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JAMA Neurology Aug 2023After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome.
OBJECTIVE
To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage.
DESIGN, SETTING, AND PARTICIPANTS
The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours.
INTERVENTION
A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage.
MAIN OUTCOMES AND MEASURES
Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage.
RESULTS
Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04).
CONCLUSION AND RELEVANCE
In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01258257.
Topics: Adult; Humans; Female; Middle Aged; Male; Subarachnoid Hemorrhage; Drainage; Cerebral Infarction; Brain Ischemia; Aneurysm; Treatment Outcome
PubMed: 37330974
DOI: 10.1001/jamaneurol.2023.1792 -
Critical Care (London, England) Aug 2023Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not... (Review)
Review
Nasogastric feeding tube insertion is a common but invasive procedure most often blindly placed by nurses in acute and chronic care settings. Although usually not harmful, serious and fatal complications with misplacement still occur and variation in practice still exists. These tubes can be used for drainage or administration of fluids, drugs and/or enteral feeding. During blind insertion, it is important to achieve correct tip position of the tube ideally reaching the body of the stomach. If the insertion length is too short, the tip and/or distal side-openings at the end of the tube can be located in the esophagus increasing the risk of aspiration (pneumonia). Conversely, when the insertion length is too long, the tube might kink in the stomach, curl upwards into the esophagus or enter the duodenum. Studies have demonstrated that the most frequently used technique to determine insertion length (the nose-earlobe-xiphoid method) is too short a distance; new safer methods should be used and further more robust evidence is needed. After blind placement, verifying correct gastric tip positioning is of major importance to avoid serious and sometimes lethal complications.
Topics: Humans; Adult; Intubation, Gastrointestinal; Enteral Nutrition; Drainage; Long-Term Care
PubMed: 37596615
DOI: 10.1186/s13054-023-04611-6 -
The Journal of Clinical Investigation Nov 2023Skull development coincides with the onset of cerebrospinal fluid (CSF) circulation, brain-CSF perfusion, and meningeal lymphangiogenesis, processes essential for brain...
Skull development coincides with the onset of cerebrospinal fluid (CSF) circulation, brain-CSF perfusion, and meningeal lymphangiogenesis, processes essential for brain waste clearance. How these processes are affected by craniofacial disorders such as craniosynostosis are poorly understood. We report that raised intracranial pressure and diminished CSF flow in craniosynostosis mouse models associate with pathological changes to meningeal lymphatic vessels that affect their sprouting, expansion, and long-term maintenance. We also show that craniosynostosis affects CSF circulatory pathways and perfusion into the brain. Further, craniosynostosis exacerbates amyloid pathology and plaque buildup in Twist1+/-:5xFAD transgenic Alzheimer's disease models. Treating craniosynostosis mice with Yoda1, a small molecule agonist for Piezo1, reduces intracranial pressure and improves CSF flow, in addition to restoring meningeal lymphangiogenesis, drainage to the deep cervical lymph nodes, and brain-CSF perfusion. Leveraging these findings, we show that Yoda1 treatments in aged mice with reduced CSF flow and turnover improve lymphatic networks, drainage, and brain-CSF perfusion. Our results suggest that CSF provides mechanical force to facilitate meningeal lymphatic growth and maintenance. Additionally, applying Yoda1 agonist in conditions with raised intracranial pressure and/or diminished CSF flow, as seen in craniosynostosis or with ageing, is a possible therapeutic option to help restore meningeal lymphatic networks and brain-CSF perfusion.
Topics: Mice; Animals; Glymphatic System; Brain; Lymphatic Vessels; Perfusion; Craniosynostoses; Drainage; Ion Channels
PubMed: 37917195
DOI: 10.1172/JCI171468 -
La Tunisie Medicale 2023Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly and bilaterally. It can affect the submandibular, sublingual or submental...
Ludwig's angina is a severe diffuse cellulitis that presents an acute onset and spreads rapidly and bilaterally. It can affect the submandibular, sublingual or submental spaces resulting in a state of emergency. Early diagnosis and urgent management could be a life-saving procedure. We report a case of wide spread sialadenitis infection extending to the neck with trismus and elevation of the floor of the mouth that caused an obstruction of the airway and resulted in an inspiratory dyspnea and a stridor. The patient was directed to maintain the airway by elective tracheostomy. An appropriate use of parenteral antibiotics, airway protection techniques, and potential surgical drainage of the infection remain the standard protocol of treatment in advanced cases of Ludwig's angina. The aim of this case report is to emphasize on the importance of early diagnosis and appropriate management of Ludwig's angina.
