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Background This study aimed to compare high-flow nasal cannula (HFNC) oxygenation vs nasal intermittent ventilation (NIV) oxygenation for respiratory care after extubation in postoperative paediatric cardiac patients. Methods This study was a randomised controlled trial. One hundred twenty-one paediatric patients with acyanotic congenital heart disease undergoing corrective cardiac surgery on cardiopulmonary bypass were included in the study. Patients were randomised to receive either HFNC (AIRVO) or NIV (RAM Cannula) postextubation. Arterial blood gas was analysed at different time points perioperatively. Results Patients in both the groups were matched with respect to diagnosis and demographic profiles. Baseline hemodynamic and respiratory parameters were also similar in both the groups. Patients in HFNC/AIRVO group did not show improved carbon dioxide (CO2) washout but showed improved pO2 and pO2/FiO2 ratio immediate postextubation. Reintubation rate and other intensive care unit (ICU) complications were similar in both the groups. Conclusion Postcardiopulmonary bypass respiratory complications in paediatric patients with congenital acyanotic heart disease can be minimised with newer oxygen therapy devices such as AIRVO (HFNC) or RAM cannula (NIV). In comparison between these two, AIRVO did not show improved CO2 washout over RAM cannula; however, it did provide better oxygenation as measured by pO2 in arterial blood and pO2/FiO2 ratio immediate postextubation. Also, long-term results such as duration of mechanical ventilation and ICU stay were not affected by the choice of device.

Background Shock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. Methods This is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal–Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. Results We identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44–77), and Group 3, the highest (86, interquartile range = 57–101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. Conclusions Administration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.

Purpose Long-acting injectable fluocinolone releasing implants are used in clinical practice. While limited in scope, situations may arise where removal of the implant is warranted. We set out to describe possible explantation techniques and to determine whether these implants can be safely removed from a standard sclerotomy or eliminated using a vitrectomy system. Methods A vitreoretinal surgery system was designed using a porcine eye model. A fluocinolone implant was injected into the vitreous cavity. Pars plana vitrectomy was performed and the vitreous cavity was infused with balanced salt solution. The injected implants were removed from 23-Gauge (G) and 25-Gauge (G) vitrectomy cannulas with 27-G forceps. The implants were examined under the microscope for induced defects. Implants were injected into the eye model and eliminated using a 23-G and 25-G vitrector system. Results The implant was removed from both the 23-G and 25-G vitrectomy cannulas with only mild structural damage to the implant. During implant extraction through the 25-G sclerotomy, the cannula was dislodged from the incision along with the implant. The most technically challenging portion involved aligning the implant coaxially to allow for removal en bloc through the sclerotomy site. Implants could be eliminated using both the 23-G and 25-G vitrector using a low-cut rate. Conclusion The fluocinolone implant was removed safely via standard 23-G or 25-G vitrectomy systems. It is unknown whether intraocular manipulation will affect pharmacokinetics of drug delivery if the implant is not explanted.

Purpose To evaluate the utility of extending the limbus-to-cannula distance to 6.0 mm during pars plana vitrectomy (PPV) for highly myopic eyes. Methods Four eyes with axial lengths exceeding 31.0 mm, that underwent 25-gauge PPV were retrospectively evaluated. Assuming that cannulas were inserted 3.5 and 6.0 mm from the corneal limbus, the distance from the cannula to the fovea (CF distance) was preoperatively evaluated using anterior segmental optical coherence tomography. Surgical complications were also investigated. Results The CF distance was shortened by 1.22±0.05 mm and 1.22±0.09 mm on the temporal and nasal sides, respectively, by inserting the cannula at 3.5 to 6.0 mm from the corneal limbus. As per the preoperatively measured CF distance, one of the cannulas was inserted 6.0 mm from the corneal limbus in 3 eyes. Their cannulas were confirmed to be inserted at the pars plana, and no surgical complications associated with this technique were observed. Conclusion Extending the limbus-to-cannula distance to 6.0 mm during PPV could be one of the options to reach the posterior pole in highly myopic eyes. A preoperatively measured CF distance can be a clinical criterion in determining the cannula position.

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) is widely performed not only as an alternative to transpapillary biliary drainage, but also as primary drainage for malignant biliary obstruction. For anatomical reasons, this technique carries an unavoidable risk of mispuncturing intrahepatic vessels. We report a technique for troubleshooting EUS-guided portal vein coiling to prevent bleeding from the intrahepatic portal vein after mispuncture during interventional EUS. EUS-HGS was planned for a 59-year-old male patient with unresectable pancreatic cancer. The dilated bile duct (lumen diameter, 2.8 mm) was punctured with a 19-gauge needle, and a guidewire was inserted. After bougie dilation, the guidewire was found to be inside the intrahepatic portal vein. Embolizing coils were placed to prevent bleeding. Embolization coils were successfully inserted under stabilization of the catheter using a double-lumen cannula with a guidewire. Following these procedures, the patient was asymptomatic. Computed tomography performed the next day revealed no complications.

To compare the computed tomography (CT) number for paediatric cardiac computed tomography angiography (CCTA) and visualisation score of the three-dimensional (3D) images using the conventional T-shaped extended tube (T-tube) and spiral flow-generating extended tube (spiral-tube) connected between the contrast injector and cannula.In total, 108 patients suspected to have congenital heart disease (CHD) were considered for inclusion. We utilised the T-tube for intravenous contrast and spiral-tube in 54 patients each. Observers individually inspected randomized volume rendering images of the internal thoracic artery, each acquired from the with or without spiral-tube groups, using a four-point scale. We compared the mean CT number of the ascending aorta (AAO) and pulmonary artery (PA), contrast noise ratio (CNR), CT number for the AAO and PA enhancement ratio, and the visualisation scores between the groups.There were no significant differences in patient characteristics between the with or without spiral-tube groups (p 0.05). The mean CT number ±standard deviation for the AAO and PA, and the CNR without or with spiral-tube groups were 441.2 ± 89.2 and 489.8 ± 86.1 HU for the AAO, 436.3 ± 100.6 and 475.3 ± 85.2 HU for the PA, and 9.5 ± 2.2 and 10.8 ± 2.4 for the CNR, respectively (p 0.05). In the spiral-tube group, the CT number, CNR, and visualisations score of the 3D images were significantly higher for the AAO and PA than those in the T-tube group (p 0.05).The spiral-tube proved to be beneficial in improving the CT number for the AAO and PA, CNR, and visualisation score compared with the conventional T-tube during paediatric CCTA.The spiral-tube may allow the visualisation of smaller blood vessels than those visualised by the conventional T-tube for paediatric patients in CCTA.

Purpose To report the results of a first-in-human study using a robotic device to assist subretinal drug delivery in patients undergoing vitreoretinal surgery for macular haemorrhage. Design Double armed, randomized controlled surgical trial (ClinicalTrials.gov identifier: NCT03052881). Methods Setting Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom. Participants In total, 12 participants were recruited: 6 in the robot-assisted and 6 in the control manual surgery arm according to the pre-specified inclusion and exclusion criteria. All subjects presented with acute loss of vision due to a sub-foveal haemorrhage secondary to neovascular age-related macular degeneration. Intervention After standard vitrectomy, intraoperative OCT-guided subretinal injection of tissue plasminogen activator (TPA) was performed either by robot-assisted or conventional manual technique under local anaesthesia. The robotic part of the procedure involved advancement of a cannula through the retina and stabilizing it during foot-controlled injection of up to 100µl of TPA solution. Main Outcome Measures We assessed surgical success, duration of surgery, adverse events, and tolerability of surgery under local anaesthesia. Results The procedure was well tolerated by all participants and safely performed in all cases. Total duration of surgery, time taken to complete the injection and retinal microtrauma were similar between the groups and not clinically significant. Subretinal haemorrhage was successfully displaced at 1-month post-intervention, except for one control subject, and the median gain in visual acuity was similar in both arms. Conclusions This first-in-human study demonstrates the feasibility and safety of high precision robot-assisted subretinal drug delivery as part of the surgical management of sub-macular haemorrhage, simulating its potential future application in gene or cell therapy.

