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Purpose: Nowadays, it is largely accepted that albumin should not be used in hypoalbuminemia or for nutritional purpose. The most discussed indication of albumin at present is the resuscitation in shock states, especially distributive shocks such as septic shock. The main evidence-based indication is also liver disease. In this review, we provided updated evidence-based instruction for definite and potential indications of albumin administration in clinical practice, with appropriate dosing and duration. Methods: Data collection was carried out until November 2023 by search of electronic databases including PubMed, Google Scholar, Scopus, and Web of Science. GRADE system has been used to determine the quality of evidence and strength of recommendations for each albumin indication. Results: A total of 165 relevant studies were included in this review. Fluid replacement in plasmapheresis and liver diseases, including hepatorenal syndrome, spontaneous bacterial peritonitis, and large-volume paracentesis, have a moderate to high quality of evidence and a strong recommendation for administering albumin. Moreover, albumin is used as a second-line and adjunctive to crystalloids for fluid resuscitation in hypovolemic shock, sepsis and septic shock, severe burns, toxic epidermal necrolysis, intradialytic hypotension, ovarian hyperstimulation syndrome, major surgery, non-traumatic brain injury, extracorporeal membrane oxygenation, acute respiratory distress syndrome, and severe and refractory edema with hypoalbuminemia has a low to moderate quality of evidence and weak recommendation to use. Also, in modest volume paracentesis, severe hyponatremia in cirrhosis has a low to moderate quality of evidence and a weak recommendation. Conclusion: Albumin administration is most indicated in management of cirrhosis complications. Fluid resuscitation or treatment of severe and refractory edema, especially in patients with hypoalbuminemia and not responding to other treatments, is another rational use for albumin. Implementation of evidence-based guidelines in hospitals can be an effective measure to reduce inappropriate uses of albumin. [ABSTRACT FROM AUTHOR]

Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development, and Evaluation methodology. The guidelines were revised after public consultation. The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin. [ABSTRACT FROM AUTHOR]

Abdominal paracentesis is a common procedure performed for both diagnostic and therapeutic purposes in patients with chronic liver disease and ascites. This review aims to provide an overview of the current evidence on the risk of bleeding associated with abdominal paracentesis. Electronic search was performed using PubMed, MEDLINE, and Ovid EMBASE from inception to 29 October 2023. Studies were included if they examined the risk of bleeding post‐abdominal paracentesis or the efficacy of interventions to reduce bleeding in patients with chronic liver disease. Random‐effects model was used to calculate the pooled proportions of bleeding events following abdominal paracentesis. Heterogeneity was determined by I2, τ2 statistics, and P‐value. Eight studies were included for review. Six studies reported incident events of post‐abdominal paracentesis bleeding. Pooled proportion of bleeding events following abdominal paracentesis was 0.32% (95% CI: 0.15–0.69%). The mean values for pre‐procedural INR and platelet count of patients in these studies ranged between 1.4 and 2.0, and 50 and 153 × 109/L, respectively. The highest recorded INR was 8.7, and the lowest platelet count was 19 × 109/L. Major bleeding after abdominal paracentesis occurred in 0–0.97% of the study cohorts. Two studies demonstrated that the use of thromboelastography (TEG) before paracentesis in patients with chronic liver disease identified those at risk of procedure‐related bleeding and reduced transfusion requirements. The overall risk of major bleeding after abdominal paracentesis is low in patients with chronic liver disease and coagulopathy. TEG may be used to predict bleeding risk and guide transfusion requirements. [ABSTRACT FROM AUTHOR]

Background: Repeated paracentesis for ascites can place significant demands on the emergency department (ED). A new general internist-led outpatient procedure clinic to alleviate this demand required ED staff and patients to accept this transition of care. Aim: This qualitative study evaluates barriers and facilitators to implementing the FLuid ASPiration (FLASP) clinic in a safety net hospital. Methods: The FLASP clinic opened during the COVID-19 pandemic in March 2021. From February to April 2022, semi-structured interviews were conducted with: 10 ED physicians and nurses; 5 FLASP clinic patients; and 4 patients receiving paracentesis in the ED. Interviews were recorded, transcribed, and analyzed using a Grounded Theory approach for themes categorized by Theory of Planned Behavior (TPB) domains including: attitudes/knowledge; social norms; and logistics. Results: Thematic analysis found that ED staff appreciated reduced demand for paracentesis, but barriers included: lack of knowledge; concerns about unstable patients and patient expectations (norms); and scheduling logistics. FLASP clinic patients had only favorable themes: belief in clinic safety; positive relationship with staff; and clinic efficiency. Patients using the ED for paracentesis expressed only concerns: possible need for testing or hospitalization; care usually in the ED; and unclear clinic scheduling. Conclusion: This study reveals challenges to transitioning sites of care for paracentesis including the need for greater ED staff education and standardizing methods to triage patients to appropriate site of care. Greater support and education of ED patients about the benefits of an outpatient procedure clinic may also reduce ED burden for paracentesis. [ABSTRACT FROM AUTHOR]

Introduction and Objectives: Sarcopenia is a common complication of end-stage liver disease (ESLD), but its exact relationship to myosteatosis and frailty remains unclear. In this pilot study, we tested the feasibility of a specialized MRI protocol and automated image analysis in patients with ESLD. Materials and Methods: In a single-center prospective study, adult liver transplant candidates with ESLD underwent assessment of muscle composition between 3/2022 and 6/2022 using the AMRA( MAsS Scan. The primary outcome of interest was feasibility of the novel MRI technique in patients with ESLD. We also tested if thigh muscle composition correlated with validated measures of frailty and sarcopenia. Results: Eighteen subjects (71 % male, mean age 59 years) were enrolled. The most common etiologies of cirrhosis were alcohol-related liver disease (44 %) and non-alcohol-associated fatty liver disease (33 %), with a mean MELD-Na of 13 (§ 4). The mean time needed to complete the MRI protocol was 14.9 min and only one patient could not complete it due to metal hardware in both knees. Forty-one percent of patients had adverse muscle composition (high thigh fat infiltration and low-fat free muscle volume) and these patients were more likely to have undergone a recent large volume paracentesis (43 % vs. 0 %, p < 0.02). The adverse muscle composition group performed significantly worse on the 6-minute walk test compared to the remainder of the cohort (379 vs 470 m, p < 0.01). Conclusions: The AMRA® MAsS Scan is feasible to perform in patients with ESLD and can be used to quantify myosteatosis, a marker of muscle quality and potentially muscle functionality in ESLD. [ABSTRACT FROM AUTHOR]

