens: rates of lymph node retrieval and effect on TNM staging

AimsThe Royal College of Pathologists recommend that a median of at least 12 lymph nodes should be harvested during pathological staging of colorectal cancer. It is not always easy to...

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement. Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α=0.05). Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18years) underwent PEH surgery, 84.7% were performed laparoscopically and 15.3% open. 24.6% of cases were classified urgent/emergent upon admission, and almost 70% of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30% of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9% LHR vs. 26.3% OHR). Almost 90% of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement. We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician's comfort with laparoscopic surgery and surgical practices than the patient's condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.

Fulminant Bacterial Meningitis

Fulminant bacterial meningitis is a rare host reaction to infection characterized by sudden onset, rapid deterioration, abrupt cerebral edema and refractory intracranial hypertension associated with an extremely high mortality rate. A search of all relevant medical literature since 1900 was conducted to clarify the nature of this entity and its medical management. Fulminant meningitis occurs in a small percentage of all cases of bacterial meningitis, at all ages and with all infecting organisms. The mortality rate exceeds 50%. Descriptions of fulminant bacterial meningitis are found in medical literature from the preantibiotic era. Its incidence and clinical character have not changed since the introduction of antibiotics and advanced intensive care medicine. The explosive cerebral edema cannot be predicted, and the underlying molecular pathophysiology remains poorly understood. Vigorous neuroresuscitation and the use of adjunctive techniques to control the cerebral edema have not been shown to modify the extreme intracranial hypertension and risk of herniation. Fulminant bacterial meningitis is an example of an aberrant host response to infection that challenges available medical intervention.

Training Emergency Medicine Residents—the Skill of Endotracheal Intubation: Comparison of Human Cadavers vs Mannequins

ABSTRACT Introduction and objectives There are multiple approaches to teach residents the skill of endotracheal intubation, including classroom teaching, cadaveric specimens, and simulation mannequins. The hypothesis of our study is training in the technique of intubation is equally mastered (resident confidence and competency) in training on human cadavers or simulation mannequins. Materials and methods Emergency medicine interns were asked to voluntarily enroll in the study prior to the beginning of intern year and randomized into two groups. The first group practiced intubation using mannequins. The second group practiced intubation using human cadavers. Both groups were given the same brief introductory lecture on the basics of endotracheal intubation. One week later, all the interns returned and attempted to intubate cadavers and mannequins. Competency assessment was based on the number of successful intubations, number of attempts, and use of adjunctive techniques. Interns were also surveyed after their anesthesia rotation with a Likert scale on confidence of being able to perform intubation. Results The overall average number of attempts was 1.67 in the mannequin group and 1.85 in the cadaver group. Mannequin trained interns had a total of 24 poor techniques noted over the 2 years. The cadaver trained group had a total of 35 poor techniques over the 2 years. Adjunct use was nearly identical in the two groups. Intubation success rate during anesthesia rotation and preparation ratings were nearly identical in the two groups. However, the cadaver-trained group reported feeling slightly more confident. Conclusion Overall, mannequins require fewer attempts to intubate and being mannequin trained results in fewer attempts. Adjunct use is independent of training type. The mannequintrained group had less episodes of poor technique than the cadaver-trained group. A mannequin training appears to be equivalent or better than cadaveric training for securing an airway, although cadaver trained interns reported slightly more confidence. How to cite this article Rothstein J, Gullo J, Cuningham L, Murphy P, Sochor M. Training Emergency Medicine Residents— the Skill of Endotracheal Intubation: Comparison of Human Cadavers vs Mannequins. Panam J Trauma Crit Care Emerg Surg 2014;3(1):8-10.

Using Telemedicine to Improve the Care Delivered to Sexually Abused Children in Rural, Underserved Hospitals

We used live telemedicine consultations to assist remote providers in the examination of sexually assaulted children presenting to rural, underserved hospitals. We hypothesized that telemedicine would increase the ability of the rural provider to perform a complete and accurate sexual assault examination. Child abuse experts from a university children's hospital provided 24/7 live telemedicine consultations to clinicians at 2 rural, underserved hospitals. Consultations consisted of videoconferencing to assist in the examination and interpretation of findings during live examinations. Consecutive female patients <18 years of age presenting to the 2 participating hospitals were included. We developed and used an instrument to assess the quality of care and the interventions provided via telemedicine as it related to patient history, physical examination, colposcopic and manual manipulation techniques, interpretation of findings, and treatment plans for victims of child sexual abuse. Data from 42 live telemedicine consultations were analyzed. The mean duration of the consultations was 71 minutes (range: 25-210 minutes). The consultations resulted in changes in interview methods (47%), the use of the multimethod examination technique (86%), and the use of adjunct techniques (40%). There were 9 acute sexual assault telemedicine consults that resulted in changes to the collection of forensic evidence (89%). Rankings of practitioners' skills and the telemedicine consult effectiveness were high, with the majority of cases scoring > or =5 on a 7-point Likert scale. The use of telemedicine to assist in the examination of sexually assaulted children presenting to underserved, rural communities results in significant changes in the methods of examination and evidence collection. It is possible that this model of care results in increased quality of care and appropriate forensic evidence collection.