Rationale and Objectives We evaluated the availability of cytological diagnosis with outer cannula washing solution (C-OCWS) as a clinical diagnostic tool for computed tomography (CT)-guided needle biopsy. Materials and Methods We retrospectively assessed 109 consecutive patients (71 males, 38 females; median age 68 years), who underwent CT-guided needle biopsy. In all patients, the specimens sampled by the inner needle were used for histological diagnosis, and those taken from the outer cannula were rinsed with 0.9% saline solution: outer cannula washing solution for cytological diagnosis. The accuracy of C-OCWS in addition to histological diagnosis were compared with that of histological diagnosis alone. We used binary logistic regression analysis to determine the variables associated with diagnostic accuracy for malignancy and lesion characteristics. Results The C-OCWS method precisely diagnosed 7 (6.4%) malignant lesions (i.e., effective cases) in the 109 patients characterized as “negative for malignancy” via histological diagnosis alone. The accuracy of the combination of C-OCWS and histological diagnoses was significantly higher than that of histological diagnosis alone (0.95 vs. 0.89, respectively; p = 0.023). Multivariate logistic regression analysis showed that increasing only a marginal ratio (failure rate for proper position of biopsy needle within the tumor) was independently associated with a high rate of effective cases (p = 0.003). Conclusion C-OCWS may be helpful for improving the quality of CT-guided needle biopsy, and is a simple method that may not necessarily increase the patients’ physical burden.

Background Percutaneous dilation tracheostomy is an aerosol-generating procedure carrying a documented infectious risk during respiratory virus pandemics. For this reason, during the COVID-19 outbreak, surgical tracheostomy was preferred to the percutaneous one, despite the technique related complications increased risk. Methods We describe a new sequence for percutaneous dilation tracheostomy procedure that could be considered safe both for patients and healthcare personnel. A fiberscope was connected to a video unit to allow bronchoscopy. Guidewire positioning was performed as usual. While the established standard procedure continues with the creation of the stoma without any change in mechanical ventilation, we retracted the bronchoscope until immediately after the access valve in the mount tube, allowing normal ventilation. After 3 minutes of ventilation with 100% oxygen, mechanical ventilation was stopped without disconnecting the circuit. During apnea, the stoma was created by dilating the trachea and the tracheostomy cannula was inserted. Ventilation was then resumed. We evaluated the safeness of the procedure by recording any severe desaturation and by performing serological tests to all personnel. Results Thirty-six patients (38%) of 96 underwent tracheostomy; 22 (23%) percutaneous dilation tracheostomies with the new approach were performed without any desaturation. All personnel (150 operators) were evaluated for serological testing: 9 (6%) had positive serology but none of them had participated in tracheostomy procedures. Conclusion This newly described percutaneous dilation tracheostomy technique was not related to severe desaturation events and we did not observe any positive serological test in health workers who performed the tracheostomies.

Overview: The use of extracorporeal membrane oxygenation (ECMO) is becoming commonplace worldwide in ICUs for the care of patients with respiratory and/or cardiac failure. Understanding the use of ECMO and the management of these complex patients will be vital to current and future clinicians as ECMO use continues to grow.

Background Neonates often receive noninvasive respiratory support via continuous positive airway pressure (CPAP) or high-flow nasal cannula oxygen (HHFNC). The decision to change from one mode to the other, however, is not evidence based, hence not standardized and does not consider cost implications. Purpose To assess the introduction of a care bundle for the medical and nursing staff in a tertiary medical and surgical neonatal center with regard to any financial savings or adverse outcomes. Methods An education package and written guidelines were used to increase the awareness of the durations for which CPAP and HHFNC Vapotherm (VT) circuits could be used and the costs of the circuits. Results This resulted in a cost saving of £17,000 ($22,254) for the year without adverse outcomes. Implications for practice Introduction of a care bundle involving an education package and written guidelines to increase the awareness of the durations that circuits could be used and the costs of CPAP and HHFNC circuits among the medical and nursing staff can lead to cost savings when incorporated into clinical practice. Implications for research Strategies, particularly during weaning, which involve changing from one form of noninvasive respiratory support to another, need a greater evidence base. Future research should include awareness of the duration different circuits could be used and the cost implications of changes between modes and hence circuits.

Trigeminal neuralgia is a chronic pain condition affecting one or more distributions of the trigeminal nerve. Patients with this condition experience short, sharp, shooting pain attacks, which can progress to longer, more frequent durations. The pain is often difficult to control. We report of a man who was admitted with severe neuralgia of the third division of the trigeminal nerve. Talking and any oral intake triggered a severe agonising pain. The latter made the regular oral intake of analgesia challenging. The pain was temporarily controlled with frequent local anaesthesia (LA). Dental core trainees were performing regular inferior alveolar nerve blocks which significantly improved patients’ condition allowing him to communicate and have oral intake. Subsequently, a catheter was placed allowing for a continuous anaesthesia. The connecting tube of the cannula was then used by nursing staff to administer LA providing pain relief without the need of repeated intraoral injections.

Background: Ventilation limitation has a significant adverse effects on cardiovascular function and tissue oxygenation during exercise in patients with chronic obstructive pulmonary disease (COPD). High flow nasal cannula (HFNC) improve ventilation by washing out the anatomical dead space and providing oxygen at constant concentration. This study aimed to examine the effects of HFNC on the exercise performance and hemodynamic status in COPD patients. Methods: Fifteen patients with COPD performed two constant load exercise tests (CLET) at the 70% of maximum workload achieved at a previous incremental exercise test on arm ergometer. The CLET were performed with HFNC and with nasal cannula (NC) in random order. The hemodynamics parameters of subjects during exercises were measured by a bioelectrical impedance device. The tissue oxygenation status (oxygenated hemoglobin, deoxygenated hemoglobin (hHb), total hemoglobin) was measured by a near infrared spectrophotometer. Results: The exercise duration was longer for HFNC test than NC test (962.9 ± 281.7 s, vs 823.9 ± 184.9 s, p < 0.05). At the end of CLET, the PetCO2 was lower for HFNC than NC (29.3 ± 5.1 mmHg vs 32.1 ± 5.5 mmHg, p 0.05), stroke volume (NC:73.5 ± 21.0 vs HFNC 67.5 ± 16.3 ml, p > 0.05). The changes of hHb in muscle tissues was significantly lower in HFNC test than that in NC test (p

PURPOSE: To report an anatomic change observed in a series of patients who underwent subretinal injection of voretigene neparvovec-rzyl (VN) for RPE65-mediated Leber congenital amaurosis. DESIGN: Multi-center retrospective chart review. PARTICIPANTS: Patients who underwent subretinal VN injection at each of four participating institutions. METHODS: Patients were identified as having perifoveal chorioretinal atrophy if: i) the areas of atrophy were not directly related to the touch-down site of the subretinal cannula; and ii) the area of atrophy progressively enlarged over time. Demographic data, visual acuity, refractive error, fundus photos, optical coherence tomography, visual fields, and full-field stimulus threshold (FST) were analyzed. MAIN OUTCOME MEASURES: Outcome measures included change in visual acuity, FST, visual fields, and location of atrophy relative to subretinal bleb position. RESULTS: 18 eyes of 10 patients who underwent subretinal injection of VN were identified as having developed perifoveal chorioretinal atrophy. 8/10 patients (80%) developed bilateral atrophy. The mean age was 11.6 years (range: 5–20), and 6 patients (60%) were male. Baseline mean logMAR visual acuity and FST were 0.82 (standard deviation (SD): 0.51) and −1.3 log cd.s/m(2)(SD: 0.44), respectively. The mean spherical equivalent was −5.7 diopters (range: 11.50 to +1.75). Atrophy was identifiable at an average of 4.7 months (SD: 4.3) following surgery, and progressively enlarged in all cases up to a mean follow-up period of 11.3 months (range: 4–18). Atrophy developed within and outside the area of the subretinal bleb in 10 (55.5%) eyes, exclusively within the area of the bleb in 7 (38.9%) eyes, and exclusively outside the bleb in 1 (5.5%) eye. There was no significant change in visual acuity (p=0.45). There was a consistent improvement in FST with a mean improvement of −3.21 log cd.s/m(2)(p

