Digital manometry to measure cerebrospinal fluid pressure during lumbar puncture

Rationale and Objectives Accurate cerebrospinal fluid (CSF) pressure measurements are critical for diagnosis and treatment of pathologic processes involving the central nervous system. Measuring opening CSF pressure using an analog device takes several minutes, which can be burdensome in a busy practice. The purpose of this study was to compare accuracy of a digital pressure measurement device with analog manometry, the reference gold standard. Secondary purpose included an assessment of possible time savings. Materials and Methods This study was a retrospective, cross-sectional investigation of 71 patients who underwent image-guided lumbar puncture (LP) with opening CSF pressure measurement at a single institution from June 2019 to September 2019. Exclusion criteria were examinations without complete data for both the digital and analog measurements or without recorded needle gauge. All included LPs and CSF pressures were measured with the patient in the left lateral decubitus position, legs extended. Acquired data included (1) digital and analog CSF pressures and (2) time required to measure CSF pressure. Results A total of 56 procedures were analyzed in 55 patients. There was no significant difference in mean CSF pressures between devices: 22.5 cm H2O digitally vs 23.1 analog ( p = .7). Use of the digital manometer resulted in a time savings of 6 min (438 s analog vs 78 s digital, p < .001). Conclusion Cerebrospinal fluid pressure measurements obtained with digital manometry demonstrate comparable accuracy to the reference standard of analog manometry, with an average time savings of approximately 6 min per case.

Splenomegaly (SPML) in Polycythemia Vera (PV): Its Clinical Significance and Relation to Myelofibrosis and Survival

Introduction: SPML is considered a hallmark of PV, but its frequency, as reported in the literature, ranges from 20% to 75%. It has been assumed, without documentation, that SPML may be accompanied by symptoms and signs and may affect prognosis. Moreover, expensive radiographic tests have become mandatory in some recent phase 2 drug trials in PV (and ET) to carefully document spleen size on trial entry and its change, if any, during therapy. Because systematic studies have not been performed, we studied SPML in patients (pts) with PV at their initial diagnosis (DX) or at first presentation (PRES) at our institution, Weill Cornell Medicine (WCM), and determined its clinical significance. Methods: This single-center retrospective study was approved by the WCM institutional review board. A systematic literature search including PubMed, Embase, and Cochrane School relevant to the specific search questions was unrevealing. We used a research data repository based on an automated query system which had aggregated longitudinal clinical information pertaining to our PV patients for our analysis of spleen size (Abu-Zeinah et al. Leukemia 2021). Standardized PV diagnostic criteria were used for all pts (Silver et al. Blood 2013). As a tertiary referral center within a major metropolitan area, our PV population is composed of those diagnosed at WCM (DX) and those presenting to WCM some time after diagnosis (PRES). Degree of SPML was categorized into 3 subgroups: (1) &lt;1 cm if the spleen was not enlarged, (2) palpable 1-5 cm, or (3) more than 5.0 cm below the left costal margin of the abdomen in the medial clavicular line in the supine or left lateral decubitus position; it was also considered enlarged after splenic ultrasound scan (US) based upon the method and verified formula of Chow KU, et al. Radiology 2016. Spleen size was correlated with age, sex, race, and ELN risk score, and symptoms including pruritus, night sweats, anorexia, abdominal discomfort and pain. Progression to myelofibrosis (MF) with myeloid metaplasia was defined per ELN/IWG-MRT criteria. Spleen measurements after progression to MF were excluded. Peripheral blood smears were routinely examined to view RBC morphology and to exclude leukoerythroblastosis. MF-free survival (MFS) and overall survival (OS) were calculated using the Kaplan-Meier log rank test among the various spleen subgroups. Multivariable survival analysis (MVA) was performed using a Cox proportional hazards model. Results: From our 470 PV dataset, 351 pts had documented spleen size at DX (165) or PRES (186). The median age for all patients was 60 years (yr), for DX 54 yr, for PRES 62 yr. The median DX ages of SPML &lt;1 cm, 1-5 cm, and &gt;5 cm were 56, 50, and 54 yr respectively (p=0.011). The median time between first evaluation for PV and first visit at WCM (PRES) was 2 years (range 0-30). 49% were female and 13% were non-white (Figure 1a). There was no correlation between spleen size and ELN risk scores. The linkage between SPML and symptoms will be reported. Overall survival of the three groups was similar at 12 years (Figure 1b). SPML at presentation, however, was associated with increased risk of MF (1-5cm versus 0: HR 2.56, p=0.026; &gt;=5cm versus 0: HR 5.64, p&lt;0.001), independent of age or disease duration in MVA. Discussion & Conclusion: Patients who had SPML &gt; 5cm at presentation had a worse MFS than those with a lesser degree of SPML or no SPML (1-5 cm or &lt;1 cm). For determining SPML, clinical examination and calculated US length were equally satisfactory. In the absence of clinical SPML, radiographic tests appear unnecessary. However, for SPML &gt; 5cm, and unusual body types, more detailed radiographic studies may still be required. SPML was more common in younger patients, suggesting more aggressive disease and earlier progression to MF. ELN risk category did not correlate with SPML, suggesting an additional reason for its revision. Our PV patients with SPML &gt; 5cm at DX or PRES did not have a decreased OS at 12 years, but did have a reduced MF-free survival. These data support the WHO mandated requirement for marrow biopsy for diagnosis of PV, especially for patients with SPML but also as a baseline requirement to establish the presence of MF less than grade 2. Patients with SPML&gt; 5cm appear to be at high risk of MF progression and must be monitored closely for this event and treated appropriately. Figure 1 Figure 1. Disclosures Silver: Abbvie: Consultancy; PharamEssentia: Consultancy, Speakers Bureau. Scandura: CR&T (Foudation): Research Funding; European Leukemia net: Honoraria, Other: travel fees ; MPN-RF (Foundation): Research Funding; Constellation: Research Funding; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Abu-Zeinah: PharmaEssentia: Consultancy.

