Needles

F ROM its origins as a modified ureteral catheter, the epidural catheter has evolved into versions made with silk, rubber, plastic, and coiled stainless steel. These changes resulted from a growing recognition that particular design elements could potentially influence catheter performance. This article reviews the history of epidural catheter design, focusing on how modifications in the materials used, tip design, and orifice number and arrangement may have affected analgesic and anesthetic outcomes, and provides a summary of the comparative studies that evaluate the clinical performance of distinct epidural catheter design features. History The most consistent entry into the epidural space for the administration of anesthesia occurred at the turn of the 20th century when the French physicians Jean A. Sicard, M.D.

The needle biopsy technique described by Bergström is the most commonly used technique to obtain samples to assess muscle metabolism. Sampling of muscle, particularly the vastus lateralis, has become an essential tool in biomedical and clinical research. Optimal sample size is critical for availability of tissue for processing. To evaluate the effectiveness of a novel technique to obtain adequate sample size using wall suction applied to needle muscle biopsy, we collected samples from subjects in on-going clinical studies for gene expression.Muscle biopsy samples of the vastus lateralis using 6 mm Bergström needles under local anesthesia were obtained from 55 subjects who had volunteered to participate in this research project. The vastus lateralis was biopsied according to the methods described by Bergström with a 6 mm biopsy needle. Wall suction was applied to the inner bore of the biopsy needle after the needle was inserted into the muscle.The mean sample of biopsy taken using the 6 mm was 233 mg (n = 55). The wall suction (200 mm Hg) applied to the needle pulled the surrounding tissue into the central bore of the needle. The quality of the samples was adequate for all biochemical assays. The biopsy technique did not result in any complications due to infection or bleeding.Using a novel technique of connecting a 6 mm Bergström biopsy needle to wall suction, we have obtained 200 to 300 mg muscle biopsy specimens uniformly, with ease, and minimal discomfort. An increase in sample size allows for a wider variety of biochemical and histopathological analysis.

Needles with asymmetric bevel tips naturally bend when they are inserted into soft tissue. In this study, we present an analytical model for the loads developed at the bevel tip during needle-tissue interaction. The model calculates the loads based on the geometry of the bevel edge and gel material properties. The modeled transverse force developed at the tip is compared to forces measured experimentally. The analytical model explains the trends observed in the experiments. In addition to macroscopic studies, we also present microscopic observations of needle-tissue interactions. These results contribute to a mechanics-based model of robotic needle steering, extending previous work on kinematic models.

A robotic system to take blood samples autonomously from the forearm is presented and preliminary results are discussed which demonstrate its feasibility. Force/position profiles, while pressing a flat-headed probe against the surface of the skin, enable the determination of a vein's location to within 1 mm on a phantom. When a needle is inserted, the characteristic force/position profile, on puncturing the vein wall, is distinctive enough to implement automatic needle withdrawal to prevent overshoot. Future developments of the project are presented that provide both an autonomous blood sampling robot and a force-feedback surgical trainer.

Background and Objectives. Brachial plexus block is clinically useful. Although the infraclavicular approach to brachial block is the less commonly used form it may offer advantages. We describe the results with three local anesthetic mixtures used during this observational study. Methods. Three hundred and sixty patients, ASA physical status I and II, scheduled for upper extremity orthopedic surgery, were anesthetized with an infraclavicular brachial plexus block. They were divided into three groups (120 patients each) by type of 40-mE anesthetic mixture: group I had even parts of 2 % plain lidocaine and 0.5 % bupivacaine with epinephrine 1:200,000; group II had even parts of 1% plain lidocaine and 0.25 % bupivacaine with epinephrine 1:200,000; and group III had even parts of 1.5% plain lidocaine and 0.37% bupivacaine with epinephrine 1:200,000. Plexus identification was made by nerve stimulator. The observational assessments were: adequacy and latency time of the block, tourniquet tolerance, postoperative analgesia, local anesthetics doses, sedative doses, complications, and side effects. Results. In groups I, II, and III, adequacy of the block was 95, 75, and 96%, latency time was 10.4, 12.9, and 10.9 minutes, tourniquet tolerance was 99, 84, and 98%, postoperative analgesia time was 663, 331, and 502 minutes, anesthetic doses of lidocaine/bupivacaine were 5.2/1.3, 2.9/0.7 and 4.i/1.i mg/kg, respectively. Differences were noted between group II and groups I and III (P range: .0I-.0001). Sedatives in adequate blocks were midazolam with/without fentanyl (2-3 mg/50-100 I~g) in all groups. There were two complication cases with no consequences: two vascular punctures that did not hold up or delay the anesthetic or surgical procedure. There were no clinical manifestations or side effects. Conclusions. The infraclavicular approach described is effective. It produced reliable anesthesia and is associated with minimal complications and side effects. The mixture of local anesthetics used in group II is not adequate for producing reliable anesthesia. Reg Anesth Pain Med 1999: 24:411-416.

