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AJOG Global Reports Nov 2022In Dutch practice, gynecologists are used to assessing the position of the LNG-IUD by performing a two-dimensional transvaginal ultrasonography (TVUS) directly after...
BACKGROUND
In Dutch practice, gynecologists are used to assessing the position of the LNG-IUD by performing a two-dimensional transvaginal ultrasonography (TVUS) directly after insertion and do not routinely invite patients for another consultation 4-12 weeks after insertion. There is no consensus whether a TVUS six weeks after insertion is routinely needed.
OBJECTIVE
This study aimed to assess the incidence of malposition using 2-dimensional transvaginal ultrasonography during routine investigation 6 weeks after insertion. In addition, we investigated the relationship between malposition of the levonorgestrel 52-mg intrauterine device and unfavorable bleeding patterns and pelvic pain.
STUDY DESIGN
We performed a large prospective cohort study. Patients seeking a levonorgestrel 52-mg intrauterine device were eligible for inclusion. Transvaginal ultrasonography was performed to check position of the levonorgestrel 52-mg intrauterine device immediately after insertion and 6 weeks later. Patients filled in questionnaires about bleeding pattern and pelvic pain 6 weeks after insertion.
RESULTS
From March 2015 to December 2016, we enrolled 500 patients. Data from the transvaginal ultrasonography assessment 6 weeks after insertion were available for 448 patients, and complete data (transvaginal ultrasonography and questionnaire data) were available for 363 patients (72.6%). Malposition rate was 6.3% (28/448 patients). Malposition was seen in 15 of 198 patients (7.6%) with unfavorable bleeding and/or pelvic pain and in 3 of 165 patients (1.8%) with favorable bleeding patterns and no pelvic pain (=.03).Malposition was seen in 14 of 186 patients (7.5%) with an unfavorable bleeding pattern and in 4 of 177 patients (2.3%) with favorable bleeding patterns (=.008). Malposition was seen in 5 of 50 patients (10%) with pelvic pain and in 13 of 313 patients (4.2%) without pelvic pain (=.08).
CONCLUSION
The malposition rate of the levonorgestrel 52-mg intrauterine device observed using transvaginal ultrasonography 6 weeks after insertion was 6.3%. If patients have no complaints of unfavorable bleeding and/or pelvic pain, the risk for malposition is low (1.8%) and a routine transvaginal ultrasonography is not necessary. However, if patients experience unfavorable bleeding, a transvaginal ultrasonography should be considered to exclude malposition, because the effect of malposition on contraceptive effectiveness is unsure. Future research should focus on cost-benefit analysis.
PubMed: 36387294
DOI: 10.1016/j.xagr.2022.100104 -
Cardiovascular Diagnosis and Therapy Dec 2020There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical... (Review)
Review
There is a plethora of cardiovascular devices used for therapy and monitoring, and newer devices are being introduced constantly. As a result of advancement of medical technology and rapid development of such technology to address unmet needs across cardiovascular care, multiple conditions which were previously treated surgically or with medications now benefit from trans-catheter device-based evaluation and management. Moreover, innovation to existing technology has transformed the structural design of many traditional cardiovascular devices, making them safer and enabling easier deployment within the chest (catheter-based versus surgical). A post-procedure chest radiography (CXR) is often the first routine imaging test ordered in these patients. A CXR is a relatively inexpensive and noninvasive imaging tool, which can be obtained at the patient's bedside if needed. Commonly implanted cardiovascular devices can be quite easily checked for appropriate positioning on routine CXRs. Potential complications associated with mal-positioning of such devices may be life-threatening. Such complications often manifest early on CXRs and may not be readily apparent on clinical examination. Prompt recognition of such abnormal radiographic appearances is critical for timely diagnosis and effective management. Clinicians need to be familiar with new devices in order to assess proper placement and identify complications related to mal-positioning. This pictorial essay aims to describe the radiologic appearances of contemporary cardiovascular devices, review indications for their usage and potential complications, and discuss magnetic resonance imaging (MRI) compatibility.