Ascites is a frequent complication in patients with cirrhosis, associated with a bad prognosis. Ascites is associated with severe complications, such as spontaneous bacterial peritonitis and kidney dysfunction, which must be diagnosed and managed rapidly. First-line management is based on diuretics use. Beta-blockers role remains debated but an early administration could probably decrease complications associated with portal hypertension. Albumin infusion is validated in large volume paracenteses, spontaneous bacterial peritonitis, or kidney dysfunction, but is debated in other situations. Technical progresses allow the worldwide use of TIPS (transjugular intrahepatic portosystemic shunt), but patient selection must be rigorous because of potential severe complications. An alternative treatment, automated low-flow ascites pump, can be offered in patients without TIPS possibility: It is a recent technique, whose patients’ selection and installation conditions were improved, with interesting results. Liver transplantation remains the gold standard, but the lack of grafts, and specific side effects, lead to prefer other methods. In case of acute kidney injury due to hepatorenal syndrome, terlipressin remains the standard of care; continuous infusion is associated with fewer side effects.

Background: Simulation-based training is effective for ultrasound (US)-guided procedures. However, commercially developed simulators are costly. This study aims to evaluate the feasibility of a hand-made phantom for US-guided paracentesis. Methods: We described the recipe to prepare an agar phantom. We collected the US performance data of 50 novices, including 22 postgraduate-year (PGY) residents and 28 undergraduate-year (UGY) students, who used the phantom for training, as well as 12 emergency residents with prior US-guided experience. We obtained the feedback after using the phantom with the Likert 5-point scale. The data were presented with medians and interquartile ranges (IQRs) and analyzed by the Wilcoxon rank sum test. Results: While emergency residents demonstrated superior performance compared to trainees, all trainees exhibited acceptable proficiency (global rating of ≥ 3, 50/50 vs. 12/12, p = 1.000) and comparable needle steadiness [5 (5) vs. 5 (5), p = 0.223]. No significant difference in performance was observed between PGYs [5 (4–5)] and UGYs [5 (4–5), p = 0.825]. No significant differences were observed in terms of image stimulation, puncture texture, needle visualization, drainage simulation, and endurance of the phantom between emergency residents and trainees. However, experienced residents rated puncture texture and draining fluid as "neutral" (3/5 on the Likert scale). The cost of the paracentesis phantom is US$16.00 for at least 30 simulations, reducing it to US$6.00 without a container. Conclusions: The paracentesis phantom proves to be a practical and cost-effective training tool. It enables novices to acquire paracentesis skills, enhances their US proficiency, and boosts their confidence. Nevertheless, further investigation is needed to assess its long-term impact on clinical performance in real patients. Trial registration: NCT04792203 at the ClinicalTrials.gov. [ABSTRACT FROM AUTHOR]

Background: Palliative care is often suboptimal for patients with end-stage liver disease (ESLD). Ascites remains the most common complication in ESLD. Though long-term abdominal drains (LTAD) are commonly used in refractory malignant ascites, the standard care for ESLD is hospital drainage (large volume paracentesis (LVP)). There is an ongoing National Institute for Health and Care Research (NIHR) funded trial (REDUCe 2 Study) (ISRCTN269936824) comparing palliative LTAD to LVP in ESLD. This 35-site trial is being conducted in England, Scotland and Wales. Aim: To understand the views and experience of healthcare professionals (HCP) on the use of palliative LTAD in ESLD. Methods: An electronic survey comprised of seven questions with fixed quantitative options and three exploratory questions was used between August--December 2019. The survey was distributed electronically via the British Association for Study of Liver newsletter and to relevant hospital departments in Southeast England and Northeast London. An email reminder was sent at 4 and 8 weeks after the initial invitation to the survey. Results: There were 211 respondents (hepatologists (36.5%), specialist nurses (24.6%), gastroenterologists (16.6%), trainees (17%) and others (5.2%)). All respondents had access to LVP, 86% to a transjugular intrahepatic portosystemic shunt procedure for patients, 67% to LTADs and 10% to other options, such as the automated low-flow ascites (ALFA) pump. The majority of respondents to the survey (68%) reported their experience of using LTAD. Almost all respondents (91%) were willing to consider LTAD in ESLD. However, the main deterrents of this were the perceived risk of infection (90%), followed by LTAD management in community (57%). Some 51% of those with prior experience of using LTAD reported clinical complications for patients (including bleeding, infection and renal impairment), 41% reported technical issues and 35% inadequate community support. Conclusions: Almost all HCPs are willing to consider palliative LTAD in refractory ascites due to ESLD, but the main deterrents are the perceived infection risk and lack of published data to guide community management. The REDUCe 2 trial will clarify if these concerns are real and provide conclusive evidence on role, if any, of palliative LTADs in this vulnerable and under researched cohort with ESLD. [ABSTRACT FROM AUTHOR]

The efficacy of surgical intervention in ameliorating long-term prognosis for moderate volume of cerebral hemorrhage in the thalamus-internal capsule region remains unsubstantiated by clinical investigations. Consequently, the acquisition of credible evidence is imperative to authenticate the effectiveness of these methodologies. One hundred and three eligible patients with moderate-volume thalamus-internal capsule region cerebral hemorrhage. Twenty-seven pairs of successful matches after using the 1:1 propensity score matching method, totaling 54 patients, were analyzed. The short- and long-term treatment outcomes of patients in the stereotactic surgery and conservative treatment groups were compared. The prognosis of the 2 groups of patients was analyzed by logistic regression analysis and model comparison. The primary outcome of this study was to assess the assessment of daily living scores after 6 months of treatment. Based on the analysis of this study, the assessment of daily living of the surgical group were significantly higher than those of the conservative treatment group after 6 months of treatment (P < 0.001), and the difference was statistically significant. The amount of residual hematoma was significantly lower in the stereotactic surgery group than in the conservative treatment group at 3 days, 7 days, and 2 weeks after the onset of the disease (P < 0.001), and the complication rate was lower than the conservative treatment group (P < 0.05). Univariate logistic regression showed that the risk of severe neurological dysfunction for patients in the surgery group was (odds ratio -0.27, 95% confidence interval: 0.08–0.86, P < 0.05). In multivariate logistic regression analysis, the odds ratio was 0.29 (95% confidence interval: 0.09–0.96, P < 0.05) after adjusting for all covariates. For moderate-volume thalamus-internal capsule region cerebral hemorrhage, stereotactic paracentesis has the advantage of a shorter hospital stay and a lower complication rate than conservative treatment. Moreover, it yields superior outcomes in terms of daily living assessment scores after six months of treatment and enhanced neurological recovery. [ABSTRACT FROM AUTHOR]

