Randy R. Sibbitt

Does Sonographic Needle Guidance Affect the Clinical Outcome of Intraarticular Injections

Objective. This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections. Methods. In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0–10 cm visual analog pain scale (VAS). Results. Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score ≥ 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score ≥ 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. Conclusion. Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Diabetic Neuropathy: Structural Analysis of Nerve Hydration by Magnetic Resonance Spectroscopy

The water content of the sural nerve of diabetic patients was quantitatively defined by magnetic resonance proton imaging as a putative reflection of activity of the aldose-reductase pathway. Thirty-nine patients were evaluated, comparing group A, symptomatic diabetic men with sensory neuropathy; group B, similarly symptomatic diabetic men treated with aldose-reductase inhibition; group C, neurologically asymptomatic diabetic men; and group D, control nondiabetic men. Marked increase in hydration of the sural nerve was seen in more than half of the symptomatic diabetic patients. Two of 11 neurologically asymptomatic diabetics had increased nerve hydration, suggesting a presymptomatic alteration of the nerve. Symptomatic diabetics treated with aldose-reductase inhibitors had normal nerve water levels. Increased level of peripheral nerve water represents a new finding in diabetes mellitus. It seems to be related to aldose-reductase activity, involved in the development of neuropathy, and similar to events that occur in other target tissue in human diabetes.

Comparison of magnetic resonance imaging and histology in collagenase-induced hemorrhage in the rat.

Complex changes in the appearance of blood on magnetic resonance images (MRis) complicate interpretation of intracerebral hemorrhage. In this study senal MRIs of intracerebral hemorrhage were obta1ned at 1. 5 T, using a recently developed model for brain hemorrhage, and the MRI findings were compared with histological findings. Hemorrhages were mduced in 24 adult rats by the stereotactic injection of 0.5 unit of bactenal collagenase into the caudate/putamen. Initially, there was hypointensity seen on both T1‐ and T2‐weighted images. Conversion to hyperintensity began on both T1‐ and T2‐weighted images around 10 hours, when red blood cell lysis was observed histologically. By 24 hours, complete conversion to marked hyperintensity had occurred. Calculated T2 values increased twofold to fivefold after lysis, indicating that T2 effects dominate the convers1on to hyper‐intensity seen after red blood cell lysis. At 24 hours there was a rim of intact red blood cells around the lesion, which was hypointense on MRI at a time when iron stains were negative. Fresh blood appears hypointense on T1‐ and T2‐weighted images both at the early stages of a bleed and at later stages when rebleeding occurs. Collagenase‐induced hemorrhage is a useful animal model to follow the evolution of paramagnetic effects of blood on MRI.

Control and Performance Characteristics of Eight Different Suction Biopsy Devices

PURPOSE To determine the control and performance characteristics of eight different suction biopsy devices. MATERIALS AND METHODS Physician control of the syringe and needle was measured precisely with the validated linear displacement method during the aspiration phase and during five biopsy passes. The visual analog scale was used to measure operator difficulty in the following domains: (i) attachment to the needle, (ii) generation of vacuum, (iii) detection of loss of vacuum, (iv) release of the vacuum, and (v) clearing of the sample from the needle. RESULTS Performance in various phases of the biopsy procedure varied widely among the biopsy devices tested. Unintended forward penetration (ie, loss of control in the forward direction) was significant with the reverse aspiration syringe (31.5 +/- 1.7 mm), three-ringed control syringe (25.4 +/- 4.1 mm), BioSuc-C7 syringe (28.3 +/- 1.9 mm), conventional syringe with a plunger lock (6.1 +/- 1.5 mm), syringe pistol (9.2 +/- 2.4 mm), and conventional syringe (3.8 +/- 2.9 mm) but was significantly less for the reciprocating procedure device (RPD; 0.7 +/- 0.7 mm; P </= .001) and RPD syringe holder (0.6 +/- 0.6 mm; P </= .001). The mean performance rankings were the best for the RPD (3.42 +/- 2.57) and RPD syringe holder (4.29 +/- 2.50) and worst for the conventional syringe (6.14 +/- 2.67; P </= .001) and conventional syringe with a plunger lock (6.86 +/- 3.80; P </= .001). CONCLUSIONS Each of the suction biopsy devices has unique advantages and disadvantages. Suction biopsy devices with the least favorable overall performance were the conventional syringe and the conventional syringe with a plunger lock. The highest overall performance was seen with the RPD and RPD syringe holder.

