Impacto de la cateterización venosa central percutánea bajo guía ecográfica en una terapia intensiva pediátrica polivalente / Impact of ultrasound-guided percutaneous central venous catheterization at a general pediatric intensive care unit

Introducción: La cateterización venosa central es un procedimiento usual en Unidades de Cuidados Intensivos (UCI). El ultrasonido (US) para guiar la cateterización, ofrece ventajas, permitiendo tener una imagen topográfica precisa del vaso, reduciendo las complicaciones, el tiempo y el número de punciones. Objetivo: determinar, si la US en la colocación de catéteres venosos centrales (CVC), podría disminuir el número de punciones y lograr la cateterización exitosa. Población y métodos: Estudio descriptivo, prospectivo de los CVC colocados mediante punción guiada por US, en una UCI polivalente del Hospital de Pediatría Juan P. Garrahan, entre el año 2018 al 2019. Población: pacientes de 1 mes a 18 años que requirieron colocación de un CVS por US. Se consideró significativo un valor de p< 0.05. Resultados: VYI en 66 pacientes (43,5%), VF fue en 86 pacientes (56,5%). 86 (56,5%) CVC, fueron insertados en el primer intento y 66 (43,5%), requirieron más de un intento. Las inserciones en VYI fueron exitosas en el primer intento en 46 pac. (53,5%) 20 pac. requirieron más de un intento (30,3%) p 0,004 OR 0,37 (IC 95% 0,18-0,78. En <6 meses los CVC colocados en VYI tuvieron menos riesgo de requerir más de un intento, con respecto a aquellos en los cuales se eligió la VF, p 0,0026 OR 0,31 (IC 95% 0,12 -0,75). 5,2% presentaron complicaciones, no hubo mortalidad relacionada al procedimiento. Conclusiones: La inserción de CVC guiados por US fue segura y significativamente exitosa en el primer intento cuando el vaso de elección fue la VYI, especialmente en < 6 meses (AU)

IIntroduction: Central venous catheterization is a common procedure in intensive care units (ICU). The use of ultrasound (US) to guide catheterization offers advantages, allowing for an accurate topographic image of the vessel, reducing complications as well as time and number of punctures. Objective: To determine whether the use of US for the placement of central venous catheters (CVCs) may decrease the number of punctures and achieve successful catheterization. Patients and methods: A descriptive, prospective study was conducted of CVCs placed by US-guided puncture at a general ICU of Hospital de Pediatría Juan P. Garrahan between 2018 and 2019. Patients from 1 month to 18 years of age who required US-guided placement of a CVC were included. A p< 0.05 was considered significant. Results: The internal jugular vein (IJV) was used in 66 (43.5%) and the femoral vein (FV) in 86 patients (56.5%). Overall, in 86 (56.5%) CVC were inserted on the first attempt and 66 (43.5%) required more than one attempt. Insertions into the VYI were successful on the first attempt in 46 (53.5%) patients and 20 (30.3%) patients required more than one attempt, p 0.004; OR 0.37 (95% CI 0.18-0.78). In patients <6 months CVCs placed in the IJV had a lower risk of requiring more than one attempt compared to those in which the FV was chosen, p 0.0026 OR 0.31 (95% CI 0.12 -0.75). Complications occurred in 5.2%; no procedure-related mortality was observed. Conclusions: US-guided insertion of CVC was safe and significantly successful on the first attempt when the vessel of choice was the IJV, especially in patients < 6 months (AU)

Using an abdominal phantom to teach urology residents ultrasound-guided percutaneous needle placement

ABSTRACT Introduction: To assess the effect of a hands-on ultrasound training session to teach urologic trainees ultrasound-guided percutaneous needle placement. Materials and methods: University of California, San Francisco (UCSF) urology residents completed a time trial, placing a needle into a phantom model target under ultrasound guidance. Participants were randomized into three educational exposure groups: Group 1's time trial occurred prior to any teaching intervention, group 2's after experiencing a hands-on training module, and group 3's after exposure to both the training module and one-on-one attending feedback. Needle placement speed and accuracy as well as trainees' perceived confidence in utilizing ultrasound were measured. Results: The study cohort consisted of 15 resident trainees. Seven were randomized to group 1, three to group 2, and five to group 3. All residents reported minimal prior ultrasound experience. Their confidence in using ultrasound improved significantly after completing the training module with the most significant improvement seen among junior residents. Time to needle placement was fastest after receiving attending feedback (46.6sec in group 3 vs. 82.7sec in groups 1 and 2, p<0.01). Accuracy also improved with attending feedback, though the number of repositioning attempts did not differ significantly between groups. Conclusions: A hands-on training module and use of an abdominal phantom trainer increased resident confidence and skill in their use of ultrasound to guide percutaneous needle positioning. Attending feedback is critical for improving accuracy in needle guidance toward a target. Ultrasound-guided needle positioning is a teachable skill and can be applicable to multiple urologic procedures.