Objectives: The objectives were to determine whether pretreatment with needleless jet-delivered lidocaine decreases self-reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self-reported pain in children undergoing needle insertion in the ED.

Accurate placement of the needle tip is essential in percutaneous therapies such as radiofrequency ablation (RFA) of liver tumors. Use of a robotic system for navigating the needle could improve the targeting accuracy. Real-time information on the needle tip position is needed, since a needle deflects during insertion in tissue. Needle shape can be reconstructed based on strain measurements within the needle. In the current experiment we determined the accuracy with which the needle tip position can be derived from strain measurements using Fiber Bragg Gratings (FBGs). Three glass fibers equipped with two FBGs each were incorporated in a needle. The needle was clamped at one end and deformed by applying static radial displacements at one or two locations. The FBG output was used for offline estimation of the needle shape and tip position. During deflections of the needle tip up to 12.5 mm, the tip position was estimated with a mean accuracy of 0.89 mm (std 0.42 mm). Adding a second deflection resulted in an error of 1.32 mm (std 0.48 mm). This accuracy is appropriate for applications such as RFA of liver tumors. The results further show that the accuracy can be improved by optimizing the placement of FBGs.

In this paper, we present design of a transdermal drug delivery system for treatment of cardiovascular or hemodynamic disorders such as hypertension. The system comprises of integrated control electronics and microelectromechanical system devices such as micropump, micro blood pressure sensor and microneedle array. The objective is to overcome the limitations of oral therapy such as variable absorption profile and the need for frequent dosing, by fabricating a safe, reliable and cost effective transdermal drug delivery system to dispense various pharmacological agents through the skin for treatment of hemodynamic dysfunction such as hypertension. Moreover, design optimization of a piezoelectrically actuated valveless micropump is presented for the drug delivery system. Because of the complexity in analysis of piezoelectric micropump, which involves structural and fluid field couplings in a complicated geometrical arrangement, finite element (FE) numerical simulation rather than an analytical system has been used. The behavior of the piezoelectric actuator with biocompatible polydimethylsiloxane membrane is first studied by conducting piezoelectric analysis. Then the performance of the valveless micropump is analyzed by building a three dimensional electric-solid-fluid model of the micropump. The effect of geometrical dimensions on micropump characteristics and efficiency of nozzle/diffuser elements of a valveless micropump is investigated in the transient analysis using multiple code coupling method. The deformation results of the membrane using multifield code coupling analysis are in good agreement with analytical as well as results of single code coupling analysis of a piezoelectric micropump. The analysis predicts that to enhance the performance of the micropump, diffuser geometrical dimensions such as diffuser length, diffuser neck width and diffuser angle need to be optimized. Micropump flow rate is not strongly affected at low excitation frequencies from 10 to 200 Hz. The excitation voltage is the more dominant factor that affects the flow rate of the micropump as compared with the excitation frequency. However, at extremely high excitation frequencies beyond 8,000 Hz, the flow rate drops as the membrane exhibits multiple bending peaks which is not desirable for fluid flow. Following the extensive numerical analysis, actual fabrication and performance characterization of the micropump is presented. The performance of the micropump is characterized in terms of piezoelectric actuator deflection and micropump flow rate at different operational parameters. The set of multifield simulations and experimental measurement of deflection and flow rate at varying voltage and excitation frequency is a significant advance in the study of the electric-solid-fluid coupled field effects as it allows transient, three dimensional piezoelectric and fluid analysis of the micropump thereby facilitating a more realistic multifield analysis. The results of the present study will also help to conduct relevant strength duration tests of integrated drug delivery device with micropump and microneedle array in future.

Two new cardiovascular monofilament sutures attached to taper point needles have been developed for use in expanded polytetrafluoroethylene (PTFE) grafts. One monofilament suture made of PTFE has a microporous structure that allows it to be channel swaged to a needle that closely approximates its suture diameter. The other suture is a monofilament polypropylene suture that has been extruded to produce a tapered swage end, which was significantly smaller than that of the remainder of the suture in order to be channel swaged to smaller diameter needles. On the basis of comprehensive biomechanical performances, the performance of the new needle suture products with needle/suture diameter ratios approaching 1 : 1 was superior to needle suture products with 2 : 1 needle/suture diameter ratios for use in PTFE vascular grafts, regardless of the suture material. 0 1993 John Wiley & Sons, Inc.

Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page. ... Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in ...

