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Background: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications., Methods: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models., Results: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar., Conclusions: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation., (© 2024. The Author(s).)

Rationale & Objective: A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion., Study Design: Retrospective cohort study., Setting & Participants: Adults undergoing their first PD catheter insertion between November 1, 2011, and November 1, 2020, at 11 institutions in Canada and the United States participating in the International Society for Peritoneal Dialysis North American Catheter Registry., Exposure: Prior abdominal procedure(s) defined as any procedure that enters the peritoneal cavity., Outcomes: The primary outcome was time to the first of (1) abandonment of the PD catheter or (2) interruption/termination of PD. Secondary outcomes were rates of emergency room visits, hospitalizations, and procedures., Analytical Approach: Cumulative incidence curves were used to describe the risk over time, and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes., Results: Of 855 patients who met the inclusion criteria, 31% had a history of a prior abdominal procedure and 20% experienced at least 1 PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome (adjusted HR, 1.12; 95% CI, 0.68-1.84). Upper-abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes., Limitations: Observational study and cohort limited to a sample of patients believed to be potential candidates for PD catheter insertion., Conclusion: A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to PD., Plain-Language Summary: Peritoneal dialysis (PD) is a life-saving therapy for individuals with kidney failure that can be done at home. PD requires the placement of a tube, or catheter, into the abdomen to allow the exchange of dialysis fluid during treatment. There is concern that individuals who have undergone prior abdominal procedures and are referred for a catheter might have scarring that could affect catheter function. In some institutions, they might not even be offered PD therapy as an option. In this study, we found that a history of prior abdominal procedures did not increase the risk of PD catheter complications and should not dissuade patients from choosing PD or providers from recommending it., (Copyright © 2024 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

National trends show rapid increases in the use of mechanical circulatory support devices (MCSD) over the last 20 years. While current literature has not proven a mortality benefit in cardiogenic shock as a complication of acute myocardial infarction (AMI-CS) with percutaneous MCSD, these devices are vital to maximizing cardiopulmonary parameters for definitive therapy. To minimize complications, many different techniques have been described including a novel off-pump direct apical cannulation for venoarterial-extracorporeal membrane oxygenation (VA-ECMO). This technique allows early ambulation and avoids peripheral artery access complications but has only been described in small case series. Our case series represents the largest summary of patients (50) using this technique and contains the only comparison data to date. Fifty-four percentage of our patients were Society for Cardiovascular Angiography and Interventions (SCAI) stage D and 22% were arrested before cannulation. We achieved flows on average >5 L/min and most patients required biventricular drainage (86%) and an oxygenator (92%). Thirty day survival was 56% and most survivors were bridged to heart transplant (30%). Our most common complication was bleeding (16%). This technique showed significant improvement in ejection fraction (EF), cardiac output/index (CO/CI), and pulmonary artery pressures. This case series demonstrates the safety and efficacy of this novel technique for central cannulation in cardiogenic shock at large scale within a single institution., Competing Interests: Disclosure: The authors have no conflicts of interest to report., (Copyright © ASAIO 2024.)

Background: Pain is a traumatic experience for most patients on hemodialysis. In this trial, we compared prilocaine/lidocaine cream with piroxicam gel for pain reduction during arteriovenous fistula needling., Methods: This randomized double-blind crossover clinical trial was done at dialysis unit of a tertiary care hospital from June to August 2022. Adult patients, aged 18-75 years, on maintenance hemodialysis through an arteriovenous fistula were selected randomly. Pain severity during needling of fistula was assessed during initial two hemodialysis sessions without application of any drug. Patients were then randomized into two groups receiving 5% prilocaine/lidocaine cream or 0.5% piroxicam gel 1 h before the next two hemodialysis sessions. After a 7-day washout period, patients crossed over to other groups for another two hemodialysis sessions. Pain was assessed on all these occasions. Primary outcome was reduction in pain with each intervention., Results: There were 32 patients aged 46.44 ± 11.58 years. Pain intensity was 6.69 ± 0.58, 3.13 ± 1.28, and 4.55 ± 1.95 without any medication, prilocaine/lidocaine cream and piroxicam gel respectively. There was greater pain reduction with prilocaine/lidocaine cream than piroxicam gel (3.56 ± 1.35 vs 2.14 ± 1.78; p  = 0.001). Local redness with prilocaine/lidocaine cream was reported by one (3.13%) patient, whereas no side effects were seen with piroxicam gel ( p  = 1.000)., Conclusion: Prilocaine/lidocaine cream provides better pain relief than piroxicam gel during arteriovenous fistula needling., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: When unintentional pancreatic duct access occurs during difficult biliary cannulation, the double guidewire (DGW) or transpancreatic sphincterotomy (TPS) may be utilized. DGW can be easily switched to TPS due to the existing guidewire in the pancreatic duct. However, the efficacy of TPS after DGW, named sequential DGW-TPS technique, versus primary TPS has not been assessed., Aims: Our aim was to compare the benefits and adverse events of sequential DGW-TPS technique and primary TPS., Methods: We performed a comparative retrospective cohort study that enrolled a total of 117 patients with native papillae. The patients were divided into one of 2 groups according to the primary bile duct access technique (sequential DGW-TPS or primary TPS), both with pancreatic stenting., Results: Between November 2017 and May 2023, a total of 84 patients were grouped into sequential DGW-TPS and 33 into primary TPS. The overall post-ERCP pancreatitis (PEP) rate was 4.3% in the entire cohort, with no statistical differences were observed between the groups in terms of PEP rates (P = 0.927), PEP severity (P = 1.000), first biliary cannulation success (P = 0.621), overall cannulation success (P = 1.000), hyperamylasemia incidence (P = 0.241), elevated amylase levels (P = 0.881), and postoperative hospital stay (P = 0.185). Furthermore, these results remained consistent in multivariable regression analysis., Conclusions: The sequential DGW-TPS technique showed a comparable safety and biliary cannulation success rate to primary TPS in difficult biliary cannulation. Given the potential long-term complications associated with TPS, DGW should be first if inadvertent pancreatic access occurs, with TPS serving as second only if DGW fails., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Buttonhole (BH) cannulation of native arteriovenous fistulas (AVFs) appears to be associated with an increased infectious risk. We previously reported a dramatic increase in the incidence of infectious events (IE) after shift to the BH technique in an in-center hemodialysis unit, which was largely reduced after staff (re)education regarding strict respect of the procedure. We assessed the evolution over the following 12-year period in our center., Methods: In this prospective follow-up of a previous, pre [rope-ladder (RL)]-post (BH) comparison (2001-10), all in-center hemodialysis patients with a native AVF were included from 1 July 2010 to 31 December 2022. Primary and secondary outcomes were IE (unexplained bacteremia due to skin bacteria and/or local AVF infection) and complicated IE (metastatic infection, AVF surgery, death). Overall, the impact of several quality improvement strategies was tested according to the events rate over six periods: Period 1: RL in all; Period 2: switch to BH; Period 3: BH in all, before workshops; Period 4: BH in all, after workshops; Period 5: BH withdrawal in problematic AVFs; Period 6: additional procedural changes., Results: This extended observation period allowed the addition of 195 180 AVF-days to our previous report. Overall, 381 661 AVF-days (366 AVFs, 345 patients) were analysed. After an increase of the IE rate in 2012, the shift to RL in problematic AVFs during Period 5 did not have a significant impact. The incidence of IE decrease significantly during Period 6 compared with Periods 3, 4 and 5 {incidence rate ratio (IRR) 0.24 [95% confidence interval (CI) 0.09-0.52], P = .0001, IRR 0.22 (95% CI 0.09-0.47), P < .0001 and IRR 0.29 (95% CI 0.11-0.66), P = .001, respectively}, and became eventually for the first time comparable to Period 1 [IRR 0.59 (95% CI 0.21-1.62), P = .27]., Conclusion: The constant observance of reinforced hygiene protocols by trained staff and central coordination succeeded in significantly mitigating the infectious risk associated with buttonhole cannulation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Background and Objectives : Thoracic epidural catheterization (TEC) can be both uncomfortable and fearful for patients when performed awake with the thought that the procedure may be painful. The aim of this study was to assess the effect of low-dose intravenous ketamine administration on pain and anxiety during the TEC procedure. Materials and Methods : Sixty patients were randomly divided into two groups to receive intravenous (IV) placebo (Group P) and IV low-dose (0.15 mg/kg) ketamine (LDK) (Group K) 3 min before the procedure in a double-blind manner. A visual analog scale (VAS) was used to measure anxiety (VAS-A) and pain (VAS-P) scores. Vital parameters were monitored before premedication (T1), 20 min after premedication (T2), during skin anesthesia (T3), during TEC (T4), and 5 min after TEC (T5). VAS-A values were recorded at T1, T3, T4, and T5 periods, and VAS-P levels were noted at T3, T4, and T5 periods. Results : During TEC (T4), both VAS-P and VAS-A were significantly lower in Group K ( p < 0.001). The mean VAS-A value was 10.6 mm lower, and the mean VAS-P value was 9 mm lower in Group K than in Group P at the T4 time point. Additionally, the mean VAS-P value was 7.7 mm lower in Group K compared to Group P at the T3 time point ( p < 0.001). Both groups showed a statistically significant difference in VAS-A measurements when compared at their respective time points ( p < 0.001). However, only Group P demonstrated a statistically significant difference in VAS-P measurements ( p < 0.001). VAS-P values remained stable in Group K. The number of patients who did not recall the procedure was significantly higher in Group K ( p < 0.001). Furthermore, the number of patients who would consent to the same procedure in the future was significantly higher in Group K ( p = 0.007). Conclusions : A preprocedural LDK (0.15 mg/kg) can effectively prevent anxiety and pain experienced by patients during the TEC procedure. Administration of LDK may provide a more comfortable procedure process without causing ketamine-induced side effects (hemodynamic, respiratory, and psychological).