Background: Silicone oil, which is one of the most commonly used endotamponades in vitreoretinal surgery, is removed after a certain period of time in most cases. In this study, we present our results with a unique cannula that provides effective and safe silicone oil removal. Aims and Objectives: To assess the aids and success of silicone oil removal with a novel 23-gauge cannula for the patients who underwent pars plana vitrectomy and silicone oil injection before. Materials and Methods: 72 eyes of 64 patients who operated by the same surgeon (FA) between May 2017 and May 2019 were involved in the study. The primary indications were proliferative diabetic retinopathy in 46 (63.9%) eyes and retinal detachment in 26 (36.1%) eyes. Phacoemulsification and intraocular lens implantation (23 eyes), membrane peeling (23 eyes), internal limiting membrane peeling (5 eyes), and argon laser endo-photocoagulation (37 eyes) performed in the same session. Furthermore, perfluorocarbon remnants aspirated in 9 eyes and 17 eyes needed suturing. Descriptive statistical analyses achieved by SPSS 10.5 statistical software. Results: The mean follow-up time was 11.7 + 2.5 months (between 3 and 23 months), and the mean age was 61.4 + 8.52 years (between 44 and 69 years). 1000 centistokes (cSt) silicone oil was removed from 61 (84.7%) eyes, and 5000 cSt silicone oil was removed from 11 (15.3%) eyes. The mean removal time was 2.04 + 0.1 min for 1000 cSt silicone oil and 5.11 + 0.3 min for 5000 cSt silicone oil. 4 re-detachment and 3 vitreous hemorrhage observed in follow-up period. Post-operative silicone oil remnants were not detected in any patient. Conclusion: The unique 23-gauge cannula provides silicone oil removal without any conjunctival cut-down and sclerotomy enlargement. Thus, it reduces the duration of surgery and post-operative recovery period.

Purpose Prediction of high flow nasal cannula (HFNC) failure in COVID-19 patients with acute hypoxemic respiratory failure (AHRF) may improve clinical management and stratification of patients for optimal treatment. We performed a systematic review and meta-analysis to determine performance of ROX index as a predictor of HFNC failure. Materials and methods Systematic search was performed in electronic databases (PubMed, Google Scholar, Web of Science and Cochrane Library) for articles published till 15 June 2021 investigating ROX index as a predictor for HFNC failure. Quality In Prognosis Studies (QUIPS) tool was used to analyze risk of bias for prognostic factors, by two independent authors. Results Eight retrospective or prospective cohort studies involving 1301 patients showed a good discriminatory value, summary area under the curve (sAUC) 0.81 (95% CI, 0.77–0.84) with sensitivity of 0.70 (95% CI, 0.59–0.80) and specificity of 0.79 (95% CI, 0.67–0.88) for predicting HNFC failure. The positive and negative likelihood ratio were 3.0 (95% CI, 2.2–5.3) and 0.37 (95% CI, 0.28–0.50) respectively, and was strongly associated with a promising predictive accuracy (Diagnostic odds ratio (DOR) 9, 95% CI, 5–16). Conclusion This meta-analysis suggests ROX index has good discriminating power for prediction of HFNC failure in COVID-19 patients with AHRF.

Clinical use of heated, high-flow nasal cannula (HFNC) for noninvasive respiratory support is increasing and may have a therapeutic role in stabilizing the upper airway in obstructive sleep apnea (OSA). However, physiological mechanisms by which HFNC therapy may improve upper airway function and effects of different temperature modes are unclear. Accordingly, this study aimed to determine effects of incremental flows and temperature modes (heated and nonheated) of HFNC on upper airway muscle activity (genioglossus), pharyngeal airway pressure, breathing parameters, and perceived comfort. Six participants (2 females, aged 35 ± 14 yr) were studied during wakefulness in the supine position and received HFNC at variable flows (0-60 L/min) during heated (37°C) and nonheated (21°C) modes. Breathing parameters via calibrated Respitrace inductance bands (chest and abdomen), upper airway pressures via airway transducers, and genioglossus muscle activity via intramuscular bipolar fine wire electrodes were measured. Comfort levels during HFNC were quantified using a visual analog scale. Increasing HFNC flows did not increase genioglossus muscle activation despite increased negative epiglottic pressure swings (

This study reviews the mechanisms of action and physiologic effects of nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) in preterm infants with respiratory distress syndrome, discusses the main characteristics of available devices and patients' interfaces, reports on risk of failure and possible adverse effects, and summarizes clinical evidence regarding effectiveness for preventing mechanical ventilation as primary respiratory support or after extubation in the neonatal intensive care unit. nCPAP is preferred to HFNC as primary mode of noninvasive respiratory support in preterm infants with respiratory distress syndrome, whereas HFNC is an effective alternative to nCPAP after extubation.

Temporary left ventricular support aims to decompress the left ventricle and provide adequate forward flow into the arterial circulation. This can be accomplished with endovascular devices such as the Impella with an internal motor, or with the implementation of cannulae to drain the left ventricle or left atrium and then return to the arterial circulation using an external pump. In this report, the authors describe the transesophageal echocardiography-guided placement of a single-cannula system with the Protek Duo RD (TandemLife, LivaNova) via a left ventricular apical approach to provide minimally invasive left ventricular support in a high-risk Jehovah's Witness patient.

OBJECTIVES Assessment of the transcaval venous pressure gradient, the central venous to inferior vena caval pressure, assists anesthetists and surgeons in management of liver transplant recipients. Traditionally, this entails insertion of a femoral central line with increased patient risk and health care cost. Here, we assessed the ability of a saphenous vein cannula to act as a surrogate for the femoral central line as a means to assess the transcaval pressure gradient in a safer and less invasive manner. MATERIALS AND METHODS A prospective cohort of 22 patients undergoing liver transplant underwent saphenous vein cannulation in addition to insertion of a femoral and internal jugular central venous catheter. Data were collected throughout each phase of surgery to assess the central, femoral, and saphenous vein pressures; results of a range of relevant physiological and ventilatory data were also collected. RESULTS The primary outcome, the correlation between saphenous and femoral venous pressure throughout surgery, was acceptable (r2 = 0.491, P < .001). During the anhepatic phase of surgery, this correlation improved (r2 = 0.912, P < .001). The correlation between the femoral to central venous pressure and saphenous to central venous pressure gradients was also reasonable throughout surgery (r2 = 0.386, P < .001), and this correlation was significantly stronger during the anhepatic phase (r2 = 0.935, P < .001). CONCLUSIONS Saphenous venous pressure, provided by peripheral cannulation, provided a reliable, less invasive, and safer alternative to femoral central line insertion for determination of the transcaval pressure gradient during the anhepatic phase of liver transplant.