Extraosseous Ewing's sarcoma is an extremely rare tumor. In the literature, intestinal Ewing's sarcoma was reported in 20 cases, and omental Ewing's sarcoma was reported in only two cases. In this case report, we report a 23-year-old female who presented with the complaint of diffuse abdominal pain. Abdominal ultrasound and whole-body computed tomography revealed a mass starting from the adnexal area and extending between the intestinal loops. Serum levels of tumor markers were high. The serum levels of carbohydrate antigen-125 (CA-125) and carcinoembryonic antigen-19.9 (CA-19.9) were high (427.5 U/mL and 67.9 U/mL, respectively). Laparotomic exploration was performed with the preliminary diagnosis of an adnexal mass, and a mass originating from the small intestine meso and completely covered by the omentum was excised. Histological evaluation reported intestinal and omental origin of Ewing's sarcoma. This case highlights the importance of rare extraosseous Ewing's sarcoma, which should be included in the differential diagnosis of a young female with intra-abdominal mass. [ABSTRACT FROM AUTHOR]

Background: Disparities in life-saving interventions for low-income patients with cirrhosis necessitate innovative models of care. Aim: To implement a novel generalist-led FLuid ASPiration (FLASP) clinic to reduce emergency department (ED) care for refractory ascites. Setting: A large safety net hospital in Los Angeles. Participants: MediCal patients with paracentesis in the ED from 6/1/2020 to 1/31/2021 or in FLASP clinic or the ED from 3/1/2021 to 4/30/2022. Program Description: According to RE-AIM, adoption obtained administrative endorsement and oriented ED staff. Reach engaged ED staff and eligible patients with timely access to FLASP. Implementation trained FLASP clinicians in safer, guideline-based paracentesis, facilitated timely access, and offered patient education and support. Program Evaluation: After FLASP clinic opened, significantly fewer ED visits were made by patients discharged after paracentesis [rate ratio (RR) of 0.33 (95% CI 0.28, 0.40, p < 0.0001)] but not if subsequently hospitalized (RR = 0.88, 95% CI 0.70, 1.11). Among 2685 paracenteses in 225 FLASP patients, complications were infrequent: 39 (1.5%) spontaneous bacterial peritonitis, 265 (9.9%) acute kidney injury, and 2 (< 0.001%) hypotension. FLASP patients rated satisfaction highly on a Likert-type question. Discussion: Patients with refractory ascites in large safety net hospitals may benefit from an outpatient procedure clinic instead of ED care. [ABSTRACT FROM AUTHOR]

Spontaneous bacterial peritonitis (SBP) is the most common infection in patients with cirrhosis and is associated with high mortality. Although recent literature reports mortality benefits to early diagnostic paracentesis, current guidelines do not offer specific recommendations for how quickly diagnostic paracentesis should be performed in patients with cirrhosis and ascites who are admitted to the hospital. Therefore, we conducted a systematic review and meta-analysis to evaluate outcomes among patients admitted to the hospital with cirrhosis and ascites receiving paracentesis within ≤ 12, ≤ 1 day, and > 1 day. Eight studies with 116,174 patients were included in the final meta-analysis. The pooled risk of in-hospital mortality was significantly lower in patients who underwent early (≤ 12 h or ≤ 1 day) compared to delayed (> 12 h or > 1 day) paracentesis (RR: 0.69, p < 0.00001), and in patients who underwent paracentesis compared to no paracentesis (RR: 0.74, p < 0.00001). On subgroup analysis, in-hospital mortality was significantly lower in both paracentesis within ≤ 12 h (RR: 0.61, p = 0.02) vs. > 12 h, and within ≤ 1 day (RR: 0.70, p < 0.00001) vs. > 1 day. While there was a trend towards decreased mortality in those undergoing paracentesis within ≤ 12 h compared to ≤ 1 day, the difference did not reach statistical significance. The length of hospital stay was significantly shorter by 5.38 days in patients who underwent early (≤ 12 h) compared to delayed (> 12 h) paracentesis (95% CI 4.24–6.52, p < 0.00001). Early paracentesis is associated with reduced mortality and length of hospital stay. We encourage providers to perform diagnostic paracentesis in a timely manner, at least within 1 day of hospital admission, for all patients with cirrhosis and ascites. [ABSTRACT FROM AUTHOR]

Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population. We designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. We analyzed a database of 614 patients who underwent TIPS in three Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12. During a median follow-up of 30 months (IQR 12-30), 293 patients developed at least one episode of OHE. Twenty-seven (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57-71] vs. 59 [50-67] years, p < 0.001), had lower albumin (3.1 [2.8-3.5] vs. 3.25 [2.9-3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and MELD scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% CI -0.042 to 0.102). Multivariable analysis showed that age (subdistribution hazard ratio 1.04, 95% CI 1.02–1.05, p < 0.001) and MELD score (subdistribution hazard ratio 1.09, 95% CI 1.05–1.13, p < 0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal re-bleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching. Episodic OHE after TIPS is not associated with mortality in patients undergoing TIPS, regardless of the indication. Overt hepatic encephalopathy (OHE) is a common complication in patients with advanced liver disease and it is particularly frequent following transjugular intrahepatic portosystemic shunt (TIPS) placement. In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival, regardless of the severity of cirrhosis or the presence of acute-on-chronic liver failure. In this multicenter, non-inferiority, observational study we demonstrated that post-TIPS OHE does not increase the risk of mortality in patients undergoing TIPS, irrespective of the indication. This finding alleviates concerns regarding the weight of this complication after TIPS. Intensive research to improve patient selection and risk stratification remains crucial to enhance the quality of life of patients and caregivers and to avoid undermining the positive effects of TIPS on survival. [Display omitted] • In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival. • OHE is considered a major complication in patients treated with TIPS. • We show that post-TIPS episodic OHE does not increase the risk of death in patients undergoing TIPS, irrespective of the indication. • This finding alleviates concerns regarding the impact of this complication on survival after TIPS. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the efficacy of hyperbaric oxygen (HBO) for the treatment of non-arteritic central retinal artery occlusion (NACRAO, CRAO). Materials and Methods: The records of patients diagnosed with CRAO between January 2017 and April 2023 at XXX Hospital were retrospectively reviewed. Treatments and detailed ophthalmological examination findings at the baseline and post-treatment follow-up of the patients were recorded. After ocular massage and acute antiglaucomatous treatment; the patients were divided into 3 groups, as group 1 received HBO therapy after anterior chamber paracentesis (ACP), group 2 received only HBO therapy, group 3 received only ACP. Data were analysed with the IBM SPSS Statistics 22 program using non-parametric tests. Results: Thirty-four patients with a median age of 72 (28-92), 12 (35.3%) women and 22 (64.7%) men, were included in the study. There were 10, 14, and 10 patients in groups 1, 2 and 3, respectively. The groups were similar in terms of age, gender, systemic diseases and time of admission (p >0.05). In groups 1, 2 and 3: baseline median visual acuity (VA) was 2.3 (2.3-3.0), 2.3 (1.3-3.0), and 2.3 (1.3-3.0) logMAR (p =0.573); the median VA at last visit was 1.9 (0.3-3.0), 1.9 (0.3-3.0), and 2.5 (1.3-3.0) logMAR (p =0.624), respectively. Only in group 1, the final VA increased significantly from baseline (p =0.035), while no significant change in VA was observed in the other groups (p =0.138 and p =0.786 for groups 2 and 3, respectively). Final VA was moderately positively correlated with baseline VA (r =0.425, p =0.012) and moderately negatively correlated with time of admission (r =-0.381, p =0.026). Conclusion: HBO therapy combined with ACP applied in the early period in the treatment of CRAO positively affects the visual prognosis. [ABSTRACT FROM AUTHOR]