Topics: Humans; Ludwig's Angina; Cellulitis; Anti-Bacterial Agents; Drainage; Neck
PubMed: 38445409
DOI: No ID Found -
Revista Espanola de Enfermedades... Jul 2023This year, 2023, marks the fiftieth anniversary of the introduction of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), which completely changed the...
This year, 2023, marks the fiftieth anniversary of the introduction of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), which completely changed the management of biliary and pancreatic diseases. As in other invasive procedures, two intrinsically related concepts soon appeared: drainage success and complications. It was observed that ERCP is the most dangerous procedure regularly performed by gastrointestinal endoscopists, with a morbidity and mortality of 5-10 % and 0.1-1 %, respectively. ERCP is by far one of the best examples of a complex endoscopic technique.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Pancreatic Diseases; Drainage; Retrospective Studies
PubMed: 36809925
DOI: 10.17235/reed.2023.9507/2022 -
World Journal of Gastroenterology May 2024The article by Ker explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are...
The article by Ker explores the treatment of peripancreatic fluid collection (PFC). The use of percutaneous drainage, endoscopy, and surgery for managing PFC are discussed. Percutaneous drainage is noted for its low risk profile, while endoscopic cystogastrostomy is more effective due to the wider orifice of the metallic stent. Surgical cystogastrostomy is a definitive treatment with a reduced need for reintervention, especially for cases with extensive collections and significant necrosis. The choice of treatment modality should be tailored to individual patient characteristics and disease factors, considering the expertise available.
Topics: Humans; Drainage; Treatment Outcome; Stents; Gastrostomy; Pancreatic Pseudocyst
PubMed: 38813046
DOI: 10.3748/wjg.v30.i17.2298 -
Saudi Medical Journal Oct 2023To compare the efficacy of negative pressure wound therapy (NPWT) and alginate dressings on wound bed preparation prior to split thickness skin graft (STSG) surgery for... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
To compare the efficacy of negative pressure wound therapy (NPWT) and alginate dressings on wound bed preparation prior to split thickness skin graft (STSG) surgery for patients with chronic diabetic foot ulcers (DFUs).
METHODS
Between September 2022 and March 2023, we completed a randomized controlled trial in Nanjing First Hospital and PLA 454 Hospital. Patients were divided into 2 groups: i) the NPWT group (with vacuum-assisted closure, n=50); ii) the control group (with alginates dressings, n=50). Once DFU wound was filled with healthy granulation tissues, STSG surgery was performed. The time to STSG surgery was regarded as the primary outcome. The survival rates of skin graft, the wound blood perfusion, the wound neutrophil extracellular traps (NETs) formation, and polarization of M1 and M2 macrophages in DFU wounds were regarded ad secondary outcomes.
RESULTS
Patients in the NPWT group had less time to STSG surgery than the control group. The patients in the NPWT group had prominently increased survival rates of skin graft, increased wound blood perfusion, and decreased NET formation in comparison with the control group. The macrophages in DFU wounds switched from M1 to M2 phenotype in the NPWT group.
CONCLUSION
Negative pressure wound therapy is superior to conventional moist dressings in wound bed preparation prior to STSG surgery for patients with chronic DFUs.
Topics: Humans; Diabetic Foot; Negative-Pressure Wound Therapy; Wound Healing; Bandages; Skin Transplantation; Diabetes Mellitus
PubMed: 37777272
DOI: 10.15537/smj.2023.44.20230386 -
Journal of Investigative Surgery : the... Dec 2023Tendon-exposed wounds are complex injuries with challenging reconstructions and no unified treatment mode. Furthermore, insufficient tissue volume and blood circulation... (Review)
Review
BACKGROUND
Tendon-exposed wounds are complex injuries with challenging reconstructions and no unified treatment mode. Furthermore, insufficient tissue volume and blood circulation disorders affect healing, which increases pain for the patient and affects their families and caretakers.
REVIEW
As modern medicine advances, considerable progress has been made in understanding and treating tendon-exposed wounds, and current research encompasses both macro-and micro-studies. Additionally, new treatment methods have emerged alongside the classic surgical methods, such as new dressing therapies, vacuum sealing drainage combination therapy, platelet-rich plasma therapy, and live-cell bioengineering.
