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Competing Interests: Competing interests: VU and SN are Associate Editors of Regional Anesthesia and Pain Medicine. SN is a Director at Large for the American Society of Regional Anesthesia and Pain Medicine Board of Directors.

Introduction: Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH., Methods: Based on input from committee members and stakeholders, the committee cochairs developed 10 review questions deemed important for the prevention, diagnosis and management of PDPH. A literature search for each question was performed in MEDLINE (Ovid) on 2 March 2022. The results from each search were imported into separate Covidence projects for deduplication and screening, followed by data extraction. Additional relevant clinical trials, systematic reviews and research studies published through March 2022 were also considered for the development of guidelines and shared with contributors. Each group submitted a structured narrative review along with recommendations graded according to the US Preventative Services Task Force grading of evidence. The interim draft was shared electronically, with each collaborator requested to vote anonymously on each recommendation using two rounds of a modified Delphi approach., Results: Based on contemporary evidence and consensus, the multidisciplinary panel generated 50 recommendations to provide guidance regarding risk factors, prevention, diagnosis and management of PDPH, along with their strength and certainty of evidence. After two rounds of voting, we achieved a high level of consensus for all statements and recommendations. Several recommendations had moderate-to-low certainty of evidence., Conclusions: These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified., Competing Interests: Competing interests: VU: Associate editor of the Canadian Journal of Anesthesia. RVS: Consultant for CIVCO Medical systems. GL receives salary support from NIH/ORWH NIH K12HD04344; NIH UH3CA261067; consulting fees from Heron Pharmaceuticals; consulting fees from Octapharma; research funding from Edwards Lifesciences; consulting fees for medical expert testimony; honoraria for lectures; royalties from Cambridge University Press for textbooks. DSD: European Society of Regional Anesthesia and Pain Therapy (ESRA)—council member and past-board member. Romanian Society of Regional Anesthesia and Pain Therapy (ARAR)—chairman. NK: Consultant on the scientific advisory board for Bright Minds Biosciences, received funding for unrelated investigator—initiated study from Nevro Corporation investigating the use of spinal cord stimulation in painful diabetic neuropathy, and received royalties from Up To Date. EM: ESRA President Elect and ESRA Board Member, ESRA Hellas Vice President and Board Member. SER: Affiliated with the DoD, Department of Navy Thomas Volk: Lecture fees from BBraun and Pajunk. SN: Immediate past president ASRA Pain Medicine., (© American Society of Regional Anesthesia & Pain Medicine 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Recent advances in developing disease-modifying therapies (DMT) for Alzheimer's disease (AD), and the recognition that AD pathophysiology emerges decades before clinical symptoms, necessitate a paradigm shift of health-care systems toward biomarker-guided early detection, diagnosis, and therapeutic decision-making. Appropriate incorporation of cerebrospinal fluid biomarker analysis in clinical practice is an essential step toward system readiness for accommodating the demand of AD diagnosis and proper use of DMTs-once they become available. However, the use of lumbar puncture (LP) in individuals with suspected neurodegenerative diseases such as AD is inconsistent, and the perception of its utility and safety differs considerably among medical specialties as well as among regions and countries. This review describes the state-of-the-art evidence concerning the safety profile of LP in older adults, discusses the risk factors for LP-associated adverse events, and provides recommendations and an outlook for optimized use and global implementation of LP in individuals with suspected AD., (© 2021 Eisai, Inc. Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: Neonatal bacterial infections must be bacteriologically confirmed from laboratory samples to best adjust antibiotic therapy. Lumbar puncture (LP) has been recommended for infants younger than 1 month with suspected serious bacterial infection (SBI) to manage possible meningitis. However, the incidence of bacterial meningitis associated with other infections and particularly with urinary tract infections (UTIs) is low. Recourse to systematic LP may be less essential if infants have a UTI. We aimed (a) to determine the management and frequency of bacterial meningitis coexisting with a documented diagnosis of UTI in infants aged < 1 month who had an LP, and (b) to evaluate the management of infants in emergency admissions with suspected SBI while assessing antibiotic treatment., Methods: We conducted a retrospective single-center study from January 2010 to April 2019 including all cases of neonatal bacterial infections, and collected data on the clinical, laboratory, and radiological features., Results: In all, 409 infants were included in the study. Of these, 162 (39.6%) presented with a UTI and eight (2%) had bacterial meningitis. Of the infants diagnosed with UTI, 74.7% had an LP, of whom 34.7% experienced LP complications. No coexistence of UTI and bacterial meningitis was found among infants who had an LP and a documented UTI., Conclusion: Although not all infants had an LP and a urine culture at the same time, these results show that bacterial meningitis coexisting with a confirmed UTI diagnosis in infants is rare. Furthermore, LP can be traumatic in some cases and therefore its utility should be assessed according to the clinical context., Competing Interests: Declaration of Competing Interest The authors declare they have no conflict of interest., (Copyright © 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Background: The cerebrospinal fluid tap test (CSF TT) is used for selecting shunt surgery candidates among patients with idiopathic normal pressure hydrocephalus (iNPH). We aimed to evaluate the predictive value of the CSF TT, by using the Hellström iNPH scale for shunted iNPH patients with a standardized method., Methods: One hundred and sixteen shunt-operated iNPH patients were retrospectively included in this study. The gait and balance domains in the iNPH scale were used as outcome measures for the CSF TT and the total iNPH scale score as the postoperative outcome. A positive response to CSF TT was defined as a change of ≥ 5 points in the gait domain and ≥ 16 points in the balance domain. Differences between CSF TT responders and non-responders, sensitivity, specificity, positive and negative predictive values, accuracy, and correlations between changes from baseline to post CSF TT and from baseline to the postoperative follow-up, were calculated., Results: In the CSF TT there were 63.8% responders in the gait domain and correspondingly 44.3% in the balance domain. CSF TT responders had a significantly better postoperative outcome in the total scale score (gait P ≤ 0.001, balance P ≤ 0.012) and gait CSF TT responders improved more in gait (P ≤ 0.001) and balance CSF TT responders in balance (P ≤ 0.001). No differences between CSF TT gait or balance responders could be found in neuropsychological or urinary continence assessments postoperatively. The sensitivity and specificity of the CSF TT and the outcome of the total iNPH scale score postoperatively were 68.1% and 52.0% for gait and 47.8% and 68.0% for balance, respectively., Conclusions: The CSF TT, with the Hellström iNPH scale as the outcome measure, has clear limitations in predicting postoperative results. The gait domain may be used to predict outcomes for gait, but the balance domain is too insensitive.