Abstract: The potential benefits of epidural anesthesia on mortality, atrial fibrillation, and pulmonary complications must be weighed against the risk of epidural hematoma associated with intraoperative heparinization. This study aims to provide an updated assessment of the clinical risks of epidural anesthesia in cardiac surgery, focusing on the occurrence of epidural hematomas and subsequent paralysis. A systematic search of Embase, Medline, Ovid Central, Web of Science, and PubMed was conducted to identify relevant publications between 1966 and 2022. Two independent reviewers assessed the eligibility of the retrieved manuscripts. Studies reporting adult patients undergoing cardiac surgery with epidural catheterization were included. The incidence of hematomas was calculated by dividing the number of hematomas by the total number of patients in the included studies. Risk calculations utilized various denominators based on the rigor of trial designs, and the risks of hematoma and paralysis were compared to other commonly encountered risks. The analysis included a total of 33,089 patients who underwent cardiac surgery with epidural catheterization. No epidural hematomas were reported across all published RCTs, prospective, and retrospective trials. Four case reports associated epidural hematoma with epidural catheterization and perioperative heparinization. The risks of epidural hematoma and subsequent paralysis were estimated at 1:7643 (95% CI 1:3860 to 380,916) and 1:10,190 (95% CI 1:4781 to 0:1), respectively. The risk of hematoma is similar to the non-obstetric population (1:5405; 95% CI 1:4784 to 6134). The risk of hematoma in cardiac surgery patients receiving epidural anesthesia is therefore similar to that observed in some other surgical non-obstetric populations commonly exposed to epidural catheterization., (Copyright © 2024 Copyright: © 2024 Annals of Cardiac Anaesthesia.)

Study Objective: To assess the duration needed for regaining normal bladder voiding function in patients with postoperative bladder dysfunction requiring intermittent self-catheterization after deep endometriosis surgery and identify risk factors that might affect the recovery process., Design: Retrospective study based on data recorded in a large prospective database., Setting: Endometriosis referral center., Patients: From September 2018 to June 2022, 1900 patients underwent excision of deep endometriosis in our center; 61 patients were discharged with recommendation for intermittent self-catheterization and were thus included in the study., Interventions: Intermittent self-catheterization after endometriosis surgery., Measurements and Main Results: A total of 43 patients (70.5%) stopped self-catheterization during the follow-up period. Median follow-up was 25 weeks (range, 7-223 wk). Surgery was performed laparoscopically in 48 patients (78.7%) and robotically in 13 (21.3%); 47 patients (77%) had nodules involving the digestive tract, 11 (18%) had urinary tract involvement, 29 had parametrial nodules (47.5%), and 13 (21.3%) had sacral plexus involvement. The probability of bladder voiding function recovery and arrest of self-catheterization was 24.5%, 54%, 59%, 72%, and 77% at 4, 8, 12, 52, and 78 weeks, respectively. Cox's multivariate model identified preoperative bladder dysfunction as the only statistically significant independent predictor for arrest of self-catheterization (hazard ratio, 0.36; 95% confidence interval, 0.15-0.83)., Conclusion: Patients requiring intermittent self-catheterization for bladder dysfunction after deep endometriosis excision may spontaneously recover bladder function in 77% of cases. Symptoms suggesting preoperative bladder voiding dysfunction should be reviewed before planning surgery, and patients should be informed of the higher postoperative risk of long-term bladder voiding dysfunction., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary therapeutic procedure for pancreaticobiliary disorders, and studies highlighted the impact of papilla anatomy on its efficacy and safety. Our objective was to quantify the influence of papilla morphology on ERCP outcomes. We systematically searched three medical databases in September 2022, focusing on studies detailing the cannulation process or the rate of adverse events in the context of papilla morphology. The Haraldsson classification served as the primary system for papilla morphology, and a pooled event rate with a 95% confidence interval was calculated as the effect size measure. Out of 17 eligible studies, 14 were included in the quantitative synthesis. In studies using the Haraldsson classification, the rate of difficult cannulation was the lowest in type I papilla (26%), while the highest one was observed in the case of type IV papilla (41%). For post-ERCP pancreatitis, the event rate was the highest in type II papilla (11%) and the lowest in type I and III papilla (6-6%). No significant difference was observed in the cannulation failure and post-ERCP bleeding event rates between the papilla types. In conclusion, certain papilla morphologies are associated with a higher rate of difficult cannulation and post-ERCP pancreatitis., (© 2024. The Author(s).)