We aim to compare the incision and drainage against ultrasound-guided aspiration for the treatment of breast abscesses. Sixty-four patients were randomly allocated to Group A (incision and drainage) and Group B (needle aspiration). Incision and drainage was done under general, whereas aspiration was done under local anesthesia with antibiotic coverage after the pus sample was taken for cultures. Time taken to resolve symptoms including point tenderness, erythema and hyperthermia, recurrence of breast abscess, and healing time was recorded. Patients were followed until 8 weeks. Culture and sensitivity of the pus were done. Data were analyzed in SPSS 16.0. The mean difference of healing time was significant (P = 0.001). A total of 93.3 per cent were healed in Group B and 76.6 per cent in Group A (P = 0.033). Twenty-two samples (34.37%) had no bacterial yield and the remaining 42 samples (65.6%) yielded 11 anaerobic cultures (17.18%) and 31 aerobic cultures (48.4%). Ultrasound-guided a...

The objective of this study was to evaluate electronic beam steering to improve needle visualization. Various needles ranging from 27 to 12 gauge were evaluated with a modified CX50 (Philips Ultrasound, Bothell, Wash) using a 12-MHz linear probe. For proof of concept, the needles were placed in a pork roast at various random angles. The ultrasound beam was electronically steered at angles from 0 to 50 degrees. Images were obtained at the various angles and compared. Two patients undergoing a thyroid biopsy, one patient undergoing biopsy of the supraclavicular node, and one undergoing a breast biopsy were evaluated using electronic beam steering at various angles. The images were stored and subjectively compared. All needles were better visualized when the ultrasound beam was steered as close to perpendicular to the needle as possible. Significant improvements in needle including tip visualization by subjective visual inspection were found by applying the appropriate beam angle. Elec...

Despite a lack of evidence that needle exchange programs (NEPs) cause an increase in injection drug use, there are still concerns over fostering increased injection behavior with NEPs. The design was a randomized controlled trial conducted from May 1997 to June 2000 comparing injection drug users (IDUs) who are randomly assigned to have access to an NEP versus training in how to purchase needles and syringes (NS) at pharmacies. Of 653 IDUs recruited into the study, 600 were randomized: 426 were followed-up at 6 months, and 369 were followed-up at 12 months. Four hundred ninety were followed up at least once. There was no difference in the number of injections over time between the NEP and the Pharmacy Sales arms of the study or in the percentage of positive urine test results over time between the NEP and the Pharmacy Sales arms of the study for morphine and amphetamine. The decrease in the presence of cocaine was marginally greater between the arms of the study. The results do not support the hypothesis of NEPs causing an increase in injection drug use. This clinical trial provides the strongest evidence to date that needle exchanges do not produce this negative effect.

Previous work has shown that infusion flow rates can be increased by an order of magnitude by partially retracting microneedles after insertion into the skin. This study sought to determine the mechanism by which retraction increases fluid infusion by piercing human cadaver skin with single microneedles, fixing the skin after retracting microneedles to different distances, and examining skin microstructure by histology. We found that microneedle insertion to 1080 μm from the skin surface resulted primarily in skin indentation and only 100-300 μm penetration into the skin. This caused significant compaction of the skin, which probably pressed out most water and thereby dramatically lowered the flow conductivity of skin beneath the needle tip. Retraction of the microneedle allowed the skin to recoil back toward its original position, which relieved the skin compaction and increased local flow conductivity. Altogether, these results suggest that microneedle insertion to penetrate into the skin followed by microneedle retraction to relieve skin compaction is an effective approach to infuse fluid into the skin in a minimally invasive manner.

In this review we provide the updates on last years' advancements in basic science, imaging methods, efficacy, and safety of dry needling of myofascial trigger points (MTrPs). The latest studies confirmed that dry needling is an effective and safe method for the treatment of MTrPs when provided by adequately trained physicians or physical therapists. Recent basic studies have confirmed that at the site of an active MTrP there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response. Two new modalities, sonoelastography and magnetic resonance elastography, were recently introduced allowing noninvasive imaging of MTrPs. MTrP dry needling, at least partially, involves supraspinal pain control via midbrain periaqueductal gray matter activation. A recent study demonstrated that distal muscle needling reduces proximal pain by means of the diffuse noxious inhibitory control. Therefore, in a patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling.

To describe the intravitreal injection technique practice patterns of retinal specialists in the United States from April 8, 2010 to April 21, 2010. • DESIGN: Questionnaire survey. • METHODS: All members of the American Academy of Ophthalmology who self-categorized as "Retinal/Vitreous Surgery" were contacted by e-mail to complete an anonymous, 20-question, internet-based survey. • RESULTS: A total of 765 retinal specialists (44%) responded to the survey. Most respondents wear gloves (58%) and use an eyelid speculum (92%) when performing an intravitreal injection. More than 99% use povidone-iodine preinjection. The majority measure the injection site from the limbus (56%) and inject straight into the vitreous cavity (96%). Most do not displace the conjunctiva (83%). Seventy-two percent routinely assess postinjection optic nerve perfusion, primarily by gross visual acuity measurement (32%). While nearly one third of participants use prophylactic topical antibiotics preinjection, more than two thirds use topical antibiotics postinjection. Forty-six percent perform bilateral simultaneous intravitreal injections. The majority of respondents use a 30-gauge needle for the injection of ranibizumab (78%) and bevacizumab (60%). However, respondents use both a 27-and 30-gauge needle for the injection of triamcinolone acetonide. • CONCLUSIONS: Retinal specialists in the United States participate in a range of techniques for the care before, during, and after intravitreal injections. Further study is needed to elucidate best practice patterns. (Am J Ophthalmol 2011;151:329-332.

