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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).)

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., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Objectives: To characterize patterns of surgery among pediatric patients during terminal hospitalizations in children's hospitals., Methods: We reviewed patients ≤20 years of age who died among 4 424 886 hospitalizations from January 2013-December 2019 within 49 US children's hospitals in the Pediatric Health Information System database. Surgical procedures, identified by International Classification of Diseases procedure codes, were classified by type and purpose. Descriptive statistics characterized procedures, and hypothesis testing determined if undergoing surgery varied by patient age, race and ethnicity, or the presence of chronic complex conditions (CCCs)., Results: Among 33 693 terminal hospitalizations, the majority (n = 30 440, 90.3%) of children were admitted for nontraumatic causes. Of these children, 15 142 (49.7%) underwent surgery during the hospitalization, with the percentage declining over time (P < .001). When surgical procedures were classified according to likely purpose, the most common were to insert or address hardware or catheters (31%), explore or aid in diagnosis (14%), attempt to rescue patient from mortality (13%), or obtain a biopsy (13%). Specific CCC types were associated with undergoing surgery. Surgery during terminal hospitalization was less likely among Hispanic children (47.8%; P < .001), increasingly less likely as patient age increased, and more so for Black, Asian American, and Hispanic patients compared with white patients (P < .001)., Conclusions: Nearly half of children undergo surgery during their terminal hospitalization, and accordingly, pediatric surgical care is an important aspect of end-of-life care in hospital settings. Differences observed across race and ethnicity categories of patients may reflect different preferences for and access to nonhospital-based palliative, hospice, and end-of-life care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Abstract: Umbilical Vein Recanalization (UVR) may occur in patients with long-standing portal hypertension and liver cirrhosis. This study aimed to investigate the clinical significance of UVR.Medical records of a cohort of patients with cirrhosis (n = 247) who were hospitalized at the Digestive Medicine Center of the Second Affiliated Hospital of Nanchang University from January 2012 to October 2015 were accessed. The UVR diagnosis was made by ultrasound examination and was confirmed by computerized tomography scan.The UVR incidence was 20.2% (50/247) in the cohort. The size of UVR was 9.9 ± 4.7 mm (range: 5-26.5 mm) in diameter. The UVR and non-UVR groups showed no difference in grades of hepatic encephalopathy (P = .496), Child-Pugh classification (P = .401), the incidence of moderately severe ascites (26% vs 26%, P = 1), the esophageal variceal bleeding rate (32% vs 39%, P = .402), or portal vein thrombosis (8% vs 12%, P = .580). However, the incidence of cavernous transformation of the portal vein was statistically different, that there was 0 case in the UVR group and 8 cases in the non-UVR group (P < .05).Our results suggested that UVR had little impact on the clinical manifestations of patients with liver cirrhosis, the significance of UVR as an intervention method requires further studies., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives/hypothesis: To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself., Study Design: Case series with chart review., Methods: We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR., Results: Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank)., Conclusion: In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation., Level of Evidence: 4 Laryngoscope, 131:2141-2147, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Objectives//hypothesis: To characterize long-term outcomes in pediatric patients requiring tracheotomy in the first year of life., Study Design: Retrospective case series., Methods: A retrospective longitudinal registry of tracheostomy patients was queried for patients who underwent tracheotomy from birth to 11 months. Primary outcomes were decannulation and survival. Secondary outcomes included neurocognitive quality of life assessed with the PedsQL Family Impact Module (scored from worst to best, 0 to 100 points)., Results: The study included 337 children. Thirty (8.90%) were neonates and 307 (91.10%) were infants. The population was 56.08% male (n = 189), and the racial and ethnicity composition were equally distributed (29.97% White, 31.45% Black, and 31.16% Hispanic). Significant differences between neonates and postneonates included birth weight in grams (2,731.40 vs. 1,950.44, P < .05), extreme prematurity (13.33% vs. 38.88%, P = .01), upper airway obstruction (80.00% vs. 42.67%, P < .05), and the need for mechanical ventilation (40.00% vs. 83.71%, P < .05). Despite these differences, long-term outcomes were similar: decannulation (X 2  = 2.19, P = .14), death (X 2  = 2.63, P = .11), and neurocognitive quality of life (X 2  = 2.63, P = .27). Having a child with a tracheostomy caused the most problems with being physically tired (mean = 75.32 ± 3.90), emotional frustration (mean = 77.31 ± 5.05), and worry (mean standard deviation = 74.23 ± 6.48)., Conclusion: There were demographic differences between neonatal and infantile tracheostomy patients, but they did not affect long-term outcomes. The presence of a tracheostomy caused a significant impact on a family's quality of life., Level of Evidence: 3 Laryngoscope, 131:2115-2120, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Although literature is sparse, there are guidelines regarding optimal placement technique for peritoneal dialysis (PD) catheters in the pediatric population. Through this study, we sought to identify commonly used techniques among pediatric surgeons and identify areas for future work., Materials and Methods: A 16-question anonymous survey was emailed to American Pediatric Surgery Association members in September 2018 regarding routine practices for PD catheter placement. Descriptive statistics and Fisher's exact test were used for analysis., Results: In all, there were 221 respondents, 6.8% of whom did not place PD catheters in their practice. Of the remaining 206, the majority have been in practice >15 y. PD catheter placement during fellowship training varied widely, with 6.5% reporting no fellowship experience to 6% reporting >25 placed during fellowship. Almost half (48%) reported placing catheters via laparoscopic approach (versus open or combined approach). Most (62%) respondents reported an annual practice volume of 1-5 catheters, with only 11% placing >10 per year. Exit-site sutures were placed "always" by 33% of participants and "never" by 49% of participants. There was no association between years in practice or fellowship experience and exit-site suture placement. However, there was a trend for "never" placement (72%) with more recent graduates. Omentectomy was performed by 91% of respondents, whereas 8.3% reported never performing omentectomy/omentopexy. Similarly, there was no association between practice and fellowship experience and omentectomy. In the setting of abdominal stoma, 96% reported placing the exit site on the opposite side of the abdomen. Fibrin glue was used along the tunnel by 21% of participants, ranging from "always" to "sometimes", whereas 79% "never" used it., Conclusions: Fellowship, posttraining experience, and techniques in PD catheter placement vary widely among American Pediatric Surgery Association member respondents. Despite guidelines, practices differ among providers without an association between the number of cases performed in fellowship and postfellowship volume., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Percutaneous insertion of a peritoneal dialysis catheter (PDc) is an alternative to open surgical techniques, and the anatomical characteristics of the abdominal wall may predict PDc dysfunction. We evaluated the role of rectus abdominis muscle (RAM) thickness as a predictor of PDc dysfunction., Materials and Methods: A prospective cohort of emergency-start PD patients (EmPD) who had their first percutaneous PDc insertion were included. PDc failure was defined as the removal of a PDc due to mechanical failure within the first 30 PD fluid exchanges. Clinical variables were recorded. The skin to parietal peritoneum depth and RAM thickness were determined by abdominal ultrasound. Univariate and multivariate logistic regression models were developed to test associations between clinical parameters and PDc dysfunction., Results: Over 6 months, 119 patients underwent PDc insertion; 73 (61.3%) were males, with a mean age of 46.0 ± 17.8 years. The mean skin-to-peritoneum depth was 2.5 ± 1.0 cm, the RAM thickness was 0.91 ± 0.3 cm, and catheter implantation was successful in 116 (97.4%) patients. Insertion failed in 3 (2.5%) cases, and 30 (25.8%) patients presented with catheter dysfunction. Univariate analysis indicated that RAM thickness ≥ 1.0 cm, skin-to-peritoneum depth > 2.88 cm, abdominal waist > 92.5 cm, and skin-to-RAM fascia distance > 2.3 cm were associated with PDc dysfunction; in multivariate logistic regression analysis, only greater RAM thickness remained a significant predictor (OR 1.6, 95% CI 1.38 - 1.88, p < 0.001)., Conclusion: In EmPD patients, RAM thickness is associated with PDc dysfunction and could aid in identifying patients at risk for PDc dysfunction in emergency settings. Additional adequately powered studies are needed to confirm our findings.

