Search

Background & Aims: Despite the poor prognosis associated with missed or delayed spontaneous bacterial peritonitis (SBP) diagnosis, <15% get timely paracentesis, which persists despite guidelines/education in the United States. Measures to exclude SBP non-invasively where timely paracentesis cannot be performed could streamline this burden., Methods: Using Veterans Health Administration Corporate Data Warehouse (VHA-CDW) we included patients with cirrhosis between 2009 and 2019 who underwent timely paracentesis and collected relevant clinical information (demographics, cirrhosis severity, medications, vitals, and comorbidities). XGBoost-models were trained on 75% of the primary cohort, with 25% reserved for testing. The final model was further validated in 2 cohorts: Validation cohort #1: In VHA-CDW, those without prior SBP who received 2nd early paracentesis, and Validation cohort #2: Prospective data from 276 non-electively admitted University hospital patients., Results: Negative predictive values (NPVs) at 5%,10%, and 15% probability cutoffs were examined. Primary cohort: n = 9643 (mean age, 63.1 ± 8.7 years; 97.2% men; SBP, 15.0%) received first early paracentesis. Testing-set NPVs for SBP were 96.5%, 93.0%, and 91.6% at the 5%, 10%, and 15% probability thresholds, respectively. In Validation cohort #1: n = 2844 (mean age, 63.14 ± 8.37 years; 97.1% male; SBP, 9.7%) with NPVs were 98.8%, 95.3%, and 94.5%. In Validation cohort #2: n = 276 (mean age, 56.08 ± 9.09; 59.6% male; SBP, 7.6%) with NPVs were 100%, 98.9%, and 98.0% The final machine learning model showed the greatest net benefit on decision-curve analyses., Conclusions: A machine learning model generated using routinely collected variables excluded SBP with high NPV. Applying this model could ease the need to provide paracentesis in resource-limited settings by excluding those unlikely to have SBP., (Published by Elsevier Inc.)

Introduction: Ascites, a severe complication of cirrhosis, significantly impacts patient morbidity and mortality especially in Black patients. Access to disease optimizing care has been proposed as a potential driver of this disparity. In this study, we evaluate TIPS utilization across racial and ethnic groups., Methods: We examined data from a 20% random sample of US Medicare enrollees with continuous Part D coverage. We required 180 days of continuous outpatient enrollment prior to cirrhosis diagnosis and all patients had ≥1 paracentesis within 180 days of their cirrhosis diagnosis. Time zero was the date of the first paracentesis. We assessed the likelihood of TIPS placement. Analyses were conducted to determine the independent associations between each outcome and race/ethnicity., Results: 5915 patients (average age 68.2, 64.4% male) were included in the analysis. 439 (7.4%) patients were identified as Black, 223 (3.8%) as Hispanic, and 4942 (83.6%) as white. When compared to white patients in a multivariable analysis, Black patients were less likely to receive a TIPS procedure (hazard ratio 0.4; 95% confidence interval (CI) 0.2-0.8) and had less days alive outside of the hospital (-100.5; 95% CI -189.4 - -11.6). There were no significant differences in transplant-free survival or number of paracenteses per year between ethnic and racial groups., Conclusion: Black patients are less likely to receive a TIPS procedure when controlling for common patient- and disease-specific variables. Access to optimal specialized services may be a significant driver for disparities in outcomes of patients with cirrhosis between racial and ethnic groups., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Malignant ascites often causes discomfort in advanced cancer patients. Paracentesis is the most common treatment modality, but it requires frequently repeated treatment. Cell-free and concentrated ascites reinfusion therapy (CART) may prolong the paracentesis interval, but controlled trials are lacking. We assessed the feasibility of a randomized controlled trial of CART vs. paracentesis alone for patients with refractory malignant ascites., Methods: This study was an open-label, fast-track, randomized controlled, feasibility trial. Patients admitted to four designated cancer hospitals who received no further anticancer treatments were eligible. Patients were randomly assigned 1:1 to a CART arm or control (simple paracentesis) arm. The feasibility endpoint was the percentage of patients who completed the study intervention. Secondary endpoints included paracentesis-free survival, patient's request on the questionnaire for paracentesis (PRO-paracentesis)-free survival (the period until the patients first reported that they would want paracentesis if indicated), and adverse events., Results: We screened 953 patients for eligibility. Of 61 patients with refractory malignant ascites, 21 patients were determined as eligible. Finally, 20 patients consented and were allocated; 18 patients (90%, 95% CI: 68.3-98.8) completed the study intervention. All patients had an ECOG performance status of 3 or 4. The median drained ascites volume was 3,200 mL in the CART arm and 2,500 mL in the control arm. In the CART arm, the median reinfused albumin volume was 12.6 g. Median paracentesis-free survivals were 5 days (95% CI: 2-6) in the CART arm, and 6 days (3-9) in the control arm. Median PRO-paracentesis-free survivals were 4 days (2-5) and 5 days (1-9), respectively. A total of 73% of patients received paracentesis within 2 days from their first request for the next paracentesis. One patient in the CART arm developed Grade 1 fever., Conclusions: A fast-track randomized controlled trial of CART for patients with malignant ascites is feasible. The efficacy and safety of CART should be assessed in future trials. PRO-paracentesis-free survival may be a complementary outcome measure with paracentesis-free survival in future trials., Trial Registration: Registered at University Hospital Medical Information Network Clinical Trial Registry as UMIN000031029 . Registered on 28/01/2018., (© 2022. The Author(s).)

Objective: To explore the 3D-slicer software-assisted endoscopic treatment for patients with hypertensive cerebral hemorrhage., Methods: A total of 120 patients with hypertensive cerebral hemorrhage were selected and randomly divided into control group and 3D-slicer group with 60 cases each. Patients in the control group underwent traditional imaging positioning craniotomy, and patients in the 3D-slicer group underwent 3D-slicer followed by precision puncture treatment. In this paper, we evaluate the hematoma clearance rate, nerve function, ability of daily living, complication rate, and prognosis., Results: The 3D-slicer group is better than the control group in various indicators. Compared with the control group, the 3D-slicer group has lower complications, slightly higher hematoma clearance rate, and better recovery of nerve function and daily living ability before and after surgery. The incidence of poor prognosis is low., Conclusion: The 3D-slicer software-assisted endoscopic treatment for patients with hypertensive intracerebral hemorrhage has a better hematoma clearance effect, which is beneficial to the patient's early recovery and reduces the damage to the brain nerve of the patient., Competing Interests: The authors declare no conflict of interest for this paper., (Copyright © 2022 Rongfang Liao et al.)