BACKGROUND Acne scarring can lead to social and psychological distress. OBJECTIVE To compare the safety, efficacy, and long-term improvement of subcision using tri-beveled hypodermic (Th) needle versus cannula for the treatment of atrophic post-acne scars. METHODS Forty-six patients with atrophic post-acne scars were treated with subcision using (Th) needle on one side of the face and a blunt cannula on the other side of the face for 6 sessions one month apart. The primary outcome was based on the clinical improvement and patient satisfaction score. Skin biopsies were taken at baseline and 3months after the final session. Follow-up was 9 months. RESULTS Three months after the final session, a statistically highly significant difference was detected in both sides from the baseline (p

Aim To describe clinical characteristics, procedural details, specific challenges, and outcomes in patients with HeartMate3™ (HM3), a left ventricular assist device system with a magnetically levitated pump, undergoing ventricular tachycardia ablation (VTA). Methods and results Data were collected from patients with an HM3 system who underwent VTA in seven tertiary centres. Data included baseline patient characteristics, procedural data, mortality, and arrhythmia-free survival. The study cohort included 19 patients with cardiomyopathy presenting with ventricular tachycardia (VT) (53% with VT storm). Ventricular tachycardias were induced in 89% of patients and a total of 41 VTs were observed. Severe electromagnetic interference was present on the surface electrocardiogram. Hence, VT localization required analysis of intra-cardiac signals or the use of filter in the 40–20 Hz range. The large house pump HM3 design obscured the cannula inflow and therefore multi imaging modalities were necessary to avoid catheter entrapment in the cannula. A total of 32 VTs were mapped and were successfully ablated (31% to the anterior wall, 38% to the septum and only 9% to the inflow cannula region). Non-inducibility of any VT was reached in 11 patients (58%). Over a follow-up of 429 (interquartile range 101–692) days, 5 (26%) patients underwent a redo VT ablation due to recurrent VTA and 2 (11%) patients died. Conclusions Ventricular tachycardia ablation in patients with HM3 is feasible and safe when done in the appropriate setup. Long-term arrhythmia-free survival is acceptable but not well predicted by non-inducibility at the end of the procedure.

Introduction: Infertility is best defined as the inability to conceive after one year of unprotected regular intercourse or many couples, infertility and its treatment cause a serious strain on their interpersonal relationship, and cause disturbed relationships with other people. Diagnostic laparoscopy is generally not a part of initialinfertility evaluation, however, number of reports haveshown that it is effective procedure for evaluation of long- term infertility. Materials and Methods: A total of 207 patients were studied from at GMCH, Gondia, Maharashtra. Total 207 patients had primary/secondary infertility and 5 patients had primary amenorrhea were selected for study. Uterus, ovaries, tubes and cul de sac were inspected and findings noted. Next chromopertubation test was done with 10-15 ml of 1% aqueous methylene blue via the leech-Wilkinson cannula was inserted and findings noted and statistical Analysis was done. Results: India showed the mean age of infertility was 28.4years. 81.16% subjects had primary whereas 16.43% had secondary infertility. In the present study maximum 165 (79.7%) had normal size uterus. Out of which 8 (3.86%) had bicornuate uterus.6.28% subjects had large size uterus. Out of which 5.80% had fibroid and 0.48% had adenomyosis. Conclusion: Diagnostic Laparoscopy and hysteroscopy is a better modality for diagnosing uterine, tubal and ovarian causes of infertility compared to hysterosalpingography and ultrasonography. Most of the patients had normal ultrasonographic, hysterosalpingographic and laparoscopic findings. Out of the rest, Structural adhesions were the most common cause of infertility among women in reproductive group. Keywords: HSG, Infertility, Laproscopy in infertility.

Hypoxia is the most frequently occurring adverse effect during endoscopic retrograde cholangiopancreatography (ERCP) under sedation; thus, oxygen must be properly supplied to prevent a reduction of oxygen saturation. In this study, we intend to verify the preventive effect for hypoxia during ERCP, using a high-flow nasal cannula (HFNC), in elderly patients. As a multicenter prospective randomized trial, patients who underwent ERCP with propofol-based sedation were randomly assigned into two groups: Patients in the HFNC group were supplied with oxygen via an HFNC, and those in the standard nasal cannula group were supplied with oxygen via a low-flow nasal cannula. The co-primary end points were the lowest oxygen saturation rate and hypoxia during the overall procedure. A total of 187 patients (HFNC group: 95; standard nasal cannula group: 92) were included in the analysis. Unexpected hypoxia events were more frequently observed among patients in the standard nasal cannula group than among patients in the HFNC group (13% vs. 4%, odds ratio 3.41, 95% confidence interval 1.06–11.00, p = 0.031). The mean of the lowest oxygen saturation rate during ERCP was significantly lower in the standard nasal cannula group than in the HFNC group (95% vs. 97%, p = 0.002). Oxygen supplementation with an HFNC can prevent oxygen desaturation and hypoxia events in patients undergoing ERCP under sedation. Trial registration Clinical Research Information Service (CRIS; KCT0004960).

Background For children and adults, the standard treatment for obstructive sleep apnea is the delivery of continuous positive airway pressure (CPAP). Though effective, CPAP masks can be uncomfortable to patients, contributing to adherence concerns. Recently, nasal high flow (NHF) therapy has been investigated as an alternative, especially in CPAP-intolerant children. The present study aimed to compare and contrast the positive airway pressures and expired gas washout generated by NHF versus CPAP in child nasal airway replicas. Methods NHF therapy was investigated at a flow rate of 20 L/min and compared to CPAP at 5 cmH2O and 10 cmH2O for 10 nasal airway replicas, built from computed tomography scans of children aged 4–8 years. NHF was delivered with three different high flow nasal cannula models provided by the same manufacturer, and CPAP was delivered with a sealed nasal mask. Tidal breathing through each replica was imposed using a lung simulator, and airway pressure at the trachea was recorded over time. For expired gas washout measurements, carbon dioxide was injected at the lung simulator, and end-tidal carbon dioxide (EtCO2) was measured at the trachea. Changes in EtCO2 compared to baseline values (no intervention) were assessed. Results NHF therapy generated an average positive end-expiratory pressure (PEEP) of 5.17 ± 2.09 cmH2O (mean ± SD, n = 10), similar to PEEP of 4.95 ± 0.03 cmH2O generated by nominally 5 cmH2O CPAP. Variation in tracheal pressure was higher between airway replicas for NHF compared to CPAP. EtCO2 decreased from baseline during administration of NHF, whereas it increased during CPAP. No statistical difference in tracheal pressure nor EtCO2 was found between the three high flow nasal cannulas. Conclusion In child airway replicas, NHF at 20 L/min generated average PEEP similar to CPAP at 5 cm H2O. Variation in tracheal pressure was higher between airway replicas for NHF than for CPAP. The delivery of NHF yielded expired gas washout, whereas CPAP impeded expired gas washout due to the increased dead space of the sealed mask.

Purpose To describe a novel surgical technique to remove retained subfoveal perfluorocarbon liquid (PFCL). Methods After setting up for 23-G pars plana vitrectomy, a 38-G flexible-tip macular hydrodissection cannula connected to the automated viscous fluid infusion kit was used to create a small retinotomy approximately 700 μm to 800 μm inferior to the fovea and induce macular detachment involving the retained PFCL bubble. The flexible cannula was bent at its junction with the shaft and was carefully advanced through the same retinotomy into the subretinal space to access and directly aspirate the retained subfoveal PFCL bubble. Fluid-air exchange was then performed, and surgery was concluded. Results The retained subfoveal PFCL bubble was successfully removed with restoration of normal foveal architecture on optical coherence tomography and with objective and subjective improvement of central vision. Conclusion We report a novel surgical technique combining macular detachment with direct aspiration of the retained subfoveal PFCL without direct perforation of the foveal center. This technique may provide an alternative approach to manage this difficult complication.