Objective: To characterize afferent nipple valve obstruction in Kock diversions presenting with hydronephrosis and discuss appropriate work-up and management., Methods: We retrospectively reviewed 7 cases of afferent nipple valve obstruction., Results: The median time from diversion creation to afferent nipple valve intervention was 17-years. Presentations included febrile-UTIs, worsening renal function and hydronephrosis. All patients underwent upper tract imaging confirming bilateral hydronephrosis or hydronephrosis of a solitary kidney followed by nephrostomy tube insertion to drain the obstructed kidney(s). On nephrostogram assessment afferent nipple valve obstruction was confirmed by a lack of contrast passing through the valve. In 4 of these patients the afferent valve could not be cannulated while in one patient endoscopic retrograde balloon dilation was performed but failed after 12-months. One patient had successful antegrade balloon dilation (four-years follow-up). In five patients and the one patient who failed retrograde balloon dilation open surgical repair of the afferent nipple valve was successful (median follow-up time 5-years)., Conclusion: It is essential to consider afferent nipple valve obstruction in a patient with a Kock diversion presenting with bilateral hydronephrosis/hydronephrosis of a solitary kidney, even after many years following the original diversion. Appropriate work-up consists of upper tract imaging, endoscopy and retrograde studies or nephrostomy insertion with nephrostogram. Management options include endoscopic retrograde or antegrade balloon dilation or valve incision. Failing that, surgical repair may be successful with long-term upper tract preservation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: To analyze the efficacy and safety between bipolar transurethral enucleation of the prostate (BipoLEP) and bipolar transurethral resection of the prostate (B-TURP).One hundred twenty eight patients with benign prostatic hyperplasia were recruited and divided into group 1 (BipoLEP group, n = 72) and group 2 (B-TURP group, n = 56). The study period was from October 2016 to February 2019. All data parameters were prospectively collected and analyzed.In these 2 groups, there were no significant differences of the mean ages (71.88 ± 6.54 years vs 73.05 ± 7.05 years, P = .407), prostate volumes (99.14 ± 9.5 mL vs 95.08 ± 10.93 mL, P = .302) and the mean operation times (93.7 ± 27.5 minutes vs 89.8 ± 22.4 minutes, P = .065). In BipoLEP group, it had more prostate tissue resected (64.2 ± 22.1 g vs 52.7 ± 28.6 g, P = .018), less duration of continuous bladder irrigation (20.7 ± 6.5 hours vs 29.6 ± 8.3 hours, P = .044), shorter catheterization time (4.3 ± 1.5 days vs 5.6 ± 2.1 days, P = .032), shorter hospitalization stay (5.2 ± 1.4 days vs 6.5 ± 1.9 days, P = .031) and less complications (3 cases vs 9 cases, P = .021). There were significant improvements in 3-month postoperative parameters, including: post void residual urine, maximum flow rate, International Prostatic Symptoms Scale, and quality of life in each group (p < 0.01). However, there were no significant differences of preoperative and 3-month postoperative parameters, including: post void residual urine, maximum flow rate, International Prostatic Symptoms Scale, and quality of life between these 2 groups (P > .05).BipoLEP can produce a more radical prostatic resection with better safety profile and faster postoperative recovery. It may become a more favorable surgical alternative to the B-TURP, especially for the prostate larger than 80 g., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019., Methods: A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time., Results: There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups., Conclusions: We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Adrenal vein sampling (AVS) is the preferred method for subtyping patients with primary aldosteronism, while the procedure is technically challenging. This study evaluated the feasibility and effectiveness of a single-catheter approach for AVS., Methods: A retrospective analysis of 106 consecutive patients who underwent AVS was performed to determine the procedural success and complication rates. Bilateral AVS procedures were performed using a single 5-Fr Tiger catheter with repeated manual reshaping., Results: We successfully advanced the catheter into the bilateral adrenal veins of all patients and reached a 90.6% procedural success rate of AVS. The procedural period was 33.0 ± 8.2 min, the fluoroscopy period was 5.8 ± 1.7 min, and the diagnostic contrast used was 17.3 ± 5.5 ml. Only one patient (0.9%) had a hematoma at the femoral puncture site. No other complications were observed. The operation period gradually shortened as the cumulative number of operations increased. The number of procedures required to overcome the learning curve was about 33 cases., Conclusions: The single-catheter approach is feasible and effective for AVS. Moreover, this approach required a relatively short learning curve for an inexperienced trainee.

Background: Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution., Methods: The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed., Results: Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d., Conclusions: Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To describe the practice of high-flow nasal cannula (HFNC) use in the pediatric ward setting across North America., Methods: A survey was distributed through the Pediatric Research in Inpatient Settings Network, which represents 114 hospital sites. Questions included indication for HFNC use, flow and oxygen parameters, guideline availability, and use of outcomes measures., Results: There was a response rate of 68% to the survey from sites representing all regions from the United States. Thirty-seven sites (48%) used HFNC in the pediatric ward setting. All 37 sites used HFNC for patients with bronchiolitis. All children's hospital sites providing HFNC on the wards had an on-site ICU, compared with only 60% of non-children's hospital sites ( P = .003). Seventy-six percent of sites used local protocols, including parameters for patient assessment, initiation, weaning, and feeding practices., Conclusions: HFNC is used outside the ICU in nearly 50% of responding hospitals, with variation related to flow rate, feeding, and protocol use. HFNC is used for management of acute respiratory distress due to bronchiolitis, asthma, and pneumonia. Study findings suggest that HFNC is often used by pediatric hospitalists, but its use across North American hospitals remains variable and based on local consensus., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Gastrostomy tubes (G-tubes) are frequently used in children for feeding and nutrition. Complications related to G-tubes (and G-buttons) in children represent a common presentation to the emergency department (ED). G-tube replacement is usually performed by pediatric emergency medicine physicians. Misplacement may lead to tract disruption, perforation, fistula tract formation, or feeding into the peritoneum. Contrast-enhanced radiographs are traditionally used for confirmation. In addition to a longer length-of-stay, repeat ED visits result in repeated radiation exposure. The use of point-of-care ultrasound (POCUS) instead of radiography avoids this exposure to ionizing radiation. Here, we describe three patients who presented with G-tube complications in whom POCUS alone performed by pediatricians was used for confirmation of the tubes' replacement. Two children presented to the ED with G-tube dislodgement, and one child presented with a ruptured balloon. In all three cases, a new G-tube was replaced at the bedside using POCUS guidance without the need for further radiographic studies. There were no known ED or clinic returns for G-tube complaints over the next 30 days. This is the first report of pediatricians using POCUS to guide and confirm G-tube replacement in children. The success of these cases suggests the technique's feasibility. Future prospective studies are needed to evaluate the learning curves, diagnostic accuracy, ED length-of-stay, and use of confirmatory imaging.