Background: While headache is a common neurologic symptom, subarachnoid hemorrhage (SAH) is a rare and potentially catastrophic cause of sudden-onset severe headache. The utility of the imaging modalities and interventional procedures are central to the investigation of the causes of headache; however, they are not without their limitations, risks, and complications., Methods: A meta-analysis in accordance with the Preferred Reporting for Systematic Reviews and Meta-analysis guidelines was conducted searching PubMed, EMBASE, and Google Scholar. Patients investigated for suspected subarachnoid hemorrhage (SAH) with a negative computed tomography (CT) and positive lumbar puncture (LP) and final diagnosis of SAH were included. The sensitivity of LP in the context of a negative CT and vsubsequent imaging confirming the cause of SAH (computed tomography angiography, magnetic resonance angiography, digital subtraction angiography [DSA]) was quantified. The pooled data were analyzed using the DerSimonian-Laid random effects model., Results: Four studies with 2782 patients who presented with headache suspicious for SAH were included with an initial negative CT report and a subsequent LP to rule out SAH. All included studies had an observational prospective cohort design. A combined pooled proportion of 0.383 (0.077, 0.756); 0.086 (0.007, 0.238); and 0.22 (0.04, 0.49) for LP+, DSA+, and DSA/computed tomography angiography+ investigations were estimated with a 95% confidence interval., Conclusions: The current clinical workflow of an LP after a negative CT head for a patient presenting with a sudden-onset severe headache is observed to have a high enough proportion to warrant its continued use despite the sensitivity of modern CT scanners of ≥97%., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The main objective of this study was to compare cerebrospinal fluid (CSF) collection time and patient's discomfort between 20G (a)traumatic and 22G atraumatic needles., Background: Risk of post-dural puncture headache (PDPH) is decreased using atraumatic needles. Smaller needles may give lower risk but possibly at the cost of increased CSF collection time (due to lower flow), leading to additional patient's discomfort., Methods: We performed a retrospective study of lumbar puncture data from a research program on CSF metabolomics and compared traumatic 20G (n = 210) with atraumatic 20G (n = 39) and 22G (n = 105) needles. In this cohort, incidence of PDPH was prospectively registered with other procedure details. Primary outcome was CSF collection time (time to fill the tube). Secondary outcomes were pain and stress scores during procedure, and incidence of PDPH., Results: The time to collect 10 mL of CSF was longer for 22G needles (6.1 minutes; 95% CI 5.8-6.5) than for 20G traumatic (2.2 minutes; 95% CI 2.1-2.2) and 20G atraumatic needles (2.9 minutes; 95% CI 2.8-3.1). There were no differences in pain and stress scores. PDPH was lower for 22G atraumatic needles: odds ratio 0.41 (95% CI 0.25-0.66) versus 20G traumatic needles and 0.53 (95% CI 0.40-0.69) versus 20G atraumatic needles. Absolute PDPH rates were 69/210 (32.9%) for 20G traumatic, 13/39 (33.3%) for 20G atraumatic, and 19/105 (18.1%) for 22G atraumatic needles., Conclusions: CSF collection time is slightly longer for smaller 22G needles, but this does not lead to more discomfort for the patient., (© 2021 The Authors. Headache: The Journal of Head and Face Pain published by Wiley Periodicals LLC on behalf of American Headache Society.)

Background: Our objectives were to determine the prevalence of and to identify risk factors for coexisting bacterial meningitis (BM) in neonates with urinary tract infection (UTI)., Methods: A cross-sectional study was conducted at pediatric emergency department of a tertiary teaching hospital from 2001 to 2017. Infants <29 days of age with UTI (≥10,000 colony-forming units/mL of a single pathogen from a catheterized specimen in association with positive urinalysis) were included. Definite BM was defined as growth of a single bacterial pathogen from a cerebrospinal fluid (CSF) sample and probable BM as (1) positive blood culture with CSF pleocytosis and treatment consistent with BM or (2) antibiotic pretreatment before lumbar puncture, CSF pleocytosis and treatment consistent with BM. Univariate testing was used to identify possible risk factors associated with BM. Receiver operating characteristics curves were constructed for the laboratory markers associated with BM., Results: Three hundred seventy-one infants were included. Five [1.3%; 95% confidence interval (CI): 0.6%-3.1%] had BM: 4 definite BM and 1 probable BM. Risk factors detected for BM were classified as not being well-appearing and a procalcitonin value ≥0.35 ng/mL [sensitivity of 100% (95% CI: 56.6%-100%) and negative predictive value of 100% (95% CI: 96.1%-100%)]., Conclusions: Coexisting BM occurs uncommonly in neonates with UTI. Well-appearing neonates with UTI and procalcitonin value <0.35 ng/mL were at very low risk for BM; avoiding routine lumbar puncture in these patients should be considered.

Objective: Lumbar punctures (LPs) are important for obtaining CSF in neurology studies but are associated with adverse events and feared by many patients. We determined adverse event rates and pain scores in patients prospectively enrolled in two cohort studies who underwent LPs using a standardized protocol and 25 g needle., Methods: Eight hundred and nine LPs performed in 262 patients age ≥ 60 years in the MADCO-PC and INTUIT studies were analyzed. Medical records were monitored for LP-related adverse events, and patients were queried about subjective complaints. We analyzed adverse event rates, including headaches and pain scores., Results: There were 22 adverse events among 809 LPs performed, a rate of 2.72% (95% CI 1.71-4.09%). Patient hospital stay did not increase due to adverse events. Four patients (0.49%) developed a post-lumbar puncture headache (PLPH). Twelve patients (1.48%) developed nausea, vasovagal responses, or headaches that did not meet PLPH criteria. Six patients (0.74%) reported lower back pain at the LP site not associated with muscular weakness or paresthesia. The median pain score was 1 [0, 3]; the mode was 0 out of 10., Conclusions: The LP protocol described herein may reduce adverse event rates and improve patient comfort in future studies.

Objectives: Though the Japanese version of the Montreal Cognitive Assessment (MoCA-J) scores change after a cerebrospinal fluid tap test (CSFTT), their characteristics remain unclear. To compare patient response rate to changes in cognitive function observed in the cerebrospinal fluid tap test, and to determine which group of patients were good responders., Patients and Methods: This study included 32 patients who were suspected of having idiopathic normal pressure hydrocephalus (iNPH) between May 2017 and October 2018. Cases were divided into, following a CSFTT, a gait responder group and a non-responder group. Scores of the MoCA-J were compared and examined before, one day after, and one week after the CSFTT., Results: Significant changes in MoCA-J scores were observed 1 day and 1 week after the CSFTT in the gait responder group. The change in scores was larger, and had a larger effect size, one week after the CSFTT. On assessment, MoCA-J sub-items began to show changes in attention and abstract items one day after the CSFTT, and significant changes were noted in attention and abstract items in addition to executive functions and orientation one week after the CSFTT. The degree of cognitive function before the CSFTT was less closely related to the amount of change. Changes in cognitive function can be assessed at each time point after the CSFTT, and changes in cognitive function are measured regardless of the level of cognitive function., Conclusion: These results suggest that evaluating patients with the MoCA-J may potentially support a more accurate iNPH diagnosis., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Executive Summary: When ultrasound equipment is available, along with providers who are appropriately trained to use it, we recommend that ultrasound guidance should be used for site selection of lumbar puncture to reduce the number of needle insertion attempts and needle redirections and increase the overall procedure success rates, especially in patients who are obese or have difficult-to-palpate landmarks. We recommend that ultrasound should be used to more accurately identify the lumbar spine level than physical examination in both obese and nonobese patients. We suggest using ultrasound for selecting and marking a needle insertion site just before performing lumbar puncture in either a lateral decubitus or sitting position. The patient should remain in the same position after marking the needle insertion site. We recommend that a low-frequency transducer, preferably a curvilinear array transducer, should be used to evaluate the lumbar spine and mark a needle insertion site. A high-frequency linear array transducer may be used in nonobese patients. We recommend that ultrasound should be used to map the lumbar spine, starting at the level of the sacrum and sliding the transducer cephalad, sequentially identifying the lumbar spine interspaces. We recommend that ultrasound should be used in a transverse plane to mark the midline of the lumbar spine and in a longitudinal plane to mark the interspinous spaces. The intersection of these two lines marks the needle insertion site. We recommend that ultrasound should be used during a preprocedural evaluation to measure the distance from the skin surface to the ligamentum flavum from a longitudinal paramedian view to estimate the needle insertion depth and ensure that a spinal needle of adequate length is used. We recommend that novices should undergo simulation-based training, where available, before attempting ultrasound-guided lumbar puncture on actual patients. We recommend that training in ultrasound-guided lumbar puncture should be adapted based on prior ultrasound experience, as learning curves will vary. We recommend that novice providers should be supervised when performing ultrasound-guided lumbar puncture before performing the procedure independently on patients.

