EZ-IO intraosseous device implementation in a pre-hospital emergency service : a prospective study and review of the literature

Introduction : La prise en charge des patients critiques nécessite dans la majorité des situations l'obtention rapide d'un accès vasculaire, afin d'administrer des médicaments, des solutés de remplissage, ou des produits sanguins. La mise en place d'un accès vasculaire peut s'avérer difficile chez ces patients. En cas d'échec de pose d'une voie veineuse périphérique, des abords vasculaires alternatifs existent. Il s'agit essentiellement de la pose d'une voie veineuse centrale, la réalisation d'une dénudation veineuse, ou la pose d'une voie intra-osseuse. Depuis le développement de dispositifs d'insertion « semi-automatique » à la fin des années 90, la voie intra-osseuse, traditionnellement réservée aux cas pédiatriques, est de plus en plus fréquemment utilisée chez les patients adultes. Le Service des Urgences du CHUV a introduit en 2009 les dispositifs d'insertion d'aiguilles intra-osseuses de type EZ-IO® (perceuse électrique), en salle de réanimation des urgences vitales (déchoquage), ainsi qu'au sein du secteur préhospitalier pour les interventions du SMUR de Lausanne et de l'hélicoptère REGA de la base de Lausanne. Par cette étude, nous voulions mettre en évidence les aspects épidémiologiques des patients ayant dû être perfusés par cet abord dans un contexte préhospitalier, ainsi que les circonstances cliniques ayant justifié un tel usage, le taux de succès, les éventuelles complications, les médicaments perfusés et la mortalité des patients ayant bénéficié de ce dispositif. Méthode: Chaque patient ayant bénéficié de la mise en place d'une voie intra-osseuse par EZ-IO® du 1er janvier 2009 au 31 décembre 2011 a été inclus. Les données récoltées étaient l'âge, le sexe, l'indication à la mise en place de l'intra-osseuse, la localisation, le taux de succès, les médicaments et fluides administrés, les complications, la mortalité à 48 heures et à la sortie de l'hôpital. Tous les articles mentionnant l'utilisation de ΙΈΖ-ΙΟ® dans des situations cliniques ont également été analysés par une revue de littérature structurée exhaustive, afin de comparer nos résultats avec les données de la littérature. Résultats : Cinquante-huit patients, représentant 60 intra-osseuses EZ-IO®, ont été inclus. Leur âge moyen (47 ans), le taux de succès (90%), les indications, la localisation de l'aiguille (98% au niveau du tibia proximal) et le taux de complications (0%) correspondent aux valeurs trouvées dans la littérature. Le taux de survie de nos patients est de 38% à 48 heures et de 29% à la sortie de l'hôpital. De nombreux médicaments ou solutés de perfusion ont été administrés; l'adrénaline restant le médicament le plus fréquemment administré par cette voie. Dans 7 cas, les patients ont bénéficié d'une induction d'anesthésie par voie intra-osseuse. La revue de littérature a permis de compiler 30 études distinctes, représentant un total de 1603 accès vasculaires de type EZ-IO®. Conclusion : La voie intra-osseuse s'avère fiable et rapide pour obtenir un accès vasculaire, avec un taux de complications très faible et permet l'administration d'un grand nombre de substances. D'autres études sont nécessaires pour évaluer l'impact de la voie intra osseuse, notamment en termes de mortalité, de complications tardives, ainsi que d'analyse coût/bénéfice de ce matériel.

Electronic control device exposure: a review of morbidity and mortality.