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a life-saving therapy for critically ill patients, but it carries an increased risk of thrombosis due to blood interacting with non-physiological surfaces. While the relationship between clinical variables and thrombosis remains unclear, our study aimed to identify which factors are most predictive of thrombosis. The Extracorporeal Life Support Organization Registry was queried to obtain a cohort of VV-ECMO patients aged 18 years and older from 2015 to 2019. Patients who were over 80-years-old, at the extremes of weight, who received less than 24 h of ECMO, multiple rounds of ECMO, or had missing data were excluded. Multivariate logistic regression modeling was used to assess predictors of thrombosis and mortality. A total of 9809 patients were included in the analysis, with a mean age of 47.1 ± 15.1 years and an average ECMO run time of 305 ± 353 h. Thrombosis occurred in 19.9% of the cohort, with circuit thrombosis (8.6%) and membrane lung failure (6.1%) being the most common. Multivariate analysis showed that ECMO runs over 14 days (OR: 2.62, P < 0.001) and pregnancy-related complications (OR: 1.79, P = 0.004) were associated with an increased risk of thrombosis. Risk factors for circuit thrombosis included incremental unit increases in the pump flow rate at 24 h (OR: 1.07 [1.00-1.14], P = 0.044) and specific cannulation sites. Increased body weight (OR: 1.02 [1.00-1.04], P = 0.026) and increased duration on ECMO (OR: 3.82 [3.12-4.71], P < 0.001) were predictive of membrane lung failure. Additionally, patients with thrombosis were at increased likelihood of in-hospital mortality (OR: 1.52, P < 0.001). This study identified multiple thrombotic risk factors in VV-ECMO, suggesting that future studies investigating the impact of pregnancy associated complications and ECMO flow rate on hemostasis would be illuminating., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Catheter implantation techniques for peritoneal dialysis (PD) have advanced significantly in recent years. We aimed to analyze the survival and associated complications of catheters inserted using a new technique that is guided by ultrasound and fluoroscopy and requires minimal tissue dissection. The procedure was performed by nephrologists in the outpatient basis, we compared these results of the minimally invasive insertion with traditional implantation using trocars., Methods: A total of 152 PD catheters were placed in 152 patients with stage 5 chronic kidney disease; 62.5% of the patients were men, with a mean age of 56.6 ± 18.5 years. The following two methods were used: minimally invasive insertion (MI group, n  = 73) and trocar insertion (T group, n  = 79). Patients in both the groups were followed prospectively for 26 months from the date of the first implantation., Results: Gender, age, and prevalence of diabetes mellitus were not significantly different between the groups, while the body mass index, presence of obesity, and abdominal scars from previous surgeries were higher in the MI group ( p  = 0.021). The incidence of catheter dysfunction was lower in the MI group compared to group T (6.8% vs 20.3%; p  = 0.019). Exit site infection was also lower with the new technique (4.1% vs . 18.9%; p  = 0.005). Further, the cumulative incidence of peritonitis also reduced with MI ( p  = 0.034). Finally, the overall catheter survival at 1 year was 89%, which has been shown as higher in group MI (95% vs 82% in group T; p  = 0.025)., Conclusion: The MI technique for catheter insertion showed low complication rates and excellent catheter survival as compared to traditional implantation methods; thus, it may be an alternative method for PD catheter placement., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Airway balloons are widely used by otolaryngologists to treat laryngotracheal stenosis. We review an adverse event and interventions that may prevent similar occurrences. There are no other reports of similar incidents in the Food and Drug Administration Manufacturer and User Facility Device Experience. We implore Acclarent to redesign their airway balloon device to prevent accidental airway irrigation., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Purpose: This study aimed to determine the effect of goldfish and aquatic turtle nursing interventions on children's pain, anxiety, and fear during IV catheter insertion., Design and Methods: The randomized controlled trial included 98 children (control group = 32, goldfish group = 33, aquatic turtle group = 33) aged 5-6 years, attending outpatient clinic for blood sampling and catheterisation procedures. Pain was measured using the Wong Baker Facial Pain Scale, anxiety was measured using the Child Anxiety Scale-State, and child fear was measured using the Child Fear Scale, before, during, and after catheterization., Results: When analyzing the pain, anxiety, and fear findings, no statistical difference was found between the scores of the mother, child, and researcher before the procedure. During the catheterization procedure, the pain, anxiety, and fear scores of the children in the fish and turtle groups increased statistically less than those in the control group. When analyzing the post-procedure findings, the pain, anxiety, and fear scores of the control group were similar to those before the procedure. In the fish and turtle groups, anxiety and fear scores were statistically the lowest (p < 0.05)., Conclusion: It can be concluded that animal-assisted practices reduce anxiety and fear during and after the catheterization procedures while diverting attention from pain., Practice Implications: Goldfish or aquatic turtle intervention improve children's attitudes toward pain, anxiety, and fear during IV catheter insertion. Pediatric nurses could consider incorporating, such as the animal assisted intervention, into their clinical practice to reduce the pain, anxiety, and fear experienced by children during medical/nursing procedures., Competing Interests: Declaration of Competing Interest The authors declare that they have no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Although adverse events related to extracorporeal membrane oxygenation have been reported, epidemiological data on life-threatening events are insufficient to study the causes of such adverse events. Data from the Japan Council for Quality Health Care database were retrospectively analyzed. The adverse events extracted from this national database included events associated with extracorporeal membrane oxygenation reported between January 2010 and December 2021. We identified 178 adverse events related to extracorporeal membrane oxygenation. At least 41 (23%) and 47 (26%) accidents resulted in death and residual disability, respectively. The most common adverse events were cannula malposition (28%), decannulation (19%), and bleeding (15%). Among patients with cannula malposition, 38% did not undergo fluoroscopy-guided or ultrasound-guided cannulation, 54% required surgical treatment, and 18% required trans-arterial embolization. In this epidemiological study in Japan, 23% of the adverse events related to extracorporeal membrane oxygenation had fatal outcomes. Our findings suggest that a training system for cannulation techniques may be needed, and hospitals offering extracorporeal membrane oxygenation should perform emergency surgeries., (© 2023. The Author(s).)

Background and Aims: Needle-knife papillotomy (NKP) is widely performed when biliary cannulation is difficult during endoscopic retrograde cholangiopancreatography (ERCP). However, its safety and efficacy in different types of duodenal papilla are not clear., Patients and Methods: This retrospective study analyzed 217 patients with difficult biliary cannulation who underwent NKP during ERCP procedures from June 2013 to May 2022 in our institution. Patients were classified according to Haraldsson classification type of duodenal papilla: type 1, regular; type 2, small; type 3, protruding or pendulous; and type 4, creased or ridged. Outcome measures were successful biliary cannulation and incidence of adverse events., Results: Haraldsson classification was type 1 in 115 patients, type 2 in 29, type 3 in 52, and type 4 in 21. Biliary cannulation was successful in 166 patients (76.5%) Success rates according to Haraldsson type were as follows: type 1, 74.8%; type 2, 82.8%; type 3, 80.8%; and type 4, 66.7%. The rates did not significantly differ among the types (p = 0.48). Overall incidence of adverse events was 9.22%. Incidence of adverse events did not significantly differ among the types (p = 0.69)., Conclusions: NKP was useful to achieve successful cannulation in patients with difficult biliary cannulation. The rate of successful cannulation and incidence of adverse events were similar among the different types of duodenal papilla., (© 2024. The Author(s).)

Introduction: PD catheter tip migration is a common complication and a significant cause of catheter malfunction. In this perspective, we present our experience with a new catheter and a new technique that involves the use of a new triple cuff PD catheter and a low entry site in an attempt to prevent PD catheter migration., Methods: A total of 503 incident PD patients have been studied in more than one PD center over a period of 5 years., Results: During the 5-year follow up we recorded zero percent catheter migration. Other technical complications were poor drainage in 3.4%, omental wrap in 2.8%, early leakage in 3.4%, and catheter replacement in 2.4%. By the end of the study, the one-year PD catheter survival was 97.6%., Conclusion: Our new triple cuff PD catheter and our low-entry approach seem to be effective in preventing PD catheter migration and minimizing other mechanical complications., (© 2023 International Society for Apheresis and Japanese Society for Apheresis.)