Objectives: There are three surgical treatment options for patients with peritonsillar abscess (PTA): needle aspiration, incision and drainage (ID), and abscess tonsillectomy (ATE). The updated German national guideline (2015) included changes in the treatment of PTA. The indication for tonsillectomy (TE) in patients became more stringent and preference was given to ID in certain cases., Study Design: Retrospective analysis., Methods: We performed a retrospective systematic analysis of patient data using the in-house electronic patient records and considered a 4-year period from 2014 to 2017. About 584 patients were identified. Our aim was to analyze the influence of the updated guideline on clinical practice., Results: 236 of 584 patients (40.4%) underwent ATE with contralateral TE. In 225 patients (38.5%), unilateral ATE was performed. Mean surgery time was significantly shortened when only unilateral ATE was performed. Concerning postoperative bleeding, we noted a tendency toward a lower incidence after ATE in comparison to ATE with contralateral TE. Less than 1% of patients who underwent ATE had to be revised surgically due to postoperative hemorrhage. After the revision of the guideline, unilateral ATE and ID were conducted more frequently., Conclusion: These results support that ATE in an inpatient setting is a considerably safe and effective primary therapeutic option. ID represents a favorable treatment option for patients with PTA and comorbidities, nevertheless, patient compliance is required and insufficient drainage or recurrence of PTA may occur. The revision of the guideline had a significant impact on the choice of interventions (P < .001), which is reflected by the increased number of unilateral ATE., Level of Evidence: 4 Laryngoscope, 131:2706-2712, 2021., (© 2021 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield., Methods: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan., Results: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred., Conclusion: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point., Level of Evidence: Diagnostic, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study is to investigate the various treatment methods and recurrence rates regarding Bartholin's gland abscesses under office conditions in our clinic., Methods: In our study, the data of 155 patients who applied to the gynaecology and obstetrics clinic of our hospital between January 2017 and November 2020 and had Bartholin's abscess that was treated with surgical methods under office conditions were analyzed retrospectively., Results: Of the 155 patients included in the study, 111 underwent incision drainage, 22 underwent marsupialization, and 22 underwent incision drainage+ silver nitrate. Bartholin's abscess was localized on the right side in 48.4% of the patients and on the left side in 51.6% of the patients. Recurrence was detected in 53 of 155 patients included. Recurrence was detected in 39.6% of the patients who underwent incision drainage in the first treatment, 31.8% of those who underwent marsupialization, and 9.1% of those who underwent incision+silver nitrate. The difference in success, based on recurrence rates, was found to be statistically significantly in favour of silver nitrate (p<0.05). In secondary treatments for recurrent cases, marsupialization or incision+silver nitrate treatment was effective in over 90% of cases, while incision drainage was effective in 30% of patients., Conclusion: The findings of our study show that silver nitrate application led to a lower recurrence rate than the other two methods. In view of this, we recommend that marsupialization or silver nitrate be preferred, especially in the treatment of recurrent cases., Competing Interests: Declaration of Competing Interest No conflict of interest was declared by the authors., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Abstract: Acute kidney injury (AKI) can become complicated after paracentesis due to extrarenal fluid loss and inadequate blood flow to the kidneys. The objective of this study was to explore the incidence and clinical implications of postparacentesis AKI.A retrospective cohort of 137 liver cirrhosis patients (mean age: 61.3 ± 11.8 years, male: 100 [73.0%], viral hepatitis: 93 [67.9%]) who underwent paracentesis was analyzed. The incidence of AKI as defined by the international club of ascites (ICA) criteria, the risk factors, and its impact on early mortality were all assessed.Thirty two patients (23.4%) developed AKI after paracentesis. In multivariate analysis, the Model for end-stage liver disease (MELD)-Na score was an independent factor associated with AKI development (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.07-1.23) after paracentesis. The incidence of early mortality was significantly higher for those with AKI than without AKI (71.9% [23/32 patients] vs 11.4% [12/105 patients], P < .001). AKI (hazard ratio [HR], 7.56; 95% CI, 3.40-16.8) and MELD-Na score (HR, 1.08; 95% CI, 1.02-1.14) were independent factors associated with early mortality. In subgroup analysis, AKI after paracentesis was associated with significantly higher early mortality in both MELD-Na groups, that is, patients with a MELD-Na score >26 (87.5% vs 22.2%, P < .001) and those with a MELD-Na score ≤26 (56.3% vs 9.2%, P < .001).Postparacentesis AKI occurred frequently in cirrhotic patients. Furthermore, it was associated with early mortality. Baseline MELD-Na score was associated with AKI, indicating that careful attention is required for those with a higher MELD-Na score who are being considered for therapeutic paracentesis., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Pregnancy complicated with ovarian endometrioma is a risk factor for preterm delivery and rupture or infection during pregnancy. This study aimed to clarify the effectiveness and safety of transvaginal aspiration during pregnancy for endometrioma diagnosed in the first trimester., Design: This retrospective observational study included 8 pregnant women with endometrioma who underwent transvaginal cyst aspiration at 12-14 weeks (aspiration group) between March 2011-March 2018 and 23 pregnant women with endometrioma who refused aspiration during the same period (observation group)., Methods: Characteristics of patients were compared in both groups. Safety, feasability and complications of transvaginal cyst aspiration were reported. Complications and obstetrical outcomes were reported and compared in both groups., Results: The maximum cyst diameter was 8.9 ± 1.5 cm (mean ± standard deviation) in the aspiration group, which was significantly larger than that in the observation group (4.7 ± 0.2 cm). Four preterm deliveries (17.3%) occurred in the observation group and none in the aspiration group. The emergency cesarean section rate during delivery was 14.2% in the aspiration group and 43.7% in the observation group., Conclusions: The aspiration group tended to have lower rate of preterm deliveries and emergency cesarean sections, suggesting that cyst aspiration could be an effective, minimally invasive, and safe management option for endometrioma during pregnancy., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 The Author(s). Published by Elsevier Masson SAS.. All rights reserved.)

The differential diagnosis of benign ascites and malignant ascites is incredibly challenging for clinicians. This research aimed to develop a user-friendly predictive model to discriminate malignant ascites from non-malignant ascites through easy-to-obtain clinical parameters. All patients with new-onset ascites fluid were recruited from January 2014 to December 2018. The medical records of 317 patients with ascites for various reasons in Renmin Hospital of Wuhan University were collected and reviewed retrospectively. Thirty-six parameters were included and selected using univariate logistic regression, multivariate logistic regression, and receiver operating characteristic (ROC) curve analyses to establish a mathematical model for differential diagnosis, and its diagnostic performance was validated in the other groups. Age, cholesterol, hypersensitivity C-reactive protein (hs-CRP) in serum, ascitic fluid adenosine deaminase (AF ADA), ascitic fluid lactate dehydrogenase (AF LDH) involvement in a 5-marker model. With a cut-off level of 0.83, the sensitivity, specificity, accuracy, and area under the ROC of the model for identifying malignant ascites in the development dataset were 84.7%, 88.8%, 87.6%, and 0.874 (95% confidence interval [CI], 0.822-0.926), respectively, and 80.9%, 82.6%, 81.5%, and 0.863 (95% CI,0.817-0.913) in the validation dataset, respectively. The diagnostic model has a similar high diagnostic performance in both the development and validation datasets. The mathematical diagnostic model based on the five markers is a user-friendly method to differentiate malignant ascites from benign ascites with high efficiency., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes., Materials and Methods: A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed., Results: Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring., Conclusions: Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting., Materials and Methods: We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting., Results: A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035)., Conclusions: Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

