Treatment of Postoperative Neck Dissection Cervical Lymphocele With Percutaneous Bleomycin Sclerotherapy.

Lymphatic leak after lymph node dissection is a rare but well-known surgical complication that is often treated with conservative management and ultimately reoperation. The purpose of this report is to offer an alternative treatment for chyle leak that avoids hospitalization and subsequent surgery. Sclerotherapy has been used to treat lymphatic leaks in the past and has been shown to be safe and effective. This report presents a patient with a known cervical lymphocele who was followed through multiple sclerotherapy appointments until resolution of the lymphocele.

Evaluation of the Clinical Utility of Transesophageal Echocardiography and Invasive Monitoring to Assess Right Ventricular Function During and After Pulmonary Endarterectomy.

OBJECTIVE: Patients undergoing pulmonary endarterectomy (PEA) have impaired right ventricular function. The authors sought to assess the clinical utility of commonly used perioperative echocardiographic and right heart catheter measurements in patients undergoing PEA. DESIGN: A single-center prospective observational study. SETTING: The study was conducted in a quaternary care cardiac surgical center in the United Kingdom. PARTICIPANTS: Patients undergoing PEA between April 2015 and January 2016. INTERVENTIONS: Thermodilution cardiac index and echocardiography variables were measured at 3 time points: before sternotomy (T1), after pericardial incision (T2), and after sternal closure (T3). Six-month follow-up echocardiography and 6-minute walk (6-MWT) test were performed. MEASUREMENTS AND MAIN RESULTS: Fifty patients were recruited and complete data sets were available for 41 patients. Tricuspid annular plane systolic excursion declined after pericardial incision and cardiopulmonary bypass (T1: 15 ± 4 mm, T2: 13 ± 4 mm, T3: 7 ± 2 mm; p < 0.0001), returning to baseline 6 months postoperatively. Cardiac index (T1: 2.5 ± 0.7 L/min/m2, T2: 2.6 ± 0.6 L/min/m2, T3: 2.3 ± 0.5 L/min/m2; p = 0.07) and right ventricular fractional area change (T1: 36 ± 11%, T2: 40 ± 12%, T3: 40 ± 9%; p = 0.12) were preserved perioperatively. 6-MWT improved from baseline (294 ± 111 m) to follow-up (357 ± 107 m) (p < 0.001). Pulmonary vascular resistance at T3 correlated moderately with follow-up 6-MWT (R = -0.60). CONCLUSIONS: In patients undergoing PEA, invasive measurements and echocardiography assessment of right ventricular function are not interchangeable. Tricuspid annular plane systolic excursion is not a reliable measure of right ventricular function perioperatively. Pulmonary vascular resistance shows moderate correlation with postoperative functional capacity.

Reduction of MRI signal distortion from titanium intracavitary brachytherapy applicator by optimizing pulse sequence parameters.

PURPOSE: To demonstrate that optimized pulse sequence parameters for a T2-weighted (T2w) fast spin echo acquisition reduced artifacts from a titanium brachytherapy applicator compared to conventional sequence parameters. METHODS AND MATERIALS: Following Institutional Review Board approval and informed consent, seven patients were successfully imaged with both standard sagittal T2w fast spin echo parameters (voxel size of 0.98 × 0.78 × 4.0 mm3; readout bandwidth of 200 Hz/px; repetition time of 2800 ms; echo time of 91 ms; echo train length of 15; 36 slices; and imaging time of 3:16 min) and an additional optimized T2w sequence (voxel size of 0.98 × 0.98 × 4.0 mm3; readout bandwidth of 500 Hz/px; repetition time of 3610 ms; echo time of 91 ms; echo train length of 25; 18-36 slices; and imaging time of 1:15-2:30 min), which had demonstrated artifact reduction in prior phantom work. Visualized intracavitary tandem was hand-segmented by two of the authors. Three body imaging radiologists assessed image quality and intraobserver agreement scores were analyzed. RESULTS: The average segmented volume of the intracavitary applicator significantly (p < 0.05) decreased with the experimental pulse sequence parameters as compared to the standard pulse sequence. Comparison of experimental and standard T2w sequence qualitative scores for each reviewer showed no significant differences between the two techniques. CONCLUSIONS: This study demonstrated that pulse sequence parameter optimization can significantly reduce distortion artifact from titanium applicators while maintaining image quality and reasonable imaging times.