Background: Microdochectomy is the gold-standard for definitive diagnosis for pathological nipple discharge (PND); however, problem of over-treating exists since majority of PND are self-limiting and due to benign causes. Ductoscopy may assist diagnosis, and triage patients for intervention or expectant management. This study aimed to evaluate if ductoscopy could reduce unnecessary microdochectomy but not compromising the diagnosis of malignancy., Method: A multicenter, retrospective study was conducted in consecutive patients of PND without a suspected malignancy on routine diagnostic evaluation. Ductoscopy was performed with attempts to remove intraductal lesions if they were found. Microdochectomy was carried out if there were positive intraductal lesions, but failed endoscopic extraction, or failed ductoscopy and persistent PND. Efficacy of ductoscopy was determined by cannulation success rate, number of avoided surgery and number of missed malignancy., Results: In a 3-year period between 2016 and 2018, a total of 223 ductoscopy were performed and 94.2% had successful cannulation. Within such, 59.5% (N = 125) had intraductal mass identified, and 82 microdochectomy were carried out. The final histology showed 15 malignancy, making the overall malignancy rate 6.7%. Ductoscopy successful and negative patients (N = 85, 37.8%) were triaged for surveillance and the malignancy rate is 0% in a median follow-up of 2 years; hence, microdochectomy was avoided., Conclusion: PND with non-suspicious conventional imaging and negative ductoscopy have rare malignancy rate which makes subsequent microdochectomy unnecessary. However, intraductal mass in ductoscopy is a predictor for malignancy so definitive histology diagnosis is mandatory.

Background and Aim: Many post-ERCP pancreatitis (PEP) risk factors, including pancreatic duct cannulation, have been identified; however, whether the number of repeated and unintentional wire placements (WPs) in the pancreatic duct during wire-guided cannulation affects PEP risk is unknown. We aimed to identify the effects of repeated WP in the pancreatic duct and other potential risk factors on PEP incidence., Methods: We retrospectively analyzed 877 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP). We examined potential patient-related and procedure-related risk factors, and PEP incidence by univariable and multivariable logistic regression analyses., Results: Thirty-four patients (3.9%) had PEP. Univariable analysis revealed younger age, malignant common bile duct or ampulla of Vater stricture, two or more episodes of WPs in the pancreatic duct, and metal biliary stent as risk factors for PEP. Following multivariable analysis, two or more episodes of WPs in the pancreatic duct and metal biliary stent remained in the final model. PEP did not increase significantly in case of a one episode of WP (4.0%) compared with no episode of WP in the pancreatic duct (2.7%). However, patients with two episodes of WPs had 8.0% incidence and three or more episodes of WPs had 14.3%., Conclusions: A WP in the pancreatic duct and a metal biliary stent were associated with increased PEP incidence in patients undergoing ERCP. As for the pancreatic duct wire cannulation, two or more WPs considerably increased PEP incidence. This suggests that preventive measures or alternative procedures might be considered in patients with such cases during and after ERCP., (© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Contrast-induced acute kidney injury is a common complication in patients undergoing invasive procedures and is associated with increased mortality and morbidity. There is no effective approach to the management of this complication, and prevention remains of paramount importance. The 3 pillars of prevention are identification of high-risk patients, appropriate hydration before and after contrast exposure, eGFR-based contrast dosing and use of ultra-low contrast volume in high-risk patients. Most evidence supporting these practices is derived from patients undergoing coronary angiography or percutaneous coronary intervention but these basic principles can be applied to most patients undergoing contrast-based procedures in the catheterization laboratory., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Introduction and widespread use of cricotracheal resection and anastomosis (CTRA) as routine treatment for high-grade benign laryngotracheal stenosis (LTS) led to the need for a new classification system that could accurately predict surgical outcomes by integrating crucial stenosis and patient-related information. In 2015, the European Laryngological Society (ELS) proposed a new classification for benign LTS. We retrospectively tested it in adults treated at three referral centers to assess its reliability in predicting surgical outcomes., Study Design: Retrospective cohort study., Methods: We included 166 adults treated by open tracheal resection and anastomosis (TRA) and CTRA procedures, restaged according to the ELS classification evaluating grade of stenosis (I-IV, Myer-Cotton), number of subsites involved, and presence of systemic comorbidities. We correlated these parameters with decannulation, number of retreatments, and complications., Results: Final decannulation was predicted by a proposed ELS score ≥ IIIb, history of previous treatment, and length of resection (P < .05). Decannulation was achieved in 99% of patients without and in 88% of patients with surgical complications (P < .01). The incidence of surgical complications was related to the proposed ELS score (P < .01); an ELS score < IIIb showed a lower complication rate compared to patients with a ≥ IIIb score (32.8% vs. 57.7%, P < .01). Additional treatment was required in 73 (44%) patients (mean = 2.7 ± 2.2, range = 1-11). ELS score ≥ IIIb, length of resection, and occurrence of surgical complications predicted the number of such treatments (P < .05, P < .05, and P < .001, respectively)., Conclusions: ELS classification of benign LTS is able to accurately predict success in adult TRA/CTRA procedures and may be helpful in choice of therapy and patient counseling., Level of Evidence: 2b Laryngoscope, 130:1640-1645, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Identify predictors of decannulation failure after cricotracheal resection (CTR) and thyrotracheal anastomosis (TTA) in patients with subglottic stenosis (SGS)., Study Design: Retrospective cohort study., Methods: Charts of patients undergoing CTR and TTA for SGS at the University Health Network, Toronto, Ontario, Canada between 1988 and 2017 were reviewed. Patient, pathology, treatment, and outcome data were collected. The end points for statistical analysis were development of restenosis and permanent tracheostomy., Results: One hundred fourteen patients (n = 114) were eligible for inclusion in this review. The mean age at primary resection was 46.9 years, 95 (83%) were females, and 19 (17%) were males. The rate of restenosis and permanent tracheostomy was 13% and 5%, respectively. Sixty-two patients (54%) underwent a CTR and TTA, and 52 patients (46%) underwent a CTR, laryngofissure, and TTA. Traumatic stenosis (odds ratio [OR] = 10.3, P = .017), longer T-tube duration (OR = 1.2, P = .011), combined glottic/subglottic stenosis (OR = 10.47, P = .010), start of the stenosis at the vocal cords (OR = 6.6, P = .029), postoperative minor complications (OR = 13.6, P = .028), and need for repeat surgery (OR = 44.1, P < .001) were associated with an increased risk of requiring permanent tracheostomy., Conclusions: CTR and TTA are excellent surgical approaches for adult patients with subglottic stenosis. In this study, 5% of patients required permanent tracheostomy. Factors predicting treatment failure include traumatic stenosis, longer T-tube duration, combined glottic/subglottic stenosis, start of stenosis at the level of vocal cords, postoperative minor complications, and need for repeat surgery., Level of Evidence: 4 Laryngoscope, 130:1634-1639, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Patient selection and cannulation arguably represent the key steps for the successful implementation of extracorporeal membrane oxygenation (ECMO) support. Cannulation is traditionally performed in the operating room or the catheterization laboratory for a number of reasons, including physician preference and access to real-time imaging, with the goal of minimizing complications and ensuring appropriate cannula positioning. Nonetheless, the patients' critical and unstable conditions often require emergent initiation of ECMO and preclude the safe transport of the patient to a procedural suite., Aims: Therefore, with the objective of avoiding delay with the initiation of therapy and reducing the hazard of transport, we implemented a protocol for bedside ECMO cannulation., Matherial and Methods: A total of 89 patients required ECMO support at Hennepin County Medical Center between March 2015 and December 2019. Twenty-eight (31%) required veno-venous support and were all cannulated at the bedside. Overall survival was 71% with no morbidity or mortality related to the cannulation procedure., Conclusion: In the current pandemic, the strategy of veno-venous bedside cannulation may have additional benefits for the care of patients with refractory acute respiratory distress syndrome due to coronavirus-disease-2019, decreasing the risk of exposure of health care worker or other patients to the novel severe acute respiratory syndrome coronavirus-2 occurring during patient transport, preparation, or during disinfection of the procedural suite and the transportation pathway after ECMO cannulation., (© 2020 Wiley Periodicals LLC.)