Background: The COVID-19 pandemic had a huge impact on national and regional health systems. The impact of SARS-CoV-2 on the quality of care for patients with liver disease is still unknown., Aims: The Italian Association for the Study of the Liver (AISF) conducted a survey to assess the impact of SARS-CoV-2 on hepatology units activities in Italy., Methods: A prospective web-based survey was proposed to all AISF active members. The survey was available online from April 8 2020, to May 3 2020, (lockdown phase in Italy)., Results: 194 AISF members answered the questionnaire, most of whom were specialists in Gastroenterology (41%) or Internal Medicine (28%), and worked in Northern Italy (51%). 26% of hepatology wards had been converted into COVID-19 wards, and 33% had bed reductions. All hepatological activities, including the management of patients with decompensated liver disease, liver transplant and HCC had been significantly reduced/stopped. The number of physicians answering that their practices had not been modified ranged between 0.6% (for chronic hepatitis) to 47% (for the execution of paracentesis). The recorded answers were consistent among different regions, and did not show any north-south gradient CONCLUSION: COVID-19 outbreak significantly impacted on hepatological clinical activity. This survey can serve as a basis to compare the impact of future measures aimed at delivering an acceptable level of liver care during a national pandemic or crisis., Competing Interests: Declaration of Competing Interest All Authors report no relevant conflicts of interests, (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Nosocomial infections are a particular threat for patients with liver cirrhosis. It is not uncommon that individuals develop even several consecutive infections during a single hospital stay. We aimed to investigate the impact and characteristics of multiple, consecutive nosocomial infections., Methods: A total of 514 consecutive patients with liver cirrhosis and ascites were included and followed up for 28 days for nosocomial infection, death or liver transplantation (LTx). Laboratory values were assessed at the time of hospitalization as well as at the onset of each new infectious episode., Results: 58% ( n  = 298) of the patients developed at least one nosocomial infection and in 23% ( n  = 119) even multiple infections were documented during a single hospital stay. Consecutive infections usually occurred shortly after the previous episode. Spontaneous bacterial peritonitis (SBP) was the most common infection. However, the proportion of SBP declined from 43% at the first to only 31% at the third nosocomial infection ( p  = 0.096). In contrast, the likelihood for other, less common types of infection such as blood stream infections increased. Third nosocomial infections were also more likely to be linked to the detection of fungal pathogens (21% vs. 52%; p  = 0.001). Each additional infectious episode had a dramatic detrimental impact on LTx-free survival that was independent from the stage of liver disease (adjusted-HR: 6.76, p  = 0.002 for first nosocomial infection; adjusted-HR: 14.69, p <0.001 for second nosocomial infection; adjusted-HR: 24.95, p <0.001 for third nosocomial infection)., Conclusion: In patients with decompensated liver cirrhosis LTx-free survival significantly decreases with every consecutive infectious episode. Development of prevention strategies is urgently required.

Introduction: Symptomatic ascites is the most common indication for hospitalization in patients with cirrhosis. Although guidelines recommend paracentesis for all inpatients with ascites, the timing of paracentesis is likely to be crucial. Performance of an early paracentesis and its relationship to outcomes are unknown, particularly among patients at high risk of spontaneous bacterial peritonitis (SBP)., Methods: We included 75,462 discharges of adult patients with cirrhosis presenting with ascites who underwent paracentesis from the State Inpatient Databases of New York, Florida, and Washington from 2009 to 2013. High-risk patients were identified as having concomitant hepatic encephalopathy or acute kidney injury present on admission. The primary outcome was performance of early paracentesis (within 1 hospital day) with secondary outcomes being inpatient mortality, SBP-related mortality, and 30-day readmission. Multivariable logistic regression models included a priori covariates known to impact outcomes., Results: There were 43,492 (57.6%) patients who underwent early paracentesis. High-risk patients (27,496) had lower rates of early paracentesis (52.8% vs 60.5%, P < 0.001). On multivariable analysis, high-risk patients had significantly decreased odds of undergoing early paracentesis (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.71-0.78, P < 0.001). Early paracentesis was associated with a reduced inpatient all-cause mortality (OR 0.68, 95% CI 0.63-0.73, P < 0.001), SBP-related mortality (OR 0.84, 95% CI 0.73-0.94, P = 0.01), and 30-day readmission (OR 0.87, 95% CI 0.82-0.92, P < 0.001)., Discussion: Early paracentesis is associated with reduced inpatient mortality, SBP-related mortality, and 30-day readmission. Given its impact on outcomes, early paracentesis should be a new quality metric. Further education and interventions are needed to improve both adherence and outcomes.

Objective: Population-based studies analyzing peritonsillar abscess in children are lacking. In this study, a population-based survey of the epidemiology of pediatric peritonsillar abscess in Taiwan was conducted., Methods: This cross-sectional study was conducted using the Taiwan National Health Insurance Research Database. All cases of inpatient pediatric peritonsillar abscess (age < 18 years) in Taiwan between 2000 and 2012 were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification. Incidence rates of inpatient peritonsillar abscess in children were calculated. Characteristics such as age, gender, hospital level, treatment modalities, imaging studies, drug administration, and length of hospital stays during the study period were analyzed., Results: A total of 12,965 children with peritonsillar abscess were included (mean age, 6.6 years [standard deviation, 4.8 years]; 56.5% boys). The overall incidence was 18 per 100,000 children. Incidence rates decreased from 2000 to 2012 (19.1/100,000 to 8.3/100,000 children) (p trend  < 0.001). During the study period, the proportion of peritonsillar abscess treatments at medical centers increased from 4.6% to 15.0%. The proportion of treatments involving incision and drainage or needle aspiration increased significantly (1.3%-4.1% and 49.4%-65.6%, respectively), whereas treatments with antibiotics only decreased significantly (48.9%-29.0%). The use of computed tomography (CT) increased (1.4%-12%, p trend  < 0.001). The use of nonsteroidal anti-inflammatory drugs, steroids, and penicillin increased during the study period. The mean length of hospital stays increased from 3.78 to 4.67 days., Conclusions: The incidence of peritonsillar abscess in children decreased between 2000 and 2012 in Taiwan. Moreover, increasing trends were observed in the use of CT, the rates of incision and drainage and needle aspiration procedures, and the length of hospital stay in this study cohort., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Management of spontaneous pneumothorax (SP) is still subject to debate. Although encouraging results of recent studies about outpatient management with chest drains fitted with a one-way valve, no data exist concerning application of this strategy in real life conditions. We assessed how SP are managed in Emergency departments (EDs), in particular the role of outpatient management, the types of interventions and the specialty of the physicians who perform these interventions., Methods: From June 2009 to May 2013, all cases of spontaneous primary (PSP) and spontaneous secondary pneumothorax (SSP) from EDs of 14 hospitals in France were retrospectively included. First line treatment (observation, aspiration, thoracic drainage or surgery), type of management (admitted, discharged to home directly from the ED, outpatient management) and the specialty of the physicians were collected from the medical files of the ED., Results: Among 1868 SP included, an outpatient management strategy was chosen in 179 PSP (10%) and 38 SSP (2%), mostly when no intervention was performed. Only 25 PSP (1%) were treated by aspiration and discharged to home after ED admission. Observation was the chosen strategy for 985 patients (53%). In 883 patients with an intervention (47%), it was performed by emergency physicians in 71% of cases and thoracic drainage was the most frequent choice (670 patients, 76%)., Conclusions: Our study showed the low level of implementation of outpatient management for PS in France. Despite encouraging results of studies concerning outpatient management, chest tube drainage and hospitalization remain preponderant in the treatment of SP.