Background A needle placement system using a serial robot arm for manipulation of biopsy and/or treatment needles is introduced. A method for fast calibration of the robot and the preliminary accuracy tests of the robotic system are presented. Methods The setup consists of a DLR/KUKA Light Weight Robot III especially designed for safe human/robot interaction mounted on a mobile platform, a robot-driven angiographic C-arm system and a navigation system. Results Calibration of the robot with the navigation system has a residual error of 0.23 mm (rms) with a standard deviation of ±0.1 mm. Needle targeting accuracy with different trajectories was 1.2 mm (rms) with a standard deviation of ±0.4 mm. Conclusions Robot absolute positioning accuracy was reduced to the navigation camera accuracy. The approach includes control strategies that may be very useful for interventional applications.

We evaluated impact of the needle length, sex, and body condition on chemical immobilization induction time in 50 (29 males and 21 females) free-ranging fallow deer (Dama dama) in Sweden, 2006-2011. Induction time is probably the single most important factor when immobilizing free-ranging wildlife with the use of a remote drug-delivery system (RDDS). Induction times should be short to minimize stress and risk of injury, and to ensure that immobilized animals can be found and clinically monitored as soon as possible. We measured the distance between the darting location and where we recovered the immobilized animal and also the time occurring between the two events. We used two types of needles: 2.0 × 30- or 2.0 × 40-mm barbed needles with side ports. The most important result is that a 10-mm-longer dart needle can reduce the retrieval time substantially (>20 min) until an animal is under monitoring. On average after the darting, the retrieval time decreased from 51 to 29 min and ...

Background:  The efficacy of injection therapy in diabetes depends on correct injection technique and, to provide patients with guidance in this area, we must understand how they currently inject.Methods:  From September 2008 to June 2009, 4352 insulin-injecting Type 1 and Type 2 diabetic patients from 171 centers in 16 countries were surveyed regarding their injection practices.Results:  Overall, 3.6% of patients use the 12.7-mm needle, 1.8% use the 12-mm needle, 1.6% use the 10-mm needle, 48.6% use the 8-mm needle, 15.8% use the 6-mm needle, and 21.6% use the 5-mm needle; 7% of patients do not know what length of needle they use. Twenty-one percent of patients admitted injecting into the same site for an entire day, or even a few days, a practice associated with lipohypertrophy. Approximately 50% of patients have or have had symptoms suggestive of lipohypertrophy. Abdominal lipohypertrophy seems to be more frequent in those using the two smaller injection size areas, and less frequent in those using larger areas. Nearly 3% of patients reported always injecting into lipohypertrophic lesions and 26% inject into them sometimes. Of the 65% of patients using cloudy insulins (e.g. NPH), 35% do not remix it before use.Conclusions:  It is clear from the latest survey that we have improved in certain areas, but that, in others, we have either not moved at all or our efforts have not yielded the results we expected. The results of the present survey are available online on a country-by-country and question-by-question basis at http://www.titan-workshop.org.

Causes and circumstances related to 162 needlestick injuries in nursing homes were analyzed. In addition to nurses, geriatrics helpers were found to be an important occupational group at risk. Insulin pens were the most frequent cause of needlestick injuries among nursing personnel. Insulin pens are a major instrument involved with unsafe needle-handling practices.

Objective: To compare access site complications with the Micropuncture V R 21 gauge (G) needle set to the standard 18G needle in patients undergoing percutaneous coronary intervention (PCI) using the femoral approach. Background: Vascular access site complications are the most common problems after PCI. The Micropuncture 21G needle set was recently introduced to minimize such complications. Methods: A cohort of 3,243 consecutive patients was studied. Patients receiving thrombolytics, IIb/IIIa antagonist, coumadin, or intra-aortic balloon pump were excluded. Micropuncture access was used in 544 patients and standard 18G needle in 2,699. All access sites were managed with a vascular closure device. Primary endpoints included vascular perforation or limb ischemia requiring repair, retroperitoneal bleeding, pseudoaneurysm, arteriovenous fistula, and groin hematoma (>4 cm). Results: Patients undergoing PCI with Micropuncture were at higher risk: they were older (65.9 6 9 vs. 64.7 6 11.8, P 5 0.03); had lower body surface area (1.9 6 0.2 vs. 2.0 6 0.3, P 5 0.02); more prevalent peripheral vascular disease [119 (21.9%) vs. 380 (14.1%), P < 0.001] and renal failure [106 (19.6%) vs. 318 (11.8%), P < 0.001]. Overall, there was no significant difference in the access site complications rate using Micropuncture vs. standard needle, 7 (1.3%) vs. 27 (1.0%), respectively, P 5 0.54. The Micropuncture group had significantly higher retroperitoneal bleeding, 0.7% vs. 0.18%, P 5 0.04. After multivariable adjustment, only age remained significantly associated with vascular complications (OR 1.03, P 5 0.04). Conclusions: Femoral access using the Micropuncture technique did not reduce the incidence of vascular complications and the marginally higher than expected retroperitoneal bleeding is based on very small numbers. The routine use of the Micropuncture set and its technique should be revisited. V C 2012 Wiley Periodicals, Inc.