Objectives: Non‐immune hydrops fetalis (NIHF) is the pathological accumulation of fluids in fetal compartments, without maternal isoimmunization. Fetal interventions (e.g. shunting, fetal paracentesis, fetal thoracocentesis, fetal pleurodesis) are used to alleviate fluid accumulations, but the outcome is uncertain because the underlying causes of NIHF vary. We aimed to explore the etiology and long‐term outcome of NIHF after fetal intervention. Methods: This was a retrospective review of fetuses with NIHF, defined by the presence of fetal ascites, pleural or pericardial effusion, skin edema or cystic hygroma, or a combination of these features, who underwent intervention at our institution during the period 2012–2021. Clinical surveillance, genetic analysis and viral infection screening were used to define the etiology. Chart reviews and telephone interviews were conducted to assess the long‐term outcomes. Results: In total, 55 fetuses were enrolled and 46 cases had final follow‐up data after delivery. Etiology was identified in 33 cases, including four for which the underlying causes were not identified initially using small‐gene‐panel tests but which were later diagnosed with monogenic disorders by whole‐exome sequencing (WES). Twenty‐three cases with follow‐up survived, having a follow‐up period of 2–11 years at the time of writing, of which 17 were healthy. All 11 cases initially presenting as congenital chylothorax survived with favorable outcome. Conclusions: The etiologies of NIHF are heterogeneous, and the long‐term (spanning 2–11 years) outcome of fetal intervention varies, according to the underlying etiology, with cases caused by congenital chylothorax having the best prognosis. Genome‐wide tests, such as WES, may be helpful in determining the underlying condition in cases caused by a genetic disorder, and this may affect fetal therapy approaches in the future. © 2023 International Society of Ultrasound in Obstetrics and Gynecology. Linked article: There is a comment on this article by Zhao and Li. Click here to view the Correspondence. [ABSTRACT FROM AUTHOR]

The article discusses the outpatient management of symptomatic ascites, a condition commonly seen in patients with decompensated cirrhosis and/or portal hypertension. Currently, many patients with symptomatic ascites are admitted to the hospital due to the lack of availability of therapeutic paracentesis in emergency departments (ED). The article proposes the implementation of a flexible paracentesis clinic within an internal medicine office as a solution to avoid unnecessary ED visits and hospitalizations. The clinic, called FLuid ASPiration (FLASP), provides patient-centered care and has the potential to improve ascites care, but faces barriers such as patient, provider, and administrator buy-in. The article suggests educational initiatives, simplified scheduling, and behavioral interventions as tools to overcome these barriers and improve outpatient decision making. [Extracted from the article]

Abstract Background Simulation-based training is effective for ultrasound (US)-guided procedures. However, commercially developed simulators are costly. This study aims to evaluate the feasibility of a hand-made phantom for US-guided paracentesis. Methods We described the recipe to prepare an agar phantom. We collected the US performance data of 50 novices, including 22 postgraduate-year (PGY) residents and 28 undergraduate-year (UGY) students, who used the phantom for training, as well as 12 emergency residents with prior US-guided experience. We obtained the feedback after using the phantom with the Likert 5-point scale. The data were presented with medians and interquartile ranges (IQRs) and analyzed by the Wilcoxon rank sum test. Results While emergency residents demonstrated superior performance compared to trainees, all trainees exhibited acceptable proficiency (global rating of ≥ 3, 50/50 vs. 12/12, p = 1.000) and comparable needle steadiness [5 (5) vs. 5 (5), p = 0.223]. No significant difference in performance was observed between PGYs [5 (4–5)] and UGYs [5 (4–5), p = 0.825]. No significant differences were observed in terms of image stimulation, puncture texture, needle visualization, drainage simulation, and endurance of the phantom between emergency residents and trainees. However, experienced residents rated puncture texture and draining fluid as “neutral” (3/5 on the Likert scale). The cost of the paracentesis phantom is US$16.00 for at least 30 simulations, reducing it to US$6.00 without a container. Conclusions The paracentesis phantom proves to be a practical and cost-effective training tool. It enables novices to acquire paracentesis skills, enhances their US proficiency, and boosts their confidence. Nevertheless, further investigation is needed to assess its long-term impact on clinical performance in real patients. Trial registration NCT04792203 at the ClinicalTrials.gov.