Introduction: Catheter-associated infections are the main cause of nosocomial bacteremia. The main objective of this study was to demonstrate a possible decrease in CLABSI rates in perioperative environment after the implementation of a bundle of measures. Secondary objective was to determine which factors were associated with an increased risk of CLABSI, after the implementation of the bundle., Methods: Insertion bundle consisted of: subclavian vein as access of choice, disinfection with alcoholic 2% chlorhexidine, central-line full body drapes, sterile ultrasound probe-cable covers and insertion check-list. Cumulative Incidence (CI) and Incidence Density Rate (IR) of CLABSIs were compared before and after the intervention. Associations between patient or CVC characteristic and CLABSI were summarized with odds ratios and 95% confidence interval, obtained from multiple logistic regression, adjusting for age, sex, comorbidities and days with CVC., Results: Before implementing the bundle, from January to November 2016, CI of CLABSI was 5.05% and IR was 5.17 ‰. In the same period of 2018, CI of CLABSI was 2.28% and IR was 2.27 ‰, which means a reduction of 54.8% in CI (P=.072) and of 56% in IR (P=.068) In multivariable analyses, replacement of CVC was associated with a higher risk of CLABSI (OR 11.01, 95%CI 2.03-59.60, P=.005), as well as 2 or more catheterizations (OR 10.05, 95%CI 1.77-57.16, P=.009), and parenteral nutrition (OR 23.37, 95%CI 4.37-124.91, P<.001)., Conclusions: CLABSI rates decreased after the implementation of the insertion bundle. CVC replacement, 2 or more catheterizations and parenteral nutrition were associated with CLABSI after bundle implementation., (Copyright © 2020 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Importance: Chronic rhinosinusitis is among the most common and costly conditions treated by physicians. After failure of medical treatment, surgical intervention in the form of endoscopic sinus surgery is traditionally offered. Balloon catheter dilation (BCD) has become a less-invasive alternative with increasing popularity among otolaryngologists., Objective: To evaluate the most recent BCD data in the Medicare population, with a specific focus on the percentage of procedures performed by surgeons who perform high volumes of this procedure, their reimbursements, and their national geographic distributions., Design, Setting, and Participants: This retrospective review included data from 2011 through 2017 from Medicare Part B National Summary Data Files and Medicare Provider Utilization and Payment Data. Patients with procedures including Current Procedural Terminology codes 31295 (maxillary sinus dilation), 31296 (frontal sinus dilation), and 31297 (sphenoid sinus dilation) were included., Exposures: Balloon catheter dilation of the paranasal sinuses., Main Outcomes and Measures: Total and mean reimbursements over time to physicians for BCDs, as well as the percentage of BCDs performed by and reimbursed to ear, nose, and throat (ENT) surgeons who perform high volumes of BCDs (>10 procedures) in a given year., Results: The total number of BCDs rose from 7496 in 2011 to 43 936 in 2017 (a 486% increase). The overall reimbursement increased from $11 773 049 in 2011 to $63 927 591 in 2017 (a 433% increase). From 2012 to 2016, ENT surgeons who performed high volumes of the procedures rose from 101 to 382 surgeons (a 270% increase). In 2016, 25 214 of 41 960 BCDs (60.1%) were performed by ENT surgeons performing high volumes of the procedure, compared with 5603 of 13 109 procedures (42.7%) in 2012. In a line of best fit, at the 75th percentile of procedure volume, there was an increase of 4.2 BCDs in the median number of procedures done per physician per year, compared with an increase of 1.5 BCD procedures per physician per year in the line of best fit for the 50th percentile., Conclusions and Relevance: Balloon catheter dilation continues to increase in popularity among otolaryngologists treating chronic rhinosinusitis. Most BCDs are performed by ENT surgeons who perform high volumes of the procedure.

Objective: To compare the efficiency of double balloon catheters with that of intravaginal prostaglandins alone for the labor induction of unfavourable cervices in term nulliparous women., Methods: 50 nulliparous patients induced with a double balloon device were compared to 53 patients induced using intravaginal prostaglandins alone. The main outcome measure was labour induction failure, characterized by the absence of active labour. The secondary outcome measures were the improvement of the Bishop score, the average durations of ripening and labour induction, the average time to active labour, the need for a second cervical ripening agent, the total dose of prostaglandins used in each group, the use of oxytocins, as well as the rates of vaginal delivery, abnormal foetal heart rate during labour and perinatal maternal infection., Results: The rate of failed labour induction was of 28% in the double balloon group, against 13% in the prostaglandins group. The average durations of ripening and labour induction, as well as the time to active labour were higher in the double balloon group. The improvement of the Bishop score was significantly lower in the double balloon group., Discussion and Conclusion: In our study, the use of double balloon catheters does not seem to reduce the rate of failed labour induction in nulliparous women when compared to the use of prostaglandins alone. In addition, it could lengthen the labour induction duration, although more powerful studies would be necessary not to recommend its use for nulliparous women., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Background: In the intensive care unit, invasive devices can be accidentally removed by the patient or by the operators, increasing workload, staff stress level and hospitalisation costs., Objective: to know the incidence of accidental removal of devices in critical patients, to identify their cause, when they occur and if they are repositioned., Methods: Retrospective observational study carried out in an academic, tertiary-level critical care department composed of three intensive care units. All adult patients recovered between 2011 and 2018 were enrolled. We calculated rates per 1000 device-years., Results: In the study period 10514 patients (194372 device-days) were admitted to the intensive care units and the number of reported accidental removal of devices was 451, corresponding to a rate of 2.3 episodes per 1000 device-days (95% confidence interval: 2.1-2-5). The overall rates of accidental removals were as follows: gastric tubes 10.2 (n = 270), intracranial devices 3.9 (n = 9), endotracheal tubes 2.4 (n = 27), central venous catheters and arterial catheters 1.5 (n = 92), peripheral intravenous catheters 1.2 (n = 25), surgical drains 0.5 (n = 15), urinary catheters 0.4 (n = 11), Extra Corporeal Membrane Oxygenation cannulas 0.4 (n = 1), tracheostomy cannulas 0.1 (n = 1)., Conclusion: Compared to the literature, this study shows fewer incidents of accidental removal of devices. The number of accidental removals could be an indicator of the quality and safety of the care., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Difficult biliary cannulation is a risk factor for post-ERCP pancreatitis. In these cases, precutting is the most used technique., Objective: To demonstrate that precut fistulotomy is safe and effective., Materials and Methods: Data from May 2016 to May 2018 were reviewed. Difficult cannulation was defined as: impacted lithiasis, inadvertent cannulation of the pancreatic duct on three occasions and inability to achieve deep biliary cannulation in 3 minutes. The outcome measures were successful biliary cannulation and post-ERCP Pancreatitis., Results: Precut fistulotomy was performed in 96 cases (67 women, 29 men). The success rate of biliary cannulation was 95.8% (92/96). Eighty patients had risk factors for post-ERCP pancreatitis: 29 had 1 risk factor, 26 had 2 risk factors, 19 had 3 risk factors, and 6 had four risk factors. Ampullary risk factors of difficult cannulation: impacted stone in the papilla: 9 cases, papilla bulging: 10 cases, lower location of the hole papillary 38 cases, partial location of the papillary pore 23 and papillary orifice stenosis 16 cases. Ten patients had periampullary diverticulum, 7 patients had normal bile duct. None of the patients experienced Pancreatitis. Three patients had early bleeding, one patient had late bleeding. One patient (2%) had a fever and was hospitalized., Conclusions: In cases of difficult biliary cannulation, the precut fistulotomy is safe and effective.