To evaluate the feasibility and safety of using the sacro-spinous ligament (SSL) as a fixation point for anterior-apical pelvic floor compartment mesh implants. The apical support achieved with the sacro-spinous ligament mesh fixation is considered adequate, as it provides a high and stronger anchoring point. Even though, meshes for anterior pelvic floor reconstruction are traditionally anchored to the arcus tendineous fascia pelvis (ATFP). The authors presumed that fixing the anterior mesh to the sacro-spinous ligament instead of the ATFP is both feasible and safe. The present study evaluated the anatomical aspects and relations of a modified tissue passage with sacro-spinous fixation of the anterior apical mesh arms.

Within the past 20 years there has been an explosion of devices designed to allow connection of multiple intravenous sets and catheter hubs without the use of needles. Currently, the number of devices, their internal and external designs, and their functions can be quite confusing. There is a lack of clear definitions and terminology universally accepted by all professionals involved, leading to additional confusion. The purpose of this article is to provide an overview of the many types of technological designs, clarify the characteristics, and recommend clear and concise definitions.

A modified Watson fundoplication technique is described using curved needles introduced through the anterior abdominal wall. This technique has clear advantages over ski needles, allows for a wider choice of sutures and helps curtail costs in laparoscopic fundoplication in the small child.

The scope of ultrasound imaging guidance for regional anesthesia is growing rapidly. Preliminary data, although limited, suggest that ultrasound can improve block success rate and decrease complications. In this review, we describe the basic principles of ultrasound scanning and needling techniques for nerve blocks, highlight some of the data on clinical outcome, discuss specific limitations of ultrasound for regional anesthesia, and speculate on the future direction for physician training and competency assessment with this technology.

Introduction: A final flush with chelating agents and antiseptic irrigating solutions is needed to remove the smear layer. The improvement of these protocols is possible by using specific delivery and agitation techniques. This study examined the effect of different final irrigation regimens and methods of activation on smear layer removal in curved canals after root canal instrumentation. Methodology: Mesial root canals of 50 extracted mandibular molars were prepared using ProTaper rotary files (Dentsply Maillefer, Ballaigues, Switzerland) and 3% NaOCl. Teeth were then allocated to two control groups and four experimental groups (n = 10) for final irrigation as follows: no-activation group (final rinse with a 27-gauge needle and 17% EDTA/3% NaOCl), manual-dynamic activation group (final rinse 17% EDTA/3% NaOCl + gutta-percha agitation), automated-dynamic activation group (final rinse 17% EDTA/3% NaOCl + RinsEndo [Dü rr Dental GmbH & Co KG, Bietigheim-Bissingen, Germany]), and sonicactivation group (final rinse 17% EDTA/3% NaOCl + Endoactivator [Advanced Endodontics, Santa Barbara, CA]). All mesial roots were split with a new approach to allow visualization of every third of the canal, particularly the apical third. The samples were prepared for scanning electron microscopic observation to assess the smear layer removal. Blind scoring was performed by two calibrated observers using a five-score scale. The differences in smear layer scores between the experimental groups were analyzed with the Kruskal-Wallis test and the Mann-Whitney U test. The level of significance was set at p = 0.05. Results: Very high levels of root canal cleanliness (#score 3) were found for each test group with activation. For the middle and apical third, the no-activation group was significantly less effective than the three other activation groups (p < 0.05). The manual-dynamic activation group (final rinse 17%EDTA/3%NaOCl + gutta-percha agitation) and the sonic-activation group (final rinse 17%EDTA/ 3%NaOCl + Endoactivator) showed significantly better smear layer removal (p < 0.05) in comparison with the other test groups in the apical third. Conclusion: Root canal cleanliness benefits from solutions activation (especially sonic activation and manual-dynamic activation) in comparison with no activation during the final irrigation regimen. (J Endod 2010;36:1361-1366

Needle visualization is important for safe and successful ultrasound-guided peripheral nerve block. However, accurate and consistent visualization of the needle tip can be difficult to achieve. This review article describes many of the challenges affecting needle visualization, summarizes the relevant literature on ultrasound imaging of needles, and offers practical strategies for improving needle tip visibility. Finally, future directions for research and development are suggested. Reg Anesth Pain Med 2008;33:532-544.