Prostate biopsy: a survey of practice among Nigerian urologists

Background Prostate biopsy is a commonly performed outpatient procedure in urology. It is a rapidly changing field with wide variation in practice pattern. The aim of this study is to document the current practice of prostate biopsy among Nigerian urologists. Methods A prospectively designed, self-administered, 16-item survey questionnaire was distributed among urologists and trainees at the 24th Annual General Meeting and Scientific Conference of the Nigerian Association of Urological Surgeons (NAUS). The survey covers various aspect of prostate biopsy including indications for biopsy, prophylactic antibiotic regimen use, methods of bowel preparation, number of biopsy cores taken, complications among others. Results Fifty-one completed questionnaires were returned, out of 76 distributed, giving a response rate of 67%. Majority of the respondents were Consultant urologist 47 (92%), most of them practice in the public health system 46 (90.2%), and performed more than 5 prostate needle biopsy per month 37 (72.5%). All respondents administer prophylactic antibiotics prior to biopsy, with intravenous Gentamycin being the most commonly administered prophylactics 14 (27.5%), only a few perform bowel preparations prior to biopsy 8 (15.7%) with Dulcolax suppository being the most commonly employed agents 5 (63%). Most of the biopsy were done under transrectal ultrasound guidance 29 (56.9%). None of the respondents performed MRI-guided transrectal biopsy. Most respondents take 8–12 core biopsy 20 (39.2%), using 18G trucut biopsy needle 31 (60.8%), with the patient in left lateral decubitus position 26 (51%), under 2% intrarectal xylocaine instillation 28 (54.9%). The commonest complication after the procedure was bleeding per rectum 20 (39.2%), followed by haematuria 9 (17.6%), and infection 8 (15.7%). Conclusion There is universal use of prophylactic antibiotic prior to biopsy. However, bowel preparation prior to biopsy is not common among Nigerian urologist, and MRI-guided biopsy is very rarely done for prostate biopsy. There is need for a prostate biopsy guideline among Nigerian urologists to ensure uniformity of practice, and enhance standardized service delivery.