Percutaneous puncture of renal calyxes guided by a novel device coupled with ultrasound

ABSTRACT Purpose: To evaluate the efficiency of a novel device coupled with ultrassound for renal percutaneous puncture. Materials and Methods: After establishing hydronephrosis, ten pigs had three calyxes of each kidney punctured by the same urology resident, with and without the new device ("Punctiometer"). Time for procedure completion, number of attempts to reach the calyx, puncture precision and puncture complications were recorded in both groups and compared. Results: Puncture success on the first attempt was achieved in 25 punctures (83%) with the Punctiometer and in 13 punctures (43%) without the Punctiometer (p=0.011). The mean time required to perform three punctures in each kidney was 14.5 minutes with the Punctiometer and 22.4 minutes without the Punctiometer (p=0.025). The only complications noted were renal hematomas. In the Punctiometer group, all kidneys had small hematomas. In the no Punctiometer group 80% had small hematomas, 10% had a medium hematoma and 10% had a big hematoma. There was no difference in complications between both groups. Conclusions: The Punctiometer is an effective device to increase the likelihood of an accurate renal calyx puncture during PCNL, with a shorter time required to perform the procedure.

Gelatin model for training ultrasound-guided puncture / Treinamento de punção ecoguiada em modelo de gelatina

It is indispensable that members of the medical profession receive the technical training needed to enable them to rapidly obtain effective vascular access. Training procedures should be used judiciously to familiarize students with the technique. However, existing models are expensive or ineffective, and models need to be developed that are similar to what will be encountered in real patients.OBJECTIVES: To demonstrate creation and application of a gelatin model for training ultrasound-guided puncture.METHOS: The model was made using a mixture of colorless gelatin and water in a transparent plastic receptacle with two pairs of orifices of different diameters, through which two plastic tubes were inserted, to simulate blood vessels.RESULTS: The model was a close approximation to the real medical procedure in several aspects, since gelatin has a similar consistency to human tissues, providing a more faithful reproduction of the tactile sensation at the moment when the needle reaches the interior of a vessel and its contents are aspirated.CONCLUSIONS: The method proposed here can be used to easily construct a low-cost model using everyday materials that is suitable for large-scale training of ultrasound-guided puncture.

É imprescindível a capacitação técnica da classe médica para a obtenção de um acesso vascular rápido e eficiente, sendo que os procedimentos de treinamento devem ser usados sabiamente como forma de familiarizar o aluno à técnica. Os modelos comerciais existentes são de alto custo ou não são eficientes, devendo ser criados novos modelos semelhantes ao que será visto num paciente.OBJETIVOS: Demonstrar a criação e a utilização de um modelo de gelatina para o treinamento da punção ecoguiada por ultrassom.MÉTODOS: Modelo criado através da mistura de água com gelatina incolor num recipiente plástico transparente com dois orifícios de diferentes diâmetros, nos quais foram colocados dois canos plásticos simulando os vasos sanguíneos.RESULTADOS: O modelo proposto se aproxima da realidade do procedimento médico em vários aspectos, pois a consistência da gelatina é próxima aos tecidos humanos, promovendo a preservação da sensação tátil ao atingir o interior do vaso e durante a aspiração do conteúdo.CONCLUSÕES: O método proposto permite criar um modelo de baixo custo e fácil confecção utilizando-se materiais de uso cotidiano para treino de punção ecoguiada em larga escala.

Role of Balloon-Sheathed Intraductal Ultrasonography for Patients with Extensive Pneumobilia

Intraductal ultrasonography (IDUS) is one of the most useful diagnostic tools for various extrahepatic biliary diseases. However, conventional IDUS has some limitations in providing accurate cross-sectional imaging of the bile duct in patients with extensive pneumobilia. Using a balloon-sheathed catheter, the US system (balloon-sheathed IDUS) can overcome these limitations. Sixteen patients underwent balloon-sheathed IDUS during endoscopic retrograde cholangiography. The balloon-sheathed IDUS was inserted via a transpapillary route when visualization of the bile duct with conventional IDUS was distorted by extensive pneumobilia. The patient group had a mean age of 65.5 years, and 56.3% (9/16) were male. The balloon-sheathed IDUS permitted successful visualization of the bile duct in all patients, regardless of the extent of pneumobilia. Using this system, remnant common bile duct stones were detected in five patients (31.3%), and cholangiocarcinoma was detected in one patient (6.3%). The balloon-sheath IDUS aided in stone sweeping. No significant complications, including bleeding, perforation, or pancreatitis, occurred in any of the patients. The balloon-sheathed catheter US system was useful and safe for biliary IDUS in patients with extensive pneumobilia.