Aims: Current guidelines recommend an early (<24 h) invasive coronary angiography (ICA) strategy in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with Global Registry of Acute Coronary Events (GRACE) score over 140. Evidence for this recommendation is based on older trials., Methods and Results: Between 1 February 2016 and 31 July 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA underwent ICA during index hospitalization. Six hundred and fifty-five patients underwent early invasive ICA (within 24 h) and 1112 underwent late ICA (between 24 h and 1 week). One hundred and seven patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent myocardial infarction (MI). Median time from admission to ICA was 13.3 h (IQR 6.0-20.6) for the early group and 59.9 h for the late group (IQR 23.5-96.3). There was no difference between the early and late ICA groups in the primary composite outcome [late catheterization >24 h hazard ratio 1.196, 95% confidence interval (CI) 0.969-1.475, P -value 0.096]. A multivariable Cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late catheterization >24 h hazard ratio 1.0735, 95% CI 0.862-1.327, P -value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (hazard ratio 1.291, 95% CI 0.910-1.831, P -value 0.151)., Conclusion: An early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year., (Copyright © 2023 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Introduction:  Umbilical vein catheterization (UVC) can cause portal venous thrombosis, leading to the development of extrahepatic portal venous obstruction (EHPVO) and portal hypertension (PHT). The feasibility of the Meso-Rex bypass (MRB) for the treatment of EHPVO in patients with a history of UVC has been questioned. We compared the feasibility of performing an MRB in patients with or without a history of previous UVC., Methods:  A retrospective review of patients with EHPVO and known UVC status explored for a possible MRB at our institution was performed (1997-2022). Patients were categorized in two groups: with (UVC(+)) or without (UVC(-)) a history of UVC for comparison. A p -value less than 0.05 was considered significant., Results:  One hundred and eighty-seven patients were included ( n  = 57 in UVC(+); n  = 130 in UVC(-)). Patients in the UVC group were significantly younger at surgery and the incidence of prematurity was higher. Other risk factors for the development of EHPVO were similar between the groups, but only history of UVC could predict the ability to receive MRB (odds ratio [OR]: 7.4 [3.5-15.4]; p  < 0.001). The success rate of MRB was significantly higher in patients with no history of UVC (28/57 [49.1%] in UVC(+) vs. 114/130 [87.7%] in UVC(-); p  < 0.001). However, MRB patency at discharge (25/28 [89.3%] in UVC(+) vs. 106/114 [94.7%] in UVC(-); p  = 0.3) was equally high in both groups., Conclusion:  Our results indicate that a history of UVC is not a contraindication to MRB. Half of the patients were able to successfully receive an MRB. Patients with symptomatic PHT from EHPVO should not be excluded from consideration for MRB based on UVC history., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Arterial thrombosis (AT) is an increasingly recognized complication in pediatrics. Consensus clinical practice guidelines suggest immediate removal of the indwelling arterial catheter and a short course (5-7 days) of anticoagulation. The optimal duration and modality of antithrombotic therapy in children are yet to be determined., Aims: Describe treatment patterns and outcomes in pediatric patients with AT and explore predictors for complete thrombus resolution or long-term complications., Methods: Single-institution retrospective study. Patients were identified by ICD-9 and ICD-10 codes for the diagnosis of AT or reports of AT on ultrasound from January 1, 2012, to October 1, 2022. Descriptive and logistic regression analyses were used., Results: 101 patients were included. The median age was 2.2 months. The most common underlying diagnoses were congenital heart disease (39.6%) and infection (22.8%). A majority of patients had symptomatic thrombosis in an extremity, and 78% were catheter-associated. 81% of patients received anticoagulation with a median duration of 35 days. Out of the 70 patients who were treated with anticoagulation alone and had a follow-up imaging, 70% had complete resolution after 90 days of anticoagulation. No clear predictors of complete resolution were identified. Eighteen patients had long-term sequelae secondary to arterial insufficiency. Those with infection-associated AT were more likely to have long-term complications. The major and clinically relevant non-major bleeding rate was 11%., Conclusion: Duration of anticoagulation was widely variable, and 70% of patients achieved complete resolution by 90 days of anticoagulation. A significant proportion of patients developed long-term sequelae secondary to arterial insufficiency. Sepsis/infection at the time of diagnosis with AT was more likely to be associated with long-term complications., (© 2023 Wiley Periodicals LLC.)

Peritoneal dialysis (PD) catheter is the lifeline of PD patients, and despite the overall strength of the PD program in many countries, PD catheter survival remains the major weakness of the program. The prompt and effective implantation of the PD catheter, as well as speedy management of complications arising from catheter insertion, remains crucial for the success of the program., (© 2022 Wiley Periodicals LLC.)

Purpose: Cannulation of the major papilla is the most challenging part of endoscopic retrograde cholangiopancreatography (ERCP) for which physician-controlled wire-guided cannulation (PCWGC) and assistant-controlled wire-guided cannulation (ACWGC) are used as the cannulation techniques. PCWGC can reportedly save up to about 30% of the labor cost by reducing the number of assistants. This study aims to compare the safety and efficacy of PCWGC and ACWGC., Materials and Methods: Of the 2151 patients aged >20 years (4193 cases) who underwent ERCP at Yonsei University Medical Center between January 2015 and December 2016, 989 were included in this study., Results: Among efficacy outcomes, cannulation success rate, rate of precut sphincterotomy (PCWGC vs. ACWGC: 21.3% vs. 25.9%), bile duct cannulation time (PCWGC vs. ACWGC: median 3.0 minutes vs. 3.6 minutes), and total procedure time (PCWGC vs. ACWGC: median 13.6 minutes vs. 13.1 minutes) were not significantly different. Among safety outcomes, lower rates of post-ERCP pancreatitis were observed with PCWGC than with ACWGC (PCWGC vs. ACWGC: 5.8% vs. 8.8%, p =0.128). Among other post-ERCP adverse events (bleeding, perforation, and cholangitis), the difference was not significant between the groups. Radiation exposure (total dose area product, PCWGC vs. ACWGC: median 1979.9 µGym² vs. 2062.0 µGym², p =0.194) and ERCP cost excluding labor cost (PCWGC vs. ACWGC: $1576 vs. $1547, p =0.606) were not significantly different., Conclusion: Requiring less assistants, PCWGC showed comparable efficacy and safety to ACWGC. PCWGC can be considered as an alternative option, especially in facilities lacking manpower and resources., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2024.)

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) are essential skills for performing endoscopic cholangiopancreatic procedures. However, these procedures have a high incidence of adverse events, and current training predominantly relies on patient-based approaches. Herein, we aimed to develop an ERCP/EST simulator model to address the need for safer training alternatives, especially for learners with limited ERCP experience., Methods: The model was designed to facilitate the use of actual endoscopic devices, supporting learning objectives that align with the components of the validated Bethesda ERCP Skill Assessment Tool (BESAT). BESAT focuses on skills, such as papillary alignment, maintenance of duodenoscope position, gentle and efficient cannulation, controlled sphincterotomy in the correct trajectory, and guidewire manipulation. Thirty gastroenterology trainees used the simulator between May 2022 and March 2023, and their satisfaction was assessed using a visual analog scale (VAS) and pre- and post-training questionnaires., Results: The novel simulator model comprised a disposable duodenal papillary section, suitable for incision with an electrosurgical knife, alongside washable upper gastrointestinal tract and bile duct sections for repeated use. The duodenal papillary section enabled reproduction of a realistic endoscope position and the adverse bleeding events due to improper incisions. The bile duct section allowed for the reproduction of fluoroscopic-like images, enabling learners to practice guidewire guidance and insertion of other devices. Following training, the median VAS score reflecting the expectation for model learning significantly increased from 69.5 (interquartile range [IQR]: 55.5-76.5) to 85.5 (IQR: 78.0-92.0) (p &lt; 0.01). All participants expressed a desire for repeated simulator training sessions., Conclusions: This innovative simulator could serve as a practical educational tool, particularly beneficial for novices in ERCP. It could facilitate hands-on practice with actual devices, enhancing procedural fluency and understanding of precise incisions to minimize the risk of bleeding complications during EST., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Background: Iatrogenic portal vein (PV) injuries following pleural drainage catheter (PDC) insertion are rare but life-threatening. This case report emphasizes the importance of prompt recognition and effective interventional radiology (IR) management., Case Presentation: A 38-year-old Asian male, admitted for a non-ST-segment elevation myocardial infarction, suffered a critical PV injury during PDC insertion, leading to rapid clinical deterioration. The IR team conducted a portogram, retrieved the catheter, and successfully executed an embolization procedure. The patient's recovery, confirmed through imaging and improving liver function tests, enabled discharge with follow-up instructions., Conclusions: This case highlights the clinical significance of promptly recognizing and effectively managing iatrogenic PV injuries during PDC insertion, with the pivotal role of IR. Collaboration between IR and surgical teams is crucial for optimizing patient outcomes., (© 2023. The Author(s).)