Time to resuscitate cardiopulmonary resuscitation! The 3R/CPR: Refill-Recoil-Rebound.

Introduction Sudden cardiac arrest (SCA) remains a major health issue worldwide with gloomy outcomes due to poor perfusion of cardiopulmonary resuscitation (CPR), deemed unsuitable for hemostatic conditions, cardiotorsal anatomy, electrophysiology and thoracic biomechanics. Alternatively, we propose a new management, implementing rational mobilization of stagnant blood: manually with a novel technique of cardiac massage and mechanically with a circulatory flow restoration (CFR) device. Methods Simulated chest compressions were performed through the 5th intercostal space in professional Lifeguards volunteers, placed in the left lateral decubitus position with raised legs and abdominal compression. Expected results Compared to CPR, bypassing the sternal barrier, refilling the heart and then compressing the chest with a recoil-rebound maneuver (3R / CPR) can significantly promote ROSC. Results of CFR device were previously demonstrated. Conclusion 3R/CPR adapts human morphology promoting adequate perfusion and ROSC safely, under all circumstances. Preclinical computational models can confirm the effectiveness of 3R/CPR versus CPR.

535 EVALUATION OF THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER FROM 650 CASES IN A SINGLE INSTITUTE

Minimally invasive surgery (MIS) for esophageal cancer has been wide-spreading in worldwide since the first report in 1992. In Japan, we firstly introduced thoracoscopic esophagectomy as a MIS for esophageal cancer in 1994 and performed more than 650 cases over the last two decades. The aim of the present study is to evaluate an oncological feasibility and less invasiveness of this operation from short and long term results. Methods Thoracoscopic esophagectomy was performed in almost all resectable thoracic esophageal cancer patient, briefly indication for this operation is cT1-T3 tumors and lymph node involvement within the regional lesion. We performed thoracoscopic esophagectomy with one lung ventilation in left lateral decubitus position (Group L) up to 2011. From 2012, prone thoracoscopic esophagectomy with bilateral ventilation and artificial pneumothorax (Group P) has been undergone. We analyzed the long-term outcome in all patients who received thoracoscopic esophagectomy with or without neoadjuvant treatment. Furthermore, we evaluated the less invasiveness from the results of short-term outcome and operation-related morbidity between Group L and Group P. Results The 5-year survival rates in no treatment before surgery cases were 61.9% overall, and 86.9%, 71.5%, 68.1%, 40.9%, 37.4% for pathological stages I, IIA, IIB, III and IVa, respectively (TNM classification 6th edition). 30 days mortality in this series was 0.6%. 5-year survival in cStage II and III with neoadjuvant chemotherapy was 65.7%. 3-year survival in salvage esophagectomy after failure of definitive chemoradiotherapy with R0 resection was 43.0%. Total amount of blood loss, rate of postoperative pulmonary complications and the postoperative inflammatory response were significantly lower in Group P than in Group L. Conclusion Thoracoscopic esophagectomy is safety and oncologically feasible. From the view point of less invasiveness benefits, prone esophagectomy has advantages than lateral decubitus procedure and this operation is recommended in almost all patients with a resectable esophageal cancer.

