Lumbar puncture simulation in pediatric residency training: improving procedural competence and decreasing anxiety.

BACKGROUND: Pediatric residents must become proficient with performing a lumbar puncture (LP) during training. Residents have traditionally acquired LP skills by observing the procedure performed by a more senior resident or staff physician and then attempting the procedure themselves. This process can result in variable procedural skill acquisition and trainee discomfort. This study assessed changes in resident procedural skill and self-reported anxiety when residents were provided with an opportunity to participate in an interactive training session and practice LPs using a simulator. METHODS: All pediatric residents at our institution were invited to participate. Residents were asked to report their post-graduate year (PGY), prior LP attempts and self-reported anxiety scores as measured by the standardized State-Trait Anxiety Inventory - State Anxiety Scale (STAI-S) prior to completing an observed pre-test using an infant-sized LP simulator. Staff physicians observed and scored each resident's procedural skill using a previously published 21-point scoring system. Residents then participated in an interactive lecture on LP technique and were given an opportunity for staff-supervised, small group simulator-based practice within 1 month of the pre-test. Repeat post-test was performed within 4 months. RESULTS: Of the pediatric residents who completed the pre-test (N = 20), 16/20 (80 %) completed both the training session and post-test. Their PGY training level was: PGY1 (38 %), PGY2 (25 %), PGY3 (25 %) or PGY4 (12 %). Procedural skill improved in 15/16 residents (paired t-test; p < 0.001), driven by a significant improvement in skill for residents in PGY1 (P = 0.015) and PGY2 (p = 0.003) but not PGY3 or PGY4. Overall anxiety scores were higher at baseline than at post testing (mean ± SD; 44.8 ± 12.1 vs 39.7 ± 9.4; NS) however only PGY1 residents experienced a significant reduction in anxiety (paired t-test, p = 0.04). CONCLUSION: LP simulation training combined with an interactive training session may be a useful tool for improving procedural competence and decreasing anxiety levels, particularly among those at an earlier stage of residency training.

Cognitive dysfunction after total knee arthroplasty: effects of intraoperative cerebral embolization and postoperative complications.

Cerebral emboli identified as high-intensity transient signals (HITS) occur during total knee arthroplasty (TKA). Their effects on cognitive outcome remain speculative. Intraoperative HITS and postoperative complications were correlated with the cognitive function of TKA patients. Cognitive function was assessed both before and after surgery (1 week and 3 months). High-intensity transient signals occurred in 22 of 37 patients. Counts of HITSs were higher in patients with sonographically detected intracardiac shunts. Cognitive dysfunction was found in 41% of patients at 1 week, but in only 18% at 3 months. High-intensity transient signal counts were not associated with the prevalence of cognitive deficits. At 1 week, 58% of patients with cognitive deficits had at least 1 postoperative complication (6% in nondeficit patients). All cognitively impaired patients at 3 months had complications (17% in the nondeficit group). This raises the possibility that postoperative complications might be associated with cognitive dysfunction in TKA patients.

A randomized, controlled trial of albumin versus saline for the treatment of intradialytic hypotension.

Intradialytic hypotension (IDH) is the most common complication of hemodialysis. Symptomatic IDH requires the administration of fluid and often results in the early termination of dialysis, both of which may prevent adequate fluid removal. The optimal fluid for the treatment of IDH remains unknown. A randomized, double-blind, crossover trial was performed in 72 chronic hemodialysis patients to determine whether 5% albumin was more effective than normal saline for the treatment of IDH. The primary outcome measure was the percentage of target ultrafiltration achieved, which was defined as the actual ultrafiltration volume divided by target ultrafiltration volume. Secondary outcome measures included postdialysis BP, time to restore BP, recurrent IDH, and treatment failure (inability to restore BP with 750 ml of study fluid). The percentage of target ultrafiltration achieved was 0.84 +/- 0.17 for 5% albumin compared with 0.80 +/- 0.16 for saline (P = 0.14). The postdialysis systolic BP (121 +/- 19 mmHg versus 117 +/- 19 mmHg; P = 0.32), postdialysis diastolic BP (63 +/- 9 mmHg versus 61 +/- 9 mmHg; P = 0.33), volume of study fluid used to treat IDH (403 +/- 170 ml versus 428 +/- 191 ml; P = 0.34), time required to restore the BP (7.9 +/- 6.6 min versus 9.9 +/- 7.5 min; P = 0.09), total nursing time required to manage the hypotensive episode (15.1 +/- 7.2 min versus 15.9 +/- 7.3 min; P = 0.47), number of treatment failures (22% versus 24%; P = 1.0), and the frequency of recurrent IDH (36% versus 36%) were not significantly different when 5% albumin was used compared with saline. It is concluded that 5% albumin is no more effective than normal saline for the treatment of IDH in chronic hemodialysis patients. Normal saline should be used as the initial fluid for the treatment of IDH.