Peripheral venous cannulation (PVC) is a commonly performed invasive medical procedure. Topical treatments such as the eutectic mixture of local anaesthetics (EMLA®, Aspen Pharmacare Australia Pty Ltd, St Leonards, NSW) attenuate the associated pain, but are limited by requiring up to one hour of application before becoming effective. The Coolsense® (Coolsense Medical Ltd., Tel Aviv, Israel) pain numbing applicator is a new device using a cryoanalgesic means to anaesthetise skin within seconds. Coolsense is being increasingly used for cannulation, but comparative studies are lacking. We recruited 64 healthy adult volunteers to this open-label two sequence, two period randomised crossover trial. Participants had two 20 gauge venous cannulae inserted, one on the dorsum of each hand. Each cannulation attempt was preceded by treatment with Coolsense or an EMLA patch containing 2.5% lidocaine and 2.5% prilocaine. The primary outcome was participant pain using the 0–10 numerical pain rating scale. Secondary outcomes were participant satisfaction scores on a 0–10 scale, treatment preference, and failed cannulation attempts. Participants were randomly assigned to either the Coolsense EMLA ( n = 32) or EMLA Coolsense ( n = 32) sequence. All participants completed the trial. The pooled mean paired difference of the numerical pain rating scale was –1.84 (95% confidence intervals –1.28 to –2.41; P

The pandemic of SARSCov2 infection has created a challenge in health services worldwide. Some scales have been applied to evaluate the risk of intubation, such as the ROX and HACOR. The objective of this study is to compare the predictive capacity of the HACOR scale and the ROX index and define the optimal cut-off points. Study of diagnostic tests based on a retrospective cohort. Composite outcome was the proportion of patients that needed endotracheal intubation (ETI) or died of COVID19 pneumonia. Discrimination capacity was compared by the area under the curve of each of the two scales and the optimal cut-off point was determined using the Liu method. 245 patients were included, of which 140 (57%) required ETI and 152 (62%) had the composite end result of high-flow nasal cannula (HFNC) failure. The discrimination capacity was similar for the two scales with an area under receiver operating characteristic curve of 0.71 and 0.72 for the HACOR scale for the ROX index, respectively. The optimal cut-off point for the ROX index was 5.6 (sensitivity 62% specificity 65%), while the optimal cut-off point for the HACOR scale was 5.5 (sensitivity 66% specificity 65%). The HACOR scale and the ROX index have a moderate predictive capacity to predict failures to the HFNC strategy. They can be used in conjunction with other clinical variables to define which patients may require invasive mechanical ventilation.

Occupational exposure of healthcare workers to blood and body fluids following skin injury constitutes a risk for transmission of blood-borne pathogens. The risk of exposure is greater as well. The present study aimed to determine the burden and risk factors of sharp object injuries in two tertiary hospitals in the Taif City KSA. Retrospective review of needle stick injury records was included from the two hospital's staff clinics. A Total of 131 health professionals (employees) recorded as exposed to sharp object injuries from both hospitals were enrolled during period 2016–2018. The collected data was cleaned, reviewed and analyzed using Statistical Package of Social Sciences SPSS ver. 25. The result of the study revealed that, the mean age for the 131 enrolled participants was 31 ± 6.6, Male to Female Ratio was 1:3. The most affected age group was 20–30 years (55.7%). Females were more affected 98 out of 131 (74.8%) than male (33out of 131 (25.2%). And there is increasing incidence rates of exposure from 2.89 /10.000 patient/day in 2016 to 3.42/ 10.000 patients'/day in 2017, with highest exposed nationalities; Filipino 42 (32.1%), Saudi 31 (23.7%), and Indians 26 (19.8%), the remaining 24.5% were from 10 mixed nationalities. The frequent affected divisions were: ER, surgical ward, operation room, ICU, laboratory, Medical W, Medical waste facilities (19.8%, 15%, 12.2%, 9.2%, 92% respectively). The most affected HCWs categories were nurses 74(56.5%), doctor 23(17.6%) and housekeeping 18 (13.7%). And the needle prick 104(79.4%) and cut wound 15(11.5%) constitute the highest type of injuries and were during operation 23 (17.6%), waste collection 15 (11.5%), cannulation 12 (9.2%) and giving injection 12 (9.2%). The common devices caused injuries were bore hole needle 63(48.1%), suture needle **(13.7%), cannula and insulin syringe 13 (9.9%) each. This study concluded that, as from 2016−2018, there was an increasing rate of reported accidental exposure to sharp needle injuries amongst HCWs from 3.0 to 3.4/10.000 patient/day, and the younger and nurses were mostly impacted. Workplace, distress, work types and load had influences on injuries rates and types. Fortunately, no exposure among employee with HBV, HCV and HIV seroconversion were documented.

Introduction Data on catheter ablation of ventricular arrhythmias (VA) are scarce in patients with left ventricular assist devices (LVADs) and current evidence predominantly consists of case reports with outdated LVAD. This prospective observational study reports our experience in terms of catheter ablation of VAs in patients with novel 3rd generation LVADs. Methods and results Between 2018 and 2020, nine consecutive patients undergoing a total number of ten ablation procedures for VAs were analyzed. The mean duration between LVAD implantation and catheter ablation was 23 ± 16 months. Acute procedural success was achieved in all patients. VA substrates were not related to the LVAD scarring (cannula) site in the majority of patients. All procedures were conducted without any relevant procedure-related complications. In terms of follow-up, only one patient presented with a repeat episode of electrical storm requiring ICD-shocks 16 months after the initial ablation procedure. Four patients suffered of singular VA effectively treated with antitachycardia pacing via their ICD. The remainder were free of any VA relapse (n = 4). Two non-procedure-related deaths occurred during follow-up. Conclusions Catheter ablation of VAs in patients with 3rd generation LVAD is feasible and leads to satisfying clinical results in terms of freedom from VA recurrence and quality of life. The majority of arrhythmia substrates in these patients are not directly related to the LVAD cannulation site and may represent a progress of heart failure. Graphic abstract

BACKGROUND Oxygen therapy is required to prevent hypoxaemia during the endobronchial ultrasonography (EBUS) procedure. AIMS To compare the effectiveness of oxygen therapy delivered through high-flow nasal cannula (HFNC) and conventional nasal cannula (CNC) in patients undergoing EBUS. The primary outcome was the proportion of patients who desaturated. Patient compliance and satisfaction were also evaluated. METHODS This single-centre prospective interventional study was conducted in a tertiary hospital among patients who presented to the EBUS unit in 2018 and 2019. Patients were randomly assigned to the HFNC group or the CNC group. RESULTS The study included 170 patients (111 men and 59 women) with a mean age of 58 ± 14 years. The number of patients experiencing desaturation while receiving oxygen was statistically significantly lower (P

BACKGROUND: The delivery of a high and consistent [Formula: see text] is imperative to treat acute hypoxemia. The objective of this study was to analyze the effective inspired oxygen concentration delivered by different low-flow oxygen therapy systems challenged with different oxygen flows and respiratory patterns in an experimental lung model. METHODS: An adult lung model ventilated in volume control mode simulated different respiratory patterns to obtain mean inspiratory flow of 22.5, 30.0, 37.5, or 45.0 L/min. The oxygen concentration sampled inside the lung model by nasal cannula, simple face mask, non-rebreather mask, and double-trunk mask above nasal cannula tested at oxygen flows of 10, 12.5, and 15 L/min was quantified. The 3 masks were sealed tight onto the model’s airway opening. They were also tested with standardized leaks to determine their clinical performance. RESULTS: All oxygen delivery systems delivered higher oxygen concentration with increasing oxygen flows, regardless of the respiratory pattern. Within each device, the increase in inspiratory flow decreased oxygen concentration when using nasal cannula (P = .03), the simple face mask (P = .03), but not the non-rebreather mask (P = .051) nor the double-trunk mask (P = .13). In sealed condition, the double-trunk mask outperformed the non-rebreather mask and simple face mask (P < .001); mean oxygen concentration was 84.2%, 68.5%, and 60.8%, respectively. Leaks amplified oxygen concentration differences between the double-trunk mask and the other masks as the oxygen delivery decreased by 4.6% with simple face mask (95% CI 3.1–6.1%, P < .001), 7.8% with non-rebreather mask (95% CI 6.3–9.3%, P < .001), and 2.5% with double-trunk mask (95% CI 1–4%, P = .002). With leaks, the oxygen concentration provided by the simple face mask and the non-rebreather mask was similar (P = .15). CONCLUSIONS: Lung oxygen concentration values delivered by the double-trunk mask were higher than those obtained with other oxygen delivery systems, especially when leaks were present.