Purpose: The purpose of the study is to describe the effect of a dedicated paracentesis clinic on healthcare utilization by patients with decompensated cirrhosis and refractory ascites., Methods: This Institutional Review Board-approved retrospective study identified cirrhotic patients receiving paracenteses over a 6-month period before and after creating the paracentesis clinic. Patients were followed for 12 months to collect outcome data including characteristics of subsequent hospitalizations and paracenteses. Logistic regression was used to examine the association between the paracentesis clinic and outcomes., Results: There were 183 patients and 1364 paracenteses performed during the study time period. Age, gender, cirrhosis etiology, MELD, Child-Pugh, and Charlson comorbidity index were comparable between the two groups. Rates of mortality, transplant, and hospitalization were also similar during 1 year follow-up. After establishment of the paracentesis clinic, median paracenteses per patient increased from 2 (IQR 1-7) to 4 (IQR 2-11) (P = 0.01); albumin replacement after paracenteses ≥ 5 L improved from 76.3% to 91.7% (P < 0.001); and the fraction of outpatient paracenteses performed in the emergency department decreased from 13.4% to 3.8% (P < 0.001). Major complications remained negligible at 0.81% across both time periods. While fewer patients were admitted for ascites after the paracentesis clinic (39.6% vs. 20.8%, P = 0.009), more patients had acute kidney injury (AKI) during follow-up (47.2% vs. 65.9%, P = 0.02), with a trend towards more AKI admissions (22.6% vs. 35.4%, P = 0.09)., Conclusion: A dedicated paracentesis clinic can improve access and wait times, while also reducing admissions for ascites and paracenteses performed in the emergency department.

Background: Liver disease mortality increased by 400% in the UK between 1970 and 2010, resulting in rising pressures on acute hospital services, and an increasing need for end-of-life care. We aimed to assess the effect of demographic, clinical, and health-care factors on costs, patterns of health-care use, and place of death in a national cohort of patients with cirrhosis and ascites in their last year of life., Methods: We did a retrospective, nationwide analysis of all patients who died from cirrhosis in England between 2013 and 2015, who required large-volume paracentesis in their last year of life. The outcomes measured were health-care costs accrued in the last year of life, number of inpatient days in last year of life, 30-day readmission rate, and occurrence of unplanned hospital death (probability of dying in hospital after unplanned admission). Using generalised linear and logistic regression models, we examined the effect of 12 independent variables on each outcome: sex, ethnicity, age at death, index of multiple deprivation quintile, year of death, liver disease causing death, place of death, time from index presentation in last year of life to death, whether enrolled in a day-case paracentesis service (care group), paracentesis ratio (number of day-case large-volume paracentesis procedures as a proportion of the total number of procedures in the last year of life), number of hospital episodes in the last year of life (not involving large-volume paracentesis), and number of large-volume paracentesis procedures in the last year of life., Findings: Between Jan 1, 2013, and Dec 31, 2015, 13 818 people in England died from liver disease and had large-volume paracentesis within their last year of life. For all patients, mean cost of the last year of life was £21 113 (SD 16 881), 17 888 (52·5%) of 34 068 readmissions occurred within 30 days of discharge, and 10 341 (74·8%) of 13 818 deaths occurred in hospital, of which 10 045 (97·1%) followed an emergency hospital admission. Patients who attended a day-case large-volume paracentesis service within their last year of life had significant reductions in cost (-£4240, 95% CI -4829 to -3651; p<0·0001), number of inpatient bed days (-16·98 days, -18·45 to -15·51; p<0·0001), probability of early readmission (odds ratio [OR] 0·35, 95% CI 0·31 to 0·40; p<0·0001), and probability of dying in hospital after unplanned admission (0·31, 0·27 to 0·34; p<0·0001), compared with patients who had unplanned care. For patients enrolled in day-case services, improvements in outcomes correlated with the proportion of large-volume paracentesis procedures done in a day-case (vs unplanned) setting., Interpretation: The use of day-case large-volume paracentesis services in the last year of life was associated with lower costs, reduced pressure on acute hospital services, and a lower probability of dying in hospital, compared with patients who received exclusively unplanned care in their last year of life. Wider adoption of day-case models of care could reduce costs and improve outcomes in the last year of life., Funding: David Telling Charitable Trust., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a "2-probe technique, " which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding., (© 2017 Society of Hospital Medicine.)

Patients with combined liver and kidney failure may remain on dialysis for years while awaiting simultaneous liver-kidney transplantation (SLKT). The role of peritoneal dialysis (PD) in patients with advanced liver and kidney failure awaiting SLKT remains to be defined. We present our single-institution experience with PD in cirrhotics, 3 of whom went on to receive successful SLKT. Patients initiated in our PD program between 2006 and 2016 who had both liver and kidney failure were identified. Medical and dialysis records were reviewed retrospectively. Outcomes included mortality, transplantation status, hospitalizations, need for large-volume paracentesis (LVP), peritonitis rates, PD treatment longevity, and albumin level. Twelve patients with combined liver and kidney failure were treated in our PD program. No patients died and 3 patients received SLKT. Four patients remain listed for transplantation. There was no need for LVP after initiating dialysis. The rate of peritonitis was 0.2 events per patient per year, most commonly due to coagulase-negative Staphylococcus Our data illustrate that PD is a viable bridging therapy for patients with liver and kidney failure who await SLKT., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Background and Study Aims: There are currently limited data available summarizing the clinical outcomes and safety of transjugular intrahepatic portosystemic shunts (TIPS) in cases of advanced chronic kidney disease (CKD). The study aimed to assess efficacy and safety of TIPS in patients with advanced CKD., Patients and Methods: Seventeen patients (M :F 8 :9, age 55 years, MELD 24) with grade 4-5 CKD who underwent TIPS for ascites (n = 7) or varices (n = 10) were analyzed. The primary outcome was TIPS efficacy - assessed by comparing paracentesis frequency and diuretic regimen pre- and post-TIPS among ascites patients - and through bleeding cessation in variceal bleeding patients. Other outcomes included hepatic encephalopathy (HE), GFR increase, and mortality., Results:   Median baseline GFR was 19.9 mL/min. No patients were hemodialysis dependent. Median post-TIPS pressure gradient was 8 mm Hg. Among ascites patients, 5/6 (83%) were TIPS responsive, with reduced or stable diuretics in 4/5 (80%). Among variceal hemorrhage cases, bleeding cessation rate was 90% (9/10). New or worsening HE incidence was 47% (8/17), and one patient required shunt reduction. Of 8 patients with lab follow-up, 6 (75%) demonstrated significant GFR increase (42.2 versus 20.0 mL/min, P = 0.028). The 90-day mortality incidence was 29% (5/17)., Conclusions: In conclusion, TIPS can potentially address ascites and variceal bleeding in advanced CKD patients, though HE incidence may be increased. Further investigation in larger cohorts may corroborate these results., (© Acta Gastro-Enterologica Belgica.)