Needle aspiration of peritonsillar abscess with the new safety technology: The reciprocating procedure device

Peritonsillar abscess is the most common deep infection of the head and neck. The peritonsillar bulging and deviation of the uvula are characteristic, and can be confirmed by ultrasound or CT. The next diagnostic step is needle aspiration of the abscess, which decompresses the abscess and permits bacterial cultures. Usually the technique for aspiration of a peritonsillar abscess requires using one hand to apply a tongue depressor while using the other hand to simultaneously aspirate with a syringe. One-handed aspiration with a syringe is a difficult and dangerous maneuver. Even experienced surgeons may lose control of the needle tip, resulting in unintentional forward penetration as much as several centimeters, which can cause puncture of the carotid artery, hemorrhage, hematoma formation, respiratory compromise, and massive aspiration of blood and pus into the lungs. In the present report, we report safer abscess aspiration with new surgical safety syringe technology: the reciprocating procedure device.

Integration of Patient Safety Technologies Into Sclerotherapy for Varicose Veins

The American College of Surgeons, the Joint Commission, the Needlestick Safety and Prevention Act, and the Occupational Safety and Health Administration all direct surgical departments, including vascular surgeons who supply sclerotherapy services, to develop formal mechanisms to improve the safety of the patient and health care worker (HCW), including integration of new safety technologies. The purpose of the present study was to identify and evaluate new safety technologies for outpatient sclerotherapy for chronic venous disease. Using national resources for patient safety and literature review, the following safety technologies were identified: (1) a safety needle to reduce inadvertent needlesticks to workers, and (2) the reciprocating procedure device (RPD) to reduce iatrogenic injuries to patients. Both devices were evaluated in the clinic, and physician responses were determined. Although the safety sheath of the needle was somewhat bulky and could interfere with the ultrasound transducer, sclerotherapy could be performed with it. The RPD safety device required instruction to show how the RPD functioned (“push-push” to aspirate-inject with the RPD rather than the usual “push-pull” with the conventional syringe), but the RPD permitted better needle control and more precise injections. The RPD was well accepted by physicians who found it to be convenient, safer, and less painful. Subsequently, the involved services successfully integrated these safety technologies into their routine clinical practices. As recommended by the Joint Commission, safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during physician-performed syringe and needle procedures, including sclerotherapy.

A possible role for MRI in polyarteritis nodosa: the creeping fat sign

We describe a case of polyarteritis nodosa with diffuse abnormalities in subcutaneous fat by magnetic resonance imaging. These abnormalities returned to normal following treatment. Magnetic resonance imaging may have a role in the identification and diagnosis of systemic vasculitis.

Integration of new safety technologies for needle aspiration of breast cysts

IntroductionNational and international regulatory agencies and professional societies mandate systematic improvements in both the safety of patients and heath care workers (HCW), including the integration of safety technologies into the procedures of obstetrics and gynecology (Ob-Gyn).Materials and Methods Using national resources for patient safety and literature review, these safety technologies were identified: (1) a safety needle to reduce needle sticks to HCW, and (2) the reciprocating procedure device (RPD) to reduce injuries to patients. These technologies were introduced in a trial fashion into routine breast cyst aspiration, and physician responses were determined.Results The safety needle presented a number of difficulties associated with the safety sheath, but could be used efficiently for breast cyst aspiration. The RPD safety device functioned well for breast aspiration procedures and was well accepted by physicians.Conclusions New safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during outpatient breast procedures. Since these technologies have been demonstrated to decrease injuries to patients and HCW by 60–70%, serious efforts should be undertaken to systematically integrate safety technologies into the routine practice, including aspiration of breast cysts.

Introduction of new safety technologies into central venous access

The American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the Patient Safety and Quality Improvement Act of 2005 encourage anesthesiology departments to institute systematic improvements in patient safety, including but not limited to integration of new safety technologies. The evaluation and method of use of the reciprocating procedure device in central venous access is presented.

Polyol and water accumulation in muscle of galactose-fed rats

Skeletal muscle contains high levels of aldose reductase that catalyzes the reduction of galactose to the polyol galactitol. Galactitol and water were measured in muscle of rats fed a high galactose diet with or without addition of the aldose reductase inhibitor sorbinil. Galactitol, measured in isolated samples of muscle by HPLC, reached steady-state levels (5.9 +/- 1.0 mg/g tissue) within 3 days. Muscle water, determined in vivo by magnetic resonance imaging, increased (51 +/- 5%, P < 0.02) to steady-state levels within 7 days. Both the increased galactitol and water remained constant for the 4-month duration of this study. Aldose reductase activity also remained constant. Sorbinil prevented both the increase in galactitol and the increase in water. These results suggest that the increase in water is due to the osmotic effects of galactitol accumulation and demonstrate that galactitol and water accumulation neither up-regulate nor down-regulate aldose reductase expression in skeletal muscle.