A microelectrode array was designed to minimize the pain sensation of electroporation for enhancing transdermal drug delivery. The influence of the size of the electrode -skin contact area and of the distance between electrodes on the pain sensation was tested on human volunteers. The pain level decreased with the dimension of electrode -skin contact area and with inter-electrode distance. When both reached about 0.5 mm, the pain level was not perceptible even at the threshold of transdermal electroporation level of sixty electric pulses at 150 V, 1 ms at 1 -10 Hz. An array of 11 Â11 alternately connected electrodes with 0.6 Â 0.6 mm dimension was fabricated. The electric thresholds for effective drug delivery, using toluidine blue O as a marker on mouse skin, was found to be the same for microelectrode arrays as for larger electrodes and wider interelectrode distances. In vivo transdermal electroporation using microelectrode array with 180 pulses of 150 V, 0.2 ms at 1 Hz, followed by 30 min methotrexate (MTX) occlusion increased more than 4 fold the systemic MTX level in mice. The results demonstrated the potential of painless delivery of significant amounts of chemotherapeutic agents through skin with the new electrode arrays in a clinical setting. D

Reçu le 23 septembre 2009 ; reçu sous la forme révisée 2 février 2010; accepté le 4 février 2010 Disponible sur Internet le 10 mars 2010 MOTS CLÉS Prolapsus génital ; Sacrospinofixation ; Mini-invasif Résumé Objectif. -Étudier les risques anatomiques lors de la sacrospinofixation en utilisant le système mini-invasif CAPIO ® . Sujets et méthodes. -Sept cadavres de sexe féminin ont eu une sacrospinofixation par le dispositif mini-invasif CAPIO ® en position gynécologique puis disséqués par voie abdominale. La sacrospinofixation a été faite après une colpotomie postérieure médiane et une dissection des fosses pararectales. La dissection abdominale était faite dans la région du ligament sacroépineux. Les distances entres les points de sutures et les différents éléments vasculonerveux adjacents au ligament étaient mesurés.

Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress. The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established. First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue. Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

Many children consider getting a needle to be one of their most feared and painful experiences. Differentiating between a child's experience of fear and pain is critical to appropriate intervention. There is no gold standard one-item self-report measure of fear for use with children. Objective: To conduct an initial investigation of the psychometric properties of the Children's Fear Scale (CFS; based on the adult Faces Anxiety Scale) with young school-age children. Method: Children and their parents were filmed during venipuncture and completed pain and fear ratings immediately after the procedure (n ϭ 100) and 2 weeks later (n ϭ 48). Behavioral coding of the procedures was conducted. Results: Support was found for interrater reliability (Time 1: r s ϭ .51, p Ͻ .001) and test-retest reliability (r s ϭ .76, p Ͻ .001) of the CFS for measuring children's fear during venipuncture. Assessment of construct validity revealed high concurrent convergent validity with another self-report measure of fear (Time 1: r s ϭ .73, p Ͻ .001) and moderate discriminant validity (e.g., Time 1: r s ϭ Ϫ.30, p Ͻ .005 with child coping behavior; r s ϭ .41, p Ͻ .001 with child distress behavior). Conclusions: The CFS holds promise for measuring pain-related fear in children. In addition to further investigation into the psychometric properties of the CFS during acute pain with a wider age range, future research could validate this measure in other contexts. The utility of a one-item measure of fear extends beyond the field of pediatric pain to other contexts including intervention for anxiety disorders and children in hospital.

Background: Needle thoracostomy is an emergent procedure designed to relieve tension pneumothorax. High failure rates because of the needle not penetrating into the thoracic cavity have been reported. Advanced Trauma Life Support guidelines recommend placement in the second intercostal space, midclavicular line using a 5-cm needle. The purpose of this study was to evaluate placement in the fifth intercostal space, midaxillary line, where tube thoracostomy is routinely performed. We hypothesized that this would result in a higher successful placement rate. Methods: Twenty randomly selected unpreserved adult cadavers were evaluated. A standard 14-gauge 5-cm needle was placed in both the fifth intercostal space at the midaxillary line and the traditional second intercostal space at the midclavicular line in both the right and left chest walls. The needles were secured and thoracotomy was then performed to assess penetration into the pleural cavity. The right and left sides were analyzed separately acting as their own controls for a total of 80 needles inserted into 20 cadavers. The thickness of the chest wall at the site of penetration was then measured for each entry position. Results: A total of 14 male and 6 female cadavers were studied. Overall, 100% (40 of 40) of needles placed in the fifth intercostal space and 57.5% (23 of 40) of the needles placed in the second intercostal space entered the chest cavity (p Ͻ 0.001); right chest: 100% versus 60.0% (p ϭ 0.003) and left chest: 100% versus 55.0% (p ϭ 0.001). Overall, the thickness of the chest wall was 3.5 cm Ϯ 0.9 cm at the fifth intercostal space and 4.5 cm Ϯ 1.1 cm at the second intercostal space (p Ͻ 0.001). Both right and left chest wall thicknesses were similar (right, 3.6 cm Ϯ 1.0 cm vs. 4.5 cm Ϯ 1.1 cm, p ϭ 0.007; left, 3.5 Ϯ 0.9 cm vs. 4.4 cm Ϯ 1.1 cm, p ϭ 0.008). Conclusions: In a cadaveric model, needle thoracostomy was successfully placed in 100% of attempts at the fifth intercostal space but in only 58% at the traditional second intercostal position. On average, the chest wall was 1 cm thinner at this position and may improve successful needle placement. Live patient validation of these results is warranted.