Background This study aimed to retrospectively explore the safety and feasibility of computed tomography (CT)-guided synchronous microwave ablation (MWA) followed by core-needle biopsy (CNB) via a coaxial cannula for highly suspected malignant lung ground-glass opacities (GGOs). Methods The clinical data of 66 patients (66 GGOs) treated with CT-guided synchronous MWA followed by CNB via a coaxial cannula from January 2019 to January 2021 were included in this study. The technical success rate, curative effect, and complications were evaluated. Results Technical success rates were 100%. The pneumothorax rate was 36.4% (24/66). 72.7% (48/66) patients had the bronchopulmonary hemorrhage, 81.3% of hemorrhage was attributable to CNB. 24.2% (16/66) patients had varying degrees of pleural effusion. The pathological results were adenocarcinomas (n = 44), atypical adenomatous hyperplasia (n = 2), chronic inflammation (n = 3) and indeterminate pathological diagnosis (n = 17) with a 69.7% (46/66) positive diagnosis rate. The therapeutic response rate was 100.0% (66/66). Conclusions Synchronous MWA followed by CNB via a coaxial cannula has a satisfactory ablation effectiveness and an acceptable biopsy positive rate, which is an alternative treatment for highly suspected malignant GGOs.

Background: The current study assesses the incidences and grades of phlebitis among patients with IV cannula to determine the association of grades of phlebitis. The purpose of the study was to study the feasibility of Routine replacement versus Clinically indicated replacement of peripheral venous catheters. The study observes the incidences of removing peripheral intravenous catheters when clinically indicated compared with removing and re‐siting the catheter routinely. Methods: An observational study was conducted in the tertiary care private hospital of Mumbai, India. The study was conducted over 5 weeks from May -June 2020. Purposive sampling was considered during the collection of data. The sample size of the study was 117 patients admitted having peripheral venous catheters. The standard visual infusion phlebitis (VIP) score was used as a tool for data collection. Descriptive analysis was done. Results: Out of 117 patients (VIP score 0 -56, Score 1- 49, Score -12 no cases with score 3, 4, and 5). Routine replacement of IV cannula after every 5 days is judiciously followed, 45 healthy lines were replaced at score 0; which is the major concern (Rs. 633/- the total cost of replacing 1 PVC line). Conclusion: Following the routine practice of IV cannula replacement based on VIP score to avoid phlebitis is equally good but simultaneously clinically indicated replacement of IV cannula is advisable to make it cost-effective and reduced number of a prick to the patients; this will help to improve patient satisfaction.

Background Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia. Method A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared. Result The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques. Conclusion The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Aims Non-invasive ventilation represents an established treatment for acute cardiogenic pulmonary oedema (ACPO) although no data regarding the best ventilatory strategy are available. We aimed to compare the effectiveness of helmet CPAP (hCPAP) and high flow nasal cannula (HFNC) in the early treatment of ACPO. Methods and results Single-centre randomized controlled trial of patients admitted to the emergency department due to ACPO with hypoxemia and dyspnoea on face mask oxygen therapy. Patients were randomly assigned with a 1:1 ratio to receive hCPAP or HFNC and FiO2 set to achieve an arterial oxygen saturation >94%. The primary outcome was a reduction in respiratory rate; secondary outcomes included changes in heart rate, PaO2/FiO2 ratio, Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate (HACOR) score, Dyspnoea Scale, and intubation rate. Data were collected before hCPAP/HFNC placement and after 1 h of treatment. Amongst 188 patients randomized, hCPAP was more effective than HFNC in reducing respiratory rate [−12 (95% CI; 11–13) vs. −9 (95% CI; 8–10), P Conclusion Amongst patients with ACPO, hCPAP resulted in a greater short-term improvement in respiratory and hemodynamic parameters as compared with HFNC. Trial registration Clinical trial submission: NMRR-17-1839-36966 (IIR). Registry name: Medical Research and Ethics Committee of Malaysia Ministry of Health. Clinicaltrials.gov identifier: NCT04005092. URL registry: https://clinicaltrials.gov/ct2/show/NCT04005092.

Lower limb amputation following arterial cannulation for VA-ECMO has been described in the literature. Limb ischemia however following venous cannulation is very rare and not quite understood. We present a case of limb ischemia following venous cannulation. A combination of venous congestion, compartment syndrome and subsequent arterial insufficiency is the proposed pathophysiology. Shock and use of vasopressors are compounding factors. Limb ischemia can be transient and reversible if diagnosed immediately and treated by early removal of the cannula. Our patient was unstable and ECMO dependent, and removal of the cannula was not an option. This resulted in limb loss and eventual above knee amputation. Use of the smallest appropriate venous cannula and early fasciotomy, in addition to hemodynamic optimization are measures that could help in preventing major amputation.

Background Evidence regarding optimal management of the "Cannot Intubate, Cannot Oxygenate" (CICO) scenario in infants is scarce. When inserting a transtracheal cannula for front of neck access direct aspiration to confirm intratracheal location is standard practice. This postmortem "infant airway" animal model study describes a novel technique for cannula tracheotomy. Aims To compare a novel technique of cannula tracheotomy to an accepted technique to assess success and complication rates. Methods Two experienced proceduralists repeatedly performed tracheotomy using an 18-gauge BD InsyteTM cannula (BD, Franklin Lakes, NJ, USA) in 6 postmortem White New Zealand rabbits. Cannulas were attached either directly to a 5ml syringe (Direct Aspiration) or via a 25 cm length minimum volume extension tubing set (TUTA Healthcare Lidcombe, NSW, Australia) (Indirect Aspiration, 2 operator technique). Each technique was attempted a maximum of 12 times per rabbit with an ENT surgeon assessing success and complication rates endoscopically for each attempt. Results 72 tracheotomy attempts were made in total, 36 for each technique. Initial aspiration through the needle was achieved in 93% (97.2% direct versus 89% indirect). Advancement of the cannula and continued aspiration (success) into the trachea occurred in 67% for direct compared with 64% for indirect aspiration. Direct aspiration was associated with higher rates of lateral (10.3% versus 5.6%) and posterior (19.4% versus 13.9%) wall injury compared with the indirect 2-operator technique. Conclusion Cannula tracheotomy in infant-sized airways is technically difficult and seems frequently associated with tracheal wall injury. The reduced incidence of injury in the indirect group warrants further investigation in preclinical and clinical trials.

