Perioperative arterial catheterization: A prospective evaluation of ultrasound, infection, and patient-focused outcomes.

BACKGROUND: There is little information regarding complications of arterial catheterization in modern clinical care. We aimed to determine the incidence of abnormal duplex vascular ultrasound and catheter related infections following perioperative arterial catheterization. METHODS: Patients requiring arterial catheterization for elective surgery were included and insertion details collected prospectively. Duplex ultrasound evaluation was performed 24 h after catheter removal. Symptomatic patients were identified by self-reported questionnaire. On Day 7, patients answered questions by telephone, related to the insertion site, pain, and function. Results of catheter tip and blood culture analyses were sought. Univariate associations of patient and surgical characteristics with abnormal ultrasound were assessed with p < 0.05 considered significant. RESULTS: Of 339 catheterizations, 105 (40%) had ultrasound evaluation. Catheters were indwelling for median (IQR, range) duration of 6.0 h (4.4-8.2, 1.8-28) with no catheter-related infections. There were 16 (15.2%, 95% CI 9.0%-23.6%) abnormal results, including 14 radial artery thromboses, one radial artery dissection, and one radial vein thrombosis. Those with abnormal ultrasound results were more likely to have had Arrow catheters inserted (68.8% vs 27%, p = 0.023) and more than one skin puncture (37.5% vs 26.8%, p = 0.031). Two of the 16 (12.5%) patients with abnormal ultrasound results reported new symptoms related to the hand compared with nine of the 88 (10.2%) with normal results (p = 0.1). No patients required urgent referral for management. CONCLUSIONS: Thrombosis was the most common abnormality and was usually asymptomatic. There were no infections, few post-operative symptoms, and minimal functional impairment following arterial catheterization.

eHealth literacy of patients attending a primary care clinic in Malaysia and its associated factors: A cross-sectional study.

Background: People are overloaded with online health information (OHI) of variable quality. eHealth literacy is important for people to acquire and appraise reliable information to make health-related decisions. While eHealth literacy is widely studied in developed countries, few studies have been conducted among patients in low- and middle-income countries (LMICs). Objective: We aimed to determine the level of eHealth literacy in patients attending a primary care clinic in Malaysia and its associated factors. Methods: A cross-sectional study using a self-administered questionnaire was conducted in an urban primary care clinic. We used a systematic random sampling method to select patients aged 18 years and above who attended the clinic. The eHealth literacy scale (eHEALS) was used to measure eHealth literacy. Results: A total of 381 participants were included. The mean eHEALS was 24.4 ± 7.6. The eHEALS statements related to skills in appraising OHI were scored lower than statements related to looking for online resources. Higher education level of attending upper secondary school (AOR 2.53, 95% CI 1.05-6.11), tertiary education (AOR 4.05, 95% CI 1.60-10.25), higher monthly household income of >US$470 (AOR 1.95, 95% CI 1.07-3.56), and those who had sought OHI in the past month (AOR 1.95, 95% CI 1.13-3.36) were associated with a higher eHealth literacy level. Conclusions: This study found a low eHealth literacy level among primary care patients in Malaysia. While the patients were confident in searching for OHI, they lacked skills in appraising them. Our findings inform the interventions for improving eHealth literacy in LMICs, especially educating the public about OHI appraisal.

Recognized and unrecognized dural punctures in 12,981 labor epidurals: an audit of management.

PURPOSE: Unintentional dural puncture (DP) and post-dural puncture headache (PDPH) continue to cause discomfort and disability in a small proportion of post-partum women. We report an audit of the management of recognized and unrecognized DP over 10 years. METHODS: Clinical data were prospectively collected for women who experienced a recognized DP or developed symptoms following a neuraxial procedure. Details were documented regarding patient characteristics, the neuraxial procedure, symptoms reported, and epidural blood patches. We reported rates of recognized DP, unrecognized DP, PDPH, and blood patches performed. Data were presented as number (percent) and proportions of interest compared using Chi square analysis. RESULTS: Between January 2009 and December 2018, 12,981 women utilized labor epidural analgesia. A recognized DP occurred in 131 (1.0%) and an unrecognized DP in 60 (0.5%), with unrecognized DPs comprising 31% of the total. Of 131 recognized punctures, 86 (66%) developed a PDPH. A total of 146 (1.1%) women experienced a PDPH. Of those, a blood patch was performed in 93 (64%). Intrathecal catheters were inserted for > 24 h in 43 (33%) women with a recognized DP. Of those, 33 (77%) developed a PDPH, compared to 53 (60%) of those without an intrathecal catheter in situ for > 24 h (P = 0.06). CONCLUSIONS: Rates of DP were consistent with those reported by others. Unrecognized DP comprised a third of all DP, and systematic post-neuraxial follow-up is essential to identify these women. Epidural blood patch was performed in most women experiencing symptoms of PDPH.