The use of the faces, legs, activity, cry and consolability scale to assess procedural pain and distress in young children.

INTRODUCTION: Young children frequently undergo diagnostic and therapeutic procedures in the emergency department (ED). Although developed and validated for postoperative pain, Face, Legs, Activity, Cry, Consolability (FLACC) behavioral pain scores have been recommended and used for the assessment of procedural pain as well. We set out to assess if FLACC scores can differentiate pain and distress and establish a hierarchy of FLACC scores experienced during common ED procedures. METHODS: Prospective observational study at an urban tertiary children's hospital ED. We aimed to recruit 30 children each aged 6 to 42 months undergoing intravenous cannula (IV) insertion, nasogastric tube (NGT) insertion, metered dose inhaler (MDI) use and oxygen saturation (SpO(2)) measurement. Based on videotapes, 2 independent observers assessed pain and distress using FLACC scores during all procedural phases. RESULTS: A total of 125 patients were recruited and filmed for IV (33), NGT (30), MDI (34), and SpO2 (28). Median FLACC scores were as follows: NGT, 10 (interquartile range [IQR] 8.75-10); IV, 6.5 (IQR, 4.5-9.75); MDI, 6.5 (IQR, 0-9); and SpO(2), 0 (IQR, 0-0.5). The FLACC scores increased during each of the 3 phases, before the procedure, during restraint, and during the procedure. Procedural distress decreased with age except for NGT insertions, which remained very high irrespective of age. CONCLUSIONS: FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children. This study identified substantial levels of pain and distress in young children by FLACC during commonly performed ED procedures, with nasogastric tube insertion having very high and intravenous cannulation/venepuncture and MDI having high FLACC scores.

Procedural restraint use in preverbal and early-verbal children.

BACKGROUND: Children frequently undergo diagnostic and therapeutic procedures while in hospital. To conduct these procedures safely, preverbal and early-verbal children in particular are often restrained. However, the literature on procedural restraint use is very limited. We set out to describe the extent of restraint use in 4 common procedures. METHODS: In this prospective observational study at an urban tertiary children's hospital emergency department, children aged 6 to 42 months undergoing 4 commonly performed procedures (intravenous insertion [IV], nasogastric tube [NGT] insertion, metered-dose inhaler [MDI] use, and oxygen saturation [O2 sat] measurement) were recruited. An independent observer assessed the extent and forcefulness of restraint use. Results were analyzed descriptively by age and procedure. RESULTS: One hundred twenty-four patients were recruited. All successful procedures (n = 123) were completed in 3 or fewer attempts, with 102 (82%) successful on the first attempt. Physical restraint was used in 89 (72%) of 124 patients overall. All patients undergoing IV (n = 33) and NGT insertion (n = 30), 64% of children requiring MDI (21/33), and only 18% of children requiring O2 sat measurements (5/28) were restrained. Twenty-three (79%) of the NGT insertions and 16 (48%) of IV insertions required moderate or forceful restraint. No or gentle restraint was used for 24 (73%) of MDI use and 100% of saturation measurements. Overall, 41 (87%) of 47 children 6 to 18 months old required restraint use as compared with 28 (68%) of 41 of 18- to 30-month-olds and 20 (57%) of 35 of 30- to 42-month-olds. CONCLUSIONS: Procedural restraint use in preverbal and early-verbal children is extensive, and significant amounts of force are used, which vary by procedure. Restraint use diminishes with age. A scoring system for restraint use is suggested based on the number of body parts restrained.

Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting.