Objective: Current Infectious Disease Society of America (IDSA) guidelines for the management of purulent skin or soft tissue infections do not account for patient age in treatment recommendations. The study objective was to determine if age was associated with outpatient treatment failure for purulent skin infection after adjusting for IDSA treatment guidelines., Methods: We conducted a multicenter retrospective study of adult patients treated for a purulent skin infection and discharged home from four emergency departments between April and September 2014. Patients were followed for one month to assess for treatment failure (defined as need for a change in antibiotics, surgical intervention, or hospitalization). We used multivariable logistic regression to examine the role of patient age on treatment failure adjusting for demographic variables (gender, race), comorbidities and severity of infection., Results: A total of 467 patients met inclusion criteria (mean age 37.9years [SD 14.0], 48.2% of whom were women). Overall, 12.4% failed initial therapy. Patients 65years and older (n=35) were almost 4 times more likely to fail initial ED therapy in follow-up compared with younger patients (adjusted Odds Ratio (OR) 3.87, 95% Confidence Interval (CI) 1.24-12.10). After adjustment, for every 10years of advancing age there was a 43% increased odds of failing initial treatment (OR 1.43 95% CI 1.09-1.88)., Conclusion: Elderly patients with purulent skin infections, whose providers followed the 2014 IDSA guidelines, were more likely to fail initial treatment than younger patients. This study suggests that there is a need to re-evaluate treatment guidelines in elderly patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the effects of implementing an "enhanced recovery after surgery" (ERAS) program on the feasibility, safety, and effectiveness of extensive and potentially curative liver resection for hepatocellular carcinoma (HCC)., Methods: We compared clinicopathologic factors, surgical factors, and outcomes of patients who underwent extended hepatectomy (defined as resection of more than two sections) for HCC, before and after the introduction of an ERAS program., Results: Operating times and postoperative hospital stay were significantly shorter, and total volume infused during surgery was significantly lower, for the ERAS group than for the control group. Although the ERAS group had a significantly lower percentage of patients with retention of abdominal drainage, this group had a higher frequency of abdominal paracentesis in patients without intraoperative abdominal drainage. Oral dietary intake and the ability to walk steadily resumed significantly earlier in the ERAS group. Postoperative serum concentrations of albumin and cholinesterase were significantly higher in the ERAS group than in the control group., Conclusions: The ERAS program was feasible and effective for patients with chronic liver disease undergoing extended liver resection for HCC, because it allowed earlier oral dietary intake and promoted faster postoperative recovery.

Backgrounds and Aims: The occurrence of refractory ascites in nearly 17% of patients with decompensated cirrhosis is an unresolved issue. Advanced liver disease, functional renal impairment, and vascular insensitivity to vasopressors are the main causes of its refractoriness. Therefore, the aim of this study was to evaluate the impact on diuresis, weight loss, and short-term survival if midodrine and rifaximin were added to the diuretic therapy (DT)., Materials and Methods: The study evaluated the eligibility of 650 patients with cirrhosis and refractory ascites who were selected during the period from November 2011 to May 2015. A total of 50 patients were excluded and finally 600 were selected and divided into the following groups: patients exposed to DT (n=200) as a control group, or DT with midodrine and rifaximin group (n=400). Body weight, mean arterial pressure, and glomerular filtration rate were determined. Plasma renin and aldosterone were also determined. Follow-up was performed after 2, 6, and 12 weeks, and then every 2 months for 24 months., Results: The mean arterial pressure was significantly higher in the midodrine and rifaximin group (P=0.000), and there was a highly significant weight loss after 12 weeks (12.5 kg) (P=0.000), a highly significant increase in serum sodium, urine output, and urinary sodium excretion (P=0.000), and creatinine clearance was more reduced in the control group. With rifaximin and midodrine, a complete response occurred in 310 (78%) patients, a partial response in 72 (18%), and no response in 18 (4%) versus 30 (15%), 110 (55%), and 60 (30%) in the control group, respectively (P=0.000). Midodrine and rifaximin significantly reduced paracentesis needs when compared with the controls (18 study patients vs. 75 DT-only patients, P=0.000)., Conclusion: Adding rifaximin and midodrine to DT enhanced diuresis in refractory ascites with improved systemic, renal hemodynamics and short-term survival.

Background and Aim: The aim of this study is to assess paracentesis utilization and outcomes in hospitalized adults with cirrhosis and ascites., Methods: The 2011 Nationwide Inpatient Sample was used to identify adults, non-electively admitted with diagnoses of cirrhosis and ascites. The primary endpoint was in-hospital mortality. Variables included patient and hospital demographics, early (Day 0 or 1) or late (Day 2 or later) paracentesis, hepatic decompensation, and spontaneous bacterial peritonitis., Results: Out of 8 023 590 admissions, 31 614 met inclusion criteria. Among these hospitalizations, approximately 51% (16 133) underwent paracentesis. The overall in-hospital mortality rate was 7.6%. There was a significantly increased mortality among patients who did not undergo paracentesis (8.9% vs 6.3%, P < 0.001). Patients who did not receive paracentesis died 1.83 times more often in the hospital than those patients who did receive paracentesis (95% confidence interval 1.66-2.02). Patients undergoing early paracentesis showed a trend towards reduction in mortality (5.5% vs 7.5%) compared with those undergoing late paracentesis. Patients admitted on a weekend demonstrated less frequent use of early paracentesis (50% weekend vs 62% weekday) and demonstrated increased mortality (adjusted odds ratio 1.12 95% confidence interval 1.01-1.25). Among patients diagnosed with spontaneous bacterial peritonitis, early paracentesis was associated with shorter length of stay (7.55 vs 11.45 days, P < 0.001) and decreased hospitalization cost ($61 624 vs $107 484, P < 0.001)., Conclusion: Paracentesis is under-utilized among cirrhotic patients presenting with ascites and is associated with decreased in-hospital mortality. These data support the use of paracentesis as a key inpatient quality measure among hospitalized adults with cirrhosis. Future studies are needed to investigate the barriers to paracentesis use on admission., (© 2015 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Objectives: This study sought to define the competencies in ultrasound knowledge and skills that are essential for medical trainees to master to perform ultrasound-guided central venous catheterization, thoracentesis, and paracentesis., Methods: Experts in the 3 procedures were identified by a snowball technique through 3 Canadian tertiary academic health centers. Experts completed 2 rounds of surveys, including an 88-item central venous catheterization survey, a 96-item thoracentesis survey, and an 89-item paracentesis survey. For each item, experts were asked to determine whether the knowledge/skill described was essential, important, or marginal. Consensus on an item was defined as agreement by at least 80% of the experts. For items on which consensus was not reached during the first round of surveys, a second survey was created in which the experts were asked to rate the item in a binary fashion (essential/important versus marginal/unimportant)., Results: Of the 27 experts invited to complete each survey, 25 (93%) completed the central venous catheterization survey; 22 (81%) completed the thoracentesis survey; and 23 (85%) completed the paracentesis survey. The experts represented 8 specialties from 8 cities within Canada. A total of 22, 32, and 28 items were determined to be essential competencies for central venous catheterization, thoracentesis, and paracentesis, respectively, whereas 47, 38, and 42 competencies were determined to be important, and 8, 13, and 10 were determined to be marginal. The ability to perform real-time direct ultrasound guidance was considered essential only for the performance of central venous catheterization insertion., Conclusions: Our study presents expert consensus-derived ultrasound competencies that should be considered during the design and implementation of procedural skills training for learners.