Rationale: Vascular complications associated with extracorporeal membrane oxygenation (ECMO) increase the in-hospital mortality. Perforation of the inferior vena cava (IVC) during venovenous extracorporeal membrane oxygenation (V-V ECMO) cannulation and subsequent emergency management prior to vascular surgery has rarely been reported., Patient Concerns: A 72-year-old female was diagnosed with IVC perforation caused by venovenous extracorporeal membrane oxygenation cannulation., Diagnoses: Abdominal computed tomography venography with 3D reconstruction confirmed that the cannula tip had perforated the abdominal cavity from the conjunction of the iliac vein and IVC. As a result, the patient was diagnosed with inferior vena cava perforation., Interventions: Attempts to reposition the dislocated cannula using digital subtraction angiography were unsuccessful. However, we found that ECMO could maintain a stable blood flow; therefore, we decided to keep ECMO running, and to minimize blood loss from the puncture site, we ensured adequate blood transfusion while operating V-V ECMO. Subsequently, emergency laparotomy was performed to fix the vascular lesion, and we established a new V-V ECMO circuit through cannulation of the bilateral internal jugular veins., Outcomes: In the case of confirmed V-V ECMO-related vascular perforation of the IVC, it is crucial to continue ECMO device operation to maintain negative pressure in the IVC and position the dislocated catheter to block the perforation site, effectively controlling bleeding. Therefore, emergency laparotomy should be promptly performed for vascular repair. Fortunately, the patient recovered successfully and was subsequently discharged., Lessons: This case highlights several important lessons: When advancing a cannula, in this case, it is essential to first identify the guidewire placement to ensure proper guidance; In the event of a confirmed V-V ECMO-related vascular perforation of the IVC, maintaining negative pressure in the IVC through continued ECMO device operation and positioning the dislocated catheter to block the perforation site are crucial steps to control bleeding prior to emergency open vascular repair; After undergoing vascular repair, if ECMO support is still necessary, it is advisable to opt for a catheterization strategy that avoids previously repaired blood vessels., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Laparoscopic technique is widely used in peritoneal dialysis (PD) catheter placement. We developed a modified minimally invasive laparoscopic PD catheter (PDC) insertion with internal fixation and evaluated the early results by observing the intraoperative and postoperative conditions of the novel technique with those of conventional open surgery., Methods: Retrospective research was performed on 59 patients who underwent PDC insertion from June 2019 to January 2022, including 23 patients who received open surgery and 36 patients who received modified minimally invasive laparoscopic surgery. Information such as preoperative conditions, operation time, incision length, incidence of intraoperative complications, time from operation to starting PD, time from operation to discharge, and incidence of catheter-related complications were collected and analyzed., Results: The incision length, intraoperative blood loss, catheter migration rates and the total incidence of complications 6 months after operation in the laparoscopic group were lower than those in the conventional group. There were no statistically significant differences between the two groups in operation time, time from operation to starting PD, time from operation to discharge and the incidence of catheter blockage, leakage, exit-site infection, peritoneal dialysis associated peritonitis and hernia., Conclusions: Modified minimally invasive laparoscopic PDC insertion and internal fixation method achieved direct vision and reliable fixation of the catheter, significantly reduced incision length and blood loss. The incidence of catheter migration was significantly lower than that of open surgery. Our primary findings reveal that modified minimally invasive laparoscopic PDC insertion with internal fixation is safe, effective and beneficial for PD patients.

Biliary metal stent implantation is an effective treatment for malignant obstructive jaundice. But it's well known that stents put in for a long time can become occluded and cause jaundice and cholangitis. At this time, endoscopic intervention is usually required to replace the stent or re-insert the stent. Re-cannulation for metal stent occlusion is challenging because the guide wire may pass through the side holes of the uncovered metal stents, resulting in prolonged surgical time and exposure to radiation. Here we present a small tip that may help endoscopists complete the re-cannulation of an uncovered metal stent in a very short time.

Background: Percutaneous balloon compression is a safe and effective treatment for trigeminal neuralgia. Current technique consists of penetrating the foramen ovale using a sharp 14G needle with a stylet. Difficulty of cannulation of the foramen ovale, failures of cannulation and major neurovascular complications of the procedure, although rare, may be due to the relatively large caliber of this needle and its sharp tip., Objective: To present a novel technique to facilitate and make the cannulation of the foramen ovale with a 14G cannula safer., Methods: A rigid blunt-tip guide of 1.2 or 1.5 mm is used to penetrate the foramen ovale under lateral fluoroscopic control. Once the guide enters the foramen it is advanced further to the clival line, and a 14G cannula is then advanced over the guide to engage the foramen, at which point the guide is withdrawn and replaced with the balloon catheter., Results: The technique was employed to deliver a 4F balloon catheter to Meckel's cave successfully in 500 consecutive procedures performed on 416 trigeminal neuralgia patients. None of the patients had neurovascular complications like facial hematoma, arterial injury, carotid-cavernous fistula or cranial nerve palsies., Conclusion: A novel technique for cannulation of the foramen ovale is described. The use of blunt tip guides of smaller diameters instead of sharp 14 G needles considerably facilitated cannulation of the foramen ovale and enabled cannulation in all cases. Absence of complications of cannulation such as facial hematoma, carotid-cavernous fistula or intracranial hemorrhage in this series of patients suggests that the technique may be safer than the use of conventional sharp tipped 14G needles in terms of avoiding neurovascular complications.

Background: Intermittent self-catheterization (CISC) is the preferred treatment for patients with bladder dysfunction due to spinal cord injuries or multiple sclerosis (MS). However, the learning phase plays a crucial role in the still frequent drop-out., Aim: To examine whether the timing of training affects the treatment compliance and the prevalence of urinary tract infections in patients with neurogenic urinary retention., Design: This is a non-randomized observational study., Setting: The study was carried out from January 2017 to December 2019 in outpatient settings at the Bari Polyclinic Unipolar Spinal Unit (Bari, Italy)., Population: The study included adults with a CISC prescription for neurogenic urinary retention and learning the technique for the first time., Methods: One hundred patients were enrolled, 75 trained immediately after diagnosis and physician prescription, while 25 in the contest of a separate training visit, one or two days after physician prescription. After the training (T0), patient's data and number of prescribed daily catheterizations were recorded and compared with those collected after 6 and 12 months. Accuracy of the procedure and episodes of infections were assessed as well., Results: Adherence to prescribed CISC frequency and complications were not affected by the timing of training. However, patients adherent to the prescribe frequency of catheterization had less risk of infection than those who were not. Further post-hoc analysis confirmed that urodynamic findings and the pathology did not impact the overall occurrence of complications, but infections occurred more frequently in patients with MS (P<0.03)., Conclusions: The timing of CISC education does not affect treatment adherence or the occurrence of complications. However, the adherence to the CISC prescription seems to reduce the risk of infection., Clinical Rehabilitation Impact: Patient training can be scheduled according to the organization of the centers, as patient compliance and the occurrence of complications are not affected.

Iatrogenic type A aortic dissection is a life-threatening condition associated with high morbidity and mortality. Traditionally, cannulation of the femoral artery or axillary artery has been preferred for arterial access, but in 2007 a new technique including direct cannulation of the ascending aorta was presented. The technique is known as "samurai cannulation" because of the quick incision of the aorta. It has been shown to be less time-consuming than other techniques, which is favorable in acute situations in patients with hemodynamic instability.