Objective: Balloon sinuplasty (BS) is a surgical management option in the treatment of chronic rhinosinusitis. The purpose of this study was to examine BS utilization among children with a national database., Study Design: Retrospective review., Setting: National pediatric database., Subjects and Methods: All cases of children aged ≤18 years who underwent BS or traditional endoscopic sinus surgery (ESS) 5 years before and after the introduction of BS billing codes were studied with the Pediatric Health Information System database. We evaluated overall trends, demographics, performing physicians, readmissions, and cost data., Results: A total of 14,079 patients met inclusion criteria: 13,555 underwent traditional ESS and 524 had a BS procedure. There was no significant increase in BS rates between 2011 and 2016. BS was more commonly performed among younger children than ESS (median age [interquartile range], 6 years [4-10] vs 9 years [6-13]; P < .001). There were 23 (4.4%) readmissions within 30 days in the balloon cohort versus 474 (3.5%) in the ESS cohort. The median cost of balloon maxillary antrostomy (US $6560 [$5420-$8250]) was higher than that of traditional maxillary antrostomy (US $5630 [$4130-$7700], P < .001). Physicians who performed BS had a larger volume of ESS procedures when compared with those who did not perform BS., Conclusion: Rates of BS performance in the pediatric population have not increased over time. Results showed no difference in readmission rates between BS and ESS. BS was associated with higher costs as compared with ESS. The role of BS in the pediatric chronic rhinosinusitis population remains unclear.

Objectives: To investigate the impact of electronic medical record (EMR) on improvement of healthcare parameters in a thalassaemia centre located at the Fujairah Hospital, Fujairah, UAE., Materials and Methods: A hospital-wide EMR system (Wareed) was implemented across the hospitals in the Ministry of Health and Prevention, UAE, including two major thalassaemia centres. We aim to investigate the impact of this intervention across a number of healthcare parameters over two quarters (before and after implementation of the system)., Results: Since preimplementation data were not available for one facility, comparisons were made between parameters in two quarters in Fujairah hospital only. After introduction of Wareed, we found an increase in number of appointments (12%) (p=0.00), decrease in the number of appointment cancellations due to non-availability of blood products (p=0.02), reduction in the time to cannulation (p=0.00), decrease in number of physician days (p=0.295) among other parameters observed., Discussion: Research shows that EMR systems have a positive impact on reduction in medical expenditure, improvement of healthcare quality and overall health outcomes. thalassaemia is highly prevalent in the Middle Eastern countries and drains the medical, social and financial resources of these nations. Our study is an attempt to create an insight into the difference in healthcare parameters before and after introduction of the system., Conclusion: Being the first of a kind in this region, our study created favourable evidence that introduction of an EMR has an overall positive impact on the healthcare delivery system for thalassaemia care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients with acute kidney injury needing prolonged renal replacement therapy (AKI-RRT) may benefit from a structured care process in form of an AKI transitional care program (ATCP), to facilitate RRT weaning and recovery., Methods: We examined outcomes following ATCP implementation in adults with AKI-RRT from a tertiary institution (versus pre-ATCP controls), including mortality, cumulative hospital days, and renal function over one year; RRT and haemodialysis catheter days in initial 90 days., Results: We studied 89 patients with age 62 ( ± 15) years. 47% had septic AKI, 20% cardiorenal syndrome, and 29% had baseline eGFR < 30 mL/min/1.73 m 2 . Comparing 45 ATCP patients with 44 controls: 64% and 45% received continuous RRT (CRRT) (p = 0.07), with comparable rates of heart failure (24% versus 25%), ICU care (67% versus 70%), RRT successfully weaned (71% versus 75%), respectively; corresponding mortality rates were 24% and 32% (p = 0.44), hospital days of 205 (197-213) and 223 (215-232) per 1000 patient-days alive over one year (p = 0.002); with comparable RRT and catheter days. Serial serum creatinine in months following RRT cessation were comparable between either survivor-group. On multivariate analysis, heart failure or having received CRRT independently predicted mortality and longer hospital days (p < 0.05); ATCP was independently associated with reduced hospital days (p < 0.001). 17 ATCP patients and 14 controls required outpatient RRT weaning, with catheter days of 607 (568-648) and 683 (638-731) per 1000 patient-days in initial 90 days, respectively (p = 0.01)., Conclusions: Implementing a structured care pathway in patients with AKI-RRT may help reduce hospitalization, and reduce haemodialysis catheter days in the subgroup for outpatient RRT weaning.

Catheter-associated asymptomatic bacteriuria (CAABU) is frequent in intensive care units (ICUs) and contributes to the routine use of antibiotics and to antibiotic-resistant infections. While nurses are responsible for the implementation of CAABU-prevention guidelines, variability in how individual nurses contribute to CAABU-free rates in ICUs has not been previously explored. This study's objective was to examine the variability in CAABU-free outcomes of individual ICU nurses. This observational cross-sectional study used shift-level nurse-patient data from the electronic health records from two ICUs in a tertiary medical center in the US between July 2015 and June 2016. We included all adult (18+) catheterized patients with no prior CAABU during the hospital encounter and nurses who provided their care. The CAABU-free outcome was defined as a 0/1 indicator identifying shifts where a previously CAABU-free patient remained CAABU-free (absence of a confirmed urine sample) 24-48 hours following end of shift. The analytical approach used Value-Added Modeling and a split-sample design to estimate and validate nurse-level CAABU-free rates while adjusting for patient characteristics, shift, and ICU type. The sample included 94 nurses, 2,150 patients with 256 confirmed CAABU cases, and 21,729 patient shifts. Patients were 55% male, average age was 60 years. CAABU-free rates of individual nurses varied between 94 and 100 per 100 shifts (Wald test: 227.88, P<0.001) and were robust in cross-validation analyses (correlation coefficient: 0.66, P<0.001). Learning and disseminating effective CAABU-avoidance strategies from top-performers throughout the nursing teams could improve quality of care in ICUs., Competing Interests: The authors have declared that no competing interests exist.

Background: Prospective studies about endoscopic retrograde cholangio-pancreatography (ERCP) in a community setting are rare., Aim: To assess success and complication rates of routinely-performed ERCP in a regional setting, and the priority quality indicators for ERCP practice., Methods: Prospective region wide observational study on consecutive patients undergoing ERCP during a 6-month period. A centralized online ERCP questionnaire was built and used for data storage. Primary quality indicators provided by the American Society of Gastrointestinal Endoscopy (ASGE) were considered., Results: 38 endoscopists from 18 centers performed a total of 2388 ERCP. The most common indication for ERCP was choledocholitiasis (54.8%) followed by malignant jaundice (22.6%). Cannulation of the desired duct was obtained in 2293 cases (96%) and ERCP was successful in 2176 cases (91.1%). Success and ERCP difficulty were significantly related to the experience of the operator (p = 0.001 and p < 0.001, respectively). ERCP difficulty was also significantly related to volume centers (p < 0.01). The overall complication rate was 8.4%: post-ERCP pancreatitis (PEP) occurred in 4.1% of procedures, bleeding in 2.9%, infection in 0.8%, perforation in 0.4%. Mortality rate was 0.4%. All the ASGE priority quality indicators for ERCP were confirmed., Conclusions: The procedural questionnaire proved to be an important tool to assess and verify the quality of routinely-performed ERCP performance in a community setting., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Our objective was to assess whether clusters of centers with similar peritoneal dialysis (PD) catheter related practices were associated with differences in the risk of technique failure., Methods: Patients on incident PD in French centers contributing to the French Language PD Registry from 2012 to 2016 were included in a retrospective analysis of prospectively collected data. Centers with similar catheter cares practices were gathered in clusters in a hierarchical analysis. Clusters of centers associated with technique failure were evaluated using Cox and Fine and Gray models. A mixed effect Cox model was used to assess the influence of a center effect, as explained by the clusters., Results: Data from 2727 catheters placed in 64 centers in France were analyzed. Five clusters of centers were identified. After adjustment for patient-level characteristics, the fourth cluster was associated with a lower risk of technique failure (cause specific-HR 0.70, 95%CI 0.54-0.90. The variance of the center effect decreased by 5% after adjusting for patient characteristics and by 26% after adjusting for patient characteristics and clusters of centers in the mixed effect Cox model. Favorable outcomes were observed in clusters with a greater proportion of community hospitals, where catheters were placed via open surgery, first dressing done 6 to 15 days after catheter placement, and local prophylactic antibiotics was applied on exit-site., Conclusion: Several patterns of PD catheter related practices have been identified in France, associated with differences in the risk of technique failure. Combinations of favorable practices are suggested in this study., Competing Interests: The authors have declared that no competing interests exist.