221 THORACOSCOPIC ESOPHAGECTOMY WITH OR WITHOUT SMALL THORACOTOMY FOR ADVANCED THORACIC ESOPHAGEAL CARCINOMA IN THE LEFT LATERAL DECUBITUS POSITION

Standardized thoracoscopic esophagectomy for thoracic esophageal carcinoma in the left lateral decubitus position under artificial pneumothorax is slightly more difficult to dissect the middle and lower mediastinum than in prone position, but it is possible to operate the upper mediastinum with good visual field. In salvage surgery after definitive chemoradiotherapy, it is difficult to complete the operation only by throscopic surgery, and it is thought that sometimes small thoracotomy can be performed safely and reliably. Methods If this procedure is considered feasible, start with thoracoscopic surgery. If it is decided that the procedure cannot be completed, add a small thoracotomy of about 10–15 cm to allow one hand. Thoracoscopy not only reduced invasiveness, shared detailed anatomy, but also improved operability by taping the esophagus and ensured emergency safety. Results This standardized procedure is applied to salvage surgery after definitive chemoradiotherapy from January 2016 to March 2019. Thoracoscopic surgery was performed in 14 of the 27 cases (52%). Thoracoscopic surgery was completed in 10 cases and small thoracotomy was used in 4 cases. There are no serious complications such as bleeding. Conclusion Starting surgery with a thoracoscopy and adding small thoracotomy as appropriate can share the advantages of thoracotomy and throcoscopic surgery. This technique has the advantage that it can be easily converted to thoracotomy even in an emergency, and is considered to be superior to advanced cancer. Video https://www.dropbox.com/sh/47jcqu3palpsfvg/AAC4PvReWDP_WPBkJufxWU3da?dl=0.

Participatory action imaging in increasing clinician confidence of trigger point dry needling or trigger point injection of muscles requiring use of intercostal blocking: A case report

Some clinicians privately report a lack of confidence of being able to safely perform trigger point dry needling (TrPDN) or trigger point injection (TrPI) on muscles that require intercostal blocking, presumably resulting in procedural underutilization. Participatory action imaging (PAI), combined with procedural training and literature review of adverse event incidence, can be a useful tool in enhancing clinician confidence. A 6’ 2”, 185 lbs, 53-year-old male clinician subject with a latissimus dorsi trigger point (TrP) and privately reported high anxiety of performing TrPDN using the intercostal blocking technique, was examined to determine how clinician subject confidence could be improved through PAI and education regarding the degree of coverage of the intercostal space and rib during intercostal blocking. The clinician subject was placed in a left lateral decubitus position and rib imaged with a Siemens Acuson S2000 Ultrasound system with an 18L6 16 Hz high definition linear probe without intercostal blocking, and subsequently with intercostal blocking during maximal exhalation and inhalation, respectively. During intercostal blocking with maximal exhalation, the pleural space and an additional 13% of each side of the rib’s superior and inferior borders were completely blocked by the examiner’s fingers. During intercostal blocking with maximal inhalation, the pleural space and an additional 3% of each side of the rib’s superior and inferior borders were completely blocked by the fingers of the clinician. On visual inspection and interpretation of the images (e.g., PAI), the clinician subject reported a “significant” decrease in self-reported anxiety in performing the intercostal blocking technique (STAI Y-1 score improvement to “low to no anxiety range”). While more study is needed to investigate how variation in patient anatomy (weight, height, and morphology), clinician anatomy (hand size), needle direction, and specific rib being used for influences patient safety, this case report presents PAI as a previously undescribed means for future research and clinician education regarding risk assessment of TrPDN or TrPI of muscles requiring intercostal blocking.

Dynamic Indices Fail to Predict Fluid Responsiveness in Patients Undergoing One-Lung Ventilation for Thoracoscopic Surgery

Thoracic surgery using CO2 insufflation maintains closed-chest one-lung ventilation (OLV) that may provide the necessary heart–lung interaction for the dynamic indices to predict fluid responsiveness. We studied whether pulse pressure variation (PPV) and stroke volume variation (SVV) can predict fluid responsiveness during thoracoscopic surgery. Forty patients were enrolled in the study. OLV was performed with a tidal volume of 6 mL/kg at a positive end-expiratory pressure of 5 cm H2O, while CO2 was insufflated to the contralateral side at 8 mm Hg. Patients whose stroke volume index (SVI) increased ≥15% after fluid challenge (7 mL/kg) were defined as fluid responders. The predictive ability of PPV and SVV on fluid responsiveness was investigated using the area under the receiver-operator characteristic curve (AUROC), which was also assessed according to the right or left lateral decubitus position considering the intrathoracic location of the right-sided superior vena cava. AUROCs of PPV and SVV for predicting fluid responsiveness were 0.65 (95% confidence interval 0.47–0.83, p = 0.113) and 0.64 (95% confidence interval 0.45–0.82, p = 0.147), respectively. The AUROCs of indices did not exhibit any statistical significance according to position. Dynamic indices of preload cannot predict fluid responsiveness during one-lung ventilation with CO2 gas insufflation.