Objective: To evaluate safety of stylet-in and stylet-out techniques for collection of CSF from the cisterna magna and to assess whether there were differences between techniques with regard to contamination of samples, sample quality, and efficiency of collection., Animals: 10 adult purpose-bred research Beagles., Procedures: A prospective crossover study was conducted. Preanesthetic physical and neurologic examinations and hematologic analyses were performed. Dogs were anesthetized, and collection of CSF samples from the cisterna magna by use of a stylet-in or stylet-out technique was performed. Two weeks later, samples were collected with the other sample collection technique. Samples of CSF were processed within 1 hour after collection., Results: Cellular debris was detected in higher numbers in stylet-in samples, although this did not affect sample quality. The stylet-out technique was performed more rapidly. No adverse effects were detected for either technique., Conclusions and Clinical Relevance: Both techniques could be safely performed in healthy anesthetized dogs. The stylet-out technique was performed more rapidly and yielded a sample with less cellular debris. Both techniques can be used in clinical practice to yield CSF samples with good diagnostic quality.

Background: Curricular constraints require being selective about the type of content trainees practice in their formal training. Teaching trainees procedural knowledge about "how" to perform steps of a skill along with conceptual knowledge about "why" each step is performed can support skill retention and transfer (i.e., the ability to adapt knowledge to novel problems). However, how best to organize how and why content for procedural skills training is unknown., Objectives: We examined the impact of different approaches to integrating why and how content on trainees' skill retention and transfer of simulation-based lumbar puncture (LP)., Design and Participants: We randomized medical students (N = 66) to practice LP for 1 h using one of three videos. One video presented only the how content for LP (Procedural Only). Two other videos presented how and why content (e.g., anatomy) in two ways: Integrated in Sequence, with why content followed by how content, or Integrated for Causation, with how and why content integrated throughout., Main Measures: Pairs of blinded raters scored participants' retention and transfer LP performances on a global rating scale (GRS), and written tests assessed participants' procedural and conceptual knowledge., Key Results: Simple mediation regression analyses showed that participants receiving an integrated instructional video performed significantly better on transfer through their intervention's positive impact on conceptual knowledge (all p < 0.01). Further, the Integrated for Causation group performed significantly better on transfer than the Integrated in Sequence group (p < 0.01), again mediated by improved conceptual knowledge. We observed no mediation of participants' skill retention (all p > 0.01)., Conclusions: When teaching supports cognitive integration of how and why content, trainees are able to transfer learning to new problems because of their improved conceptual understanding. Instructional designs for procedural skills that integrate how and why content can help educators optimize what trainees learn from each repetition of practice.

Objectives: There is wide variation in the decision of whether to perform lumbar punctures (LPs) on well-appearing febrile infants ≤8 weeks old. Our objectives were to identify factors that influence that decision and the barriers and facilitators to shared decision-making about LP with parents of febrile infants., Methods: We conducted semistructured interviews with 15 pediatric and general emergency medicine physicians and 8 pediatric emergency medicine nurses at an urban, academic medical center. Through interviews, we assessed physicians' practices and physicians' and nurses' perspectives about communication and decision-making with parents of febrile infants. Two researchers independently reviewed the transcripts, coded the data using the constant comparative method, and identified themes., Results: Five themes emerged for factors that influence physicians' decisions about whether to perform an LP: (1) the age of the infant; (2) the physician's clinical experience; (3) the physician's use of research findings; (4) the physician's values, particularly risk aversion; and (5) the role of the primary care pediatrician. Barriers and facilitators to shared decision-making identified by physicians and by nurses included factors related to their perceptions of parents' understanding and acceptance of risks, parents' emotions, physicians' assessment of whether there is clinical equipoise, and availability of follow-up with the primary care pediatrician., Conclusions: Differences in physicians' values, use of research findings, and clinical experience likely contribute to decisions of whether to perform an LP on well-appearing febrile infants. Incorporation of parents' preferences through shared decision-making may be indicated, although there are barriers that would need to be overcome., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Introduction of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to a substantial reduction in cases of acute bacterial meningitis in countries with high routine childhood immunization coverage. The majority of children hospitalized with meningitis in high-income countries have viral or aseptic meningitis and do not require antibiotic treatment. Cerebrospinal fluid analysis is irreplaceable in appropriately diagnosing and treating bacterial meningitis and avoiding unnecessary antibiotics and prolonged hospitalizations in children with viral meningitis. New diagnostic tests have improved detection of bacterial and viral pathogens in cerebrospinal fluid, underscoring the importance of promptly performing lumbar puncture when meningitis is suspected. This article provides an overview of acute bacterial and viral meningitis in children, focusing on the changing epidemiology, the advantages and limitations of conventional and newer diagnostic methods, and considerations for clinical practice.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential conflicts of interest to disclose.

Background: Low levels of success in performing lumbar puncture have been observed among paediatric trainees. This study assessed the efficacy of simulation-based education with frequency building and precision teaching for training lumbar puncture to behavioural fluency., Methods: The intervention group was assessed at baseline, at the final training trial, in the presence of distraction, and a minimum of one month after the cessation of the intervention in order to ascertain whether behavioural fluency in lumbar puncture was obtained. Subsequently, the performance of this intervention group (10 paediatric senior house officers) was compared to the performance of a comparator group of 10 more senior colleagues (paediatric registrars) who had not received the intervention. Retrospective chart audit was utilised to examine performance in the clinical setting., Results: Intervention group participants required a mean of 5 trials to achieve fluency. Performance accuracy was significantly higher in the intervention group than the comparator group. Learning was retained at follow-up and persisted during distraction. Retrospective chart audit revealed no significant difference between the performance of the intervention group and a comparator group, comprised of more senior physicians, in the clinical setting, although the interpretation of these analyses are limited by a low number of lumbar punctures performed in the clinical setting., Conclusions: The programme of simulation-based education with frequency building and precision teaching delivered produced behavioural fluency in lumbar puncture among paediatric trainees. Following the intervention, the performance of these participants was equivalent to, or greater than, that of senior paediatricians. This study supports the need for further research exploring the effectiveness of simulation-based education with precision teaching to train procedural skills to fluency, and the consideration of how best to explore the impact of these on patient outcomes.

To investigate the role of lumbar puncture (LP) after a negative head computed tomography (CT) when ruling out subarachnoid hemorrhage (SAH) within 24 h of symptom onset. In a single-center, retrospective cohort study, we studied a consecutive series of patients from 2011 to 2015. All patients underwent CT or CT following LP to rule out SAH. Patients were categorized into four groups depending on the time of symptom onset to initial head CT: 0-6 h, 6-12 h, 12-24 h, and over 24 h. Experienced radiologists interpreted all CT scans. We investigated the sensitivity, specificity, and negative predictive value (NPV) of noncontrast CT in detecting SAH. Of 539 patients with suspected SAH and negative CT, 280 (51.9%) had their CT performed within 24 h of symptom onset. None of these patients had SAH. Five (1.9%) out of 259 patients with CT performed after 24 h of symptom onset had SAH diagnosed, and two turned out to be aneurysmal. When CT was performed within 24 h of symptom onset it had a sensitivity of 100% (95% CI 95-100%), specificity of 98% (95% CI 96-99.7%), and NPV of 100% (95% CI 98-100%) in detecting SAH. Modern CT scanners seem to have high sensitivity and specificity in the diagnosis of SAH when performed within 24 h of symptom onset. Beyond this point, CT seems to lack sensitivity and further investigation with LP is required.