Background: Sepsis is a major cause of child mortality and morbidity. To enhance outcomes, children with severe sepsis or septic shock often require escalated care for organ support, sometimes necessitating interhospital transfer. The association between transfer admission for the care of pediatric severe sepsis or septic shock and in-hospital patient survival and resource use is poorly understood., Methods: Retrospective study of children 0-20 years old hospitalized for severe sepsis or septic shock, using the 2012 Kids' Inpatient Database. After descriptive and bivariate analysis, multivariate regression methods assessed the independent relationship between transfer status and outcomes of in-hospital mortality, duration of hospitalization, and hospital charges, after adjustment for potential confounders including illness severity., Results: Of an estimated 11,922 hospitalizations (with transfer information) for pediatric severe sepsis and septic shock nationally in 2012, 25% were transferred, most often to urban teaching hospitals. Compared to non-transferred children, transferred children were younger, and had a higher frequency of extreme illness severity (84% vs. 75%, p < .01), and of multiple organ dysfunction (32% vs. 24%, p < .01). They also had higher use of invasive medical devices including arterial catheters, invasive mechanical ventilation, and central venous catheters; and of specialized technology, including renal replacement therapy (6.2% vs. 4.6%, p < .01) and extracorporeal membrane oxygenation (5.7% vs. 1.8%, p < .01). Transferred children had longer hospitalization and accrued higher charges than non-transferred children (p < .01). Crude mortality was higher among transferred than non-transferred children (21.4% vs.15.0%, p < .01), a difference no longer statistically significant after multivariate adjustment for potential confounders (Odds Ratio:1.04, 95% Confidence interval: 0.88-1.24). Similarly, adjusted length of hospital stay and hospital charges were not statistically different by transfer status., Conclusion: One in four children with severe sepsis or septic shock required interhospital transfer for specialized care associated with greater use of invasive medical devices and specialized technology. Despite higher crude mortality and resource consumption among transferred children, adjusted mortality and resource use did not differ by transfer status. Further research should identify quality-of-care factors at the receiving hospitals that influence clinical outcomes and resource use.

Background: Peritoneal dialysis (PD) catheter obstruction often leads to surgical revision and may require transition to hemodialysis. The purpose of this study was to evaluate risk factors (including omentectomy) associated with early PD catheter obstruction (<6 months from insertion)., Methods: A retrospective review of all PD catheters inserted at a single high-volume referral center (2005-2018) was performed. 185 PD catheters were placed in 123 patients (45 female). Potential risk factors for early catheter obstruction were analyzed using Chi-square analysis (p < 0.05 considered statistically significant)., Results: Median age at catheter insertion was 3.42 years (3 days-39 years). Early catheter obstruction occurred in 42 cases (22.7%). Median time to early obstruction was 24 days (3-118 days). Previous PD catheter placement (p = 0.9) or prior abdominal surgery (p = 0.89) was not associated with obstruction. Weight ≥ 10 kg (p = 0.011) and age ≥ 1 year (p = 0.048) were associated with a significantly higher incidence of obstruction. Overall, omentectomy was associated with a trend in reduction of early obstruction in patients with weight ≥ 10 kg (p = 0.08) and significantly in patients ≥1 year (p = 0.028)., Conclusion: Early PD catheter obstruction appears to occur more often in older patients with a higher weight. Concomitant omentectomy seems beneficial at reducing early catheter obstruction events in those patients., Type of Study: Retrospective comparative study., Level of Evidence: III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Men with urinary retention secondary to benign prostatic hyperplasia (BPH) are prone to genitourinary infections. Physicians should be aware of the current antimicrobial susceptibility pattern in this population if empirical treatment is needed. The goal of this study was to evaluate variations in prevalence, composition and antimicrobial susceptibility of bacterial flora in men with indwelling catheters subjected to surgery for BPH in chosen time periods since 1994. Necessary changes in empirical therapy were also assessed., Methods: All patients with indwelling catheters admitted to a single urological center for BPH surgery in the years 1994-1996, 2004-2006, and 2011-2015 were considered. Catheterization times and results of urine cultures from samples collected at admission were evaluated. Susceptibility for selected antimicrobials was compared separately for Gram negative and Gram positive species. For each agent and for their combinations effectiveness of empirical therapy was calculated dividing the number of patients with bacteriuria susceptible to the agents by the total number of patients with bacteriuria., Results: Bacteriuria was present in 70% of 169, 72% of 132, and 69% of 156 men in the respective time periods. The incidence of Gram-positive strains increased from 10 to 37% (P < 0.001). Their susceptibility to amoxicillin/clavulanate was fluctuating (81, 61, 77%; P=NS). No vancomycin-resistant strain was present. Gram-negative flora composition was stable. Their susceptibility decreased to ciprofloxacin (70 to 53%; P = 0.01) and amoxicillin/clavulanate (56 to 37%; P < 0.01) while it increased to gentamycin (64 to 88%; P < 0.001) and co-trimoxazole (14 to 62%; P < 0.001); susceptibility to amikacin remained high (> 85%). Only two cases of resistance to carbapenems in 2004-2006 were found. In vitro effectiveness of amikacin + amoxicillin/clavulanate in empirical therapy was slowly decreasing (87 to 77%; P=NS). Imipenem was found the most effective single agent (90-95%) and its efficacy was even improved by adding vancomycin (97-98%)., Conclusions: Substantial rise in the incidence of Gram-positive species and fluctuations in antimicrobial susceptibility patterns were found. Empirical therapy of genitourinary infection in catheterized men with BPH should now involve antimicrobial agents effective both to Enterococci and Enterobacteriaceae. Periodic monitoring and publishing data on antimicrobial susceptibility for this population is necessary.