The use of electronic control devices has expanded worldwide during the last few years, the most widely used model being the Taser. However, the scientific knowledge about electronic control devices remains limited. We reviewed the medical literature to examine the potential implications of electronic devices in terms of morbidity and mortality, and to identify and evaluate all the existing experimental human studies. A single exposure of an electronic control device on healthy individuals can be assumed to be generally safe, according to 23 prospective human experimental studies and numerous volunteer exposures. In case series, however, electronic control devices could have deleterious effects when used in the field, in particular if persons receive multiple exposures, are intoxicated, show signs of "excited delirium," or present with medical comorbidities. As the use of electronic control devices continues to increase, the controversy about its safety, notably in potentially high-risk individuals, is still a matter of debate. The complications of electronic control device exposure are numerous but often recognizable, usually resulting from barbed dart injuries or from falls. Persons exposed to electronic control devices should therefore be fully examined, and traumatic lesions must be ruled out.

Automatic Decision-Oriented Mapping of Pollution Data

The paper deals with the development and application of the methodology for automatic mapping of pollution/contamination data. General Regression Neural Network (GRNN) is considered in detail and is proposed as an efficient tool to solve this problem. The automatic tuning of isotropic and an anisotropic GRNN model using cross-validation procedure is presented. Results are compared with k-nearest-neighbours interpolation algorithm using independent validation data set. Quality of mapping is controlled by the analysis of raw data and the residuals using variography. Maps of probabilities of exceeding a given decision level and ?thick? isoline visualization of the uncertainties are presented as examples of decision-oriented mapping. Real case study is based on mapping of radioactively contaminated territories.

Measurement with an automated oscillometric wrist device with position sensor leads to lower values than measurements obtained with an automated oscillometric arm device from the same manufacturer in elderly persons.

OBJECTIVE: Home blood pressure (BP) monitoring is recommended by several clinical guidelines and has been shown to be feasible in elderly persons. Wrist manometers have recently been proposed for such home BP measurement, but their accuracy has not been previously assessed in elderly patients. METHODS: Forty-eight participants (33 women and 15 men, mean age 81.3±8.0 years) had their BP measured with a wrist device with position sensor and an arm device in random order in a sitting position. RESULTS: Average BP measurements were consistently lower with the wrist than arm device for systolic BP (120.1±2.2 vs. 130.5±2.2 mmHg, P<0.001, means±SD) and diastolic BP (66.0±1.3 vs. 69.7±1.3 mmHg, P<0.001). Moreover, a 10 mmHg or greater difference between the arm and wrist device was observed in 54.2 and 18.8% of systolic and diastolic measures, respectively. CONCLUSION: Compared with the arm device, the wrist device with position sensor systematically underestimated systolic as well as diastolic BP. The magnitude of the difference is clinically significant and questions the use of the wrist device to monitor BP in elderly persons. This study points to the need to validate BP measuring devices in all age groups, including in elderly persons.

Accurate and early diagnosis of orthopedic device-related infection by microbial heat production and sonication.

Proper and rapid diagnosis of orthopedic device-related infection is important for successful treatment. Sonication has been shown to improve the diagnostic performance. We hypothesized that the combination of sonication with a novel method called microcalorimetry will further improve and accelerate the diagnosis of implant infection. We prospectively included 39 consecutive patients (mean age 59 years, 62% males) at our institution from whom 29 orthopedic prostheses and 10 osteosynthesis material were explanted. The explanted device was sonicated. The resulting sonication fluid was analyzed using microcalorimetry. Using standardized criteria to define orthopedic device-related infection, 12 cases (31%) were defined as infected. In all, positive periprosthetic tissue cultures were found. The sensitivity and specificity of microcalorimetry of sonication fluid were 100% and 97%, respectively. Mean time to detection, defined as time to reach a rising heat flow signal of 20 µW measured after equilibiration needed to get accurate measurement, was 10.9 h. In summary, microcalorimetry of sonication fluid is a reliable and a fast method in detecting the presence of microorganisms in orthopedic device-related infection. © 2013 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 31:1700-1703, 2013.