Background: Serious bacterial infections in young infants with bronchiolitis are rare. Febrile infants <1 month old with bronchiolitis often receive a lumbar puncture (LP), despite limited data for this practice and lack of clinical practice guidelines for this population. The primary objective was to investigate practice patterns in performance of LPs in the ED management of febrile infants aged ≤30 days with bronchiolitis., Methods: A cross-sectional survey of two national paediatric emergency research networks (PediatricEmergency Research Canada (PERC) and the PediatricEmergency Research UK/Ireland (PERUKI)) was conducted January to November 2017 using a modified Dillman technique. The survey was preceded by a clinical vignette describing a well appearing, 21-day-old infant with low-grade fever, respiratory findings typical of bronchiolitis and no perinatal serious bacterial infection (SBI) risk features., Results: The response rate from PERC was 169/250 (68%) and 172/201 (86%) from PERUKI. Nine physicians in training were excluded, leaving 332 eligible participants. Although most physicians believe that neonates with bronchiolitis rarely have meningitis (PERC 141/161 (87.6%); PERUKI 154/171 (90%)) and feel comfortable diagnosing bronchiolitis in this group (PERC 136/161 (84.5%); PERUKI 143/171 (83.6%)), there was significant variation in the proportion who would be likely/very likely to perform an LP (PERC 100/161 (62.1%); PERUKI 15/171 (8.8%)) (p<0.0001). Practice in Canada, <10 years in practice and lack of comfort with diagnosing bronchiolitis represent multivariable predictors of LP; OR 23.7 (95% CI 11.7 to 47.9), 2.3 (95% CI 1.2 to 4.2) and 2.5 (95% CI 1.1 to 5.0), respectively. Rapid knowledge of respiratory syncytial virus positivity would decrease LP probability from 35.4% to 20.2%., Conclusion: Estimated probability of performing LPs and other interventions in otherwise healthy febrile neonates with bronchiolitis is highly variable between emergency physicians in Canada and the UK/Ireland. Network, <10 years in ED practice and comfort level with diagnosing bronchiolitis in newborns constitute independent predictors of the likelihood of LP performance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To determine the outcome of ventriculo-peritoneal shunts as a treatment for idiopathic intracranial hypertension (IIH) Materials and Methods: Retrospective case series of 28 patients with IIH and evidence of raised intracranial pressure (ICP) who underwent shunt insertion. Patients were identified from a prospectively updated operative database. A case-notes review was performed and data on type of shunt, pre- and post-operative symptoms, ophthalmological findings and post-operative complications were recorded., Results: All patients had symptoms of IIH that had failed medical management. Twelve patients had previous lumbo-peritoneal shunts and 2 patients had previous venous sinus stents. All patients had evidence of raised ICP as papilloedema and raised CSF pressure on lumbar puncture. Twenty-seven patients received a ventriculo-peritoneal shunt and 1 patient a ventriculo-atrial shunt. Twenty-six patients received Orbis Sigma Valves and 2 patients Strata valves. At follow-up all patients (100%) had improvement/resolution of papilloedema, 93% had improved visual acuity and 84% had improved headaches. Mean time to last follow-up was 15 (range 4-96) months. Complications occurred in 3 patients (11%): 2 patients required revision of their peritoneal catheters and 1 patient had an anti-siphon device inserted., Conclusions: Previous literature reported a ventricular shunt revision rate of 22-42% in the management of IIH. We demonstrate ventriculo-peritoneal shunts to be an effective treatment with a revision rate of 11% compared to the previously reported 22-42%.

Background and Objectives: Potentially broadened indications for spinal anesthesia require increased understanding of the risk factors and prevention measures associated with postdural puncture headache (PDPH). This review is designed to examine the association between spinal needle characteristics and incidence of PDPH., Methods: Meta-analysis and metaregression was performed on randomized controlled trials to determine the effect of needle design and gauge on the incidence of PDPH after controlling for patient confounders such as age, sex, and year of publication., Results: Fifty-seven randomized controlled trials (n = 16416) were included in our analysis, of which 32 compared pencil-point design with cutting-needle design and 25 compared individual gauges of similar design. Pencil-point design was associated with a statistically significant reduction in incidence of PDPH (risk ratio, 0.41; 95% confidence interval, 0.31-0.54; P < 0.001; I = 29%) compared with cutting needles among studies that assessed both design types. Subgroup analysis among obstetric and nonobstetric procedures yielded similar results. After adjustment for significant covariates, metaregression analysis among all 57 included trials revealed a significant correlation between needle gauge and rate of PDPH among cutting needles (slope = -2.65, P < 0.001), but not pencil-point needles (slope = -0.01, P = 0.819)., Conclusions: Pencil-point needles are associated with significantly lower incidence of PDPH compared with the cutting-needle design. Whereas a significant relationship was noted between needle gauge and PDPH for cutting-needle design, a similar association was not shown for pencil-point needles. Providers may consider selection of larger-caliber pencil-point needle to maximize technical proficiency without expensing increased rates of PDPH.

Background: Lumbar puncture is a common procedure in many specialties. The procedure serves to diagnose life-threatening conditions, often requiring rapid performance. However, junior doctors possess uncertainties regarding performing the procedure and frequently perform below expectations. Hence, proper training and assessment of performance is crucial before entering clinical practice., Objective: To develop and collect validity evidence for an assessment tool for lumbar puncture performance, including a standard to determine when trainees are ready for clinical practice., Design: Development of a new tool, based on clinician interviews and a literature review, was followed by an explorative study to gather validity evidence., Participants and Main Measures: We interviewed 12 clinicians from different specialties. The assessment tool was used to assess 11 doctors at the advanced beginners' level and 18 novices performing the procedure in a simulated, ward-like setting with a standardized patient. Procedural performance was assessed by three content experts. We used generalizability theory to explore reliability. The discriminative ability of the tool was explored by comparing performance scores between the two groups. The contrasting groups method was used to set a pass/fail standard and the consequences of this was explored., Key Results: The interviews identified that in addition to the technical aspects of the procedure, non-technical elements involving planning and conducting the procedure are important. Cronbach's alpha = 0.92, Generalizability-coefficient was 0.88 and a Decision-study found one rater was sufficient for low-stakes assessments (G-coefficient 0.71). The discriminative ability was confirmed by a significant difference between the mean scores of novices, 40.9 (SD 6.1) and of advanced beginners, 47.8 (SD 4.0), p = 0.004. A standard of 44.0 was established which was consistent with the raters' global judgments of pass/fail., Conclusion: We developed and demonstrated strong validity evidence for the lumbar puncture assessment tool. The tool can be used to assess readiness for practice.

Objective: The objective of the study was to identify any differences between emergency physicians and emergency trainees and paediatricians and paediatric trainees in performing paediatric lumbar punctures (LPs)., Methods: Anonymous cross-sectional electronic survey was distributed to emergency physicians, emergency trainees, paediatricians and paediatric trainees within three hospitals of a single public health network. There were four standardised clinical scenarios (neonate, infant, young child and adolescent), with accompanying questions relating to neurological evaluation and imaging prior to LP, the use of written consent forms and parental presence during the procedure., Results: Paediatricians and paediatric trainees have greater confidence performing LP on neonates and infants, while emergency physicians and emergency trainees are more confident in older children. The only differences in self-reported neurological examination prior to LP was paediatricians and paediatric trainees being more likely to perform fundoscopy than were emergency physicians and emergency trainees in infants (21% vs 8%, P = 0.03) and young children (44% vs 16%, P < 0.001). Less than half of both groups of doctors would obtain written consent for paediatric LPs. Emergency physicians and emergency trainees were much more likely to encourage parents to remain in the room during the procedure than their paediatric counterparts (95% vs 37%, P < 0.0001)., Conclusion: Paediatricians and paediatric trainees are more likely to be confident in performing LP in very young children than are emergency physicians and emergency trainees. They are more likely to perform fundoscopy prior to the procedure, but are much less likely to encourage parental presence during the LP., (© 2017 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objectives: Suspected cerebrospinal fluid shunt (CSF) dysfunction in hydrocephalic patients poses a diagnostic uncertainty. The clinical picture can be non-specific and CT imaging alone is not always pathognomonic. Infusion tests are an increasingly used investigation for real-time hydrodynamic assessment of shunt patency. We report the correlation between infusion test results with the quality of ventricular drain placement on CT scans in a large retrospective group of hydrocephalic patients., Materials & Methods: Three hundred and six infusion test results performed in 200 patients were correlated with 306 corresponding CT head scans. Nominal logistic regression was used to correlate shunt catheter position on CT imaging to patency of ventricular drain as determined by infusion tests., Results: Infusion test results of shunt patency are statistically congruent with the analysis of shunt catheter position on CT head scans. Catheter tips completely surrounded by either parenchyma or CSF on CT imaging are strongly associated with evidence of occlusion or patency from infusion tests, respectively (χ² = 51.68, P < 0.0001, n = 306 and χ² = 31.04, P < 0.0001, n = 306)., Conclusions: The most important anatomical factor for shunt patency is the catheter tip being completely surrounded by CSF. Infusion tests provide functional and reliable assessment of shunt patency in vivo and are strongly correlated with the position of the ventricular catheter on CT imaging., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