PubMed: 33381431
DOI: 10.21037/cdt-20-617 -
Experimental and Therapeutic Medicine Jun 2021Pseudoexfoliation syndrome (PEX) is characterized by the deposition of proteinaceous material in the anterior ocular segment (resulting in ophthalmic pathologies such as... (Review)
Review
Pseudoexfoliation syndrome (PEX) is characterized by the deposition of proteinaceous material in the anterior ocular segment (resulting in ophthalmic pathologies such as glaucoma and increased risk of complications in cataract surgery), but also by several systemic manifestations. The involvement of peri-ocular tissues in PEX, including the eyelid skin, lacrimal gland, conjunctiva, orbital fat and vessels, as well as the optic nerve, has been reported by several previous studies. The peri-ocular effects of PEX include the development of eyelid laxity, conjunctival chalasis, tear film abnormalities, pronounced orbital fat atrophy in response to the administration of prostaglandin analogues in pseudoexfoliative glaucoma, deficient orbital vascular supply and biomechanical changes in both the eyeball and the optic nerve. These effects may have important clinical implications, including increased difficulty in cataract surgery, ocular surface disease and eyelid margin malpositions.
PubMed: 33968180
DOI: 10.3892/etm.2021.10082 -
Plastic and Reconstructive Surgery.... Jul 2022Implant malposition remains one of the main complications of aesthetic breast augmentation and alloplastic breast reconstruction with expanders and implants. Many...
Implant malposition remains one of the main complications of aesthetic breast augmentation and alloplastic breast reconstruction with expanders and implants. Many capsulorrhaphy techniques have been described to adjust the breast pocket and correct the malposition. In this study, we tested the efficacy of the argon beam coagulator (ABC) for lateral capsulorrhaphy on breast reconstruction patients at the time of expander replacement with a permanent implant. We also experimentally compared the effects of the ABC and the standard electrocautery on fragments of healthy breast capsule. We noted a 69.5% capsule shrinkage with the ABC versus 46.8% with the standard electrocautery. We concluded that breast capsulorrhaphy using the ABC is a safe and efficient technique for the correction of breast implant malposition in both reconstructive and aesthetic breast surgery.
PubMed: 35923993
DOI: 10.1097/GOX.0000000000004437 -
Clinical Biomechanics (Bristol, Avon) Jun 2022To the best of our knowledge, no report has analyzed the postoperative results of poor prosthesis position, particularly when the femoral and tibial components are...
BACKGROUND
To the best of our knowledge, no report has analyzed the postoperative results of poor prosthesis position, particularly when the femoral and tibial components are abnormally positioned relative to neutral lower limb alignment. We aimed to investigate pressure distribution in the knee at different lower limb alignments with diverse positions of femoral and tibial components.
METHODS
We established a three-dimensional model of the lower limb using computed tomography and simulated total knee arthroplasty. Tibial and femoral components were changed to 7°, 5°, and 3° of valgus and neutral and 3°, 5°, and 7° of varus positions in the coronal plane. Finite element analysis was performed after applying pressure to simulate weight-bearing, and pressure distribution on the tibial surface was analyzed. We also conducted biomechanical testing using a weight-bearing rig with six cadavers. We measured the pressure at the tibial surface with the position of different components and lower limb alignment.
FINDINGS
Peak pressure on the medial or lateral side of the tibia was determined by the mechanical axis. When tibial components are in 3°,5° and 7° of valgus/varus and femoral components are in 3°,5° and 7° of varus/valgus correspondence, no peak pressure was detected with normal alignment, despite malpositioned components.
INTERPRETATION
Lower limb alignment is more critical than the position of the component. Medial and lateral tibial compartment pressures were evenly distributed if the alignment was neutral. Malpositioned femoral or tibial components changed the femorotibial mechanical axis, and peak pressure of the proximal tibia was positively related to alignment.