Paediatric bi-ventricular external assist device based on artificial muscles

Objective: Existing VADs are single-ventricle pumps needing anticoagulation. We developed a bi ventricular external assist device that reproduces the physiological heart muscle movement completely avoiding anticoagulants. Methods: The device has a carbon fibre skeleton fitting a 30-40 kg patient's heart, to which a Nitinol based artificial muscle is connected. The artificial muscle wraps both ventricles. The strength of the Nitinol fibres is amplified by a pivot articulation in contact with the ventricle wall. The fibres are electrically driven and a dedicated control unit has been developed. We assessed hemodynamic performances of this device using a previously described dedicated bench test. Volume ejected and pressure gradient has been measured with afterload ranging from 25 to 50mmHg. Results: With anafterload of 50mmHg the system has an ejection fraction (EF) of 10% on the right side and 8% on the left side. The system is able to generate a systolic ejection of 5,5 ml on the right side and 4,4 ml on the left side. With anafterload of 25mmHg the results are reduced of about 20%. The activation frequency is 80/minute resulting in a total volume displacement of 440 ml/minute on the right side and 352 ml/minute on the left side. Conclusions: The artificial muscle follows Starling's law as the ejected volume increases when afterload increases. These preliminary studies confirmed the possibility of improving the EF of a failing heart using artificial muscle for external cardiac compression. This device could be helpful in weaning CPB and/or for short-term cardio-circulatory support in paediatric population with cardiac failure.

Automatic Comparison and Evaluation of Impressions Left by a Firearm on Fired Cartridge Cases

Recent years have been characterized by a series of publications in the field of firearms investigation questioning the reliability and objectivity of such examination. This research investigates new solutions to decrease the subjective component affecting the evaluation that follows the comparison of impressions left by a firearm on the surface of spent cartridge cases. An automatic comparison system based on 3D measurements has been developed and coupled to a bivariate evaluative model allowing assigning likelihood ratios. Based on a dataset of 79 pistols (all SIG Sauer 9 mm Luger caliber), the system shows a very high discriminating power and the LRs that it provides are very indicative of the true state under both the prosecution and the defense propositions. For example, likelihood ratios exceeding a billion are predominantly obtained when impressions originating from the same source are compared. The system is also characterized by relatively low rates (≤1%) of misleading evidence depending on the firearm considered.

Miniaturized bacterial biosensor system for arsenic detection holds great promise for making integrated measurement device.

Combining bacterial bioreporters with microfluidics systems holds great promise for in-field detection of chemical or toxicity targets. Recently we showed how Escherichia coli cells engineered to produce a variant of green fluorescent protein after contact to arsenite and arsenate can be encapsulated in agarose beads and incorporated into a microfluidic chip to create a device for in-field detection of arsenic, a contaminant of well known toxicity and carcinogenicity in potable water both in industrialized and developing countries. Cell-beads stored in the microfluidics chip at -20°C retained inducibility up to one month and we were able to reproducibly discriminate concentrations of 10 and 50 μg arsenite per L (the drinking water standards for European countries and the United States, and for the developing countries, respectively) from the blank in less than 200 minutes. We discuss here the reasons for decreasing bioreporter signal development upon increased storage of cell beads but also show how this decrease can be reduced, leading to a faster detection and a longer lifetime of the device.

Precision of the Retinal Tomograph as a Screening Device.

Purpose: To assess the diagnostic accuracy of the Heidelberg Retinal Tomograph 3 (HRT3) as a screening device in comparison with the reference standard of Octopus standard automated perimetry results (SAP) combined with clinical findings. Methods: All patients underwent screening examinations and investigations within a single day. Abnormal screening results were classified as follows: The HRT3: Either "borderline" or "outside normal limits" using the global Moorfields classification (MFC); SAP and clinical exam: A mean defect > 2.4 dB or "outside normal limits" clear text analysis of SAP; and one of the following i) IOP > 21 mmHg, ii) Van Herrick < ¼, iii) cup disc ratio > 0.55, iv) optic nerve head abnormality, v) narrow iridocorneal angle or vi) evidence of peripheral anterior synechiae on gonioscopy. Results: The mean age of the participants was 59.9 years (± 14.8 [21, 91]). Twenty-three subjects (16 %) were classified as abnormal on SAP and clinical exam. The HRT3 classification had a sensitivity of 30 % (95 % CI [16 %, 51 %]) with associated specificity of 58 % (95 % CI [49 %, 66 %]). Of the sixty subjects classified as borderline or outside normal limits with the HRT MFC global result, seven subjects were also abnormal according to SAP and clinical exam. Conclusion: The results suggest that the HRT3 may not be suitable as a sole screening device; however, further investigation is necessary.