Intestinal Caseous Lymphadenitis in Sheep

Background: Caseous Lymphadenitis (CL) is a chronic infectious disease caused by the bacterium Corynebacterium pseudotuberculosis, which is considered the main agent responsible for abscess lesions. In the visceral form it can affect the internal organs of sheep and goats, which could negatively affect animal health and cause large economic losses for producers.Case: This study aims to report a case of intestinal CL in sheep, with suspected diagnosis during physical examination and identification during the performance of the oophorectomy procedure, adopted as a management approach. It is a mixed breed sheep, aged over 5 years; weight 28 kg; emaciated on physical examination; with pale pink and moist eyelid mucosa; heart and respiratory rate: 81 beats/min and 22 movements/min, respectively; body temperature 39.2°C; ruminal movements at 1 movement/min; without identification of lymphadenomegaly on palpation, however, it was observed that the right submandibular lymph node presented tissue retraction compatible with the healing process. For the surgical procedure, an 18-h fast was used and pre-anesthetic medication with 2% xylazine (0.1 mg/kg), 10% ketamine (5 mg/kg) and 50 mg/mL tramadol (2 mg/kg) administrated intramuscularly. The animal was placed in the left lateral decubitus position, then was performed trichotomy and epidural administration of 2% lidocaine (4 mg/kg) and maintenance with propofol 10 mg/mL intravenous dose-effect and oxygen mask 3 liters/min, antibiotic prophylaxis was performed with 10% enrofloxacin (2.5 mg/kg). Flank oophorectomy was performed according to the classic technique and during abdominal inspection, abscess lesions were found in the mesentery and intestinal loops. Incisional biopsy was performed to collect samples in the jejunal segment. At the end of the procedure, 50 mg/mL (2.2 mg/kg) of flunixin meglumine was administered intravenously. A 0.6 cm x 0.2 cm sample, was submitted to histological analysis, which showed the presence of central necrosis areas formed by concentric lamellae, with the presence of large bacterial colonies and foci of mineralization, surrounded by a strip of inflammatory infiltrate with epithelial macrophages and few neutrophils. In the adjacent layer, lymphocytes and plasmocytes were found and the entire lesion was delimited by fibrous conjunctive tissue, compatible with lesions caused by Corynebacterium pseudotuberculosis, the causative agent of CL. During the whole postoperative period the animal was kept isolated from the herd. Due to the unfavorable prognosis and histological confirmation of visceral CL, euthanasia was indicated. The animal was sent for necropsy and no lesions compatible with CL were found in other organs or tissues besides the anatomical structures where the lesions were previously described (intestine and mesentery).Discussion: As it is an infectious disease, isolation and euthanasia should be indicated in cases of CL, in order to not compromise the health of the herd. Thus, justifying the orientation of euthanasia after histological confirmation. The case did not have other possibilities of diagnostic aid, however, histological lesions of CL are characteristic but not pathognomonic, as it could be confused with lesions caused by other pyogenic pathogens. In this way, clinical considerations and complementary exams are relevant to support the diagnostic. To conclude, the observation and physical examination of the herd were fundamental tools for raising the diagnostic hypothesis ante mortem. Complementary tests allowed the confirmation of the disease and prevented the spread in the herd, which could lead to large economic losses for producers and negatively affect animal health.