Background: Limited reports are available on the role of 4% citrate as a locking solution for temporary dialysis catheters. Hence, the aim of this study is to investigate the role of 4% citrate vs. heparin 5,000 µ/mL as a catheter-locking solution in a randomized controlled trial., Materials and Methods: The trial was conducted in Egypt where the use of non-tunneled temporary catheters is prevalent compared to tunneled long-term catheters. The efficacy of catheter-locking solutions was compared regarding observation of rate of catheter dysfunction, low-flow pump, fever as a sign of central-line blood-stream infection (CLBSI), catheter-site infection, thrombosis, local bleeding, and systemic bleeding in each group of the study., Results: Each group consisted of 105 patients. The number of patients who developed CLBSI in the citrate group was 11 (10.5%) compared to 23 (21.9%) in the heparin group (p < 0.025). The number of patients who developed catheter dysfunction in the citrate group was similar to those in the heparin group. The incidence of catheter-site infection, thrombosis, and local bleeding in the citrate group was similar to that in the heparin group., Conclusion: Citrate 4% lock solution is equally effective as heparin in maintaining catheter patency in dialysis patients. It may have a favorable effect on prevention of catheter-related infection due to its additional antiseptic properties as compared to heparin. Citrate-based locking solutions are a promising alternative to unfractionated heparin as a locking solution for dialysis catheters.
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Introduction: Children with kidney failure requiring PD catheter placement often require additional intraabdominal surgery. However, the risk of complication related to simultaneous abdominal surgery at time of catheter placement is unknown., Methods: Patients (0-18years) who underwent PD catheter placement (2012-2015) in the NSQIP-P database were reviewed. Complication rates between patients who underwent additional abdominal surgery at the time of PD catheter placement and those that did not were evaluated. One to one case control matching was performed for additional adjusted analysis., Results: Of 563 patients who met inclusion criteria, 82 underwent simultaneous abdominal surgery at time of PD catheter placement. Patients in the simultaneous group had a higher rate of wound contamination but there was no difference in rates of SSI, 30-day PD catheter complication, or 30-day mortality compared with the nonsimultaneous group. There was no difference when overall simultaneous abdominal surgery or gastrointestinal surgery was evaluated. In our 1:1 adjusted analysis, there was a higher rate of PD catheter complication (11.3% vs. 2.8%, p=0.049) and SSI (31.0% vs. 4.2%, p<0.001) in the nonsimultaneous group., Conclusions: Thirty-day PD catheter complication and SSI in patients who underwent simultaneous abdominal surgery at time of catheter placement were noninferior to outcomes in the nonsimultaneous., Level of Evidence: Level III, Treatment study, Retrospective comparative study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: A new endovascular tool, the Liungman Guidewire Fixator, has been developed to simplify endovascular treatment in complex aortic aneurysms. The device has been extensively tested in bench models and animal trials. To verify the safety and functionality demonstrated in the porcine model, the device was tested in ten patients undergoing endovascular aortic repair (EVAR) or fenestrated endovascular aortic repair (f-EVAR) treatment for abdominal aortic aneurysm., Methods: The Liungman Guidewire Fixator consists of a braided stent-like, cylindrical structure with conical ends and a central channel for a 0.035″ guidewire. When in use, it is slid along the guidewire and positioned in the target artery, where the Liungman Guidewire Fixator interacts with the arterial wall by anchoring the guidewire to the wall through a radial force. The Liungman Guidewire Fixator allows for uninterrupted blood flow passed the point of fixation. In this study, the Liungman Guidewire Fixator was tested in ten patients undergoing EVAR or f-EVAR treatment for abdominal aortic aneurysm. The device was deployed and retrieved crossover into the hypogastric artery, and the occurrence of thrombotic occlusion, arterial dissection, and vascular rupture or trauma was studied using angiography, as well as device ability to withstand guidewire tension., Results: There were no instances of occlusion, dissection, or vascular trauma detected using angiography. In all cases, deployment and retrieval were successful, and the devices could withstand an applied tension of 3 N. In one instance, retrieval was challenging because of significant tortuosity, which was resolved by a coaxial catheterization., Conclusions: Deployment was uneventful in all ten patients. Retrieval according to the intended instruction for use was performed in nine of the patients. In one patient, a coaxial catheterization was necessary. All devices withstood a retention force of 3 N.

This department column highlights translation of research into healthcare quality practice. Achieving the highest quality in healthcare requires organizations to understand care delivery and to proactively mitigate risks in care delivery processes. The purpose of this article was to describe the process for using the failure modes and effects analysis process to provide evidentiary support and proactive risk mitigation for the establishment of a comprehensive vascular access team within an academic medical center.

This study aimed to assess the clinical value of transprepancreatic septotomy indwelling guide wire or pancreatic duct stent in intractable endoscopic retrograde cholangiopancreatography (ERCP) for bile duct cannulation.Of the 2107 patients treated by ERCP, a total of 81 cases with difficult bile duct cannulation underwent transprebiliopancreatic septotomy (referred to as the septotomy group, 37 cases) and transprepancreatic septotomy with pancreatic duct stent (modified septotomy group, 44 cases). Success rates of cannulation and postoperative complications for both methods were compared.Among them, 77 cases were successfully administered bile duct cannulation. The success rates of the septotomy and modified septotomy groups were 91.89% and 97.73%, respectively, with no significant difference (P = .489). Of the 77 patients, 12 cases had complications. The septotomy group included 7 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases; while in the modified septotomy group, there were 1 acute pancreatitis, 1 bleeding, and 1 biliary tract infection cases. The occurrence rate of acute pancreatitis in the modified septotomy group was lower than that of the septotomy group (2.33% vs 20.59%) with a significant difference (P = .026).These findings indicate that transprepancreatic septotomy with pancreatic duct stent seems to be a safe and feasible operation with reducing complication rates., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Fistulas, the preferred form of hemodialysis access, are difficult to establish and maintain. We examined the effect of a multidisciplinary vascular access team, including nurses, surgeons, and radiologists, on the probability of using a fistula catheter-free, and rates of access-related procedures in incident patients receiving hemodialysis., Design, Setting, Participants, & Measurements: We examined vascular access outcomes in the first year of hemodialysis treatment before (2004-2005, preteam period) and after the implementation of an access team (2006-2008, early-team period; 2009-2011, late-team period) in the Calgary Health Region, Canada. We used logistic regression to study the probability of fistula creation and the probability of catheter-free fistula use, and negative binomial regression to study access-related procedure rates., Results: We included 609 adults (mean age, 65 [±15] years; 61% men; 54% with diabetes). By the end of the first year of hemodialysis, 102 participants received a fistula in the preteam period (70%), 196 (78%) in the early-team period (odds ratios versus preteam, 1.47; 95% confidence interval, 0.92 to 2.35), and 139 (66%) in the late-team period (0.85; 0.54 to 1.35). Access team implementation did not affect the probability of catheter-free use of the fistula (odds ratio, 0.87; 95% confidence interval, 0.52 to 1.43, for the early; and 0.89; 0.52 to 1.53, for the late team versus preteam period). Participants underwent an average of 4-5 total access-related procedures during the first year of hemodialysis, with higher rates in women and in people with comorbidities. Catheter-related procedure rates were similar before and after team implementation; relative to the preteam period, fistula-related procedure rates were 40% (20%-60%) and 30% (10%-50%) higher in the early-team and late-team periods, respectively., Conclusion: Introduction of a multidisciplinary access team did not increase the probability of catheter-free fistula use, but resulted in higher rates of fistula-related procedures., (Copyright © 2017 by the American Society of Nephrology.)

The aims of this study were to review and quantify the types of anesthetic procedures performed by anesthesiologists assigned to the forward surgical team (FST) deployed in Abidjan, Ivory Coast. The study includes all patients undergoing surgery by the FST from July 2012 through July 2016. The activity was retrospectively analyzed and divided according to demographics, surgical specialties, emergency versus elective surgery, types of anesthetic and post-operative analgesic procedures, and transfusion aspects. Over this period, surgeons performed 1520 operations, 98 % as medical support to the population (MSP). Elective surgery accounted for 96 % of this activity, and emergencies for only 4 %. The main surgical activities were visceral (74 %) and orthopedic (26 %). Anesthetic procedures were general anesthesia for 62 % and locoregional anesthesia in 38 %. Our study showed that the FST contributed to MSP. Anesthetic procedures for MSP required limited resources, standardization of the procedures, and specific skills beyond the original specialties of military anesthesiologists to fulfill the needs of the local population.