A retrospective observational study of patient analgesia outcomes when regional anaesthesia procedures are performed by consultants versus supervised trainees.

At teaching hospitals, consultants must provide effective supervision, including appropriate selection of teaching cases, such that the outcomes achieved by trainees are similar to that of consultants. Numerous studies in the surgical literature have compared patient outcomes when surgery is performed by consultant surgeons or surgical trainees but, to our knowledge, none exist in the field of anaesthesia. We aimed to compare analgesia outcomes of regional anaesthesia when performed by supervised trainees versus consultants. We designed a retrospective observational study using registry data. The primary outcome was inadequate analgesia, defined as a numerical rating scale (NRS) for pain >5 reported at any time in the post-anaesthesia care unit (PACU). Secondary outcomes included the maximum pain NRS, pain experienced in the PACU, and the requirement for systemic opioid analgesia in the PACU. Of the 1814 patients analysed, the primary proceduralist was a consultant for 514 (28.3%) patients and a trainee for 1300 (71.7%) patients. All trainees were supervised by an on-site consultant. There were no statistically significant differences between consultants and supervised trainees in terms of the primary outcome (NRS >5 in 24.9% and 24.5% of patients, respectively; P = 0.84) and secondary outcomes. Compared to trainees, consultants had a slightly higher rate of patients with a body mass index >30 kg/m2, an American Society of Anesthesiologists Physical Status Classification of 3 or 4, nerve blocks performed under general anaesthesia, paravertebral/neuraxial blocks and blocks with perineural catheter placement. Regional anaesthesia performed by supervised trainees can achieve similar analgesia outcomes to consultant-performed procedures.

Online health information-seeking behaviour of patients attending a primary care clinic in Malaysia: a cross-sectional study.

BACKGROUND: The internet has become a common source of health information; however, little is known about online health information-seeking behaviour (HISB) among patients in low- and middle-income countries (LMICs). OBJECTIVES: This study aimed to determine the prevalence of online health information-seeking and its associated factors among patients in primary care in Malaysia. We also examined the reasons for, and the sources of, online health information-seeking, patients' level of trust in the information found and what the information was used for. METHODS: A cross-sectional study using a self-administered questionnaire was conducted on patients who attended a primary care clinic. The questionnaire included the use of the internet to seek health information, sources and types of health information, eHealth literacy, patients' trust in online information, and how patients appraise and use online health information. RESULTS: Out of 381 patients in this study, 54.7% (n = 208) used the internet to search for health information. Patients mainly sought information via Google (96.2%) and the most common websites that they visited were Wikipedia (45.2%) and MyHEALTH (37.5%). Higher levels of education, longer duration of internet use, and higher eHealth literacy were significantly associated with online HISB. Patients' trust in websites (45.6%) and social media (20.7%) was low when compared to trust in healthcare professionals (87.9%). Only 12.9% (n = 22) of patients had discussed online health information with their doctors. CONCLUSION: Online HISB was common among primary care patients; however, their eHealth literacy was low, with suboptimal appraisal skills to evaluate the accuracy of online health information.

Factors associated with low levels of patient satisfaction following peripheral nerve block.

Peripheral nerve blocks can provide surgical anaesthesia as well as excellent postoperative analgesia. When questioned postoperatively, however, some patients report low levels of satisfaction with their nerve block experience. At our hospital, patients undergoing regional anaesthesia have their patient characteristics, block characteristics and postoperative feedback routinely recorded in a block registry. We analysed data from 979 consecutive patients undergoing peripheral nerve block for orthopaedic surgery to identify factors associated with low levels of patient satisfaction. The primary outcome was patient satisfaction with their peripheral nerve block (scale 1-5: 4-5 is 'satisfied', 1-3 is 'not satisfied'). Eighty-nine percent (871/979) of patients reported being 'satisfied' with their block. Factors negatively associated with patient satisfaction were rebound pain (adjusted odds ratio (aOR) 0.19, 95% confidence interval (CI) 0.04 to 0.85 for moderate rebound pain; aOR 0.11, 95% CI 0.03 to 0.48 for severe rebound pain), discomfort during the block (aOR 0.37, 95% CI 0.16 to 0.82 for moderate discomfort; aOR 0.19, 95% CI 0.05 to 0.76 for severe discomfort) and pain in the post-anaesthesia care unit (aOR 0.30, 95% CI 0.17 to 0.55 for pain ≥8/10). Only 24% (26/108) of patients who reported being 'not satisfied' stated that they would be unwilling to undergo a hypothetical future nerve block. Rebound pain of at least moderate intensity, procedural discomfort of at least moderate intensity and severe pain in the post-anaesthesia care unit are all negatively associated with patient satisfaction. Of these factors, rebound pain occurs most frequently, being present in 52% (403/777) of our respondents.

