Does the Type of Surgery in Brain Abscess Patients Influence the Outcome? Analysis Based on the Propensity Score Method

There are different options for surgical treatment of brain abscess, mainly standard craniotomy and stereotactic aspiration. It has not yet been established which of these options is associated with a more favorable outcome under similar baseline conditions of patients. Demographic characteristics, microbiology, clinical presentation, and treatment outcome were analyzed for surgically treated adult patients with brain abscess over a 14-year period. A propensity score model was applied to account for baseline conditions that may determine the choice of neurosurgical method. The propensity score was included in the prediction of a favorable outcome, defined as a Glasgow Outcome Scale (GOS) score 4 or 5. We analyzed 91 adult surgically treated patients, of which 53 had standard craniotomy and 38 stereotactic aspiration of brain abscess. Focal neurological deficit was the most common symptom present in 60 (65.9%) patients on admission. Sixty-seven (73.6%) patients had GOS 4 or 5, and seven (7.7%) patients died. The choice of surgery did not influence the outcome (OR 1.181, 95% CI 0.349-3.995), neither did the time elapsed from diagnosis to surgery (OR 0.998, 95% CI 0.981-1.015). Propensity towards standard craniotomy procedure did not influence outcome in brain abscess patients (OR 1.181, 95% CI 0.349-3.995). Worse outcome (GOS below 4) was independently associated with Glasgow Coma Score (GCS) on admission (OR 0.787, CI 0.656-0.944). The choice of neurosurgical procedure did not influence the outcome in patients with brain abscess. Patients with brain abscess who had lower GCS on admission also had worse outcome.

Specialties performing paracentesis procedures at university hospitals: implications for training and certification

BACKGROUND

Paracentesis procedure competency is not required for internal medicine or family medicine board certification, and national data show these procedures are increasingly referred to interventional radiology (IR). However, practice patterns at university hospitals are less clear.

OBJECTIVE

To evaluate which specialties perform paracentesis procedures at university hospitals, compare characteristics of patients within each specialty, and evaluate length of stay (LOS) and hospital costs.

DESIGN, SETTING, PATIENTS

Observational administrative database review of patients with liver disease who underwent paracentesis procedures in hospitals participating in the University HealthSystem Consortium (UHC) Database from January 2010 through December 2012. UHC is an alliance of 120 academic medical centers and their 290 affiliated hospitals.

EXPOSURE

Patients with liver disease who underwent inpatient paracentesis procedures.

MEASUREMENTS

We compared characteristics of patients who underwent paracentesis procedures by physician specialty, modeling the effects of patient characteristics on the likelihood of IR referral. We also analyzed LOS and hospital costs among patients with a >20% predicted probability of IR referral.

RESULTS

There were 97,577 paracentesis procedures performed during 70,862 hospital stays in 204 hospitals. IR performed 29% of paracenteses versus 49% by medicine and medicine subspecialties including gastroenterology/hepatology. Patients who were female, obese, and those with lower severity of illness were more likely to be referred to IR. Patients with a medicine or gastroenterology/hepatology paracentesis had a similar LOS compared to IR. Hospital costs were an estimated as $1308 less for medicine and $803 less for gastroenterology/hepatology compared to admissions with IR procedures (both P = 0.0001).

CONCLUSIONS

Internal medicine- and family medicine-trained clinicians frequently perform paracentesis procedures on complex inpatients but are not currently required to be competent in the procedure. Increasing bedside paracentesis procedures may reduce healthcare costs.