Objectives: The purpose of this study was to determine the rate of major bleeding complications for ultrasound-guided paracentesis performed in thrombocytopenic patients., Methods: We retrospectively reviewed the electronic medical records of patients with platelet counts of less than 50,000/μL who had ultrasound-guided paracenteses performed in the Department of Radiology without correcting preprocedural platelet transfusions between 2005 and 2011. Medical records were evaluated for evidence of major bleeding complications (grade 3 or higher as defined by the National Institutes of Health's Common Terminology Criteria for Adverse Events, version 4.03) and their clinical sequelae. Platelet count and bleeding complications were evaluated for an association, and a sensitivity analysis was performed to determine whether analysis of a control group of patients without thrombocytopenia would yield added confidence in this assessment., Results: Among 304 procedures in 205 thrombocytopenic patients (69% male; mean age ± SD, 56.6 ± 11.9 years), the mean platelet count was 38,400 ± 9300/μL (range, 9000-49,000/μL). Three major bleeding complications requiring red blood cell transfusion were observed in patients with platelet counts of 41,000 to 46,000/μL, for a complication rate of 0.99% (95% confidence interval, 0.3%-2.9%). No patient required an additional procedure or died because of the bleeding complication. There was no association of platelet count with bleeding complications. The sensitivity analysis showed that further evaluation of patients with normal platelet counts would not add to the conclusion., Conclusions: The risk of major bleeding after ultrasound-guided paracentesis in thrombocytopenic patients is very low. In most patients, routine assessment of the preprocedural serum platelet concentration is not necessary, and correction of such an abnormal laboratory value is not indicated., (© 2015 by the American Institute of Ultrasound in Medicine.)

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The prevalence of advanced liver disease and its complications may be on the rise within the Medicare population. The study aim was trend assessment for prevalence, mortality and resource utilization of patients with advanced liver disease., Methods: A retrospective, cross-sectional design was used to analyze a national sample of non-institutionalized Medicare in/outpatients from 2005 to 2009. Cases were ascertained by International Classification of Diseases, 9th Edition. Outcomes were overall mortality (within 1 year) and resource utilization [hospital length of stay (LOS/days) and institutional costs to Medicare]. Multivariate analyses were used to estimate the odds ratios for mortality predictors; linear regression was used for resource utilization predictors., Results: A total of 21,913 beneficiaries with advanced liver disease were identified in the Medicare inpatient and outpatient administrative data sets from 2005 to 2009. Over 70 % of the beneficiaries with advanced liver disease died during study time period with 17 % dying while hospitalized. Predictors of mortality were: admission to the intensive care unit (ICU) and increasing Charlson Comorbidity Index. Predictors for increased LOS and cost were: ICU admission and having a thoracentesis procedure (both indicators of the levels of illness)., Conclusions: Advanced liver disease and its related complication are increasing in the Medicare population and are associated with very high mortality. Further study is warranted to understand the drivers of the increased prevalence of advanced liver disease for earlier identification and treatment.

The aim of our study is to demonstrate the difficulties of diagnosis of peritoneal tuberculosis in endemic areas and the value of laparoscopy for diagnostic confirmation. We report a retrospective study of 60 cases of peritoneal tuberculosis, collected from January 2004 to December 2009. The patients' median age was 41 years, and the sex ratio 0.4. The dominant reasons for consultation were pain and abdominal distension. Abdominal ultrasound found ascites in all patients. Computed tomography (CT) was performed in 30 patients and confirmed the ultrasound data. Paracentesis of the ascites took place in all patients, collecting exudative fluid in all cases; lymphocytes predominance in 83%. Screening for Mycobacterium tuberculosis in the ascites on direct examination and after culture was performed in 43 cases and negative in all of them. Surgical biopsy was performed laparoscopically in 29 patients and by laparotomy in 31 patients. Histological examination of the peritoneal biopsies confirmed the diagnosis of peritoneal tuberculosis in all cases.

Background: Ascites, the most frequent complication of cirrhosis, is associated with poor prognosis and reduced quality of life. Recurrent hospital admissions are common and often unplanned, resulting in increased use of hospital services., Aims: To examine use of hospital services by patients with cirrhosis and ascites requiring paracentesis, and to investigate factors associated with early unplanned readmission., Methods: A retrospective review of the medical chart and clinical databases was performed for patients who underwent paracentesis between October 2011 and October 2012. Clinical parameters at index admission were compared between patients with and without early unplanned hospital readmissions., Results: The 41 patients requiring paracentesis had 127 hospital admissions, 1164 occupied bed days and 733 medical imaging services. Most admissions (80.3%) were for management of ascites, of which 41.2% were unplanned. Of those eligible, 69.7% were readmitted and 42.4% had an early unplanned readmission. Twelve patients died and nine developed spontaneous bacterial peritonitis. Of those eligible for readmission, more patients died (P = 0.008) and/or developed spontaneous bacterial peritonitis (P = 0.027) if they had an early unplanned readmission during the study period. Markers of liver disease, as well as haemoglobin (P = 0.029), haematocrit (P = 0.024) and previous heavy alcohol use (P = 0.021) at index admission, were associated with early unplanned readmission., Conclusion: Patients with cirrhosis and ascites comprise a small population who account for substantial use of hospital services. Markers of disease severity may identify patients at increased risk of early readmission. Alternative models of care should be considered to reduce unplanned hospital admissions, healthcare costs and pressure on emergency services., (© 2014 The Authors; Internal Medicine Journal © 2014 Royal Australasian College of Physicians.)