Objective The study introduced uniportal‐bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD). Methods This is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal‐bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement. Results PETD via lumbar foraminoplasty was successfully performed in all cases. The follow‐up points were 3 months, 6 months, and 12 months. The average follow‐up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow‐up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P, Lumbar foraminoplasty is a crucial and challenging step in PETD. In conventional TESSYS, surgeons could not get a direct view of the anatomic structure around the foramen during foraminoplasty with bone reamers or trephines, which is difficult to control the direction and may cause some unexpected complications including neural injury and bleeding. Also, the articular surface of facet joints is not in a sagittal plane or coronal plane, and oblique articular surface makes reamers and trephines easier deviated to ventral direction, which leads to unsatisfactory foraminoplasty. As an original designed technique, UBiSES allows operation with two surgical instruments simultaneously under full‐time and real‐time visualization in just one incision, which could be less invasive and more efficient. Uniportal‐bichannel foraminoplasty assisted by UBiSES could control the direction easier and get a satisfactory bone resect at the dorsal side of foramen with extensive view and space.

Extracorporeal membrane oxygenation (ECMO) has diverse applications. In the present report, we have described a case of tracheomalacia from a thoracic aortic aneurysm causing respiratory failure. Total arch replacement with reverse frozen elephant trunk grafting was performed. Perioperative ECMO support was accomplished with venopulmonary artery ECMO. This strategy allowed for preoperative oxygenation support, venous drainage during cardiopulmonary bypass, and postoperative support without cannula exchanges. Our patient required ECMO support for 12 days postoperatively. We have illustrated a unique case of acquired tracheomalacia but also an ECMO cannulation strategy allowing for preoperative oxygenation, seamless transition to cardiopulmonary bypass, and postoperative support.

It is common practice to use cannulated rats for pharmacokinetic (PK) in-life studies as it yields high quality PK parameter estimation. While offering many benefits, cannulation requires surgery, post-surgical care, and cannula maintenance. As an alternative approach, the strategy of dosing and bleeding rats via the tail vein in a single experiment is technically feasible and theoretically offers many benefits. Unfortunately, however, as reported by F Tse et al. in 1984 (J Pharm Sci 73: https://doi.org/10.1002/jps.2600731128), parallel tail dosing and bleeding is scientifically flawed and yields inaccurate estimation of PK parameters following intravenous administration. The underlying causality of poor data quality has not been addressed in over 35 years. To overcome the technical flaws associated with parallel tail dosing and bleeding, we have developed a Tail-Dose-Bleed (TDB) method as a substitute for use of cannulated rats. Specifically, the method introduces a flush procedure after dosing, uses separate tail veins for dosing and bleeding, and adjusts dosing and sampling to the proximal and distal portions of the tail, respectively. To demonstrate the proof of principle for this TDB technique, several cassette dosing studies were conducted. The performance of the TDB technique is compared in both stand alone and animal crossover studies employing conventional jugular/femoral bleeding and dosing. The poor data via tail dosing and bleeding previously described by Tse et al. are also recapitulated using their described approach. To ensure broad applicability of the TDB technique, data were generated utilizing compounds of diverse physical chemical properties manifesting a range of clearance and/or volume of distribution characteristics. These data demonstrate that the TDB approach yields comparable PK profiles and parameters as compared to conventional femoral dosing / jugular bleeding. Using this newly described TDB procedure, we demonstrate the ability to overcome documented data quality issues when dosing and bleeding via the tail. The TDB technique has numerous operational advantages of reduced study turnaround time and improved cost effectiveness, but most importantly, addresses key animal welfare concerns relevant to institutional animal care and use committees (IACUC). The notable advantage here is reduced animal stress and discomfort by eliminating the need for surgery and recovery. And by consequence, allows for animals to be group housed and re-used without concern for loss of cannula patency. The tail dose and bleed method is simple and appears readily transferable to other laboratories.

Purpose To determine the association between lung collapse and treatment failure in high-flow nasal cannula oxygen therapy (HFNC) or noninvasive ventilation (NIV). Methods We performed a quantitative analysis of chest computed tomography in patients with de novo acute respiratory failure who received HFNC (HFNC group) or NIV (NIV group) between January 2012 and December 2017. In the HFNC and NIV group, the nonaerated lung weight were compared between patients in whom respiratory treatment succeeded or failed, respectively. We used logistic regression to examine the association between the nonaerated lung weight and treatment failure. Results Treatment failed in 70/118 (59%) patients in the HFNC group and 66/101 (65%) patients in the NIV group. The nonaerated lung weight was significantly greater in unsuccessfully treated patients than in successfully treated patients in the HFNC group (p = 0.005), but not in the NIV group (p = 0.535). Logistic regression revealed that greater nonaerated lung weight was associated with increased risk of HFNC failure (adjusted odds ratio 1.30 per 5% increase, 95% confidence interval 1.09–1.55, p = 0.003) but not of NIV failure. Conclusions Patients with a greater nonaerated lung weight had a higher risk of HFNC failure, but not of NIV failure.

Background Timing of swallows in relation to respiratory phases is associated with aspiration events. Oxygen therapy possibly affects the timing of swallows, which may alter airway protective mechanisms. Objectives To compare the coordination between swallowing and respiration during water infusion in post-extubation patients using high flow nasal oxygen (HFNO) with the coordination in those using low flow nasal oxygen (LFNO). Methods We conducted a randomized controlled crossover study in post-extubation patients. The patients extubated within 48 h were randomly assigned to two groups, namely, HFNO and LFNO. The eligible patients in each group received either HFNO with fraction of inspired oxygen (FiO2) 0.35, flow 50 L per minute (LPM), and temperature 34 °C or LFNO 5 LPM for 5 min. The coordination between swallowing and respiration was observed during continuous infusion of 10-ml water one minute three times. Respiratory phases and swallowing were monitored using electrocardiogram (EKG)-derived respiratory signals and submental electromyography (EMG), respectively. The swallowing frequency and timing of swallows in relation to respiratory phases were recorded. The coordination between swallowing and respiration was classified into 4 patterns, namely I, E, I-E, and E-I swallows. (I; inspiration and E; expiration) Subsequently, after a 5-min washout period, the patients were switched to the other type of oxygen therapy using the same procedure. The Wilcoxon Signed-Rank Test was used for statistical analysis. Results A total of 22 patients with a mean age of 56 years were enrolled in the study. The major indication for invasive mechanical ventilation was pneumonia with a median duration of endotracheal intubation of 2.5 days. The median total swallowing numbers (three minutes) were 18.5 times in the HFNO period and 21 times in the LFNO period (p = NS). The most common swallowing pattern was E-swallow. The patients using HFNO had higher numbers of E-swallow pattern (74.3% in HFNO vs 67.6% in LFNO; p = 0.048) and lower numbers of I-swallow pattern (14.3% in HFNO vs 23.1% in LFNO; p = 0.044). The numbers of other swallowing patterns were not different between the 2 groups. Conclusions Compared with LFNO, HFNO significantly increased the E-swallow and decreased the I-swallow in post-extubation patients. The findings indicated that HFNO might reduce a risk of aspiration during the post-extubation period. Clinical trial No.: Thai clinical trial TCTR20200206004 Registered February 4, 2020. URL: http://www.clinicaltrials.in.th/index.php?tp=regtrials&menu=trialsearch&smenu=fulltext&task=search&task2=view1&id=5740.