CONCLUSIONS
This review summarizes the latest treatment methods for tendon-exposed wounds to provide ideas and improve their treatment.
Topics: Humans; Plastic Surgery Procedures; Wound Healing; Drainage; Tendons; Vacuum; Treatment Outcome
PubMed: 37813390
DOI: 10.1080/08941939.2023.2266758 -
Archives of Dermatological Research Sep 2023Drainage from chronic wounds can significantly negatively impact a patient's quality of life. Change in severity of wound drainage is an important measure of treatment... (Review)
Review
Drainage from chronic wounds can significantly negatively impact a patient's quality of life. Change in severity of wound drainage is an important measure of treatment efficacy for wounds. This study reviews existing tools used to assess wound drainage. Qualitative drainage tools are overall less burdensome, and however, differences in user interpretation may reduce inter-rater reliability. Quantitative drainage tools enable more reliable comparisons of drainage severity and treatment response between patients but sometimes require equipment to administer, increasing responder burden. Gaps in the current wound drainage measurement landscape are highlighted. Many of the existing scales have not been validated in robust studies. There is also a lack of validated global drainage measurement tools for patients with chronic inflammatory skin disorders with drainage, such as hidradenitis suppurativa or pyoderma gangrenosum. Development of a succinct drainage measurement tool for inflammatory skin diseases where drainage is a prominent symptom will improve monitoring of meaningful treatment response.
Topics: Humans; Quality of Life; Reproducibility of Results; Hidradenitis Suppurativa; Drainage; Treatment Outcome
PubMed: 36680593
DOI: 10.1007/s00403-023-02525-5 -
Gastroenterology Nov 2023Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary... (Comparative Study)
Comparative Study Randomized Controlled Trial
Endoscopic Ultrasound-Guided Biliary Drainage of First Intent With a Lumen-Apposing Metal Stent vs Endoscopic Retrograde Cholangiopancreatography in Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Study (ELEMENT Trial).
BACKGROUND & AIMS
Endoscopic ultrasound-guided choledochoduodenostomy with a lumen-apposing metal stent (EUS-CDS) is a promising modality for management of malignant distal biliary obstruction (MDBO) with potential for better stent patency. We compared its outcomes with endoscopic retrograde cholangiopancreatography with metal stenting (ERCP-M).
METHODS
In this multicenter randomized controlled trial, we recruited patients with MDBO secondary to borderline resectable, locally advanced, or unresectable peri-ampullary cancers across 10 Canadian institutions and 1 French institution. This was a superiority trial with a noninferiority assessment of technical success. Patients were randomized to EUS-CDS or ERCP-M. The primary end point was the rate of stent dysfunction at 1 year, considering competing risks of death, clinical failure, and surgical resection. Analyses were performed according to intention-to-treat principles.
RESULTS
From February 2019 to February 2022, 144 patients were recruited; 73 were randomized to EUS-CDS and 71 were randomized to ERCP-M. The mean (SD) procedure time was 14.0 (11.4) minutes for EUS-CDS and 23.1 (15.6) minutes for ERCP-M (P < .01); 40% of the former was performed without fluoroscopy. Technical success was achieved in 90.4% (95% CI, 81.5% to 95.3%) of EUS-CDS and 83.1% (95% CI, 72.7% to 90.1%) of ERCP-M with a risk difference of 7.3% (95% CI, -4.0% to 18.8%) indicating noninferiority. Stent dysfunction occurred in 9.6% vs 9.9% of EUS-CDS and ERCP-M cases, respectively (P = .96). No differences in adverse events, pancreaticoduodenectomy and oncologic outcomes, or quality of life were noted.
CONCLUSIONS
Although not superior in stent function, EUS-CDS is an efficient and safe alternative to ERCP-M in patients with MDBO. These findings provide evidence for greater adoption of EUS-CDS in clinical practice as a complementary and exchangeable first-line modality to ERCP in patients with MDBO.
CLINICALTRIALS
gov, Number: NCT03870386.
Topics: Humans; Male; Female; Cholangiopancreatography, Endoscopic Retrograde; Aged; Cholestasis; Middle Aged; Drainage; Stents; Endosonography; Treatment Outcome; Ultrasonography, Interventional; Choledochostomy; Metals; Aged, 80 and over
PubMed: 37549753
DOI: 10.1053/j.gastro.2023.07.024