Autologous osteoarticular transfer from the proximal tibiofibular joint to the scaphoid and lunate facets in the treatment of severe distal radial fractures: a report of two cases.

PURPOSE: This study was conducted to determine the appropriateness of using the articular cartilaginous surfaces of the proximal tibiofibular joint to resurface damaged distal radial articular surfaces and to assess the clinical results in the first 2 patients. METHOD: Cadaveric specimens of the facets of the proximal tibiofibular joints and distal radius were sized and compared. Two patients underwent transfer of a fibular facet. RESULTS: The surface area of each of the proximal tibiofibular facets were larger than either the scaphoid or lunate facets of the distal radius. The 2 patients had excellent clinical results with minimal donor morbidity. CONCLUSIONS: Use of the articular surfaces from the proximal tibiofibular joint to replace damaged distal radial facets is possible and can be accomplished with excellent results and minimal morbidity.

Effect of arthroscopic débridement for osteoarthritis of the knee on health-related quality of life.

BACKGROUND: The available evidence supporting the use of arthroscopic débridement for the treatment of symptomatic osteoarthritis of the knee is largely retrospective and lacks validated health-related quality-of-life measures. The goal of the study was to prospectively assess a cohort of patients with osteoarthritis of the knee who were selected for arthroscopic débridement and determine which clinical criteria favor a sustained improvement in health-related quality of life after two years of follow-up. METHODS: One hundred and twenty-six patients with symptomatic primary osteoarthritis of the knee underwent arthroscopic débridement of the knee after failure of medical management. Two groups of surgeons (postgraduate fellows and attending staff) independently evaluated the patients preoperatively with use of a standardized assessment of clinical symptoms and signs and plain radiography. The intervention was arthroscopic débridement, which included resection of unstable chondral flaps and meniscal tears. Abrasion was not performed. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a disease-specific scale, and the Short Form-36 (SF-36), a generic outcome measure. RESULTS: Sixty-seven (53%) of the 126 patients were female, and the mean age (and standard deviation) was 61.7 +/- 8.6 years (range, forty-three to seventy-five years). The medial compartment was more frequently and severely involved, with 57% showing Grade-III or IV involvement, according to the system of Dougados et al. Seventy-nine patients (63%) had an unstable meniscal tear. Fifty-six patients (44%) were rated as having had a clinically important reduction in pain, as determined with the WOMAC pain scale, at two years after the arthroscopic débridement. Physicians were poor at predicting which patients would have improvement. The rate of accuracy of the fellows and staff was 54% and 59%, respectively, and their agreement was only slightly better than chance, with a kappa of 0.27 (95% confidence interval, 0.09 to 0.45). Only three variables were significantly associated with improvement: the presence of medial joint-line tenderness (p = 0.04), a positive Steinman test (p = 0.01), and the presence of an unstable meniscal tear at arthroscopy (p = 0.01). CONCLUSIONS: The prospectively evaluated quality-of-life benefit from arthroscopic débridement of the osteoarthritic knee is less than that reported in previous retrospective surveys on satisfaction. These results may serve as a baseline for comparison against more sophisticated procedures for resurfacing of the articular cartilage. Clinical variables were only partially helpful for predicting a successful result after arthroscopic débridement, and a search for other biologic markers (such as synovial fluid) may be of benefit. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See p. 2 for complete description of levels of evidence.

Refracture rate after plate removal from the radial metaphysis.

OBJECTIVES: To document the refracture rate after removal of internal fixation at the metaphyseal region of the distal radius and to compare this rate to that associated with diaphyseal plate removal reported in the literature. DESIGN: A chart review with telephone follow-up. SETTING: Three tertiary care hospitals (in Ottawa, Burlington, Vt., and London, Ont.). PATIENTS: Fifty-three patients (54 radii) underwent elective removal of internal fixation of the distal radius after distal metaphyseal procedures. The mean follow-up was 46.8 months. MAIN OUTCOME MEASURE: The refracture rate. RESULTS: No refractures were reported after plate removal, and the overall complication rate was minimal. CONCLUSIONS: The refracture rate at the metaphvsis of the radius after plate removal is lower than the rate after diaphyseal plate removal reported in the literature.