Objectives: Falls and fall-related injuries are major problems in hospitals. In hematologic patients, both disease and its treatment, including chemotherapy and allogeneic hematopoietic cell transplantation (allo-HCT), can cause anemia, febrile neutropenia, and bleeding tendency, which may result in falls and fall-related injuries., Materials and Methods: We retrospectively analyzed 397 consecutive admissions to the hematology unit at our institute which included 201 adult patients with hematologic disease., Results and Conclusions: A total of 56 fall events were observed in 43 patients, and the incidence of falls was 2.49 per 1000 person-days. The median hemoglobin, platelet, and serum albumin levels prior to fall events were 8.65g/dl (range, 6.3-12.7), 38×10 9 /l (range, 7-454), and 2.85g/dl (range, 1.6-4.3), respectively. Despite the presence of thrombocytopenia among the majority of patients who fell, no serious injury was observed. Multiple variable logistic regression analysis demonstrated that age older than 65years (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.17-6.99, P=0.02), admission for allo-HCT (HR, 9.48; 95% CI, 3.35-26.80, P<0.001), hypnotic medication (HR, 3.57; 95% CI, 1.56-8.20, P=0.002), urinary or intravenous catheter placement (HR, 2.34; 95% CI, 1.08-5.09, P=0.03), and hypoalbuminemia (HR, 2.30; 95% CI, 1.07-4.96, P=0.03) were significantly associated with increased fall risk. These findings indicated that special attention should be paid to patients with such risk factors during their treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to evaluate the efficacy of oral misoprostol and Foley's catheter versus oral misoprostol alone for induction of labor., Methods: This open-label randomized controlled trial included 335 women requiring induction of labor. A total of 166 women were randomly allocated to induction with oral misoprostol alone and 169 women were assigned for induction with Foley's balloon catheter and oral misoprostol using a computer-generated allocation sequence. The primary outcome was rate of failure to achieve vaginal delivery within 24 h of induction., Results: The proportion of women failing to achieve vaginal delivery within 24 h in the combination group was lower (11.8% vs 28.7%, P = 0.001). When the two groups were stratified according to parity, the difference remained statistically significant only for parous women. The median induction-to-delivery interval (13.0 h vs 19 h, P = 0.000) and the median number of doses of misoprostol used (2 vs 3, P = 0.000) were lower in the combination group. The number of women who delivered vaginally in the combination group was significantly higher (91% vs 79%, P = 0.001). More neonates born to women in the misoprostol group had Apgar scores < 7 and were admitted to the neonatal intensive care unit (P = 0.016 and P = 0.007, respectively)., Conclusion: The rate of failure to achieve vaginal delivery within 24 h was lower with Foley's balloon and oral misoprostol as compared to oral misoprostol alone., (© 2017 Japan Society of Obstetrics and Gynecology.)

Background: The modalities of tracheostomy for critically ill patients are still controversially discussed. Although the use of percutaneous dilatational tracheostomy (PDT) is generally accepted to be a safe procedure, it is still not considered to be suitable for patients requiring a permanent tracheostomy., Methods: This was an observational cohort study investigating long-term outcome parameters of PDT. All patients having received a PDT at the interdisciplinary ICU at the University of Leipzig between October 2008 and August 2009 that survived to discharge were asked for consent to participate ( n = 103). Baseline data, admitting diagnosis, reasons for tracheostomy, and timing for tracheostomy were recorded. Subjects and medical providers were asked for neurological outcome, adverse events, and personal discomfort related to the tracheostomy. The study period was 2 y from the time of tracheostomy., Results: Seventy-one subjects were finally included in the survey. Data of 8 subjects (11%) were incomplete. Reasons for tracheostomy were the need for long-term ventilation (42%), weaning (31%), and neurological deficits (27%). No severe adverse events were registered. Sixty-five percent of all subjects could finally be decannulated. Two subjects remained with their initial tracheostomy, and in 5 subjects (7%) tracheostomy was modified to a surgical tracheostomy. Thirty-seven percent of subjects died during the 2 y. Twenty-five of the surviving subjects (35%) had only minor or moderate neurological and psychological deficits. Complaints were mostly connected to swallowing and breathing., Conclusions: Decannulations after PDT are easily done. Complications after PDT requiring a transformation to a surgical tracheostomy are rare. Elective surgical conversions are not necessary., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2017 by Daedalus Enterprises.)

Since being introduced more than 10 years ago, balloon catheter technology (BCT) has undergone several generations of innovations. From construction to utilization, there has been a myriad of advancements in balloon technology. The ergonomics of the balloon dilation systems have improved with a focus on limiting the extra assembly. "Hybrid" BCT procedures have shown promise in mucosal preservation, including treating isolated complex frontal disease. Multiple randomized clinical trials report improved long-term outcomes in stand-alone BCT, including in-office use. The ever-expanding technological innovations ensure BCT will be a key component in the armamentarium of the modern sinus surgeon., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: In an effort to minimize periprocedural stroke risk, increasingly, electrophysiological (EP) procedures are being performed on anticoagulation. The decrease in stroke has been accompanied by an increase in potentially devastating vascular access complications. Ultrasound guidance for femoral vein cannulation reduces complications in other applications. The aim of this study is to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral vein cannulation in EP., Methods and Results: A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Five years of conference abstracts from the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society were reviewed. Two independent reviewers identified trials comparing ultrasound-guided with standard cannulation in EP procedures. Data were extracted on study design, study size, operator and patient characteristics, use of anticoagulation, vascular complication rates, first-pass success rate, and inadvertent arterial puncture. Four trials, with a total of 4065 subjects, were included in the review, with 1848 subjects in the ultrasound group and 2217 subjects in the palpation group. Ultrasound guidance for femoral vein cannulation was associated with a 60% reduction of major vascular bleeding (relative risk, 0.40; 95% confidence interval, 0.28-0.91). Additionally, there was a 66% reduction in minor vascular complications (relative risk, 0.34; 95% confidence interval, 0.15-0.78)., Conclusion: The use of real-time 2D ultrasound guidance for femoral vein cannulation decreases access-related bleeding rates and life-threatening vascular complications., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

Background and Objectives: Little published information is available about access failure in children undergoing chronic peritoneal dialysis. Our objectives were to evaluate frequency, risk factors, interventions, and outcome of peritoneal dialysis access revision., Design, Setting, Participants, & Measurements: Data were derived from 824 incident and 1629 prevalent patients from 105 pediatric nephrology centers enrolled in the International Pediatric Peritoneal Dialysis Network Registry between 2007 and 2015., Results: In total, 452 access revisions were recorded in 321 (13%) of 2453 patients over 3134 patient-years of follow-up, resulting in an overall access revision rate of 0.14 per treatment year. Among 824 incident patients, 186 (22.6%) underwent 188 access revisions over 1066 patient-years, yielding an access revision rate of 0.17 per treatment year; 83% of access revisions in incident patients were reported within the first year of peritoneal dialysis treatment. Catheter survival rates in incident patients were 84%, 80%, 77%, and 73% at 12, 24, 36, and 48 months, respectively. By multivariate logistic regression analysis, risk of access revision was associated with younger age (odds ratio, 0.93; 95% confidence interval, 0.92 to 0.95; P<0.001), diagnosis of congenital anomalies of the kidney and urinary tract (odds ratio, 1.28; 95% confidence interval, 1.03 to 1.59; P=0.02), coexisting ostomies (odds ratio, 1.42; 95% confidence interval, 1.07 to 1.87; P=0.01), presence of swan neck tunnel with curled intraperitoneal portion (odds ratio, 1.30; 95% confidence interval, 1.04 to 1.63; P=0.02), and high gross national income (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.19; P=0.01). Main reasons for access revisions included mechanical malfunction (60%), peritonitis (16%), exit site infection (12%), and leakage (6%). Need for access revision increased the risk of peritoneal dialysis technique failure or death (hazard ratio, 1.35; 95% confidence interval, 1.10 to 1.65; P=0.003). Access dysfunction due to mechanical causes doubled the risk of technique failure compared with infectious causes (hazard ratio, 1.95; 95% confidence interval, 1.20 to 2.30; P=0.03)., Conclusions: Peritoneal dialysis catheter revisions are common in pediatric patients on peritoneal dialysis and complicate provision of chronic peritoneal dialysis. Attention to potentially modifiable risk factors by pediatric nephrologists and pediatric surgeons should be encouraged., (Copyright © 2016 by the American Society of Nephrology.)