We sought to establish a guide for identifying fellowship competency in performing fluoroscopically guided lumbar punctures. With a linear mixed-effects model, we compared the fluoroscopy time between the first and last 3 months of neuroradiology training. During 7 years, 55 fellows performed 1142 and 861 lumbar punctures in the first and last quarters of training. A target fluoroscopy time of 0.26 minutes, the upper 95% confidence interval, can serve as a fellowship benchmark for successfully achieving competence in fluoroscopically guided lumbar punctures., (© 2017 by American Journal of Neuroradiology.)

Objectives: The cerebrospinal fluid tap test for idiopathic normal pressure hydrocephalus (iNPH) is one of the good predictors of the shunt treatment, although this test has a low sensitivity. We aimed to identify key parameters that could be used to improve this sensitivity., Materials & Methods: During 2010-2011, we recruited and then followed 93 patients with possible iNPH for 12 months after shunt. Among them, 82 patients were finally enrolled in this study. The modified Rankin Scale, iNPH grading scale, and several quantitative measurements were evaluated at entry, after the tap test, before and after shunt. Area under the receiver-operating characteristic curves (AUCs), sensitivities, and specificities of the tap test for predicting shunt effectiveness were calculated for each measurement. They were additionally assessed after stratification by disease duration since the initial presentation of iNPH symptoms., Results: The gait disturbance on the iNPH grading scale had the highest accurate scale at the tap test for predicting effectiveness 12 months after shunt: AUC 0.74, sensitivity 56.5%, specificity 91.7%. This AUC increased to 0.76, 0.91 and 0.94 in the subgroup of disease duration <24, <12, and <6 months, respectively. The sensitivity and specificity of the gait disturbance on the iNPH grading scale in the subgroup of <12 months' duration were 92.3% and 90.0%., Conclusions: The shorter period of clinical symptoms, for example, <12 months, made the tap test sufficiently accurate examination for predicting improvement 12 months after shunt surgery. The findings imply that the tap test should be applied to patients being considered for shunt surgery as soon as possible., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: The aims of this study were to provide validity evidence for infant lumbar puncture (ILP) checklist and global rating scale (GRS) instruments when used by residents to assess simulated ILP performances and to compare these metrics to previously obtained attending rater data., Methods: In 2009, the International Network for Simulation-based Pediatric Innovation, Research, and Education (INSPIRE) developed checklist and GRS scoring instruments, which were previously validated among attending raters when used to assess simulated ILP performances. Video recordings of 60 subjects performing an LP on an infant simulator were collected; 20 performed by subjects in 3 categories (beginner, intermediate, and expert). Six blinded pediatric residents independently scored each performance (3 via the GRS, 3 via the checklist). Four of the 5 domains of validity evidence were collected: content, response process, internal structure (reliability and discriminant validity), and relations to other variables., Results: Evidence for content and response process validity is presented. When used by residents, the checklist performed similarly to what was found for attending raters demonstrating good internal consistency (Cronbach α = 0.77) and moderate interrater agreement (intraclass correlation coefficient = 0.47). Residents successfully discerned beginners (P < 0.01, effect size = 2.1) but failed to discriminate between expert and intermediate subjects (P = 0.68, effect size = 0.34). Residents, however, gave significantly higher GRS scores than attending raters across all subject groups (P < 0.001). Moderate correlation was found between GRS and total checklist scores (P = 0.49, P < 0.01)., Conclusions: This study provides validity evidence for the checklist instrument when used by pediatric residents to assess ILP performances. Compared with attending raters, residents appeared to over-score subjects on the GRS instrument.

Cerebrospinal fluid (CSF) is an extremely useful matrix for biomarker research for several purposes, such as diagnosis, prognosis, monitoring, and identification of prominent leads in pathways of neurologic diseases. Such biomarkers can be identified based on a priori hypotheses around prominent protein changes, but also by applying -omics technologies. Proteomics is widely used, but metabolomics and transcriptomics are rapidly revealing their potential for CSF studies. The basis of such studies is the availability of high-quality biobanks. Furthermore, profound knowledge and consequent optimization of all aspects in biomarker development are needed. Here we discuss current knowledge and recently developed protocols for successful biomarker studies, from collection of CSF by lumbar puncture, processing, and biobanking protocols, preanalytic confounding factors, and cost-efficient development and validation of assays for implementation into clinical practice or research., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: The objective was to determine the testing threshold for lumbar puncture (LP) in the evaluation of aneurysmal subarachnoid hemorrhage (SAH) after a negative head computed tomography (CT). As a secondary aim we sought to identify clinical variables that have the greatest impact on this threshold., Methods: A decision analytic model was developed to estimate the testing threshold for patients with normal neurologic findings, being evaluated for SAH, after a negative CT of the head. The testing threshold was calculated as the pretest probability of disease where the two strategies (LP or no LP) are balanced in terms of quality-adjusted life-years. Two-way and probabilistic sensitivity analyses (PSAs) were performed., Results: For the base-case scenario the testing threshold for performing an LP after negative head CT was 4.3%. Results for the two-way sensitivity analyses demonstrated that the test threshold ranged from 1.9% to 15.6%, dominated by the uncertainty in the probability of death from initial missed SAH. In the PSA the mean testing threshold was 4.3% (95% confidence interval = 1.4% to 9.3%). Other significant variables in the model included probability of aneurysmal versus nonaneurysmal SAH after negative head CT, probability of long-term morbidity from initial missed SAH, and probability of renal failure from contrast-induced nephropathy., Conclusions: Our decision analysis results suggest a testing threshold for LP after negative CT to be approximately 4.3%, with a range of 1.4% to 9.3% on robust PSA. In light of these data, and considering the low probability of aneurysmal SAH after a negative CT, classical teaching and current guidelines addressing testing for SAH should be revisited., (© 2016 by the Society for Academic Emergency Medicine.)