Umbilical artery catheterisation (UAC) is crucial in the management of clinically sick infants. One of its dreaded complications is aortic thrombus formation which accounts for significant morbidity and mortality. We present the case of a premature infant born at 32 weeks of gestation and with a birth weight of 960 gm, who developed signs of acute lower limb ischaemia following UAC cannulation. Ultrasound Doppler scan confirmed large aortic thrombus involving iliac arteries. Heparin infusion was started with clinical improvement over the next 12 hours and eventual complete resolution of clot size. This case underscores the importance of prompt detection of acute aortic thrombosis and cautions the use of heparin infusion in preterm infants can be lifesaving. Management can be challenging as risk of bleeding from anticoagulation and thrombolytic therapy can be catastrophic in extreme low birthweight premature infants and need to weigh with risk of severe intravascular haemorrhage., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives : To analyze the patient outcome and complication rate of axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients who could not be weaned from cardiopulmonary bypass after cardiothoracic surgery. Materials and Methods: We analyzed the data of 179 patients who were supported with VA-ECMO with femoral-axillary access (FA VA-ECMO) after cardiothoracic surgery between January 2014 and January 2019 in our department. Patients requiring central aortic cannulation and patients with respiratory failure requiring veno-venous ECMO were excluded. Primary outcomes were in-hospital mortality and 1-year survival rate of patients who were weaned from VA-ECMO support. Secondary outcomes were cannulation-related complications at the axillary site, VA-ECMO-related complications, and systemic complications. Results: In our cohort, 60 (33.5%) patients were female. Mean age was 67.0 ± 10.9 years. Overall, 78 (43.5%) patients were operated upon electively, 37 (20.7%) patients underwent urgent surgery, and 64 (35.8%) patients underwent emergency surgical treatment. Sixty-seven patients (37.4%) were resuscitated preoperatively. The mean duration of VA-ECMO support was 8.4 ± 5.1 days. Weaning from VA-ECMO was successful in 87 (48.6%) patients; 62 (34.6%) patients survived the hospital stay. The 1-year survival rate was 74%. Subclavian bleeding occurred in 24 (13.4%) patients, femoral bleeding in 4 (2.2%) patients, ischemia of the upper limb in 11 (6.1%) patients, intracerebral bleeding in 9 (5%) patients, and stroke in 19 (10.6%) patients. Conclusions: In patients with acute LV dysfunction after cardiothoracic surgery who cannot be weaned from cardiopulmonary bypass, right axillary artery cannulation is a safe and reliable method for VA-ECMO support with an acceptable complication rate.

Purpose: To summarize evidence related to (1) research studies examining patient/caregiver educational interventions related to intermittent self/caregiver catheterization (ISC), (2) studies examining issues related to teaching ISC, and (3) evidence-based clinical practice guidelines addressing ISC., Problem: Avoiding lower urinary tract trauma during catheter insertion, adequate frequency of catheterization, and complete emptying of the bladder are essential to prevent and reduce complications associated with ISC. Consequently, proper patient/caregiver education is essential to achieving good outcomes., Methods: Scoping review of literature., Search Strategy: We searched PubMed, EMBASE, and CINAHL databases, and the reference lists of background and included studies for quantitative and qualitative research studies and professional and healthcare organization-generated evidence-based clinical practice guidelines published between 2005 and September 2021. Eleven studies and 2 clinical practice guidelines met our eligibility criteria and are included in the review., Findings: Research conducted in the United States examining the effectiveness of educational interventions for patients needing ongoing ISC is extremely limited. The single study identified was a small pilot feasibility study. Eight studies examining issues potentially related to patient/caregiver ISC education were identified, suggesting that catheter characteristics, patient barriers, and complications, particularly urinary tract infections, adherence, and upper extremity function, are important considerations when developing education interventions. The small number of studies and limitations in the methodologies limit the current evidence base to support patient/caregiver education about ISC. We also identified 2 evidence-based guidelines generated by European professional organizations that included recommendations related to ISC education., Conclusions: Additional research is needed to support the development of patient/caregiver educational interventions and to examine their effectiveness., (Copyright © 2023 by the Wound, Ostomy and Continence Nurses Society.)

Background: Posterior wall puncture of the AVG causes serious vascular access complications, but there is no concrete technical recommendation for AVG cannulation with plastic cannula. The purpose of this study is to identify cannulation techniques to reduce posterior wall puncture of the AVG using plastic cannula., Methods: Sixty-three hemodialysis nurses' cannulations on experimental models were recorded and included in this study. Cannulations were conducted on AVG and AVF models with a plastic cannulation needle. We analyzed the angle of the needle, the motion of the needle, and the location of the needle in the graft lumen., Results: The occurrence of posterior wall puncture of the AVG model was 22.2%. The cannulation angles in the AVG model were greater than those in the AVF model ( p < 0.05). In the posterior wall puncture group of the AVG model, after the tip of the needle had reached into the graft lumen, the angle of the needle was not flattened ( p < 0.05) and the outer sleeve of the needle was not inserted into the graft ( p < 0.05). Furthermore, posterior wall puncture of the AVG model were observed in the group with less than 5 years of dialysis nursing experience ( p < 0.05)., Conclusions: From this study, after the tip of the needle had reached into the graft lumen, flattening the angle of the needle and inserting the outer sleeve of the needle into the graft were suggested as specific cannulation techniques to reduce posterior wall puncture of the AVG. Furthermore, this study also suggests the importance of cannulation technique education for new dialysis nurses to reduce cannulation-caused complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Infusion set function remains the limiting factor of insulin pump therapy due to nonmetabolic complications. Here, we tested an investigational extended-wear infusion set prototype with a soft, angled, wire-reinforced cannula with three additional side holes, and compared failure mechanisms and tissue response with a commercial Teflon control., Methods: A total of 48 Teflon and 48 prototype infusion sets were inserted subcutaneously every other day for 14 days in 12 swine and infused with dilute insulin. After two weeks, tissue around cannulas was excised, and occlusions, leaks, and kinks were determined. Tissue was processed and stained to assess the total area of inflammation (TAI) and the inflammatory layer thickness (ILT) around the cannulas. Data were analyzed using Fisher's exact, analysis of variance-general linear model, Kruskal-Wallis, and post hoc tests., Results: On average, the TAI surrounding the investigational cannula was 52.6% smaller than around the commercial control. The ILT was 66.3% smaller around investigational cannulas. Kinks occurred in 2.1% (investigational) vs 32.4% (commercial) cannulas ( P  < .001). There was no difference in occlusion alarms and leaks onto skin., Conclusions: The data suggest that the infusion set prototype elicits less inflammation over an extended wear time and is resistant to kinking, compared with a commercial Teflon device. This is consistent with previously published data on the impact of cannula material/angle on the inflammatory tissue response. We highlight the following important aspects of infusion set design: (1) secure skin adhesion, (2) reliable cannula insertion, (3) automatic removal of the stylet, (4) cannula material/design that resists kinking, and (5) minimization of local tissue inflammation., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JIJ is a founder, equity owner, and consultant to Capillary Biomedical and has received research supports. PJS is a founder, equity owner, and employee of Capillary Biomedical. MCT is an equity owner and member of Capillary Biomedical’s Scientific Advisory Board. JRK is a consultant to and equity owner of Capillary Biomedical.

Objectives: The stepwise initiation of peritoneal dialysis (PD) using Moncrief and Popovich's technique (SMAP) for catheter insertion is recommended for the systemic introduction of PD and prevention of catheter-related infections. In this study, we investigated patient outcomes in patients who underwent insertion of a PD catheter with a direct method versus the SMAP method., Methods: We enrolled 295 consecutive patients who underwent PD as a primary renal replacement therapy and underwent insertion of a PD catheter at our institute between 2006 and 2021. We retrospectively reviewed their data and investigated patient outcomes, including mortality and PD catheter-related complications., Results: Median age at PD induction was 65 years in the direct insertion group and 65 years in the SMAP group (P = 0.80). The rate of PD introduction after emergency hemodialysis was significantly higher in the direct insertion group than in the SMAP group (P < 0.001). There was no significant difference in survival between the direct insertion and SMAP groups during the median follow-up period of 54 months (P = 0.12). Additionally, patients who transitioned to hemodialysis or kidney transplantation after PD showed significantly longer survival (P < 0.001). The incidence of PD catheter-related complications was not significantly different between the two groups. A body mass index ≥ 23 kg/m 2 was an independent risk factor for peritonitis and exit-site infection (P = 0.006 and P = 0.011, respectively)., Conclusions: Planned sequential renal replacement therapy including hybrid hemodialysis, complete hemodialysis, and kidney transplantation after PD is important for improving patient outcomes. PD catheter insertion by SMAP may not be mandatory in our clinical practice., (© 2023. The Author(s), under exclusive licence to The Japanese Society of Nephrology.)