OBJECTIVES To determine the safety and efficacy of a rapidly deployed intensivist-led venovenous extracorporeal membrane oxygenation cannulation program in a preexisting extracorporeal membrane oxygenation program. DESIGN A retrospective observational before-and-after study of 40 patients undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation in an established cannulation program by cardiothoracic surgeons versus a rapidly deployed medical intensivist cannulation program. SETTING An adult ICU in a tertiary academic medical center in Camden, NJ. PATIENTS Critically ill adult subjects with severe respiratory failure undergoing percutaneous cannulation for venovenous extracorporeal membrane oxygenation. INTERVENTIONS Percutaneous cannulation for venovenous extracorporeal membrane oxygenation performed by cardiothoracic surgeons compared with cannulations performed by medical intensivists. MEASUREMENTS AND MAIN RESULTS Venovenous extracorporeal membrane oxygenation cannulation site attempts were retrospectively reviewed. Subject demographics, specialty of physician performing cannulation, type of support, cannulation configuration, cannula size, imaging guidance, success rate, and complications were recorded and summarized. Twenty-two cannulations were performed by three cardiothoracic surgeons in 11 subjects between September 2019 and February 2020. The cannulation program rapidly transitioned to an intensivist-led and performed program in March 2020. Fifty-seven cannulations were performed by eight intensivists in 29 subjects between March 2020 and December 2020. Mean body mass index for subjects did not differ between groups (33.86 vs 35.89; p = 0.775). There was no difference in days on mechanical ventilation prior to cannulation, configuration, cannula size, or discharge condition. There was no difference in success rate of cannulation on first attempt per cannulation site (95.5 vs 96.7; p = 0.483) or major complication rate per cannulation site (4.5 vs 3.5; p = 1). CONCLUSIONS There is no difference between success and complication rates of percutaneous venovenous extracorporeal membrane oxygenation canulation when performed by cardiothoracic surgeons versus medical intensivist in an already established extracorporeal membrane oxygenation program. A rapidly deployed cannulation program by intensivists for venovenous extracorporeal membrane oxygenation can be performed with high success and low complication rates.

A number of cell transplantation and gene therapy trials have been performed over the last three decades in an effort to restore function in Parkinson’s disease. Much has been learned about optimizing delivery methods for these therapeutics. This is particularly true in gene therapy, which has predominated the clinical trial landscape in recent years; however, cell transplantation for Parkinson’s disease is currently undergoing a renaissance. Innovations such as cannula design, iMRI-guided surgery and an evolution in delivery strategy has radically changed the way investigators approach clinical trial design. Future therapeutic strategies may employ newer delivery methods such as chronically implanted infusion devices and focal opening of the blood brain barrier with focused ultrasound.

BACKGROUND Large-volume fat grafting results in high absorption and complication rates. Low-density fat includes small numbers of viable cells and considerable oil, resulting in nodules and oil cysts. This study evaluated a strategy for large-volume fat grafting using a mechanical process to condense low-density fat and transplanting it with high-density fat. METHODS Low-density fat, defined as the upper half of centrifuged lipoaspirates, was emulsified by intersyringe shifting and centrifuged to obtain condensed low-density fat. Fresh condensed low-density fat was analyzed by counting cells in the stromal vascular fraction, and by electron scanning and Western blotting. The retention rate and histologic changes of the product were analyzed using a fat grafting model in nude mice. Transplantation with a combination of condensed low-density fat and high-density fat was tested in patients undergoing breast reconstruction and breast augmentation. RESULTS The condensed low-density fat derived from low-density fat contained a large number of stromal vascular fraction cells and collagens, comparable to that of high-density fat and much higher than in low-density fat and Coleman fat. Retention rates 12 weeks after transplantation were higher for condensed low-density fat (55.0 ± 7.5 percent) than for low-density fat (31.1 ± 5.7 percent) and Coleman fat (41.1 ± 6.8 percent), with condensed low-density fat having fewer oil cysts and lower macrophage infiltration. Patients grafted with combined condensed low-density fat and high-density fat showed good long-term volume retention. CONCLUSIONS Using mechanical methods to condense low-density fat to a level comparable to that of high-density fat is a practical method of improving fat graft retention and avoiding severe complications. This new strategy may improve the quality of lipoaspirates for patients requiring large-volume augmentation.

BACKGROUND Nontuberculous mycobacteria are commonly found pathogens; however, skin and soft tissue infections due to nontuberculous mycobacteria are often associated with surgical procedures, particularly after lipoplasty. Although nontuberculous mycobacteria are resistant to some chemical disinfectants, glutaraldehyde, peracetic acid, povidone iodine, alcohol, and chlorine are still used for the sterilization of medical instruments. This study investigated the efficacy of various disinfectants in a fatty environment with adipose and a bloody environment without adipose. In addition, this study was also used to identify the most effective disinfectant against nontuberculous mycobacteria. METHODS Three nontuberculous mycobacteria (Mycobacterium avium, M. abscessus, and M. fortuitum), pathogens frequently found in skin and soft tissue infections, were used. Seven chemical disinfectants were tested in both fatty and bloody environments. The disinfectants used were considered to have a sterilization effect when the log10 reduction factor exceeded 5. RESULTS Most disinfectants had some sterilizing effects against nontuberculous mycobacteria; however, glutaraldehyde was the most effective against all 3. Chlorhexidine and povidone iodine also displayed sterilizing effects. Of the disinfectants tested, only alkyldiaminoethylglycine hydrochloride showed a diminished effect with statistical significance, specifically against M. fortuitum in a fatty environment, whereas it had effective results in a bloody environment. CONCLUSIONS Glutaraldehyde showed the greatest sterilizing effect on nontuberculous mycobacteria with a log10 reduction factor >5 in both fatty and bloody environments. However, some chemical disinfectants did not show sufficient sterilizing effects in a fatty environment and, therefore, should be used with caution for the sterilization of nontuberculous mycobacteria. LEVEL OF EVIDENCE Level II.

During the coronavirus disease 2019 (COVID-19) pandemic, noninvasive respiratory support has played a central role in managing patients affected by moderate-to-severe acute hypoxemic respiratory failure, despite inadequate scientific evidence to support its usage. High-flow nasal cannula (HFNC) treatment has gained tremendous popularity because of its effectiveness in delivering a high fraction of humidified oxygen, which improves ventilatory efficiency and the respiratory pattern, as well as its reported high tolerability, ease of use, and application outside of ICUs. Nevertheless, the risk of infection transmission to health-care workers has raised some concerns about its use in the first wave of the pandemic outbreak, with controversial recommendations provided by different scientific societies. This narrative review provides an overview of the recent evidence on the physiologic rationale, risks, and benefits of using HFNC instead of conventional oxygen therapy and other types of noninvasive respiratory support devices, such as continuous positive airway pressure and noninvasive ventilation in patients affected by COVID-19 pneumonia with associated acute hypoxemic respiratory failure. It also summarizes the available evidence with regard to the clinical use of HFNC during the current pandemic and its reported outcomes, and highlights the risks of bioaerosol dispersion associated with HFNC use.

Background Hypoxemia is the most frequent complication of fiberoptic bronchoscopy (FB) in children. Guidelines recommend oxygen supplementation and conventional nasal prongs (NC) are used for this purpose. The aim of this study was to evaluate if the use of high-flow nasal cannula therapy (HFNC) in children undergoing FB result in a lower incidence of hypoxemia than standard oxygen administration. Methods Patients aged 1 month-16 years undergoing elective FB were included in a prospective randomized controlled, nonblinded, single-center clinical trial and randomly assigned to receive oxygen via NC or HFNC. Patients' baseline characteristics were recorded pre-bronchoscopy. The primary outcome was oxygen desaturation during the procedure defined as saturation less than 94%. Results An intention to treat analysis for 53 patients receiving NC and 51 receiving HFNC, showed HFNC patients were less likely to have hypoxemia than were NC patients (p = .011), with an absolute risk reduction of 0.27 (95% confidence interval [CI]: 0.08-0.45) and a number needed to treat of 3.75 (95% CI: 2.22-12.04). Moderate hypoxemia (SpO2 ≥ 90% and 30 s) was not different between groups. Patients undergoing bronchoalveolar lavage (BAL) presented fewer desaturations with HFNC (p = .0003). Conclusions HFNC offers optimized oxygenation during elective FB with a significant reduction in desaturations and can be considered for oxygen administration, especially when BAL is performed.