Vacuum-assisted closure device for the management of infected postpneumonectomy chest cavities.

BACKGROUND: Infected postpneumonectomy chest cavities may be related to chronic postpneumonectomy empyema or arise in rare situations of necrotizing pneumonia with complete lung destruction where pneumonectomy and pleural debridement are required. We evaluated the safety and efficacy of an intrathoracic vacuum-assisted closure device (VAC) for the treatment of infected postpneumonectomy chest cavities. METHOD: A retrospective single institution review of all patients with infected postpneumonectomy chest cavities treated by VAC between 2005 and 2013. Patients underwent surgical debridement of the thoracic cavity, muscle flap closure of the bronchial stump when a fistula was present, and repeated intrathoracic VAC dressings until granulation tissue covered the entire chest cavity. After this, the cavity was obliterated by a Clagett procedure and closed. RESULTS: Twenty-one patients (14 men and 7 women) underwent VAC treatment of their infected postpneumonectomy chest cavity. Twelve patients presented with a chronic postpneumonectomy empyema (10 of them with a bronchopleural fistula) and 9 patients with an empyema occurring in the context of necrotizing pneumonia treated by pneumonectomy. In-hospital mortality was 23%. The median duration of VAC therapy was 23 days (range, 4-61 days) and the median number of VAC changes per patient was 6 (range, 2-14 days). Infection control and successful chest cavity closure was achieved in all surviving patients. One adverse VAC treatment-related event was identified (5%). CONCLUSIONS: The intrathoracic VAC application is a safe and efficient treatment of infected postpneumonectomy chest cavities and allows the preservation of chest wall integrity.

Percutaneous Endovascular Salvage Techniques for Implanted Venous Access Device Dysfunction.

PURPOSE: Implanted venous access devices (IVADs) are often used in patients who require long-term intravenous drug administration. The most common causes of device dysfunction include occlusion by fibrin sheath and/or catheter adherence to the vessel wall. We present percutaneous endovascular salvage techniques to restore function in occluded catheters. The aim of this study was to evaluate the feasibility, safety, and efficacy of these techniques. METHODS AND MATERIALS: Through a femoral or brachial venous access, a snare is used to remove fibrin sheath around the IVAD catheter tip. If device dysfunction is caused by catheter adherences to the vessel wall, a new "mechanical adhesiolysis" maneuver was performed. IVAD salvage procedures performed between 2005 and 2013 were analyzed. Data included clinical background, catheter tip position, success rate, recurrence, and rate of complication. RESULTS: Eighty-eight salvage procedures were performed in 80 patients, mostly women (52.5 %), with a mean age of 54 years. Only a minority (17.5 %) of evaluated catheters were located at an optimal position (i.e., cavoatrial junction ±1 cm). Mechanical adhesiolysis or other additional maneuvers were used in 21 cases (24 %). Overall technical success rate was 93.2 %. Malposition and/or vessel wall adherences were the main cause of technical failure. No complications were noted. CONCLUSION: These IVAD salvage techniques are safe and efficient. When a catheter is adherent to the vessel wall, mechanical adhesiolysis maneuvers allow catheter mobilization and a greater success rate with no additional risk. In patients who still require long-term use of their IVAD, these procedures can be performed safely to avoid catheter replacement.

Automatic target validation based on neuroscientific literature mining for tractography.