We conducted a cross-sectional study using an online questionnaire to investigate the current status of urinary tract infections (UTIs) and the use of clean intermittent catheterization (CIC) in Chinese community-based SCI patients and to explore the risk factors for UTIs in patients using CIC. Our findings suggest that the prevalence of UTIS is higher in Chinese community-based SCI patients compared with patients in medically developed countries. In addition, we found that CIC had the lower incidence of UTIs than urinary indwelling catheter (UIC) and suprapubic catheter (SPC), and that SCI patients with CIC had low rates of use and poor compliance. Further analysis indicated that most of the risk factors for UTIs in CIC patients were associated with irregular use of CIC. Therefore, we call for not only the need to provide stronger caregiver support and financial assistance to improve CIC adherence in Chinese community SCI patients, but also the establishment of a database of Chinese SCI patients in order to enhance the management of bladder emptying methods and further standardize the CIC operation in such patients, thus reducing the risk of UTIs in Chinese community SCI patients., (© 2023. Springer Nature Limited.)

Background: Venous catheters are widely used in clinical practice, but a drawback of their usage is the increased risk of thrombosis., Aims: The current study explored the risk factors affecting the formation of thrombosis following venous catheterization and establishes a risk nomogram prediction model for catheter-related thrombosis., Methods: Univariate and multivariate logistic regression analyses were carried out to identify the independent factors involved in venous catheter thrombosis. These factors were included in the construction of a nomogram. Finally, the C-index and calibration curves were used to validate the nomogram., Result: A total of 146 cases were included in the sample, of which 36 were cases of thrombosis. The results of the univariate logistic regression analysis showed that the following were significant factors: age, Acute Physiology and Chronic Health Evaluation scoring system (APACHE II) score, white blood cell (WBC), hematocrit (HCT), international normalized ratio (INR), fibrinogen (FIB), and D-dimer. Multivariate logistic regression analysis was performed, which confirmed that the factors of age (AUC: 0.677, 95% CI: 0.564-0.790), APACHE II score (AUC: 0.746, 95% CI: 0.656-0.837), INR (AUC: 0.743, 95% CI: 0.636-0.849), and D-dimer (AUC: 0.826, 95% CI: 0.750-0.902) were independent variables. Next, a nomogram was constructed using these independent variables for predicting venous catheter thrombosis. Favorable results with C-indexes (0.816; 95% CI: 0.780-0.882) and calibration curves closer to ideal curves indicated the accurate predictive ability of this nomogram., Conclusion: The individualized nomogram demonstrated effective prognostic prediction for patients with venous thrombosis., (© 2023. The Author(s), under exclusive licence to Royal Academy of Medicine in Ireland.)

Objective: Evaluate the impact of peritoneal dialysis catheter (PDC) tail-end design variations on PDC-related complications., Method: Effective data were extracted from databases. The literature was evaluated according to the Cochrane Handbook for Systematic Reviews of Interventions, and a meta-analysis was conducted., Results: Analysis revealed that the straight-tailed catheter was superior to the curled-tailed catheter in minimizing catheter displacement and complication-induced catheter removal (RR = 1.73, 95%CI:1.18-2.53, p = 0.005). In terms of complication-induced PDC removal, the straight-tailed catheter was superior to the curled-tailed catheter (RR = 1.55, 95%CI: 1.15-2.08, p = 0.004)., Conclusion: Curled-tail design of the catheter increased the risk of catheter displacement and complication-induced catheter removal, whereas the straight-tailed catheter was superior to the curled-tailed catheter in terms of reducing catheter displacement and complication-induced catheter removal. However, the analysis and comparison of factors such as leakage, peritonitis, exit-site infection, and tunnel infection did not reveal a statistically significant difference between the two designs., (© 2023 International Society for Apheresis and Japanese Society for Apheresis.)

The last few years have seen several developments in the field of peritoneal dialysis (PD), including successful use of acute PD, increasing emphasis on home dialysis utilization, and improved understanding of models of peritoneal solute transfer. This installment of AJKD's Core Curriculum in Nephrology emphasizes the latest data available for prevention and management of infectious and noninfectious complications of PD. Through case vignettes, appropriate strategies for diagnosis and care of patients with PD peritonitis are reviewed as well as noninfectious complications evident in clinical practice including complications from increased intra-abdominal pressure, namely pericatheter and abdominal leaks, hernia formation, and complications from pleuroperitoneal communication (hydrothorax). Although rates of incisional hernias and pericatheter leaks have decreased with improved peritoneal dialysis catheter insertion techniques, these mechanical complications continue to be common occurrences and are reviewed via pertinent clinical vignettes which aim to address and discuss common implications of these scenarios. Finally, this Core Curriculum article covers a practical overview of peritoneal dialysis catheter dysfunction., (Copyright © 2023 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The effects of standardized risk-adjusted periprocedural management of cardiac catheterization procedures in Non-ST segment elevation myocardial infarction (NSTEMI) remain unknown. We implemented a standard operating procedure (SOP) specifying risk assessment (RA, using National Cardiovascular Data Registry (NCDR) risk models) and risk-adjusted management (RM, e.g. intensified monitoring) in 2018 and aimed to investigate staff SOP adherence and associations with patient outcomes., Methods and Results: All 430 invasively managed NSTEMI patients (mean age 72y; 70.9% male) in 2018 were analyzed for staff SOP adherence and in-hospital clinical outcomes. 207 patients (48.1%; RM+) received both RA and RM; 92 patients (21.4%; RM-) received RA but no RM; 131 patients (30.5%; RA-) received neither RA nor RM. Lower staff adherence to RA was associated with emergency settings (51.9% (RA-) vs. 22.1% (RA+); p<0.01), presentation in cardiogenic shock (17.6% (RA-) vs. 6.4% (RA+); p<0.01) and invasive mechanical ventilation (12.2% (RA-) vs. 3.3% (RA+); p<0.01). Early sheath removal (87.9% (RM+) vs. 56.5% (RM-); p<0.01) and intensified monitoring (p<0.01) were more frequent in the RM+ group. All-cause mortality was not different (1.4% (RM+) vs. 4.3% (RM-); p=0.13), but there were fewer major bleeding events with associated with RM (2.4% (RM+) vs. 12% (RM-); p<0.01), which remained independently associated with RM in a multivariate logistic regression model correcting for confounders (p<0.01)., Conclusion: In an all-comer patient cohort with NSTEMI, staff adherence to risk-adjusted periprocedural management was independently associated with fewer major bleeding events. Staff adherence to SOP-specified risk assessment was frequently neglected in more critical clinical situations., Competing Interests: Declaration of Competing Interest All authors declare: no support from any industry or third-party organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: The selection of different arterial cannulation site influences the incidence of postoperative stroke in patients with DeBakey I acute aortic dissection. The study aimed to explore the optimal arterial cannulation for these patients., Methods: From January 2009 to 2019, a total of 1514 patients with DeBakey I acute aortic dissection underwent frozen elephant trunk and total arch replacement at a tertiary center. They were divided into 2 groups: the axillary artery only cannulation group (n = 1075) and the femoral artery cannulation group (n = 439). After balancing the differences of baseline condition by propensity score matching, the prognosis was compared., Results: The incidence of stroke and acute brain infarction in the femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 11.7% vs 7.0%, P = .03; acute brain infarction, 6.0% vs 2.7%, P < .01). The femoral artery cannulation group was further divided into 2 groups: femoral artery only cannulation group (n = 106) and axillary combined with femoral artery cannulation group (n = 333). The comparison was performed between the axillary combined with femoral artery cannulation group and the axillary artery only cannulation group. After propensity score matching, the incidence of stroke and acute brain infarction in the axillary combined with femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 13.5% vs 7.2%, P < .01; acute brain infarction, 6.9% vs 2.5%, P < .01)., Conclusions: Axillary artery only cannulation is recommended as the optimal arterial cannulation strategy for most patients with DeBakey I acute aortic dissection. For those patients who are not suitable for axillary artery only cannulation, axillary combined with femoral artery cannulation is not recommended., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Adverse events (AE) after endoscopic retrograde cholangiopancreatography (ERCP) are not uncommon and post-ERCP acute pancreatitis (PEP) is the most important one. Thermal injury from biliary sphincterotomy may play an important role and trigger PEP or bleeding. Therefore, this study evaluated the outcomes of 2 electric current modes used during biliary sphincterotomy., Methods: From October 2019 to August 2021, consecutive patients with native papilla undergoing ERCP with biliary sphincterotomy were randomized to either the pure cut or endocut after cannulation. The primary outcome was PEP incidence. Secondary outcomes included intraprocedural and delayed bleeding, infection, and perforation., Results: A total of 550 patients were randomized (272 pure cut and 278 endocut). The overall PEP rate was 4.0% and significantly higher in the endocut group (5.8% vs 2.2%, P = 0.034). Univariate analysis revealed >5 attempts ( P = 0.004) and endocut mode ( P = 0.034) as risk factors for PEP. Multivariate analysis revealed >5 attempts ( P = 0.005) and a trend for endocut mode as risk factors for PEP ( P = 0.052). Intraprocedural bleeding occurred more often with pure cut ( P = 0.018), but all cases were controlled endoscopically during the ERCP. Delayed bleeding was more frequent with endocut ( P = 0.047). There was no difference in perforation ( P = 1.0) or infection ( P = 0.4999) between the groups., Discussion: Endocut mode may increase thermal injury leading to higher rates of PEP and delayed bleeding, whereas pure cut is associated with increased intraprocedural bleeding without clinical repercussion. The electric current mode is not related to perforation or infection. Further RCT assessing the impact of electric current on AE with overlapping preventive measures such as rectal nonsteroidal anti-inflammatory drugs and hyperhydration are needed. The study was submitted to the Brazilian Clinical Trials Platform ( http://www.ensaiosclinicos.gov.br ) under the registry number RBR-5d27tn., (Copyright © 2023 by The American College of Gastroenterology.)