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Objectives: To develop a Canadian Internal Medicine Ultrasound (CIMUS) consensus statement on recommended mandatory point-of-care ultrasound (POCUS) competencies for ultrasound-guided thoracentesis, paracentesis, and central venous catheterizations (CVC) for internal medicine physicians. Methods: The 2022 CIMUS group consists of 27 voting members, with representations from all 17 Canadian academic institutions across 8 provinces. Members voted in 3 rounds on 46 procedural competencies as "mandatory, must include", "optional, could include" or "superfluous, do not include". These 46 competencies included 6 general competencies that apply to all POCUS-guided procedures, 11 competencies for thoracentesis, 10 competencies for paracentesis, and 19 competencies for CVC. Results: In the first round, members reached consensus on 27 competencies (5 general, 6 thoracentesis, 8 paracentesis, 8 CVC). In the second round, 10 competencies (1 general, 2 thoracentesis, 1 paracentesis, 6 CVC) reached consensus. In the third round, 2 additional competencies (1 paracentesis, 1 CVC) reached consensus for being mandatory and 3 as optional (1 thoracentesis and 2 CVC). Overall, a total of 28 competencies reached consensus as mandatory, 3 as optional, while 11 competencies reached consensus as superfluous. Four competencies did not reach consensus for either inclusion or exclusion. Conclusions: The CIMUS group recommends 28 competencies be considered mandatory and 3 as optional for internal medicine physicians performing POCUS guided thoracentesis, paracentesis, and CVC placement. National curriculum development and implementation efforts should include training these mandatory competencies. [ABSTRACT FROM AUTHOR]

Thyroglossal duct cysts (TGDCs) are congenital and developmental abnormalities in infants and young children. This retrospective case series study examined the characteristics of 7 patients <3 years (mean age, 1.9 years) with TGDC complicated with a parapharyngeal mass treated at one hospital between January 2019 and 2022. Four patients had a painless mass around the neck, 2 had a painless mass associated with snoring, and 1 presented repeated swelling and pain. B-ultrasound suggested 6 cases of TGDC and 1 possible lymphangioma. All patients were treated with Sistrunk surgery to remove the TGDC. Six patients had no cyst recurrence during follow-up (6 months to 2 years). In conclusion, TGDC complicated with a parapharyngeal mass has complex and variable clinical manifestations. Completely removing the cyst while sparing thyroid cartilage and surrounding vascular and neuroanatomical structures is important to avoid complications. The patients are likely to be free from recurrence after surgery. [ABSTRACT FROM AUTHOR]

The objective of this study was to examine the impact of a point-of-care ultrasound (POCUS) program among people with ascites receiving home-based palliative care by measuring the association of POCUS with ascites-related days spent out of the home, compared with outcomes before POCUS implementation. Open cohort study. Adults who had an ascites-related procedure (ARP) between January 1, 2014, and December 31, 2015 (ie, pre-POCUS) and January 1, 2019, and December 31, 2020 (ie, POCUS). An ARP was defined as using ultrasound to diagnose suspected ascites or a paracentesis with or without ultrasound guidance to manage ascites. The main outcome was the rate of ascites-related days spent out of the home, defined as days out of the home for either ARPs or because of ascites-related hospital admissions, relative to the time patients were at risk for spending ascites-related days out of the home. Among the 103 pre-POCUS patients (mean age 68.0; 50.4% female), there were 161 ARPs with 12.4% occurring at home. Among the 127 POCUS patients (mean age 74.0; 52.0% female) there were 193 ARPs with 82.4% occurring at home. POCUS was associated with a significantly lower rate of ascites-related days spent outside the home (pre-POCUS rate of 33 days per 1000 patient days vs POCUS rate of 9 days; unadjusted incidence rate ratio (IRR), 3.86; 95% CI, 2.95–5.12; P <.001; adjusted IRR, 3.83; 95% CI, 1.27–11.54; P =.02). POCUS was also associated with a higher likelihood of ARPs occurring in the home [unadjusted odds ratio (OR), 32.44; 95% CI, 18.15–59.90; P <.001; adjusted OR, 48.99; 95% CI, 21.04–114.10; P <.001]. The use of POCUS may contribute to maximizing time spent at home for palliative care patients with ascites. These findings support the use of POCUS for home-based palliative care programs. [ABSTRACT FROM AUTHOR]

Recent advances in the field of hepatology include new and effective treatments for viral hepatitis. Further effort is now being directed to other disease entities, such as non-alcoholic fatty liver disease, with an increased need for assessment of liver function and histology. In fact, with the evolving nomenclature of fat-associated liver disease and the emergence of the term "metabolic-associated fatty liver disease" (MAFLD), new diagnostic challenges have emerged as patients with histologic absence of steatosis can still be classified under the umbrella of MAFLD. Currently, there is a growing number of endoscopic procedures that are pertinent to patients with liver disease. Indeed, interventional radiologists mostly perform interventional procedures such as percutaneous and intravascular procedures, whereas endoscopists focus on screening for and treatment of esophageal and gastric varices. EUS has proven to be of value in many areas within the realm of hepatology, including liver biopsy, assessment of liver fibrosis, measurement of portal pressure, managing variceal bleeding, and EUS-guided paracentesis. In this review article, we will address the endoscopic applications that are used to manage patients with chronic liver disease. [ABSTRACT FROM AUTHOR]

Background/Aims: The current standard of care to perform an anterior chamber paracentesis involves the use of a multipurpose market needle and syringe. The use of standard needles for this purpose may result in injury to the patient due to increased force with insertion and increased globe displacement during the procedure. This research investigates the current market needle characteristics and the impact of each needle characteristic on force. Methods: Several comparative trials were conducted to evaluate the needles. Needle characteristics of interest were gauge, primary bevel angle, number of bevels in the lancet, and needle hub geometry. Measurements of corneal insertion forces were made using a synthetic thermoplastic polyurethane medium, and bovine and porcine models. Needle safety was investigated with corneal abrasion experiments. Results: Reduced insertion force was observed with lower lancet primary angle. There was no difference based on the number of bevels in the lancet. Rounded hub geometry had minimal distribution to the corneal epithelium. Conclusions: Needle characteristics impact the force needed for needle insertion into the tissue. Since higher force can lead to increased risk and less efficiency during the procedure, reducing this force may improve the outcomes of the procedure. Needle entry can be reduced by designing an improved needle that includes a lower gauge and reduced primary angle of the lancet. [ABSTRACT FROM AUTHOR]