Conformity of behaviors among medical students: impact on performance of knee arthrocentesis in simulation

Although the development of collaborative relationships is considered a requirement for medical education, the functioning of these relationships may be impaired by a well-documented social-psychological phenomenon known as group conformity. The authors hypothesized that students would insert a needle into an incorrect location relative to the patella when performing a knee arthrocentesis if they believed that their peers had also inserted a needle in the same incorrect location. This was a randomized controlled study conducted in 2011 with 60 medical students (24 male; 40.0 %) who were randomly assigned to either using a knee model that had a skin with holes left by peers inserting needles in the wrong location, or a knee with no marks in the skin. Each student's aspiration site was measured with a fibreglass ruler to determine whether it was correctly located within the superior third, 1 cm medial to the patella. The researchers determined that students who used the marked skin were more likely to insert the needle in the incorrect location compared to those who used the clean skin (n = 31, 86.11 vs. n = 14, 58.33 %), Fisher's exact test (1) = 5.93, p < 0.05, Cramer's ϕ = 0.31. This study demonstrates incorrect performance of the knee arthrocentesis procedure in simulation when students use a damaged model, which may be due to conformity. It suggests that further research on the impact of conformity in medical education is warranted.

Rumenozentese: Eine geeignete Methode zur pH-Bestimmung im Pansensaft beim Rind?

In the United States, rumenocentesis has been recommended especially for early diagnosis of subacute rumen acidosis (SARA). The objective of the current study was to evaluate health risks due to the technique ofrumenocentesis and to measure pH in ruminal juice using a commercial indicator paper (Pehanon) and a pH electrode (reference method). After 11 dairy cows underwent rumenocentesis, the clinical status of those animals was evaluated daily, and cows were slaughtered as well as pathologically--anatomically examined on day 7. During the observation period, the following pathological clinical signs were evident: forced inspiration (3 cows), transient episode of hyperthermia (2 cows), increased tension of the abdominal wall (8 cows) and positive foreign body tests (3 cows). One cow had to be culled on day 7 because of severe generalised septic peritonitis spreading from the site of rumenocentesis. At slaughter, hematoma formation in the area of the puncture site was found in 9 out of 10 cows. It was concluded that the severe complications encountered with this technique do not legitimate rumenocentesis as a routine procedure for collection of rumen juice samples in cows under Swiss conditions. The correlation between the pH reference method and the commercial indicator paper was the high (r = 0.926).

Development of a test to evaluate residents' knowledge of medical procedures

BACKGROUND AND AIM

Knowledge of core medical procedures is required by the American Board of Internal Medicine (ABIM) for certification. Efforts to improve the training of residents in these procedures have been limited by the absence of a validated tool for the assessment of knowledge. In this study we aimed to develop a standardized test of procedural knowledge in 3 medical procedures associated with potentially serious complications.

METHODS

Placement of an arterial line, central venous catheter, and thoracentesis were selected for test development. Learning objectives and multiple-choice questions were constructed for each topic. Content evidence was evaluated by critical care subspecialists. Item test characteristics were evaluated by administering the test to students, residents and specialty clinicians. Reliability of the 32-item instrument was established through its administration to 192 medical residents in 4 hospitals.

RESULTS

Reliability of the instrument as measured by Cronbach's alpha was 0.79 and its test-retest reliability was 0.82. Median score was 53% on a test comprising elements deemed important by critical care subspecialists. Increasing number of procedures attempted, higher self-reported confidence, and increasing seniority were predictors of overall test scores. Procedural confidence correlated significantly with increasing seniority and experience. Residents performed few procedures.

CONCLUSIONS

We have successfully developed a standardized instrument to assess residents' cognitive competency for 3 common procedures. Residents' overall knowledge about procedures is poor. Experiential learning is the dominant source for knowledge improvement, but these experiences are increasingly rare.

Asking for help: internal medicine residents' use of a medical procedure service

BACKGROUND

Little is known about the professional help-seeking behavior of residents as they perform procedures in the hospital.

OBJECTIVE

To determine when residents seek formal supervision to perform inpatient medical procedures.

DESIGN

We conducted a prospective cohort study of resident physicians' use of formal supervision through a medical procedure service (MPS) for placing central venous catheters (CVCs) and performing thoracenteses. We compared resident, procedure, and patient characteristics among MPS and non-MPS procedures. We performed bivariable and multivariable analyses to examine factors associated with use of the MPS. We also performed a subgroup analysis of non-MPS procedures to assess the influence of resident, procedure, and patient characteristics on the choice of informal supervision.

SETTING

Boston teaching hospital.