Background: Ultrasound (US) can be used to improve lumbar puncture (LP) success. How to achieve competency in LP US has not been defined. Cumulative sum statistics (CUSUM) characterized competency acquisition in other skills., Objectives: Identify the learning curve for 80% success rate in LP US insertion site (IS) identification among pediatric emergency medicine fellows., Methods: This prospective study took place in a single pediatric emergency department. Fellows with limited ultrasound experience received didactics, training, and three proctored examinations. Skills were evaluated in three 2-h sessions: using US, subjects identified LP ISs on a convenience sample of patients ages 0-20 years old. Subjects' IS markings were compared to markings by an expert, an emergency US fellowship-trained attending. Successful IS identification was defined as markings within 2 mm or 5 mm of the expert mark in infants and older children, respectively. A second expert marked 17 cases for interrater agreement. CUSUM was used to analyze individual learning curves., Results: Five fellows evaluated 72 patients (mean age 11.4 years [SD = 4, range 3-20], mean body mass index 20.5 [SD = 4.4, range 13.1-37.7]) over a 3-month period. Mean number of attempts per fellow was 14.4 ± 3.1 (R 11-19); mean time to landmark identification was 72 ± 46 s (R 27-240). The two experts demonstrated 100% observed agreement. Aggregate success rate for all fellows was 75% (54/72). Four fellows showed learning curves that trended toward, but did not achieve, the acceptable success rate of 80%., Conclusions: Nineteen attempts are insufficient among fellows to achieve competency in US-guided LP IS identification., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Headache is a common chief complaint in emergency departments, accounting for 2% of visits, and subarachnoid hemorrhage (SAH) is a life-threating cause of headache. This deadly disease is most commonly due to aneurysmal rupture. Various approaches exist for diagnosis, with recent studies evaluating these approaches. A great deal of controversy exists about the optimal diagnosis strategy for SAH., Objective: This article in the Best Clinical Practice Series seeks to educate emergency physicians on the recent literature in the diagnosis of SAH and provide an evidence-based approach., Discussion: Various diagnostic strategies exist, including use of noncontrast head computed tomography (CT) alone, CT/lumbar puncture (LP) in combination, CT/CT angiography, and magnetic resonance imaging/magnetic resonance angiography. The use of clinical decision rules has also been espoused, and several contemporary studies have evaluated cerebrospinal fluid results of red blood cell count and xanthochromia in the diagnosis of SAH. Recent literature supports that a negative head CT done within 6 h of headache onset places the patient at a < 1% risk for SAH. With the complex literature, a shared decision-making model should be followed with options, risks, and benefits discussed with the patient., Conclusions: Literature support exists for all of the diagnostic strategies. The American College of Emergency Physicians Clinical Policy supports CT and LP for definitive diagnosis. Risk stratification and a shared decision-making model with the patient should be followed, and a negative head CT within 6 h of headache onset places patient at a risk of < 1% for having SAH., (Published by Elsevier Inc.)

Context: Checklists are commonly used in the assessment of procedural competence. However, on most checklists, high scores are often unable to rule out incompetence as the commission of a few serious procedural errors typically results in only a minimal reduction in performance score. We hypothesised that checklists constructed based on procedural errors may be better at identifying incompetence., Objectives: This study sought to compare the efficacy of an error-focused checklist and a conventionally constructed checklist in identifying procedural incompetence., Methods: We constructed a 15-item error-focused checklist for lumbar puncture (LP) based on input from 13 experts in four Canadian academic centres, using a modified Delphi approach, over three rounds of survey. Ratings of 18 video-recorded performances of LP on simulators using the error-focused tool were compared with ratings obtained using a published conventional 21-item checklist. Competence/incompetence decisions were based on global assessment. Diagnostic accuracy was estimated using the area under the curve (AUC) in receiver operating characteristic analyses., Results: The accuracy of the conventional checklist in identifying incompetence was low (AUC 0.11, 95% confidence interval [CI] 0.00-0.28) in comparison with that of the error-focused checklist (AUC 0.85, 95% CI 0.67-1.00). The internal consistency of the error-focused checklist was lower than that of the conventional checklist (α = 0.35 and α = 0.79, respectively). The inter-rater reliability of both tools was high (conventional checklist: intraclass correlation coefficient [ICC] 0.99, 95% CI 0.98-1.00; error-focused checklist: ICC 0.92, 95% CI 0.68-0.98)., Conclusions: Despite higher internal consistency and inter-rater reliability, the conventional checklist was less accurate at identifying procedural incompetence. For assessments in which it is important to identify procedural incompetence, we recommend the use of an error-focused checklist., (© 2015 The Authors Medical Education Published by John Wiley & Sons Ltd.)

Objectives: Over the last decade, computed tomography scanners have gained resolution and have become the standard of care in the investigation of neurologically intact patients suffering from acute headache. The added value of the combined assessment of red blood cells count, visual and spectrophotometric xanthochromia, to detect ruptured aneurysmal subarachnoid hemorrhage (ASAH) following a negative head computed tomography (NHCT) was studied., Methods: The population consisted of all patients who had cerebrospinal fluid tested for spectrophotometric xanthochromia between 2003 and 2009 identified through the clinical-laboratory database and who met all the inclusion criteria: >14 years old, had an initial Glasgow Coma Score of 15, a non-traumatic acute headache with a suspected subarachnoid hemorrhage recorded in the initial ED differential diagnosis and an initial negative head CT scan., Results: A total of 706 patients were included. LP identified 5 ASAH (prevalence: 0.7%). In these patients, LP parameters were as follows: high red blood cell count (from 1310 to 63,000×10(6)/L), positive visual xanthochromia in 4 out of 5 ASAH, and positive spectrophotometric xanthochromia in 5 out of 5 ASAH. All ASAH patients were neurologically intact after intervention. No deaths or missed ASAH were reported. Angiographies were performed on 127 patients (19.5%) of which 47 (34.1%) had positive xanthochromia (visual or spectrophotometric)., Conclusions: Considering the low prevalence of ASAH following an NHCT, intense resources were utilized to identify all 5 ASAH. Lumbar puncture analyses combining red blood cell count, visual and spectrophotometric xanthochromia identified all ASAH, allowing intervention and a positive clinical outcome. Our data support 1) that LP identifies the presence of a ruptured ASAH after an NHCT and 2)` that a guide to define a subpopulation of patients who would benefit from a lumbar puncture after an NHCT would be desirable., (Copyright © 2015. Published by Elsevier Inc.)

Objective: The aim of this study was to assess the feasibility of incorporating the Delphi process within the simplifying conditions method (SCM) described in elaboration theory (ET) to identify conditions impacting the complexity of procedural skills for novice learners., Methods: We generated an initial list of conditions impacting the complexity of lumbar puncture (LP) from key informant interviews (n = 5) and a literature review. Eighteen clinician-educators from six different medical specialties were subsequently recruited as expert panellists. Over three Delphi rounds, these panellists rated: (i) their agreement with the inclusion of the simple version of the conditions in a representative ('epitome') training scenario, and (ii) how much the inverse (complex) version increases LP complexity for a novice. Cronbach's α-values were used to assess inter-rater agreement., Results: All panellists completed Rounds 1 and 2 of the survey and 17 completed Round 3. In Round 1, Cronbach's α-values were 0.89 and 0.94 for conditions that simplify and increase LP complexity, respectively; both values increased to 0.98 in Rounds 2 and 3. With the exception of 'high CSF (cerebral spinal fluid) pressure', panellists agreed with the inclusion of all conditions in the simplest (epitome) training scenario. Panellists rated patient movement, spinal anatomy, patient cooperativeness, body habitus, and the presence or absence of an experienced assistant as having the greatest impact on the complexity of LP., Conclusions: This study demonstrated the feasibility of using expert consensus to establish conditions impacting the complexity of procedural skills, and the benefits of incorporating the Delphi method into the SCM. These data can be used to develop and sequence simulation scenarios in a progressively challenging manner. If the theorised learning gains associated with ET are realised, the methods described in this study may be applied to the design of simulation training for other procedural and non-procedural skills, thereby advancing the agenda of theoretically based instruction design in health care simulation., (© 2015 John Wiley & Sons Ltd.)