Topics: Arthroplasty, Replacement, Knee; Biomechanical Phenomena; Humans; Knee Joint; Knee Prosthesis; Osteoarthritis, Knee; Tibia
PubMed: 35588587
DOI: 10.1016/j.clinbiomech.2022.105659 -
Anesthesiology Apr 2020Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect... (Clinical Trial)
Clinical Trial Observational Study
BACKGROUND
Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax.
METHODS
This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen's κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound.
RESULTS
In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen's κ-coefficient of 0.50 (95% CI, 0.19 to 0.80).
CONCLUSIONS
This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax.
Topics: Aged; Catheterization, Central Venous; Central Venous Catheters; Female; Humans; Male; Middle Aged; Prospective Studies; Ultrasonography, Interventional
PubMed: 31977519
DOI: 10.1097/ALN.0000000000003126 -
Orthopaedic Journal of Sports Medicine May 2022Femoral cortical button suspension fixation is a popular and reliable technique for posterior cruciate ligament reconstruction (PCLR). Button malposition during graft...
BACKGROUND
Femoral cortical button suspension fixation is a popular and reliable technique for posterior cruciate ligament reconstruction (PCLR). Button malposition during graft fixation can lead to postoperative graft loosening.
PURPOSE
To determine the risk factors of femoral cortical button malposition in PCLR when neither direct visualization nor intraoperative fluoroscopy is used.
STUDY DESIGN
Case-control study; Level of evidence, 3.
METHODS
Of the 206 consecutive patients who underwent PCLR without direct visualization or intraoperative radiographs in 2019 at a single institution, 182 met the selection criteria and were included in the study. The distance from the suspension button to the femoral cortex was measured on postoperative computed tomography scans. The button was considered malpositioned if its distance to the femoral cortex was ≥2 mm. We evaluated patient-related and surgery-related variables, including age, sex, concomitant ligament reconstruction, button type, and surgeon experience. Multivariate logistic regression was conducted to evaluate the risk factors for button malposition.
RESULTS
The overall prevalence of button malposition was approximately 17.0% (31/182), and the mean distance from the button to the femoral cortex was 6.11 ± 5.82 mm in the malposition group. Male sex was the most significant risk factor for button malposition (odds ratio [OR], 13.86; 95% confidence interval [CI], 1.73-111.17; = .013). Other independent risk factors were low surgical volume (completing ≤3 procedures; OR, 6.41; 95% CI, 1.89-21.72; = .003), concomitant ligament reconstruction (OR, 5.56; 95% CI, 2.12-14.58; < .001), and fixed-loop button (OR, 3.96; 95% CI, 1.11-14.18; = .034).
CONCLUSION
Male sex, low surgical volume, concomitant ligament reconstruction, and fixed-loop button were independent risk factors for femoral cortical button malposition during PCLR.
PubMed: 35547612
DOI: 10.1177/23259671221094292 -
Perfusion May 2020Malposition of dual lumen cannula is a frequent and challenging complication in neonates and plays a significant role in shaping the in vitro device hemodynamics. This...
OBJECTIVE
Malposition of dual lumen cannula is a frequent and challenging complication in neonates and plays a significant role in shaping the in vitro device hemodynamics. This study aims to analyze the effect of the dual lumen cannula malposition on right-atrial hemodynamics in neonatal patients using an experimentally validated computational fluid dynamics model.
METHODS
A computer model was developed for clinically approved dual lumen cannula (13Fr Origen Biomedical, Austin, Texas, USA) oriented inside the atrium of a 3-kg neonate with normal venous return. Atrial hemodynamics and dual lumen cannula malposition were systematically simulated for two rotations (antero-atrial and atrio-septal) and four translations (two intravascular movements along inferior vena cava and two dislodged configurations in the atrium). A multi-domain compartmentalized mesh was prepared to allow the site-specific evaluation of important hemodynamic parameters. Transport of each blood stream, blood damage levels, and recirculation times are quantified and compared to dual lumen cannula in proper position.