BACKGROUND: Assessing procedural pain and distress in young children is difficult. A number of behavior-based pain and distress scales exist which can be used in preverbal and early-verbal children, and these are validated in particular settings and to variable degrees. METHODS: We identified validated preverbal and early-verbal behavioral pain and distress scales and critically analysed the validation and reliability testing of these scales as well as their use in procedural pain and distress research. We analysed in detail six behavioral pain and distress scales: Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), Faces Legs Activity Cry Consolability Pain Scale (FLACC), Toddler Preschooler Postoperative Pain Scale (TPPPS), Preverbal Early Verbal Pediatric Pain Scale (PEPPS), the observer Visual Analog Scale (VASobs) and the Observation Scale of Behavioral Distress (OSBD). RESULTS: Despite their use in procedural pain studies none of the behavioral pain scales reviewed had been adequately validated in the procedural setting and validation of the single distress scale was limited. CONCLUSIONS: There is a need to validate behavioral pain and distress scales for procedural use in preverbal or early-verbal children.

Influence of Diversionary Food on Red Squirrel Populations and Damage to Crop Trees in Young Lodgepole Pine Forest.

This study was designed to test the hypothesis that large-scale provision of diversionary food (sunflower seeds) would reduce red squirrel (Tamiasciurus hudsonicus) feeding damage to lodgepole pine (Pinus contorta) crop trees. Study areas with managed lodgepole pine stands were located near Vernon and Quesnel in south-central British Columbia, Canada. Large-scale applications of sunflower seeds were conducted on a manual basis in 1989, and by manual and aerial means in 1990, and an operational level by aerial means in 1991. Feeding damage to crop trees was assessed in control and treatment blocks. Populations of the red squirrel, northwestern chipmunk (Eutamias amoenus), and Columbian ground squirrel (Spermophilus columbianus) were sampled intensively by live-trapping on control and treatment blocks in 1990. Manual application of seed (clumped distribution) significantly reduced damage in the treatment block (11.3% of trees damaged) compared with the control (57.5% of trees damaged). Aerial application of seed (uniform distribution) also significantly reduced damage in replicated treatment vs. control blocks. Provision of diversionary food resulted in a temporary increase in the overall number of red squirrels caught on the treatment areas followed by a return to control levels within 6 wk. This increase was primarily the result of an increased number of transients in the trapped sample. The population density of resident (transients excluded) red squirrels did not increase when diversionary food was added. Similarly, we could not detect differences in reproduction, body masses, or survival of squirrels between control and food-supplemented areas. Northwestern chipmunks and Columbian ground squirrels also showed a temporary increase in density when food was added. Application of sunflower seed on an operational basis significantly reduced damage by squirrels in replicated study areas covering three different forest ecological zones. Provision of diversionary food is an effective strategy to protect intensively managed stands of lodgepole pine from red squirrel feeding damage.

Population dynamics and regulation of the Douglas squirrel (Tamiasciurus douglasii) with supplemental food.

If food is in short supply, then provision of addition food should increase the density of Douglas squirrels. A squirrel population was supplied with extra food during the summers of 1977 and 1978 and winter of 1978-1979 in coastal coniferous forest at Maple Ridge, British Columbia. Food produced a 5-to 10-fold increase in squirrel density compared with control populations. Control densities generally varied from 3 to 10 squirrels per trapping area with the experimental population increasing to 65 animals during the winter feeding. This irruption was produced by immigration, more reproduction in females, and increased survival. After the food was withdrawn, the population declined to a level comparable with the controls. We conclude that Douglas squirrel populations fluctuate in accordance with the abundance of food. Territorial behavior may space individuals within populations of Tamiasciurus douglasii but to density levels determined by the available food supply.

The use of weasels for natural control of mouse and vole populations in a coastal coniferous forest.

If the natural enemy component of biological control is functional in small mammals, then the introduciton of weasels should effectively reduce populations of deer mice and Oregon voles. Seven weasels introduced to an area of forest habitat in coastal British Columbia did not appreciably lower the abundance of mice or voles. However, these natural predators may have contributed to the localized extinction of the vole population on the experimental area. Weasels were generally more abundant in the late summer and early fall and preferred clearcut (logged) successional habitats compared with forested areas. The results of this study are discussed with respect to the futility of poison baiting and related techniques of removing rodent pest populations from forest and agricultural land developments.