With growing incidence of liver cirrhosis worldwide, there is more need for a risk assessment tool to aid in perioperative management of cirrhotic patients undergoing colorectal procedures. We aim to assess the association of open (OC) versus laparoscopic (LC) approach with colorectal procedures' outcomes and develop an easy-to-use nomogram to predict outcomes. We analyzed the Veterans Affairs Surgical Quality Improvement Program to identify all patients with cirrhosis and ascites who underwent colorectal procedures from 2008 to 2015. Model for End-stage Liver Disease score was calculated as well as five-items modified frailty index. The chi-square test was utilized to analyze categorical variables. Two-sided unpaired Student's t -test or Mann–Whitney U -test were used for numerical variables as appropriate. Multivariate logistic regression adjusting for demographics, comorbidities, and other preoperative factors was used to analyze postoperative outcomes. A predictive nomogram was constructed and internally validated. A total of 731 patients were identified. Overall, complications occurred in 48.2% of patients, and 30-d mortality was 24.8%, with 57.5% were performed emergently. Malignant neoplasm was the most common indication (25.4%). LC was performed in 22.4%, with shorter operative time, less blood transfusions, shorter length of stay, and lower morbidity compared to OC. Overall, Model for End-stage Liver Disease score was an independent factor of mortality, while laparoscopic approach had a protective effect on morbidity. An easy-to-use nomogram was generated for morbidity and 30-d mortality with calculated area under cure of 74.5% and 77.9%, respectively, indicating reliability. Although colectomy is a high-risk operation in cirrhotic veterans, LC may have favorable outcomes than OC in selected patients. An easy-to-use nomogram to predict morbidity and mortality for cirrhotic patients undergoing colectomy is proposed. [ABSTRACT FROM AUTHOR]

Aim of the study: Early paracentesis before antibiotic administration reduces morbidity and mortality in patients with decompensated cirrhosis. We studied the association of variables with antibiotic administration before or after performing paracentesis. Material and methods: This was a retrospective study of 137 patients with ascites secondary to cirrhosis admitted to a community hospital in New York City. Predictor variables were demographic, disease-related, admission timing, and serum measurement. Results: We found a significantly increased relative risk for performing paracentesis after antibiotic administration for those admitted at night (relative risk ratio [RRR] = 3.01, 95% CI: 1.02-8.85, p = 0.046). Demographic, disease-related, and serum measurement variables were not significantly associated with performing paracentesis or order of antibiotic administration. Also, increased body mass index was significantly associated with decreased relative risk for paracentesis not done (RRR = 0.84, 95% CI: 0.74-0.96, p = 0.01). Conclusions: In conclusion, there was increased relative risk for performing paracentesis after antibiotic administration for patients admitted at night. We recommend ongoing resident and hospitalist training to maintain competency in bedside procedures such as paracentesis for patients with cirrhosis. Also, increased staffing or the presence of a resident/hospitalist led interventional team during night shifts may also help optimize the rates of timely paracentesis. [ABSTRACT FROM AUTHOR]

Complications associated with liver cirrhosis are various and potentially fatal. The treatment options to counteract hepatic decompensation are limited. Therefore, the study aimed to explore the use of allopurinol in preventing the recurrence of liver cirrhosis-related complications. One hundred patients with hepatic decompensation were randomized into 1:1 ratio to receive either allopurinol 300 mg or placebo tablets once daily for 6 months. The primary endpoint was the incidence of cirrhosis-related complications (overt ascites, spontaneous bacterial peritonitis, variceal bleeding, hepatorenal syndrome, and hepatic encephalopathy). Six months following treatment, allopurinol reduced the relative risk (RR) of any first complication experienced after enrollment by 56% (hazard ratio [HR] 0.44; 95% confidence interval [CI], 0.27-0.62); P ˂.001). Allopurinol decreased the RR of overt ascites by 67% (HR 0.33; 95% CI, 0.0098-0.94); P =.039] and reduced the RR of spontaneous bacterial peritonitis by about 75% (HR 0.25; 95% CI, 0.05-0.76; P =.01). Likewise, allopurinol was linked to an 80% reduction in the RR of developing hepatorenal syndrome (HR 0.2; 95% CI, 0.04-0.87; P =.033). Allopurinol significantly decreased the recurrence of overall liver cirrhosis-related complications. Therefore, allopurinol may constitute a promising agent for patients with hepatic decompensation. These positive outcomes could be a result of its ability to reduce bacterial translocation and inflammation. NCT005545670. [ABSTRACT FROM AUTHOR]

Mucinous carcinoma is a tumor composed of gastrointestinal-type cells with intracytoplasmic mucin. They are unilateral solid-cystic masses. A 38-year-old G2 L2 woman with a complaint of rapidly increasing severe abdominal distension was referred. Surgery was performed and a huge complicated mass showed up. We sucked about 42 liters of brown color fluid out of the cyst and then we could extract the residual mass. Chemotherapy protocol began under the supervision of oncologic service. Despite diagnostic delay, before any dissemination the cystadenocarcinoma was removed. To our best knowledge, our patient had the biggest tumor among other previous case presentations. [ABSTRACT FROM AUTHOR]

Background: Emergency physicians commonly perform ultrasound-assisted abdominal , using point of care ultrasound (POCUS) to identify and select a site for needle insertion. However, ultrasound-guided has the benefit of real-time needle visualization during the entire procedure. Our objective was to characterize the performance of emergency physician-performed ultrasound-guided using POCUS, their ability to achieve good in-plane needle visualization, and factors associated with procedural success. Methods: A POCUS database was retrospectively reviewed for examinations where abdominal was performed by an emergency physician at two academic urban emergency departments over a six-year period. Medical records were reviewed for demographics, presenting history, complications, and hospital course. Descriptive statistics were used to summarize the data. Results: 131 patients were included in the final analysis. The success rate for ultrasound-guided was 97.7% (84/86, 95% CI 92-100%) compared to 95.6% (43/45, 95% CI 85-99%) for ultrasound-assisted (p = .503). 58% (50/86) demonstrated good in-plane needle visualization; 17% (15/86) had partial or out-of-plane visualization; and 24% (21/86) did not demonstrate needle visibility on their saved POCUS images. All four procedural failures were performed by first- or second-year residents using a transducer, while all procedures using a linear transducer were successful. The most common complications were leak, infection at the site, and minor bleeding. Conclusions: Emergency physicians with training in real-time needle guidance with ultrasound were able to use POCUS to perform ultrasound-guided in the emergency department with a high success rate and no fatal complications. Based on our experience, we recommend performing ultrasound-guided using a linear transducer, with attention to identifying vessels near the procedure site and maintaining sterile technique.