First Human Use of a New Robotic-Assisted Fiber Optic Sensing Navigation System for Small Peripheral Pulmonary Nodules.

BACKGROUND: We tested a new, investigational robotic-assisted bronchoscope system with a remotely controlled catheter to access small peripheral bronchi with real-time driving under live visualization and distal tip articulation of the catheter. The unique catheter remains stationary once located at the biopsy position. OBJECTIVES: The primary objectives of this study were to evaluate the safety and feasibility of a new shape-sensing robotic bronchoscope system to bronchoscopically approach and facilitate the sampling of small peripheral pulmonary nodules of 1-3 cm. Secondary objectives included evaluating procedural characteristics and early performance trends associated with the use of the new robotic bronchoscope system. METHODS: Subjects were enrolled according to study eligibility criteria at a single center. Navigation pathways were semi-automatically created using pre-procedure CT scans. Simultaneous (real-time) viewing of actual and virtual bronchi was used real time during navigation to the displayed target. An endobronchial ultrasound mini-probe was used to confirm lesion location. Flexible 19- to 23-G needles specifically designed to accommodate tight bend radii in transbronchial needle aspiration were used along with conventional biopsy tools. Enrolled subjects completed follow-up visits up to 6 months after the procedure. RESULTS: The study included 29 subjects with a mean lesion size of 12.2 ± 4.2, 12.3 ± 3.3, and 11.7 ± 4.1 mm in the axial, coronal, and sagittal planes, respectively. The CT bronchus sign was absent in 41.4% of cases. In 96.6% of cases, the target was reached, and samples were obtained. No device-related adverse events and no instances of pneumothorax or excessive bleeding were observed during the procedure. Early performance trends demonstrated an overall diagnostic yield of 79.3% and a diagnostic yield for malignancy of 88%. CONCLUSION: This new robotic-assisted bronchoscope system safely navigated to very small peripheral airways under continuous visualization, and through maintenance of a static position, it provides a unique sampling capability for the biopsy of small solitary pulmonary nodules.

Increased maternal abdominal subcutaneous fat thickness and body mass index are associated with increased cesarean delivery: A prospective cohort study.

INTRODUCTION: Early pregnancy body mass index (BMI) is known to predict adverse pregnancy outcomes but does not account for body fat distribution. This study aimed to determine prospectively whether maternal abdominal subcutaneous fat thickness (SCFT) measured by ultrasound at the fetal morphology scan is a better predictor than BMI of mode of delivery and other pregnancy outcomes. MATERIAL AND METHODS: This was a prospective cohort study of women delivering singleton neonates at a tertiary public hospital. Women were included if they had appropriate images at the routine fetal anomaly ultrasound scan and delivered in the facility. The primary outcome was mode of delivery categorized as cesarean section or vaginal delivery. The relation between maternal SCFT and BMI was described using the Pearson correlation coefficient. The association of maternal abdominal SCFT BMI at booking-in was compared with pregnancy outcomes using univariate linear and logistic regression. RESULTS: SCFT and BMI were obtained for 997 women. The median (interquartile range) SCFT was 15.3 mm (12.8-19.6) and median (interquartile range) BMI 24.3 kg/m2 (21.7-28.3). Maternal abdominal SCFT and BMI were highly correlated (R2  = 0.55). Both were significantly associated with cesarean delivery: SCFT per 5 mm (odds ratio [OR] 1.32, 95% confidence interval (CI) 1.18-1.48; BMI per 5 kg/m2 OR 1.29, 95% CI 1.15-1.44. CONCLUSIONS: Maternal abdominal SCFT and BMI were both significantly associated with cesarean delivery and other outcomes. More research is needed to define the strengths of maternal SCFT in predicting pregnancy outcomes.

Measurement of pruritus in a Chinese woman with pemphigoid gestationis using a wrist movement detector.