Aims: The aims of this article are to characterize the headache in idiopathic intracranial hypertension (IIH) and to field-test the ICHD diagnostic criteria for headache attributed to IIH., Materials and Methods: We included 44 patients with new-onset IIH. Thirty-four patients with suspected but unconfirmed IIH served as controls. Headache and other IIH-related symptoms were assessed by a detailed standardized interview. In participants referred before diagnostic lumbar puncture (n = 67), we recorded headache intensity before and after cerebrospinal fluid (CSF) withdrawal., Results: Headache in patients with IIH was daily occurring in 86%, focal in 84% and pulsating in 52%. Aggravation of headache by coughing or straining and relief after CSF withdrawal were significantly more frequent in patients than in controls (p ≤ 0.002). From the ICHD-2 to the ICHD-3 beta classification the sensitivity increased from 60% to 86% whereas the specificity decreased from 86% to 53%. Based on our data the headache criteria can be revised to increase sensitivity to 95% and specificity to 65%., Conclusion: Aggravation of headache by coughing or straining, relief after CSF withdrawal, retrobulbar pain and pulsatile tinnitus may suggest intracranial hypertension. Based on data from a well-defined IIH cohort, we propose a revision of the ICDH-3 beta diagnostic criteria with improved clinical applicability and increased sensitivity and specificity., (© International Headache Society 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background and Objective: Simulation-based skill trainings are common; however, optimal instructional designs that improve outcomes are not well specified. We explored the impact of just-in-time and just-in-place training (JIPT) on interns' infant lumbar puncture (LP) success., Methods: This prospective study enrolled pediatric and emergency medicine interns from 2009 to 2012 at 34 centers. Two distinct instructional design strategies were compared. Cohort A (2009-2010) completed simulation-based training at commencement of internship, receiving individually coached practice on the LP simulator until achieving a predefined mastery performance standard. Cohort B (2010-2012) had the same training plus JIPT sessions immediately before their first clinical LP. Main outcome was LP success, defined as obtaining fluid with first needle insertion and <1000 red blood cells per high-power field. Process measures included use of analgesia, early stylet removal, and overall attempts., Results: A total of 436 first infant LPs were analyzed. The LP success rate in cohort A was 35% (13/37), compared with 38% (152/399) in cohort B (95% confidence interval for difference [CI diff], -15% to +18%). Cohort B exhibited greater analgesia use (68% vs 19%; 95% CI diff, 33% to 59%), early stylet removal (69% vs 54%; 95% CI diff, 0% to 32%), and lower mean number of attempts (1.4 ± 0.6 vs 2.1 ± 1.6, P < .01) compared with cohort A., Conclusions: Across multiple institutions, intern success rates with infant LP are poor. Despite improving process measures, adding JIPT to training bundles did not improve success rate. More research is needed on optimal instructional design strategies for infant LP., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: To identify factors influencing the success of lumbar puncture (LP) performed by neurology residents in an outpatient clinic., Background: There is a need to understand the specific influence of patient or operator characteristics in LP performance in order to identify situations at high risk for failure that could benefit from compensatory interventions., Methods: We performed a retrospective analysis of all consecutive patients who underwent elective LP in the Neurology Clinic at the University of Iowa between 2009 and 2012. We recorded demographic, anthropometric, and clinical information, and the level of training of the resident performing the procedure. Outcomes measure was unsuccessful LP, defined as no quantifiable CSF. This study was previously approved by the University of Iowa institutional review board., Results: A total of 328 patients (59% women) were included. Men were significantly older than women, and the indication of the procedure differed by sex. Headache or possible multiple sclerosis were more common indications in women than in men. Nineteen percent of the LPs were unsuccessful. We found a strong correlation between patient body mass index (BMI) and unsuccessful outcome (p < 0.0001). Age of the patient and level of training of the operator did not predict unsuccessful LP., Conclusions: Patient BMI is the key factor that determines an unsuccessful LP by neurology residents in an outpatient setting, an association that might be applicable to different clinical settings. The high failure rate in patients with BMI >35 suggests that implementing compensatory interventions such as the use of imaging guidance might be cost-effective and better tolerated by these patients., (© 2015 American Academy of Neurology.)

Unlabelled: CONSTRUCT: With the current shift toward competency-based education, rigorous assessment tools are needed for procedurally based tasks., Background: Multiple tools exist to evaluate procedural skills, each with specific weaknesses., Approach: We sought to determine if quantitative needle tracking could be used as a measure of lumbar puncture (LP) performance and added discriminatory value to a dichotomous checklist. Thirty-two medical students were divided into 2 groups. One group was asked to practice an LP once (single practice [SP]) and the other 5 times (multiple practice [MP]). Experts (attending ER physicians, senior ER residents, and a junior anesthesia resident) were used as comparators. Medical students were assessed again at 1 month to assess skill retention. Groups were assessed performing an LP with an electromagnetic tracking device that allows the needle's 3-dimensional movements to be captured and analyzed, and a dichotomous checklist., Results: Quantitative needle metrics as assessed by electromagnetic tracking showed a decreasing trend in needle movement distance with practice and with experience. The SP group made significantly more checklist mistakes initially as compared to the MP group (1.2 vs. 0.3, p <.05). At 1 month, there was a significant increase in both groups' mistakes (SP 3.4 vs. MP 1.3, p =.01). No correlation existed between individuals' needle motion and checklist mistakes., Conclusions: These findings suggest that quantitative needle tracking identifies students who struggle with needle insertion but are successful at completing the dichotomous checklist.

Issue: Pediatric residents commonly perform lumbar punctures during their clinical training. The objective of this study was to assess residents' rate of nontraumatic lumbar punctures, examine the adequacy of samples, and implement proper documentation of the procedure in an academic Level 4 Neonatal Intensive Care Unit. We hypothesize that traumatic taps are common and that documentation of the procedure is poor., Evidence: A retrospective chart review was done of infants admitted to the neonatal intensive care unit from January 2011 to November 2011 who underwent a lumbar puncture. Procedure notes were evaluated for completion of proper documentation, the lab specimen was assessed for red blood cell count less than 1,000 cells/mm(3), and individuals were assessed for their ability to obtain a cerebrospinal fluid sample to send to the lab for analysis (i.e., sample of adequate volume and not clotted) and the total number of attempts to obtain a sample. A total of 184 charts were reviewed. Procedure notes were incomplete (58%) and lacked pertinent details. Eight percent of samples obtained had no record of the procedure being preformed. There was inadequate sample acquisition in 23% of the lumbar punctures. More than three attempts were noted in 14% of lumbar punctures performed. Many specimens contained very high red blood cell counts. Seventy-five percent of lumbar punctures with full documentation (n = 60), resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) and 55% of underdocumented lumbar punctures resulted in cerebrospinal fluid with more than 1,000 red blood cells/mm(3) (n = 71)., Implications: We found that poorly documented lumbar punctures are common and the ability of residents to obtain satisfactory cerebrospinal fluid is low. The inability of residents to consistently perform nontraumatic lumbar punctures is likely a common phenomenon. New educational methods and evaluation criteria must be developed to address this gap in resident education.