Transperineal versus transrectal prostate biopsy for predicting the final laterality of prostate cancer: are they reliable enough to select patients for focal therapy? Results from a multicenter international study

Objectives: To compare the concordance of prostate cancer (PCa) laterality between the extended transperineal (TP) or transrectal (TR) prostate biopsy (BP) and radical prostatectomy (RP) specimens. To identify predictors of laterality agreement between BP and RP. Materials and Methods: Data from 533 consecutive patients with PCa (278 TP and 255 TR-diagnosed) treated with RP were analyzed. A 12-core technique was used for both TP and TR biopsies. Additional cores were obtained when necessary. Results: Overall, the percentage of agreement of PCa laterality between BP and RP was 60% (K = 0.27, p < 0.001). However, the RP confirmation of unilaterality at BP was obtained in just 33% of the cases. Considering the concordance on bilaterality as the “target” of our analysis, the sensitivity and specificity were 54.3% and 98.2%, respectively, with TP and 47.5% and 92.5%, respectively with TR. Focusing on patients with unilaterality at biopsy, none of the evaluated preoperative variables (biopsy technique, age, total positive biopsy cores, PSA, prostate volume, Gleason score on biopsy) were able to predict RP bilaterality in the multivariate analyses. Conclusions: Most of the patients with unilateral involvement at BP harbored bilateral PCa after RP. TR and TP biopsy showed no difference in their capacity to predict the concordance of tumor laterality at RP. None of the preoperative evaluated variables can predict the tumor laterality at RP. Using BP unilaterality to include patients in focal therapy (FT) protocols may hinder the oncologic efficacy of FT. .

An approach to automatically segment the media-adventitia borders in IVUS / Uma associação de técnicas para segmentação automática da fronteira da média-adventícia em IVUS

Por ser capaz de mostrar aspectos morfológicos e patológicos de ateroscleroses, o Ultrassom Intravascular (IVUS) se tornou uma das modalidades de imagens médicas mais confiáveis e empregadas em intervenções cardíacas. As características de sua imagem aumentam as chances de um bom diagnóstico, resultando em terapias mais precisas. O estudo de segmentação da fronteira média-adventícia, dentre muitas aplicações, é importante para o aprendizado das propriedades mecânicas e determinação de algumas medidas específicas (raio, diâmetro, etc.) em vasos e placas. Neste trabalho, uma associação de técnicas de processamento de imagens está sendo proposta para atingir alta acurácia na segmentação da borda média-adventícia. Para tanto, foi feita uma combinação das seguintes técnicas: Redução do Speckle por Difusão Anisotrópica (SRAD), Wavelet, Otsu e Morfologia Matemática. Primeiramente, é usado SRAD para atenuar os ruídos speckle. Posteriormente, é executada Transformada Wavelet para extração das características dos vasos e placas. Uma versão binarizada dessas características é criada na qual o limiar ótimo é definido por Otsu. Finalmente, é usada Morfologia Matemática para obtenção do formato da adventícia. O método proposto é avaliado ao segmentar 100 imagens de alta complexidade, obtendo uma média de Verdadeiro Positivo (TP(%)) = 92,83 ± 4,91, Falso Positivo (FP(%)) = 3,43 ± 3,47, Falso Negativo (FN(%)) = 7,17 ± 4,91, Máximo Falso Positivo (MaxFP(mm)) = 0,27 ± 0,22, Máximo Falso Negativo (MaxFN(mm)) = 0,31 ± 0,2. A eficácia do nosso método é demonstrada, comparando este resultado com outro trabalho recente na literatura.

By being able to show morphological and pathological aspects of atherosclerosis, the Intravascular Ultrasound (IVUS) be¬came one of the most reliable and employed medical imaging modality in cardiac interventions. Its image characteristics in¬crease the chances of a good diagnostic, resulting in a precise therapy. The study of media-adventitia borders segmentation in IVUS, among many applications, is important for learning about the mechanical properties and determining some specific measurements (radius, diameter, etc.) in vases and plaques. An approach is proposed to achieve high accuracy in media-adventitia borders segmentation, by making a combination of different image processing operations: Speckle Reducing Anisotropic Diffusion (SRAD), Wavelet, Otsu and Mathematical Morphology. Firstly, SRAD is applied to attenuate the speckle noise. Next, the vessel and plaque features are extracted by performing Wavelet Transform. Optimal thresholding is car¬ried out by Otsu method to create a binarized version of these features. Then, Mathematical Morphology operations are used to obtain an adventitia shape. The proposed approach is evaluated by segmenting 100 challenging images, obtaining an average of True Positive (TP(%)) = 92.83 ± 4.91, False Positive (FP(%)) = 3.43 ± 3.47, False Negative (FN(%)) = 7.17 ± 4.91, Max False Positive (MaxFP(mm)) = 0.27 ± 0.22, Max False Negative (MaxFN(mm)) = 0.31 ± 0.2. The effectiveness of our approach is demonstrated by comparing this result with another recent work in the literature.