Needle visualization is important for safe and successful ultrasound-guided peripheral nerve block. However, accurate and consistent visualization of the needle tip can be difficult to achieve. This review article describes many of the challenges affecting needle visualization, summarizes the relevant literature on ultrasound imaging of needles, and offers practical strategies for improving needle tip visibility. Finally, future directions for research and development are suggested. Reg Anesth Pain Med 2008;33:532-544.

We describe a reproducible and less invasive surgical approach to sacral neuromodulation (InterStim Therapy) in the treatment of voiding dysfunction. Twenty patients underwent modified lead implantation (mean operative time 45 minutes) without any difficulties or complications, with a mean follow-up of 8 months (range 1 to 14).Technical Considerations. The highlights of these modifications include (a) fluoroscopy to localize the S3 foramen; (b) paramedian incision; (c) use of a cutoff S3 finder needle and a 14-gauge Angiocath to direct permanent lead into the S3 foramen without dissection; (d) use of lateral fluoroscopy to determine the depth of the Angiocath insertion; and (e) anchoring the lead to the lumbodorsal fascia (superficial to the sacral periosteum) using a moveable lead anchor system. These modifications simplify and minimize the invasiveness of this therapy without compromising the efficacy. Because of the simplicity of these modifications, we are currently using an implanted lead, rather than the temporary percutaneous lead, to assess patients&amp;#39; clinical response before implanting a pulse generator.

Background: Skin laxity, rhytides, and photoaging are generally treated by ablative procedures that injure or destroy the epidermis and its basement membrane, at least in the beginning, and subsequently lead to fibrosis of the papillary dermis. The ideal treatment would be to preserve the epidermis and promote normal collagen and elastin formation in the dermis. Percutaneous collagen induction takes us

Although haemodialysis (HD) has become a routine treatment, adverse side effects, and occasionally life threatening clinical complications, still happen. Venous needle dislodgment (VND) is one of the most serious accidents that can occur during HD. If the blood pump is not stopped, either by activation of the protective system of the dialysis machine or manually, the patient can bleed to death within minutes. Fatal and near-fatal blood loss due to VND have been described in the literature (ECRI 1998; Sandroni 2005; Mactier &amp;amp;amp;amp;amp;amp; Worth 2007), but published reports represent only the tip of the ice berg, as such incidents are normally handled at a local or national level. The European Dialysis and Transplant Nurses Association/European Renal Care Association (EDTNA/ERCA) has produced 12 practice recommendations to help reduce the risk of VND and detect blood leakage as early as possible. A poster summarising these recommendations has been created (Van Waeleghem et al. 2008).

Jejunostomy is a surgical procedure by which a tube is situated in the lumen of the proximal jejunum, primarily to administer nutrition. There are many techniques used for jejunostomy: longitudinal Witzel, transverse Witzel, open gastrojejunostomy, needle catheter technique, percutaneous endoscopy, and laparoscopy. The principal indication for a jejunostomy is as an additional procedure during major surgery of the upper digestive tract, where irrespective of the pathology or surgical procedures of the esophagus, stomach, duodenum, pancreas, liver, and biliary tracts, nutrition can be infused at the level of the jejunum. It is also used in laparotomy patients in whom a complicated postoperatory recovery is expected, those with a prolonged fasting period, those in a hypercatabolic state, or those who will subsequently need chemotherapy or radiotherapy. As a sole procedure it is advised for neurologic and congenital illnesses, in geriatric patients who pose difficult care demands, and for patients with tumors of the head and neck. The complications seen with jejunostomy can be mechanical, infectious, gastrointestinal, or metabolic. The rate of technical complications of the Witzel longitudinal technique is 2.1%, for the transverse Witzel up to 6.6%, for the Roux-en-Y 21%, for open gastrojejunostomy from 2%, and for the needle catheter technique from 1.5% with 0.14% mortality. The percutaneous endoscopic procedures have as much as a 12% complication rate; no figures exist for laparoscopy. The complications are moderate and severe: tube dislocation, obstruction or migration of the tube, cutaneous or intraabdominal abscesses, enterocutaneous fistulas, pneumatosis, occlusion, and intestinal ischemia. The infectious complications are aspiration pneumonia and contamination of the diet. The gastrointestinal complications are diarrhea 2.3% to 6.8%, abdominal distension, colic, constipation, nausea, and vomiting. The metabolic complications are hyperglycemia 29%, hypokalemia 50%, water and electrolyte imbalance, hypophosphatemia, and hypomagnesemia. These complications are secondary to inadequate selection of nutrition relative to the characteristics of the patient, to inadequate management of the mixture, and to deficient clinical care. The ideal jejunostomy technique depends on the material resources but more importantly on the experience of the surgeon. The benefits of jejunostomy justify the risks.