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81-1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73-0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00-1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99-1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73-0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64-0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter., (© 2023 Association of Anaesthetists.)

Aims: Extracorporeal membrane oxygenation (ECMO) is a widely used technique to support neonates with severe respiratory failure. Data on percutaneous, ultrasound-guided veno-venous (VV) ECMO cannulation in neonates is still scarce. Aim of this study was to describe our institutional experience with ultrasound-guided percutaneous, VV ECMO cannulation in neonates with severe respiratory failure., Methods: Neonates receiving ECMO support at our department between January 2017 and January 2021 were retrospectively identified. Patients receiving VV ECMO cannulation performed by the percutaneous Seldinger technique by single- or multisite cannulation were analyzed., Results: A total of 54 neonates received ECMO cannulation performed by the percutaneous Seldinger technique. In 39 patients (72%) a 13 French bicaval dual-lumen cannula was inserted and in 15 patients (28%) two single-lumen cannulae were used. Cannulae positioning using the multisite approach was in all cases as desired. The tip of the 13 French cannula was located in the IVC in 35/39 patients, in four patients position was too proximal but did not dislocate during the ECMO run. One (2%) preterm neonate (weight 1.75 kg) developed a cardiac tamponade which was successfully managed with drainage. Median duration of ECMO was 7 days (interquartile range: 5-16 days). Forty-four patients (82%) were successfully weaned from ECMO and in 31/44 (71%) the ECMO cannulae were removed with a delay of 0.9-7.2 days (median 2.8 days) after weaning without noticing complications., Conclusions: A correct cannula placement using the ultrasound-guided percutaneous Seldinger technique, for both single- and multisite cannulation, seems feasible in most neonatal patients receiving VV ECMO., (© 2023 The Authors. Pediatric Pulmonology published by Wiley Periodicals LLC.)

Background: In haemodialysis is key to successfully obtaining cannulation of the arteriovenous fistula (AVF). The literature agrees that cannulation, failing in the initial maturation period, can lead to delayed dialysis, haematoma, scarring, needle phobia and loss of confidence in the cannulator. The introduction of plastic cannulae for haemodialysis has changed cannulation practice positively, preventing frequent complications such as infiltration or trauma. Despite that, most countries have continued to use metal cannulation, in particular in Europe. This study investigates the common use of plastic cannulae versus metal needles for cannulation in dialysis units and explores the implications of focusing on the side effects of cannulation., Methods: The study is a cross-sectional survey. A questionnaire was created by a team of experts from the European Dialysis Transplant Nurse Association/European Renal Care Association (EDTNA/ERCA) to address the study's aims and sent online to nurse members., Results: Data collected suggested a strong resistance towards using plastic cannulae, with few respondents claiming to use these cannulas. Most of the respondents were female (74%), Europeans, working in nephrology for more than 10 years and most worked in the public sector. There was a strong correlation between the use of plastic cannulae and fewer adverse events in elbow located AVF and newly created or fragile AVF., Conclusions: The results are in line with the current literature. Possible resistance to the use of the plastic device includes the difference in cost between the two devices in favour of metal needles. However, it should be considered that the lower number of adverse events, in particular infiltration and haematoma caused by the metal needle, involves a considerable saving both in money and in terms of time and distress for the patient., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To investigate the impact of endometriosis on the therapeutic effect of hysteroscopic fallopian tube catheterization combined with laparoscopy in infertile patients with proximal tubal obstruction., Methods: We conducted a retrospective analysis of patients who underwent hysteroscopic fallopian tube catheterization combined with laparoscopy for infertility caused by proximal fallopian tube obstruction between January 19, 2016 and March 20, 2020 at the Department of Reproductive Endocrinology, West China Second Hospital, Sichuan University. During the operation, hydrotubation was performed to verify whether there was proximal tubal obstruction. Then, the patients were categorized into an endometriosis group and a non-endometriosis group according to whether their proximal tubal obstruction was combined with endometriosis. The baseline data were balanced by propensity score matching and the rate of successful surgical unblocking of proximal tubal obstruction in infertile patients by hysteroscopic fallopian tube catheterization combined with laparoscopy was calculated. Treating cases lost to follow-up in both groups as non-pregnant cases according to the principle of intention-to-treat analysis, we followed up the pregnancy outcomes after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous pregnancy rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery. The primary indicators included overall successful surgical unblocking rate, clinical pregnancy rate, and spontaneous conception rate, while the secondary indicators included live birth rate, miscarriage rate, ectopic pregnancy rate, and the mean time to spontaneous pregnancy after surgery., Results: After propensity score matching, 113 cases were included in each of the two groups, with the overall successful surgical unblocking rate being 72.6%. The successful surgical unblocking rate of patients in the endometriosis group was higher than that of the non-endometriosis group, with the difference being statistically significant (78.8% vs. 66.4%, P <0.05). A total of 38 patients were lost after follow-up matching. Postoperative follow-up was performed to date and, through intention-to-treat analysis, the spontaneous conception rate was found to be higher in the endometriosis group than that in the non-endometriosis group (44.2% vs. 30.1%, P <0.05), while the mean time to spontaneous pregnancy after surgery was shorter in the endometriosis group than that in the non-endometriosis group (46 months vs. 53 months, P <0.05). There was no significant difference in clinical pregnancy rate, live birth rate, miscarriage rate, and ectopic pregnancy rate between the endometriosis group and the non-endometriosis group ( P >0.05)., Conclusion: When infertility caused by proximal tubal obstruction is combined with endometriosis, performing hysteroscopic fallopian tube catheterization combined with laparoscopy contributes to the improvement of reproduction outcomes., (Copyright© by Editorial Board of Journal of Sichuan University (Medical Sciences).)