In this segment of the emergency department (ED) palliative care (PC) case series, we discuss a patient on hospice who presented to the ED for the management of acute symptoms and potential procedural intervention. Hospice patients frequently visit the ED and can challenge typical ED paradigms of care that often include resuscitative efforts and broad workups. Our patient had a history of advanced liver cancer, and his ED presentation was prompted by worsening abdominal pain from ascites requiring serial paracentesis. PC consultation was requested to help address the patient's symptoms and create a plan of care. The PC clinician played an important role in supporting aggressive symptom management, re-evaluating goals of care, addressing concerns about hospice, and facilitating changes in code status requested for a procedure. [ABSTRACT FROM AUTHOR]

A meta-analysis published in Digestive Diseases & Sciences examines the benefits of early paracentesis (≤ 12 hours or ≤ 1 day after admission) in hospitalized patients with cirrhosis. The study finds that early paracentesis is associated with a 31% decrease in inpatient mortality and a 39% reduction in mortality when performed within 12 hours of admission. Additionally, patients who underwent early paracentesis had a shorter length of stay compared to those with delayed paracentesis. The study highlights the importance of timely paracentesis in improving outcomes for patients with cirrhosis and ascites. However, the analysis does not explore the reasons for delayed paracentesis or quantify other potential complications resulting from delayed paracentesis. [Extracted from the article]

This study aimed to identify risk factors associated with infections after Transrectal ultrasound-guided prostate biopsy (TRUSPB) and to analyze the efficacy of preoperative prophylactic antimicrobial administration. A retrospective analysis was conducted on 766 patients who underwent TRUSPB at our hospital from January 2020 to January 2023. Among them, 450 patients were given a three-day prophylactic course of antimicrobial fluoroquinolones before TRUSPB (Group A), while the remaining 316 patients were administered a single dose of 750 mg oral ciprofloxacin 1 h before TRUSPB (Group B). We calculated the incidence of post-TRUSPB infections in both groups and employed a binary logistic regression model to analyze factors influencing post-TRUSPB infections and evaluate the effectiveness of prophylactic antimicrobial use. Among the 766 patients who underwent prostate biopsy, 62 cases (8.1%) developed post-TRUSPB infections, and there was no statistically significant difference in the rate of post-TRUSPB infections and types of infections between Group A and Group B. Blood and urine cultures from all the 62 infected patients were positive, with Escherichia coli being the most commonly detected pathogen, demonstrating a positive detection rate of 100.0% and accounting for 76% of all infections. Logistic regression analysis identified age (Odds ratio (OR) = 1.15, 95% Confidence Interval (CI) 1.05–1.25), a history of diabetes mellitus (OR = 1.31, 95% CI 1.12–1.52), and history of indwelling urinary catheter within 7 days before biopsy (OR = 1.43, 95% CI 1.15–1.77) as risk factors for post-TRUSPB infections. In summary, a single application of ciprofloxacin demonstrated similar efficacy in reducing the risk of post-TRUSPB infection compared to a three-day course of oral fluoroquinolones before biopsy while also reducing the risk of quinolone resistance. Conversely, advanced age, comorbid diabetes mellitus, and a 7-day history of indwelling urinary catheter before TRUSPB increased the risk of post-TRUSPB infection.

This study investigated the preventive effect of 5-aminolevulinic acid combined with sodium ferrous citrate (5-ALA/SFC) on blood–aqueous barrier (BAB) breakdown induced after anterior chamber paracentesis (ACP) in beagles. 5-ALA/SFC (1/0.64 mg/kg or 3/1.92 mg/kg) or carprofen (4.0 mg/kg) was orally administered daily for 7 days prior to ACP. Then, a sample of the aqueous humor (AH) was collected from one eye via ACP (first sample) and again 60 min later (second sample). The protein and prostaglandin E2 (PGE2) concentrations in both samples were measured. Compared with the control group, high-dose 5-ALA/SFC and carprofen significantly reduced the AH protein and PGE2 concentrations in the second sample. Our findings suggest that 5-ALA/SFC suppresses BAB breakdown in dogs. [ABSTRACT FROM AUTHOR]

Background: We sought to evaluate the effect of early short-term abdominal paracentesis drainage (APD) in moderately severe and severe acute pancreatitis (MSAP/SAP) with pelvic ascites. Methods: A total of 135 MSAP/SAP patients with early pelvic ascites were divided into the Short-term APD group (57 patients) and the Non-APD group (78 patients). The effects, complications, and prognosis of short-term APD patients were evaluated. Results: The baseline characteristics in the two groups were similar. The target days of intra-abdominal hypertension relief, half-dose enteral nutrition, duration of mechanical ventilation, length of intensive care unit stay (in days) and total hospitalization (also in days) were all lower in the Short-term APD group than in the Non-APD group (P = 0.002, 0.009, 0.004, 0.006 and 0.019), while the white blood cell count and serum C-reaction protein level decreased significantly more quickly (P < 0.01 and P < 0.05), and the prevalence of intra-abdominal infection was also significantly lower (P = 0.014) in the former than the latter. No complications occurred in early APD patients, and the microbial cultures of pelvic ascites were all negative. In addition, patients with early APD presented fewer cases of residual wall-off necrosis or fluid collection (P = 0.008) at discharge and had a lower incidence of rehospitalization and percutaneous catheter drainage and/or necrosectomy (P = 0.017 and 0.009). Conclusions: For MSAP/SAP patients with pelvic ascites, the early short-term APD is feasible and safe to perform, and it can decrease clinical symptoms, reduce intra-abdominal infection and shorten the hospital stay. It may also reduce the incidence of rehospitalization and surgical intervention. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To study the outcome and complications of surgery for duodenal perforation based on the: a) Duration of perforation. b) Patients presenting in a clinical state of shock. c) Clinical presentation. d) Radiological findings and management. Methods: This prospective study was conducted at the tertiary care center. The study will follow 50 duodenal perforation cases' clinical symptoms and prognosis. All tertiary care center patients who met the inclusion criteria were included in the data collection. Results: In this study, 76% of duodenal ulcer perforations were male and 34% were female, making the male: female ratio 3.16:1. 24% of patients presented after 24 hours and were from low-income families. Most patients were unskilled and semiskilled labourers with low socioeconomic situations. In the study, 76% of patients were smokers and alcoholics, which was the biggest risk factor for perforation, followed by 32% who had taken NSAIDs for various diseases. The diagnosis was based on air under the diaphragm in 94% of cases and absent in 6%. Paracentesis fluid was turbid and bile stained in 88% of patients and absent in 12%, aiding diagnose instances. 24% of patients were in shock at the casualty, and 41.7% died during treatment (12 shock cases, 5 died). Early patients with MPI <21 or between 21 and 29 without shock and no contraindications to anaesthesia can be treated with laparoscopic closure with less morbidity and mortality at a centre with modern anaesthetic equipment, a trained anaesthetist, and a surgeon skilled in laparoscopic techniques. Conclusion: Perforated peptic ulcer patients can tolerate perforation closure and long-term medical care. If the surgeon is well-trained, laparoscopic perforation closure is better than open surgery for early, nonshocked, healthy younger and middle-aged patients. [ABSTRACT FROM AUTHOR]