The objective of this study was to identify venipuncture and blood draw factors associated with hemolysis (red blood cell damage) of ED blood samples. A convenience sample of ED blood samples was studied for degree of hemolysis and phlebotomy technique using data obtained from surveys completed by ED nurses and/or ED clinical technicians. The questionnaires were submitted with each blood sample sent to the laboratory for diagnostic testing. The level of hemolysis per sample was designated by laboratory technicians. Completed questionnaires were gathered and analyzed. Chi-square analysis was used to determine significant relationships. During the 19-day study, 598 surveys were collected, and 76% (n = 454) were complete enough to be included in the analysis. The predominant technique for drawing blood in new venipunctures (n = 372) was by intravenous catheters (69% [n = 255]), versus straight needles (31% [n = 117]). Thirty-two percent of the samples had some degree of hemolysis; 13% were so hemolyzed that tests were canceled by the laboratory. Blood drawn through intravenous catheters resulted in significantly more hemolysis and test cancellation than that drawn with a straight needle (20% versus &amp;amp;amp;amp;amp;lt;1%, significant at P &amp;amp;amp;amp;amp;lt;.001). Intravenous catheter hemolysis was higher when a vacutainer was used versus a syringe (22% canceled versus 9% canceled, significant at P =.02). Drawing blood through intravenous catheters was associated with significantly more hemolysis than drawing blood with straight needles. Using a combination of intravenous catheter and vacutainer caused more hemolysis than using an intravenous catheter with a syringe.

The development of needles, needle-insertion simulators, and needle-wielding robots for use in a clinical environment depends on a thorough understanding of the mechanics of needle-tissue interaction. It stands to reason that the forces arising from this interaction are influenced by numerous factors, such as needle type, insertion speed, and tissue characteristics. However, exactly how these factors influence the force is not clear. For this reason, the influence of various factors on needle insertion-force was investigated by searching literature for experimental data. This resulted in a comprehensive overview of experimental insertion-force data available in the literature, grouped by factor for quick reference. In total, 99 papers presenting such force data were found, with typical peak forces in the order of 1-10 N. The data suggest, for example, that higher velocity tends to decrease puncture force and increase friction. Furthermore, increased needle diameter was found to increase peak forces, and conical needles were found to create higher peak forces than beveled needles. However, many questions remain open for investigation, especially those concerning the influence of tissue characteristics.

Foam sclerotherapy has gained a great popularity among phlebologists worldwide, although a major lack of homogeneity in the material used to produce sclerosant foam (SF) and to inject SF has been reported. To highlight the literature data and a few personal clinical and experimental outcomes concerning the main variables in SF production and injection. A review of the published literature and of our own 12 year clinical and experimental experience has been undertaken in order to focus on a few variables of the material and methods used to produce SF with Tessari method and to inject SF. In SF production, differences in gas components, liquid to gas ratio, as well in disposable material can variably influence the resulting SF. Similarly SF injection through ultrasound guidance, with needle, or with short/long catheter may exhibit different foam behaviours according to the variable material and techniques which are employed. More recently the introduction of long catheters, possibly t...

In order to study Sa-Ahm's underlying thoughts on the basis of Yin-Yang and the fiveelement theory, the 12 acupuncture meridian systems and eight extra meridian systems were investigated in detail. The clinical acupuncture points for Sa-Ahm's four-needle acupuncture technique were also reviewed. The forms of the combinations using the five Shu acupuncture points, which are based on the promotion and control cycles with tonification and sedation, were shown to connect to the acupuncture points, which represent the meridian system itself. However, not all of Sa-Ahm's clinical cases were fully explained by this doctrine, so the five correlations among the meridian systems and the acupuncture points that affect the clinical treatment and the occurrence of disease were determined. The mutual efficacies for Sa-Ahm's clinical cases can be analyzed and explained with correlativity diagrams that include five interrelations.