Frozen Section Diagnosis in Pediatric Surgical Pathology: A Decade's Experience in a Children's Hospital

Intraoperative consultations, including frozen sections (FSs), are essential for patient care and are a key quality component in anatomic pathology. Little data exists about the use, frequency, and type of discrepancies and deferral rates of FS diagnoses in pediatric and adolescent surgical pathology. The purpose of this study was to analyze indications, discrepancies, and deferrals for all FSs performed at a children's hospital during a 10-year period. All FSs for 1995-2004 were reviewed for indications, discrepancies, deferred diagnoses, and turnaround time. Discrepancies were categorized into major and minor subtypes according to potential impact on patient care. A total of 35,611 surgical pathology cases were accessioned, with 2839 intraoperative consultations, which included 2783 FSs and 56 nonmicroscopic consultations. Most frequent indications included questions related to neoplasms (tumor detection, specimen adequacy, triage, classification, and margins) and suspected Hirschsprung disease. In these consultations, 115 discrepancies (4%) were identified, of which 7 (0.2%) were major, with potentially significant clinical impact, and 108 (3.9%) were minor. The major discrepancies included tumor, ganglion cell, or organism detection. The minor discrepancies involved sampling error, reclassification of benign or malignant neoplasms without clinical consequences, tumor typing or grading, and ganglion cell identification without clinical impact. Deferrals in 718 FSs (25% deferral rate) included tumor classification from generic to specific, identification of organisms, and evaluation of lymph node biopsies for lymphoma. Turnaround time exceeded 20 minutes in 403 cases (14%). The FS rate of 7.8% overall and 5% of surgical pathology cases is similar in children's and general hospitals. The major discrepancy (discordance) rate is lower, which may reflect the different indications for FS in children and adolescents. Evaluation of colonic biopsies for ganglion cells is a diagnostic pitfall. The deferral rate of 25% reflects the definition of a deferred diagnosis. Traditional definitions of deferred and discordant FS diagnoses should be refined to reflect the increasing use of adjunct techniques, especially in tumor classification. These findings emphasize that, in children and adolescents, most FSs are performed for tumor classification, triage, detection, and specimen adequacy, and for possible Hirschsprung disease. In children and adolescents, FSs are used infrequently to identify normal or unknown tissue, to analyze a lesion in a radiographically directed specimen, or to detect lymph node metastases. The differences in pediatric and adolescent FS indications and use underscore the importance of focused education in pediatric surgical pathology.

Crisis Intervention and Counseling by Telephone

DAVID LESTER (ED.): Crisis Intervention and Counseling by Telephone. Charles C. Thomas Publisher, Springfield, IL, 2002, 306 pp., $62.95, ISBN 0-398-07324-4. Crisis Intervention and Counseling by Telephone first appeared in 1973. This 2002 update is divided into six components: overview of telephone counseling, how telephone counseling fits into a variety of therapeutic modalities, dealing with specific client behaviors in counseling, the use of adjunct techniques like e-mail, selecting/training telephone counselors, and evaluating telephone counseling services. Psychotherapists who consider telephone therapy as to face-to-face contact should recall that traditional talking therapies often restrict cues available to both the client and therapists. Traditional psychoanalysis places that therapist out of sight behind the client. The Roman Catholic confessional also restricts cues. A survey of psychiatrists found that 45% use the telephone as an adjunct for face-to-face therapy and 19% use the telephone as the primary mode of treatment (p. 7). Therapists who look at telephone therapy as inferior might want to review whether their own values are interfering with sound therapeutic judgment. For example, older people grew up in an era when use of the telephone was restricted to business and emergencies. Younger people, on the other hand, consider the telephone a recreational tool. Talking to a counselor over the phone might be more natural for a young client while unnatural for an older therapist. A second problem revolves around the issue of control. During sessions, clients are in their home and not on therapists' turf. Termination can be accomplished by simply hanging up. This more equal power relationship can produce anxiety for therapists. A third problem concerns the stereotype of telephone counseling being linked to short-term crisis intervention. The book cites a case of a 19-year psychotherapeutic relationship on the phone and hypnotherapy conducted by phone. Certain types of clients are more appropriate for telephone counseling, particularly, suicidal and highly dependent clients like to know that support is close at hand. Ambivalent clients can use the telephone to maintain both distance and control over the therapeutic relationship. Hostile clients may be better able to express themselves. The mechanical and electronic nature of telephones may appeal to certain obsessionals and schizophrenics. Those who suffer from anxiety find telephone counseling of particular value. …