SUBJECTS

Sixty-nine internal medicine residents.

MAIN OUTCOME MEASURE

Use of an elective MPS for formal faculty supervision.

RESULTS

Among 191 procedures performed, 79 (41%) used the MPS. Residents were more likely to seek faculty supervision via the MPS among patients with 3 or more comorbidities (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.2-3.5). They were less likely to seek MPS supervision when procedures were performed urgently or emergently (OR, 0.4; 95% CI, 0.2-0.8). There were few differences in the characteristics of unsupervised and informally supervised procedures.

CONCLUSIONS

Resident physicians appear to seek formal assistance appropriately for procedures they perform on sicker patients. Additional research is needed to understand whether overconfidence or poor access to attending physicians is responsible for their failure to seek consultation with urgent and emergent cases.

[Italian Society of Rheumatology (SIR) recommendations for performing arthrocentesis]

Joint fluid aspiration, or arthrocentesis, is one of the most useful and commonly performed procedures for the diagnosis and treatment of rheumatic diseases, but to date no definite guidelines have been published. For this reason, a group of experts of the Italian Society of Rheumatology (SIR) produced evidence based recommendations for performing arthrocentesis. Among them, the most relevant are: a) arthrocentesis is necessary when synovial effusion of unknown origin is present, especially if septic or crystal arthritis is suspected; b) the patient should be clearly informed of the benefits and risks of the procedure in order to give an informed consent; c) ultrasonography should be used to facilitate arthrocentesis in difficult joints; d) fluid evacuation often has a therapeutic effect and facilitates the success of the following intraarticular injection; e) careful skin disinfection and the use of sterile, disposable material is mandatory for avoiding septic complications. Disposable, non sterile gloves should always be used by the operator, mainly for his own protection; f) contraindications are the presence of skin lesions or infections in the area of the puncture; g) the patient's anticoagulant treatment is not a contraindication, providing the therapeutic range is not exceeded; h) joint rest after arthrocentesis is not indicated. Several of these recommendations were based on experts' opinion rather than on published evidence which is scanty.

Safety of paracentesis in inpatients

INTRODUCTION

Prior research has suggested that paracentesis is free from complications such as acute renal failure (ARF) providing albumin is administered. Actual safety of paracentesis > 1,000 ml was assessed at a tertiary care hospital.

METHODS

300 inpatient paracenteses performed between 12/99 and 4/04 were identified by coding records, of which 40 procedures were excluded due to lack of pre- or post-procedure lab values. Charts were reviewed for serum creatinine (Scr) before and after procedures, ascites volume, and clinical outcomes.

RESULTS

44 deaths occurred after 260 paracenteses (16.9%). Among 33 patients with ARF, 13 (39.4%) died. Only 31/227 patients without ARF (13.7%) died (p < 0.001). Serum creatinine (Scr) > 1.6 mg/dl prior to paracentesis predicted a 22.5% rate of ARF, compared to 8% for Scr < 1.0 (p = 0.002). ARF increased as volume increased (9.9%, 12.4%, and 14.9%, for volumes of < 2,300, 2,300 - 3,200, and > 3,200 ml) but this trend did not have statistical significance (p = 0.426). ARF occurred in 11/69 (15.9%) of patients receiving albumin, compared to 22/191 (11.5%) of patients who did not (p = 0.462).

CONCLUSIONS

Paracentesis in inpatients has significant rates of ARF and death. Scr > 1.6 prior to paracentesis predicts an increased rate of ARF. Development of ARF is associated with an increased rate of death. No advantage was demonstrated with administration of albumin. Pre- and post-paracentesis labwork should be routine in inpatients.

