Percutaneous closure of patent ductus arteriosus via internal jugular vein in patient with interrupted inferior vena cava

Transcatheter closure of patent ductus arteriosus (PDA) using various occluders and coils via femoral vein is a well established therapeutic option. However, in patients with interrupted inferior vena cava (IVC) it is not feasible to close the PDA percutaneously using traditional methods. We present a nine-year-old girl with IVC interruption in whom percutaneous closure of PDA was successfully accomplished via the transjugular approach

Inferior Vena Cava Measurement With Ultrasound: What is The Best View and Best Mode?

Introduction: Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: subxiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”). Methods: Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance. Results: EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76-0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56-0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs. Conclusion: Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard. [West J Emerg Med. 2017;18(3)496-501.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)