Introduction: Mild or moderate liver cirrhosis increases the risk of complications after cardiac surgery. Ascites is the most common complication associated with liver cirrhosis. However, the prognostic value of ascites on postoperative morbidity and mortality after cardiac surgery remains uninvestigated. Methods: A retrospective study included 69 patients with preoperatively diagnosed liver cirrhosis who underwent cardiac surgery between January 2009 and January 2018 at the Department of Cardiothoracic Surgery, University Hospital of Cologne, Germany. The patients were divided into ascites and non-ascites groups based on preoperatively diagnosed ascites. Thirty-day mortality, postoperative complications, length of stay, and blood transfusions were analyzed postoperatively. Results: Out of the total of 69 patients, 14 (21%) had preoperatively diagnosed ascites. Ascites group had more postoperative complications such as blood transfusions (packed red blood cells: 78.6% vs. 40.0%, p = 0.010; fresh frozen plasma: 57.1% vs. 29.1%, p = 0.049), acute kidney injury (78.6% vs. 45.5%, p = 0.027), longer ICU stay (8 vs. 3 days, p = 0.044) with prolonged mechanical ventilation (57.1% vs. 23.6%, p = 0.015) and tracheotomy (28.6% vs. 3.6%, p = 0.003). The 30-day mortality rate was significantly higher in the ascites group than in the non-ascites group (35.7% vs. 5.5%, p = 0.002). Conclusion: Ascites should be implemented in preoperative risk score assessments in cirrhotic patients undergoing cardiac surgery. Preoperative treatment of ascites could reduce the negative impact of ascites on postoperative complications after cardiac surgery. However, this needs to be thoroughly investigated in prospective randomized clinical trials. [ABSTRACT FROM AUTHOR]

Background Bedside procedures are a necessary skill for many residents. Practice changes, including the discontinuation of a minimum number of procedures required by the American Board of Internal Medicine, may have resulted in decreased incentive for residents to seek procedural opportunities. Objective To improve residents' procedural output and confidence in abdominal paracentesis, arterial and central venous line placement, nasogastric intubation, and ultrasound-guided peripheral intravenous catheter insertions (USPIV). Methods A novel Resident Procedure Team (RPT) model was created using crowdsourced proficient (having completed ≥5 procedures) near-peers in combination with peer-led USPIV simulation workshops to increase the number of supervising residents available. Procedure logs and the number of residents who became qualified to perform and supervise procedures were tracked from July 2018 to June 2022 and compared before and after the implementation of the RPT in July 2020. Results Implementing the novel RPT model significantly increased the number of procedures performed (1875 procedures post-RPT vs 1292 pre-RPT; P=.02). Abdominal paracentesis increased from 411 to 482 (17.3%), central venous line placement increased from 344 to 401 (16.6%), USPIV increased from 318 to 389 (22.3%), arterial line placement increased from 189 to 360 (90.5%), and nasogastric intubation increased from 30 to 243 (710.0%). Resident confidence levels increased significantly after RPT-led USPIV workshops (P<.05 for all). Conclusions Implementation of a novel, crowdsourced, resident-led procedure team and peer-led USPIV workshops helped increase the number of procedures performed by residents. [ABSTRACT FROM AUTHOR]

Background and Objectives: Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure. Methods: The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained). Results: Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service. Conclusions: A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether the volume of paracentesis for malignant ascites in acute care hospital wards is associated with survival and symptom relief. Methods: Patients with malignant ascites caused by digestive system cancer who underwent paracentesis between January 2010 and April 2022 were retrospectively analyzed from medical records. Collected data included the drainage volume per paracentesis procedure, survival time from the first paracentesis procedure, symptoms, and adverse events. According to the volume per paracentesis procedure, we divided the patients into the "small-drainage" (≤1500 mL) and "standard-drainage" (>1500 mL) groups. Results: The median age of the 144 patients was 69 years, 33% were female, and 64% had gastrointestinal cancer. The median survival from the first paracentesis procedure was 36 days. Eighty-nine (61.8%) and 55 (38.2%) patients were allocated to the small-drainage and standard-drainage groups, respectively. The median number of paracentesis procedures in the small-drainage and standard-drainage groups was 12 and 7, respectively (P =.001). The median survival in the small-drainage and standard-drainage groups was 50 and 44 days, respectively (P =.76). The multivariate analysis showed that the amount of drainage per session was not significantly associated with survival. Symptoms improved similarly in the 2 groups. No serious adverse events were observed. Conclusions: Paracentesis was demonstrated to be effective and safe, irrespective of the amount of fluid drained, for patients with malignant ascites in an acute care hospital. Thus, a strategy of limiting the amount of drainage is not associated with longer survival. [ABSTRACT FROM AUTHOR]

We report a case of a 53-year-old male with decompensated liver cirrhosis secondary to alcohol abuse and hepatitis C infection who was admitted for hemorrhagic shock secondary to upper GI bleed. He underwent a therapeutic paracentesis 17 days after admission with the removal of 6 L of ascitic fluid. The patient became hemodynamically unstable after paracentesis and an acute drop in his hemoglobin was noted. On imaging, he was found to have massive hemoperitoneum secondary to a bleeding mesenteric varix. This is a very rare complication of paracentesis in patients with advanced cirrhosis and should be recognized early in the post-procedure period to initiate prompt life-saving measures to minimize morbidity and mortality.

Background: Large-volume paracentesis is the preferred treatment for patients with severe and refractory ascites. Several complications were reported during therapeutical paracentesis. However, there are very few published studies on the change in blood cell count after paracentesis. This study aimed to evaluate any changes in blood cell counts after ascites fluid drainage. Methods: This study was conducted on patients with severe ascites and chronic liver disease who underwent large-volume paracentesis at Namazi Hospital, in Shiraz, Iran, between March 2021 and February 2022. A data gathering form containing the patient’s medical history, cause of cirrhosis, ascites fluid volume, as well as routine tests including primarily sodium, potassium, and basal creatinine, was filled out. Before and after the surgery, the total blood cell count was measured. Before the procedure, adjustment was made in the case of coagulopathy and albumin deficiency. The effect of factors such as the volume of drained fluid, splenomegaly, antibiotics, and steroid use was assessed on the changes in the number of blood cells. Using the JAMOVI 2.3.9 software, a paired t test and multiple regression were applied for statistical analysis (P0.001).Conclusion: The findings of the present study showed that children with tense ascites who had large-volume paracentesis might experience a sharp drop in blood cell count after the procedure, which was a transient physiological condition.