Performance standards for therapeutic abdominal paracentesis

Large-volume paracentesis, the preferred treatment for patients with symptomatic tense ascites due to cirrhosis, has traditionally been performed by physicians as an inpatient procedure. Our objectives were to determine (1) whether large-volume paracentesis could be performed safely and effectively by gastrointestinal endoscopy assistants and as an outpatient procedure, (2) whether the risk of bleeding was associated with either thrombocytopenia or prolongation of the prothrombin time, and (3) the resources used for large-volume paracentesis. Gastrointestinal endoscopy assistants performed 1,100 large-volume paracenteses in 628 patients, 513 of whom had cirrhosis of the liver. The preprocedure mean international normalized ratio for prothrombin time was 1.7 +/- 0.46 (range, 0.9-8.7; interquartile range, 1.4-2.2), and the mean platelet count was 50.4 x 10(3)/microL, (range, 19 x 10(3)/microL - 341 x 10(3)/microL; interquartile range, 42-56 x 10(3)/microL). Performance of 3 to 7 supervised paracenteses was required before competence was achieved. There were no significant procedure-related complications, even in patients with marked thrombocytopenia or prolongation in the prothrombin time. The mean duration of large-volume paracentesis was 97 +/- 24 minutes, and the mean volume of ascitic fluid removed was 8.7 +/- 2.8 L. In conclusion, large-volume paracentesis can be performed safely as an outpatient procedure by trained gastrointestinal endoscopy assistants. Ten supervised paracenteses would be optimal for training the operators carrying out the procedure. The practice guideline of the American Association for the Study of Liver Diseases which states that routine correction of prolonged prothrombin time or thrombocytopenia is not required is appropriate when experienced personnel carry out paracentesis.

[Is the routine chest radiography following thoracentesis necessary?]

OBJECTIVES

To assess the routine indication of chest roentgenogram after thoracentesis in function of iatrogenic pneumothorax causation, following a procedure protocol.

PATIENTS AND METHODS

Prospective study of 104 consecutive thoracentesis procedures performed in 76 patients. The procedure was protocolized and after each thoracentesis a chest roentgenogram was obtained within 6 hours after the procedure. The attending physician completed a questionnaire relative to patients data characteristics of the pleural effusion.

RESULTS

Two pneumothorax were noted following thoracentesis (2%) which did not require pleural drainage. These pneumothorax occurred in patients with parapneumonic pleural effusions.

CONCLUSIONS

The routine practice of chest roentgenogram after thoracentesis does not seem to be warranted and should be individualized. The performance of thoracentesis by physicians in training period, with procedure protocolization, minimizes the risk of pneumothorax.

Diagnostic accuracy, tympanocentesis training performance, and antibiotic selection by pediatric residents in management of otitis media

OBJECTIVE

To assess the accuracy of pediatric residents in recognizing the physical examination findings of acute otitis media (AOM) and otitis media with effusion (OME), technical competence to perform tympanocentesis, and knowledge of guideline-recommended antibiotic management of AOM.

METHODS

A total of 383 pediatric residents from various programs in the United States viewed 9 different video-recorded pneumatic otoscopic examinations of tympanic membranes during a continuing medical education course. The ability to differentiate AOM, OME, and normal was ascertained. A mannequin of a child was used to assess technical proficiency of performing tympanocentesis on artificial tympanic membranes. A series of questions was posed regarding appropriate, pathogen-directed, second-line antibiotic selection for AOM.

RESULTS

The average +/- standard deviation correct diagnosis on the otoscopic video examination was 41% +/- 16% (range: 19%-70%; median: 38%) by pediatric residents, tympanocentesis was optimally performed by 89%, and appropriate antibiotic therapy for drug-resistant Streptococcus pneumoniae was selected by 78% and appropriate therapy for beta-lactamase-producing Haemophilus influenzae was selected by 74%.

CONCLUSIONS

According to this video-based examination, pediatric residents misdiagnose OME frequently. Pediatric residents have the skills to be trained to perform tympanocentesis. Approximately 75% of pediatric residents have knowledge of the appropriate antibiotics to select for treatment of resistant AOM pathogens. Interactive instruction with simulation technology may enhance skills and lead to improved diagnostic accuracy and treatment paradigms.

Assessing diagnostic accuracy and tympanocentesis skills in the management of otitis media

BACKGROUND

The distinction between acute suppurative otitis media (AOM) and otitis media with effusion (OME) is important for antibiotic treatment decisions. Tympanocentesis may be useful in the diagnosis of AOM in selected patients.