Background and Aims: About 10 % of cirrhotic patients are unresponsive to sodium restriction and diuretics and develop refractory ascites. Such patients usually require recurrent large-volume paracentesis and lots of hospital admissions. Hereby, we introduce a method applying a central vein (CV) catheter for large-volume paracentesis in patients with refractory ascites in up to 4 days associated with sodium restriction and high dose of diuretics., Methods: Non-tunneled triple lumen CV catheter was used to drain the ascites fluid of 30 cirrhotic patients. After precise percussion, the point of highest fluid accumulation was marked for puncture. Then, the skin and subcutaneous tissue were anesthetized. CV catheter set guide wire was entered into the peritoneal cavity and the dilator of the CV catheter set was passed through the guide wire and extracted after some rotations around its insertion site on the skin. The catheter was passed over the guide wire and the guide wire was extracted gradually from one of the lumens and fixed to the skin., Results: Nineteen males and 11 females with mean (±SD) age of 59.4 ± 11.7 years old underwent the procedure. A minimum of 9 and maximum of 29 L (12 ± 6.6 L) ascites fluid drained during a minimum of 2 and maximum of 5 days of hospital stay. All catheters were patent during the drainage. None of the patients developed hemodynamic instability. Number of re-hospitalizations for paracentesis was 1.9 times during the following year. No complication occurred., Conclusions: This technique is a simple noninvasive method that can be performed in the endoscopy unit or even at the patient's bedside and may reduce the need for repeated admissions.

Background & Aims: Diagnostic paracentesis is recommended for patients with cirrhosis who are admitted to the hospital for ascites or encephalopathy. However, it is not known whether clinicians in the United States adhere to this recommendation; a relationship between paracentesis and clinical outcome has not been reported. We analyzed a U.S. database to determine the frequency of paracentesis and its association with mortality., Methods: The 2009 Nationwide Inpatient Sample (which contains data from approximately 8 million hospital discharges each year) was used to identify patients with cirrhosis and ascites who were admitted with a primary diagnosis of ascites or encephalopathy. In-hospital mortality, length of stay, and hospital charges were compared for those who did and did not undergo paracentesis. Outcomes were compared for those who received an early paracentesis (within 1 day of admission) and those who received one later., Results: Of 17,711 eligible admissions, only 61% underwent paracentesis. In-hospital mortality was reduced by 24% among patients who underwent paracentesis (6.5% vs 8.5%; adjusted odds ratio, 0.55; 95% confidence interval, 0.41-0.74). Most paracenteses (66%) occurred ≤1 day after admission. In-hospital mortality was lower among patients who received early paracentesis than those who received it later (5.7% vs 8.1%, P = .049), although this difference was not significant after adjustment for confounders (odds ratio, 1.26; 95% confidence interval, 0.78-2.02). Among patients who underwent paracentesis, the mean hospital stay was 14% longer and hospital charges were 29% greater than for patients who did not receive the procedure., Conclusions: Paracentesis is underused for patients admitted to the hospital with ascites; the procedure is associated with increased short-term survival. These data support practice guidelines derived from expert opinion. Studies are needed to identify barriers to guideline adherence., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: Bedside sonography for diagnosis of pneumothorax has been well described in emergency and trauma medicine literature. Its role in detection of iatrogenic pneumothorax has not been well studied. We describe the performance of bedside sonography for detection of procedure-related pneumothorax and highlight some limitations., Methods: A total of 185 patients underwent thoracentesis (n = 60), transbronchial biopsy (n = 48), and computed tomography-guided needle lung biopsy (n = 77). Bedside preprocedure and postprocedure transthoracic sonography and postprocedure chest radiograph were performed in all patients. Patients in whom the pleural surface was not well imaged with sonography were said to have a limited examination. Chest radiography was the standard for diagnosing pneumothorax., Results: Chest radiography showed pneumothorax in 8 of 185 patients (4.0%). These patients had undergone computed tomography-guided needle lung biopsy (n = 7) and transbronchial needle lung biopsy (n = 1). Sonography showed pneumothorax in 7 of these patients. The sensitivity, specificity, and diagnostic accuracy were 88%, 97%, and 97%, respectively. Limited-quality sonographic examinations due to preexisting lung disease were seen in 43 of 185 patients. The positive and negative likelihood ratios for patients with adequate scans were 55 and 0.17, respectively. The likelihood ratio for patients with limited-quality scans was 1.08., Conclusions: When a good-quality scan is achieved, bedside chest sonography is a valuable tool for evaluation of postprocedure pneumothorax. Patients with preexisting lung disease, in whom the quality of the sonographic examination is limited, should be studied with chest radiography.

Pleural effusion is a common medical condition encountered by doctors. This study was conducted to ascertain the level of junior doctor (physician-in-training) training, knowledge and supervision in the management of pleural effusion. The information was collected with the help of a proforma, from 49 junior medical doctors working in a metropolitan health service. All the doctors who participated in the survey had come across pleural effusion in their practice, but only 67% of doctors had any experience with the procedure of diagnostic thoracentesis. Sixty-seven percent of doctors conveyed that they will refer the majority of cases (75-100%) for radiological-guided thoracentesis. The main reasons for referral for radiologically guided procedure were lack of experience (65%), fear of complications (61%), lack of supervision and guidance (49%), and lack of time (38%). A significant proportion of doctors interviewed (47%) was unaware of the major indications for intercostal tube drainage of parapneumonic effusions. This survey highlights deficiencies in junior doctor knowledge and procedural skills. Junior doctor training should be tailored to increase the 'hands-on' training time and increased patient contact. Senior clinicians should be given sufficient 'protected time' for teaching and training., (© 2013 The Authors; Internal Medicine Journal © 2013 Royal Australasian College of Physicians.)

Objectives: To document the practice and training opportunities of US-guided arthrocentesis and joint injection (UGAJ) among rheumatologists in the member countries of the European League Against Rheumatism (EULAR)., Methods: An English-language questionnaire, containing questions on demographics, clinical and practical aspects of UGAJ, training options in UGAJ for rheumatologists, UGAJ education in the rheumatology training curriculum and other structured education programmes in UGAJ was sent to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB); and (iii) 22 senior rheumatologists involved in EULAR musculoskeletal US training from 14 European countries, who were also asked to circulate the questionnaire among relevant colleagues., Results: Thirty-three (75%) of 44 countries responded to the questionnaire (61.3% of national rheumatology societies, 25% of the national US societies and 100% of expert ultrasonographers). In the majority of countries (85%) <10% of rheumatologists routinely perform UGAJ in clinical practice, while the remaining countries (15%) reported a rate of 10-50%. The percentage of rheumatologists receiving training in UGAJ was <10% in the majority (72.7%) of countries., Conclusion: The study highlights the relatively low prevalence of UGAJ as compared with the high (>80%) rate of rheumatologists performing conventional joint injection in most of the surveyed countries. The reported variations in practice and the lack of available structured training programmes for trainees in most countries indicates the need for standardization in areas including training guidelines.