Target identification for tractography studies requires solid anatomical knowledge validated by an extensive literature review across species for each seed structure to be studied. Manual literature review to identify targets for a given seed region is tedious and potentially subjective. Therefore, complementary approaches would be useful. We propose to use text-mining models to automatically suggest potential targets from the neuroscientific literature, full-text articles and abstracts, so that they can be used for anatomical connection studies and more specifically for tractography. We applied text-mining models to three structures: two well-studied structures, since validated deep brain stimulation targets, the internal globus pallidus and the subthalamic nucleus and, the nucleus accumbens, an exploratory target for treating psychiatric disorders. We performed a systematic review of the literature to document the projections of the three selected structures and compared it with the targets proposed by text-mining models, both in rat and primate (including human). We ran probabilistic tractography on the nucleus accumbens and compared the output with the results of the text-mining models and literature review. Overall, text-mining the literature could find three times as many targets as two man-weeks of curation could. The overall efficiency of the text-mining against literature review in our study was 98% recall (at 36% precision), meaning that over all the targets for the three selected seeds, only one target has been missed by text-mining. We demonstrate that connectivity for a structure of interest can be extracted from a very large amount of publications and abstracts. We believe this tool will be useful in helping the neuroscience community to facilitate connectivity studies of particular brain regions. The text mining tools used for the study are part of the HBP Neuroinformatics Platform, publicly available at http://connectivity-brainer.rhcloud.com/.

Automatic Segmentation of the Eye in 3D Magnetic Resonance Imaging: A Novel Statistical Shape Model for Treatment Planning of Retinoblastoma.

PURPOSE: Proper delineation of ocular anatomy in 3-dimensional (3D) imaging is a big challenge, particularly when developing treatment plans for ocular diseases. Magnetic resonance imaging (MRI) is presently used in clinical practice for diagnosis confirmation and treatment planning for treatment of retinoblastoma in infants, where it serves as a source of information, complementary to the fundus or ultrasonographic imaging. Here we present a framework to fully automatically segment the eye anatomy for MRI based on 3D active shape models (ASM), and we validate the results and present a proof of concept to automatically segment pathological eyes. METHODS AND MATERIALS: Manual and automatic segmentation were performed in 24 images of healthy children's eyes (3.29 ± 2.15 years of age). Imaging was performed using a 3-T MRI scanner. The ASM consists of the lens, the vitreous humor, the sclera, and the cornea. The model was fitted by first automatically detecting the position of the eye center, the lens, and the optic nerve, and then aligning the model and fitting it to the patient. We validated our segmentation method by using a leave-one-out cross-validation. The segmentation results were evaluated by measuring the overlap, using the Dice similarity coefficient (DSC) and the mean distance error. RESULTS: We obtained a DSC of 94.90 ± 2.12% for the sclera and the cornea, 94.72 ± 1.89% for the vitreous humor, and 85.16 ± 4.91% for the lens. The mean distance error was 0.26 ± 0.09 mm. The entire process took 14 seconds on average per eye. CONCLUSION: We provide a reliable and accurate tool that enables clinicians to automatically segment the sclera, the cornea, the vitreous humor, and the lens, using MRI. We additionally present a proof of concept for fully automatically segmenting eye pathology. This tool reduces the time needed for eye shape delineation and thus can help clinicians when planning eye treatment and confirming the extent of the tumor.

A promising new device for the prevention of parastomal hernia.

Parastomal hernia (PSH) is the most frequent long-term stoma complication with serious negative effects on quality of life. Surgical revision is often required and has a substantial morbidity and recurrence rate. The development of PSH requires revisional surgery with a substantial perioperative morbidity and high failure rate in the long-term follow-up. Prophylactic parastomal mesh insertion during stoma creation has the potential to reduce the rate of PSH, but carries the risk of early and late mesh-related complications such as infection, fibrosis, mesh shrinkage, and/or bowel erosion. We developed a new stomaplasty ring (KORING), which is easy to implant, avoids potential mesh-related complications, and has a high potential of long-term prevention of PSH. Here we describe the technique and the first use.