RESULTS
High recirculation levels (39 ± 4%) in malpositioned cases resulted in poor oxygen saturation where maximum recirculation of up to 42% was observed. Apparently, Origen dual lumen cannula showed poor inferior vena cava blood-capturing efficiency (48 ± 8%) but high superior vena cava blood-capturing efficiency (86 ± 10%). Dual lumen cannula malposition resulted in corresponding changes in residence time (1.7 ± 0.5 seconds through the tricuspid). No significant differences in blood damage were observed among the simulated cases compared to normal orientation. Compared to the correct dual lumen cannula position, both rotational and translational displacements of the dual lumen cannula resulted in significant hemodynamic differences.
CONCLUSION
Rotational or translational movement of dual lumen cannula is the determining factor for atrial hemodynamics, venous capturing efficiency, blood residence time, and oxygenated blood delivery. Results obtained through computational fluid dynamics methodology can provide valuable foresight in assessing the performance of the dual lumen cannula in patient-specific configurations.
Topics: Cannula; Catheterization; Extracorporeal Membrane Oxygenation; Hemodynamics; Humans; Infant, Newborn
PubMed: 31580212
DOI: 10.1177/0267659119874697 -
AEM Education and Training Jul 2021Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to...
OBJECTIVE
Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts.
METHODS
We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.
RESULTS
Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.
CONCLUSION
Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.
PubMed: 34124497
DOI: 10.1002/aet2.10530 -
JSES International Mar 2022Accurate glenoid component placement in shoulder arthroplasty is often difficult even with the use of preoperative planning. Computer navigation and patient-specific...
BACKGROUND
Accurate glenoid component placement in shoulder arthroplasty is often difficult even with the use of preoperative planning. Computer navigation and patient-specific guides increase component placement accuracy, but which patients benefit most is unknown. Our purpose was to assess surgeons' accuracy in placing a glenoid component in vivo using 3-dimensional preoperative planning and standard instruments among various glenoid wear patterns.
METHODS
We conducted a retrospective review of 170 primary anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) performed at a single institution. Commercially available preoperative planning software was used in all arthroplasties with multiplanar 2-dimensional computed tomography and a 3-dimensional implant overlay. After registration of intraoperative bony landmarks to the navigation system, participating surgeons with knowledge of the preoperative plan were blinded to the computer screen and attempted to implement their preoperative plan by simulating placement of a central-axis glenoid guide pin. Two hundred thirty-three screenshots of surgeon's simulated guide pin placement were included. Glenoid displacement, error in version and inclination, and overall malposition from the preoperatively planned target point were stratified by posterior wear status (with [Walch B2 or B3] or without [A1, A2, or B1]) and Walch classification (A1, A2, B1, B2, or B3). The glenoid component was considered malpositioned when version or inclination errors exceeded 10° or the starting point displacement exceeded 4 mm.
RESULTS
For rTSA, errors in version were greater for glenoids with posterior wear compared with those without (8.1° ± 5.6° vs. 4.7° ± 4.0°; < .001). On post hoc analysis, B2 glenoids had greater version error than A1, A2, and B1 glenoids. A greater proportion of glenoids undergoing rTSA that possessed posterior wear had an error in version >10° compared with those without (31% vs. 8%; < .001). Consequently, glenoids undergoing rTSA with posterior wear were malpositioned at a greater rate compared with those without (73% vs. 53%). In contrast, glenoids undergoing aTSA with and without posterior wear did not differ based on displacement error, version error, inclination error, or malposition occurrence.
CONCLUSIONS
Posterior glenoid bone loss more commonly resulted in glenoid version errors exceeding 10 degrees and component malposition in rTSA, but not for aTSA. Malposition was still relatively high in patients without significant posterior wear for both aTSA (36%) and rTSA (53%). Surgeons should consider alternate techniques beyond preoperative planning and standard instrumentation when performing shoulder arthroplasty in patients with posteriorly worn glenoids.
PubMed: 35252914
DOI: 10.1016/j.jseint.2021.11.021