Background and Purpose: Fluoroscopic-guided lumbar puncture is an effective alternative to bedside lumbar puncture in challenging patients. However, no published guidelines are available for an acceptable range of fluoroscopic time for this procedure. The purpose of this study was to set department benchmark fluoroscopic times for lumbar puncture, accounting for body mass index in our patient population., Materials and Methods: We identified and reviewed all patients who underwent fluoroscopic-guided lumbar puncture at 4 hospitals during a 2-year period (July 2011 to June 2013). Data collection included patient information (demographics, body mass index, history of prior lumbar surgery and/or lumbar hardware, scoliosis); procedure details (fluoroscopic time, level of access, approach, needle gauge and length); level of operator experience; and hospital site. A generalized linear model was used to test whether body mass index influenced fluoroscopic time while controlling other factors., Results: Five hundred eighty-four patients (mean age, 47.8 ± 16.2 years; range, 16-92 years; 33% male) had successful fluoroscopic-guided lumbar puncture s. Mean body mass index and fluoroscopic time were higher in female patients (34.4 ± 9.9 kg/m(2) and 1.07 minutes; 95% CI, 0.95-1.20) than in male patients (29.2 ± 7.3 kg/m(2) and 0.91 minutes; 95% CI, 0.79-1.03). Body mass index (P = .001), hospital site (P < .001), and level of experience (P = .03) were factors significantly affecting fluoroscopic time on multivariate analysis. Benchmark fluoroscopic times in minutes were the following: 0.48 (95% CI, 0.40-0.56) for normal, 0.61 for overweight (95% CI, 0.52-0.71), 0.63(95% CI, 0.58-0.73) for obese, and 0.86 (95% CI, 0.74-1.01) in extremely obese body mass index categories., Conclusions: In patients undergoing fluoroscopic-guided lumbar punctures, fluoroscopy time increased with body mass index We established benchmark fluoroscopic-guided lumbar puncture time ranges as related to body mass index in our patient population., (© 2014 by American Journal of Neuroradiology.)

Rationale and Objectives: To assess technical compliance among neuroradiology attendings and fellows to standard guidelines for lumbar puncture and myelography to minimize procedural complications such as iatrogenic meningitis and spinal headache., Materials and Methods: We surveyed academic neuroradiology attendings and fellows in the e-mail directory of the Association of Program Directors in Radiology. We queried use of face masks, use of noncutting needles, and dural puncture practices. All data were collected anonymously., Results: A total of 110 survey responses were received: 75 from neuroradiology attendings and 34 from fellows, which represents a 14% response rate from a total of 239 fellows. Forty-seven out of 101 (47%) neuroradiologists do not always wear a face mask during myelograms, and 50 out of 105(48%) neuroradiologists do not always wear a face mask during lumbar punctures, placing patients at risk for iatrogenic meningitis. Ninety-six out of 106 neuroradiologists (91%) use the Quincke cutting needle by default, compared to only 17 out of 109 neuroradiologists (16%) who have ever used noncutting needles proven to reduce spinal headache. Duration of postprocedure bed rest does not influence incidence of spinal headache and may subject patients to unnecessary monitoring. Only 15 out of 109 (14%) neuroradiologists in our study do not prescribe bed rest. There was no statistically significant difference in practice between attendings and fellows., Conclusions: Iatrogenic meningitis and spinal headache are preventable complications of dural puncture that neuroradiologists can minimize by conforming to procedural guidelines. Wearing face masks and using noncutting spinal needles will reduce patient morbidity and lower hospitalization costs associated with procedural complications., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

We present a navigated simulator for ultrasound-guided spine needle interventions, comprising of an ultrasound scanner, tracking system, surgical instruments, tissue-mimicking spine phantom, and augmented virtuality navigation platform. The ultrasound transducer, spine needle, and spine phantom are magnetically tracked and spatially calibrated, allowing the navigation software to render the surgical scene with streaming ultrasound video in 3D. The spine phantom provides sonoanatomically correct images, with realistic tactile sensation from needle advancement through tissues layers. The combination of a physical phantom and navigation software provides a realistic, inexpensive, and interactive environment for teaching and learning, the latter also having potential as an interventional tool for real-time ultrasound-guided spine needle insertion.

Purpose: Residents must learn which infants require a lumbar puncture (LP), a clinical decision-making skill (CDMS) difficult to evaluate because of considerable practice variation. The authors created an assessment model of the CDMS to determine when an LP is indicated, taking practice variation into account. The objective was to detect whether script concordance testing (SCT) could measure CDMS competency among residents for performing infant LPs., Method: In 2011, using a modified Delphi technique, an expert panel of 14 attending physicians constructed 15 case vignettes (each with 2 to 4 SCT questions) that represented various infant LP scenarios. The authors distributed the vignettes to residents at 10 academic pediatric centers within the International Simulation in Pediatric Innovation, Research, and Education Network. They compared SCT scores among residents of different postgraduate years (PGYs), specialties, training in adult medicine, LP experience, and practice within an endemic Lyme disease area., Results: Of 730 eligible residents, 102 completed 47 SCT questions. They could earn a maximum score of 47. Median SCT scores were significantly higher in PGY-3s compared with PGY-1s (difference: 3.0; 95% confidence interval [CI] 1.0-4.9; effect size d = 0.87). Scores also increased with increasing LP experience (difference: 3.3; 95% CI 1.1-5.5) and with adult medicine training (difference: 2.9; 95% CI 0.6-5.0). Residents in Lyme-endemic areas tended to perform more LPs than those in nonendemic areas., Conclusions: SCT questions may be useful as an assessment tool to determine CDMS competency among residents for performing infant LPs.

Object: Management of idiopathic normal-pressure hydrocephalus (iNPH) is hard because the diagnosis is difficult and shunt surgery has high complication rates. An important complication is overdrainage, which often can be treated with adjustable-shunt valve manipulations but also may result in the need for subdural hematoma evacuation. The authors evaluated shunt surgery overdrainage complications in iNPH and their relationship to lumbar puncture opening pressure (LPOP)., Methods: The authors reviewed the charts of 164 consecutive patients with iNPH who underwent shunt surgery at their institution from 2005 to 2011. They noted age, sex, presenting symptoms, symptom duration, hypertension, body mass index (BMI), imaging findings of atrophy, white matter changes, entrapped sulci, LPOP, valve opening pressure (VOP) setting, number of valve adjustments, serious overdrainage (subdural hematoma requiring surgery), radiological overdrainage (subdural hematomas or hygroma seen on postoperative imaging), clinical overdrainage (sustained or postural headache), other complications, and improvements in gait, urine control, and memory., Results: Eight patients (5%) developed subdural hematomas requiring surgery. All had an LPOP of greater than 160 mm H2O and an LPOP-VOP of greater than 40 mm H2O. Radiological overdrainage was more common in those with an LPOP of greater than 160 mm H2O than in those with an LPOP of less than 160 mm H2O (38% vs. 21%, respectively; p = 0.024). The BMI was also significantly higher in those with an LPOP of greater than 160 mm H2O (median 30.2 vs. 27.0, respectively; p = 0.005)., Conclusions: Serious overdrainage that caused subdural hematomas and also required surgery after shunting was related to LPOP and LPOP-VOP, which in turn were related to BMI. If this can be replicated, individuals with a high LPOP should have their VOP set close to the LPOP, or even higher. In doing this, perhaps overdrainage complications can be reduced.

Objective: Because of potential risks of poor outcome, lumbar puncture (LP) is recommended to exclude the presence of blood breakdown products in patients with suspected subarachnoid haemorrhage (SAH) and a normal CT scan. The aim of this study was to document how often this test proved useful., Method: A retrospective analysis of prospectively recorded data was conducted. Patients with suspected SAH and a normal CT scan in whom LP was recommended between May 2008 and May 2010 were identified using the neurosurgical referral database. CT scan results, LP results, inpatient stay, investigations and interventions were recorded., Results: One hundred and sixty-three patients were identified in whom LP was recommended after a reported negative CT scan. Thirty-six of these 163 patients had a positive LP of which seven had evidence of SAH on the initial CT scan. In 66 patients, the LP was not diagnostic and 59/66 (90%) patients underwent secondary imaging in whom five with aneurysms were identified and treated., Conclusion: LP-driven decision making in patients with a normal scan and suspected SAH is suboptimal in over a third of cases. Patients with a non-diagnostic LP harboured five aneurysms that merited treatment. These results support the need for secondary investigations following suspected SAH, but suggest that these could take the form of secondary imaging rather than a lumbar puncture.