OBJECTIVES

To assess physician accuracy in diagnosing AOM and OME from physical examination findings and technical competence in performing tympanocentesis.

DESIGN AND SUBJECTS

Five hundred fourteen pediatricians and 188 otolaryngologists viewed 9 different videotaped pneumatic otoscopic examinations of tympanic membranes during a continuing medical education course. Diagnostic differentiation of AOM, OME, and a normal tympanic membrane was ascertained. An infant mannequin model was used to assess the technical proficiency of performing tympanocentesis on artificial tympanic membranes.

RESULTS

Overall, the average correct diagnosis by pediatricians was 50% (range, 25%-73%) and by otolaryngologists was 73% (range, 48%-88%). Pediatricians and otolaryngologists correctly recognized the absence of normality 89% to 100% and 93% to 100% of the time, respectively, but overdiagnosed AOM in 7% to 53% (mean, 27%) and in 3% to 23% (mean, 10%) of examinations. Performance of tympanocentesis was optimally performed by 89% of otolaryngologists and by 83% of pediatricians.

CONCLUSIONS

The use of video-presented examinations to assess diagnostic ability suggests that AOM and OME may be misdiagnosed often. Interactive continuing medical education courses with simulation technology may enhance skills and improve diagnostic accuracy and treatment paradigms.

Analysis of first gastric compartment fluid collected via percutaneous paracentesis from healthy llamas

OBJECTIVE

To evaluate the safety and efficacy of percutaneous paracentesis for fluid collection from the first gastric compartment of healthy llamas and to describe characteristics of that fluid.

DESIGN

Prospective study.

ANIMALS

10 healthy adult llamas.

PROCEDURE

Physical examinations were performed prior to sample collection and for 14 days afterwards. A CBC was performed prior to sample collection and 5 days later. A 16-gauge, 7.5-cm stainless steel needle, positioned approximately 20 cm caudal to the costochondral junction of the last rib, was pointed in a dorsocraniomedial direction and pushed through the abdominal wall into the lumen of the first gastric compartment. Fluid was aspirated and analyzed immediately for color, odor, consistency, pH, methylene blue reduction (MBR) time, protozoa, and bacteria.

RESULTS

Fluid samples were obtained from 9 of 10 llamas. Mean volume was 4.1 ml, mean pH was 6.67, and mean MBR time was 173 seconds. Odor was slightly acidic, color was light brown-green to light yellow-green, and consistency was moderate. Small protozoa with variable iodine staining and gram-negative bacteria were commonly detected. With few exceptions, results of physical examinations and CBC remained within reference ranges.

CLINICAL IMPLICATIONS

Fluid samples from the first gastric compartment can be successfully obtained by percutaneous paracentesis. Fluid characteristics were similar to those of fluid collected via orogastric tube in llamas and cattle.

Unilateral vulvar edema associated with paracentesis in patients with severe ovarian hyperstimulation syndrome. A report of nine cases

BACKGROUND

Severe ovarian hyperstimulation syndrome is a life-threatening complication of ovulation induction. The clinical picture includes ovarian enlargement, accumulation of ascites and pleural effusion, increased coagulability and electrolyte disorders. Accumulation of ascites increases the intraabdominal pressure so that breathing difficulties ensue. Paracentesis is the only treatment that can immediately prevent respiratory deterioration.

CASES

Nine women with severe ovarian hyperstimulation syndrome were treated by paracentesis for the drainage of massive ascites. Unilateral vulvar edema developed in all cases in which the lower abdomen was the puncturing site. This phenomenon was not observed when paracentesis was carried out through the upper abdomen. The edema resolved spontaneously over the subsequent 10 days.

CONCLUSION

Apparently the puncturing needle created a fistulous tract through which the ascitic fluid was forced, by the increased intraabdominal pressure, into the subcutaneous tissues, presenting as unilateral vulvar edema. This can be prevented by using one of the abdominal hypochondriac regions as the puncturing site. This phenomenon is self-limited and causes only mild discomfort without late sequelae.