Pemphigoid gestationis (PG) is a rare itching bullous disease of pregnancy and the postpartum period. We describe the use of a new methodology for measuring the nature and intensity of itching in a 21-year-old woman with pemphigoid gestationis. At 19 weeks gestation, she developed an itchy rash over the limbs, which spread to the trunk. Blisters then appeared on the hands which subsequently also involved the feet. Intense nocturnal wrist activities in this patient, measured with a wrist monitor and defined as average acceleration in the early hours of sleep, were even higher than that in patients with severe eczema, with an average value of 181.00 +/- 43.49 (mean +/- standard error) g/min for the first three hours, versus 84.47 +/- 8.53 g/min for the group of 24 eczema subjects. Most wrist activities were slower movements at 0 to 1 Hz. This is in striking contrast to the scratching activities at 0 to 3 Hz in eczema subjects. There have been no therapeutic trials for PG. Topical steroid and oral antihistamines are usually ineffective, but worked in our patient. We also discuss the potential application of the monitor in assessing the nature of various dermatological or systemic itching disorders.

A malignant itch.

We report an unusual presentation of a previously healthy three-year-old Chinese girl with a four-week history of apparently unexplained generalized intense itch. She had no past history of atopy or xerosis. Despite the severe itch, she had only minimal scratch marks on her right gluteal region but no flexural involvement. The girl was treated as having scabies and eczema and with oral antihistamines by various dermatologists without much improvement. She subsequently presented to a regional hospital with right hip pain and fever. Radiological and histopathological investigations confirmed that she had a peripheral T-cell lymphoma. The itch pattern prior to and following chemotherapy, as documented by the DigiTrac wrist-held movement monitor, showed a dramatic reduction of her nocturnal itch. The pattern was also very different from that of atopic dermatitis in that the scratching was of much higher intensity but lower frequency. Intractable pruritus associated with a peripheral T-cell lymphoma has not been previously reported in the pediatric literature. This report serves to alert clinicians of the gold paradigm that in a patient with an unexplained generalized itch, lymphoma and other malignancies must be considered.

Innate cell-mediated immune response and peripheral leukocyte populations in Atlantic salmon, Salmo salar L., to a live Cryptobia salmositica vaccine.

The effects of a live Cryptobia salmositica (Kinetoplastida) vaccine on the humoral and cellular immune response, and changes in the peripheral leukocyte populations of Salmo salar were investigated. The vaccine produced detectable parasitemia in the blood which peaked at 5 weeks post-vaccination (w.p.v). Antibodies were detectable at 4 w.p.v. and the antibody titer increased as parasitemia declined. Respiratory burst activity in vaccinated fish was significantly higher than in control fish; the highest activity occurred with rising parasitemia and lower activity with declining parasitemia. There was a significant increase in the proportion of granulocytes (to total leukocytes) at 4 w.p.v. At 6 w.p.v., the proportion of lymphocytes and monocytes increased significantly and remained elevated. These results demonstrate innate (respiratory burst activity and an increase in the proportion of granulocytes corresponding to rising parasitemia) and adaptive (antibody production and increases in the proportion of monocytes and lymphocytes corresponding to declining parasitemia) immune responses to the live vaccine.

Effect of Cryptobia salmositica-induced anorexia on feeding behavior and immune response in juvenile rainbow trout Oncorhynchus mykiss.

At 10 degrees C, rainbow trout Oncorhynchus mykiss (n = 13 per group) infected with Cryptobia salmositica Katz, 1951 became anorexic at 3 wk post-infection (w.p.i.), with feed-intake decreasing significantly from 1.33 to 0.94% body weight (b.w.). Anorexia was most severe at 4 w.p.i. (0.80% b.w.), coinciding with peak parasitemia (9.2 x 10(6) parasites ml blood(-1)) and anemia. At 8 w.p.i., fish had recovered their appetite although they still had contained detectable parasites (6.8 x 10(5) parasites ml(-1)) and were anemic (pack cell volume, PCV, of 24.4%). However at 5 degrees C, anorexia occurred at 5 w.p.i. (0.81% b.w.), and was most severe at 7 w.p.i. (0.40% b.w.). At 8 w.p.i. (0.43% b.w.), fish displayed high parasitemia (4.6 x 10(6) parasites ml(-1)) and low PCV (10.8%). Fish at 5 degrees C had lower gastric evacuation (GE) rates (GE48h) than 10 degrees C fish, however there were no differences between infected and naive fish at both temperatures. Before anorexia, there was no significant correlation between mean share of meal (MSM, a measure of how food was partitioned within a group) and coefficient of variation in feeding but this became significant during anorexia (p = 0.02 and p = 0.0002 at 10 and 5 degrees C respectively). Significant correlations were detected between b.w. and MSM before onset of anorexia at 10 degrees C (p = 0.005) and 5 degrees C (p = 0.02); this was maintained at 10 degrees C (p = 0.001) but not at 5 degrees C (p = 0.98). Fish on an anorexic diet (0.93% b.w.) responded well at 10 degrees C to a live C. salmositica vaccine; this could partly be due to constant antigenic stimulation by the live vaccine.