Purpose: The aim of this study was to evaluate national trends in paracentesis and thoracentesis procedures and the relative roles of specialty groups providing these services., Methods: Medicare Physician Supplier Procedure Summary Master Files from 1993 to 2008 were analyzed for paracentesis and thoracentesis procedure codes. Using physician specialty identifier codes, procedure volumes were extracted for radiologists, primary care physicians, and surgeons for both procedures. Volume data were extracted for gastroenterologists and pulmonary and critical care medicine physicians, respectively, for paracentesis and thoracentesis. Frequency by site of service was similarly evaluated. Relative changes were calculated., Results: Between 1993 and 2008, paracentesis procedures on Medicare fee-for-service beneficiaries increased by 133% (from 64,371 to 149,699), and thoracentesis procedures decreased by 14% (from 147,363 to 127,444). Services by radiologists increased by 964% (from 10,456 to 111,275) and 358% (from 14,531 to 66,602), respectively, while all other targeted groups experienced declines. For paracentesis, radiologist and gastroenterologist procedure shares changed from 16% and 32%, respectively, in 1993 to 74% and 6% in 2008. For thoracentesis, radiologist and pulmonary and critical care medicine physician shares changed from 10% and 49% to 52% and 27%. Relative shifts in site of service to the hospital outpatient setting occurred for both procedures., Conclusions: Since 1993, paracentesis procedures on Medicare beneficiaries have more than doubled, while thoracentesis volumes have declined slightly. Radiologists now far exceed gastroenterologists and pulmonary and critical care medicine physicians, respectively, as the predominant providers of these services. Those shifts are likely attributable to both the incremental safety of imaging guidance and also the unfavorable economics of these procedures., (Copyright © 2010 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Intravitreal injections may lead to a significant elevation of the intraocular pressure (IOP). A paracentesis may become necessary for acute reduction of the IOP in certain cases. The purpose of this study was to determine the frequency of paracentesis performed and the grade of reflux under the conjunctiva after injection of 0.1 ml bevacizumab (1.25 mg), depending on the thickness of the needles used., Methods: A retrospective review was undertaken of the surgery reports of 234 consecutive intravitreal bevacizumab injections in 145 eyes of 144 patients within 14 months. In particular, the frequency of paracentesis, the thickness of the needles used (27-gauge versus 30-gauge), the lens status, and a semi-quantitative reflux grade were analysed., Results: A paracentesis was performed in 78 cases (33%) for acute reduction of the IOP. In the 27-gauge group the frequency was 26% (25 of 96), and in the 30-gauge group 38% (53 of 138) (p = 0.05, independent estimating equation (IEE)). The medians of the semi-quantitative assessment of the reflux grade under the conjunctiva were 2.0 in the 27-gauge group (corresponding to a mild reflux) and 1.0 in the 30-gauge group (corresponding to a minimal reflux, p < 0.001, IEE)., Conclusions: When using a 30-gauge needle for intravitreal injections, the reflux under the conjunctiva was less than with a 27-gauge needle. However, the use of a 30-gauge needle appeared to be associated with a higher frequency of paracentesis.

Internal medicine physicians have long been trained with the skills, knowledge, and attitudes to become proficient at certain medical procedures. Specifically, the lumbar puncture, paracentesis, thoracentesis, and central venous catheter placement are common medical procedures encountered during residency. Despite recent changes that no longer require documented competency in procedure performance, many residents and their attending supervisors continue to perform these procedures on a regular basis. In private practice many internists care for patients requiring these procedures. This review will summarize basic steps followed in these 4 medical procedures and highlight methods to minimize associated complications.

Background: Procedure services may improve the training of bedside procedures. However, little is known about how procedure services may affect the demand for and success of procedures performed on general medicine inpatients., Objective: Determine whether a procedure service affects the number and success of 4 bedside procedures (paracentesis, thoracentesis, lumbar puncture, and central venous catheterization) attempted on general medicine inpatients., Design: Prospective cohort study., Setting: Large public teaching hospital., Patients: Nineteen hundred and forty-one consecutive admissions to the general medicine service., Intervention: A bedside procedure service was offered to physicians from 1 of 3 firms for 4 weeks. This service then crossed over to physicians from the other 2 firms for another 4 weeks., Measurements: Data on all procedure attempts were collected daily from physicians. We examined whether the number of attempts and the proportion of successful attempts differed based on whether firms were offered the beside procedure service., Results: The number of procedure attempts was 48% higher in firms offered the service (90 versus 61 per 1000 admissions; RR 1.48, 95% CI 1.06-2.10; P = .030). More than 85% of the observed increase was a result of procedures with therapeutic indications. There were no differences between firms in the proportions of successful attempts or major complications., Conclusions: The availability of a procedure service may increase the overall demand for bedside procedures. Further studies should refine the indications for and anticipated benefits from these commonly performed invasive procedures., ((c) 2007 Society of Hospital Medicine.)

Refractory ascites is a serious complication of advanced cirrhosis with a 1-year transplant-free survival of 20-50%. The aim of our study was to investigate the short- and long-term effects of transjugular intrahepatic portosystemic shunt (TIPS) in the management of refractory ascites. In all 65 patients (39 M, 26 F; Child B 55%, Child C 45%, mean MELD score 14.8 +/- 6.6) with liver disease (alcoholic 40%, cryptogenic 20%, HCV 14%, others 26%) and refractory ascites were included in this study. Forty-eight (74%) patients had no signs of hepatic encephalopathy (HE), 16 (24%) had mild and 1 (2%) had moderate HE before TIPS; 28 (43%) had mild (> 1.2 and < 2.4 mg/dl) and 6 patients (9%) had moderate (> 2.4 mg/dl) renal dysfunction. Mean follow-up was 55.5 +/- 70.2 weeks. Treatment success, defined as complete response, partial response, and no response, and survival was determined at 3 weeks, and 3, 6, 12, 24, and 36 months after TIPS. TIPS was successful in all patients. Mean portal venous pressure gradient improved significantly after TIPS (24 +/- 8 to 10 +/- 4). During follow-up, 40 (58%) patients died and 17 (27%) patients had liver transplantation (OLT); 20 (31%) patients had 38 shunt revisions due to lack of initial response or recurrence of ascites. The response was assessed in patients who were alive, without OLT, at each time point. Complete response was seen in 10%, 23%, 17%, 11%, 22% and 33%; partial response was seen in 46%, 46%, 40%, 44%, 28%, and 8%; and no response was seen in 44%, 31%, 43%, 41 %, 39%, and 50% at 3 weeks, and 3, 6, 12, 24, and 36 months respectively. There were no pre-TIPS variables that could predict the response at 3 weeks, 3 months, or 6 months. Mild HE was seen in 8 (12%) patients and severe HE was seen in 16 (25%) immediately after TIPS. The mortality at 3 weeks, and 3, 6, 12, 24, and 36 months was 26%, 38%, 46%, 51%, 57%, and 58%, respectively. Three-week (P = 0.01) and 3-month (P = 0.04) mortality was higher in Child C patients compared to Child B. However, there were no independent predictors of survival on multivariate analysis at 3 or 6 months. Child-Pugh score 3 weeks after TIPS was a strong predictor of mortality. In conclusion, in patients with refractory ascites, TIPS was associated with a high mortality and morbidity. The response and the mortality were both unpredictable on the basis of pretransplant variables.

Background: Eosinophilic pleural effusion (EPE) is a relatively rare clinical condition. Repeated thoracenteses (RTs) are normally considered a frequent cause of EPE. Yet, to our knowledge, there is no firm evidence (apart from anecdotal case reports) supporting such a statement., Objective: To investigate potential relationships between the number, type (with or without pleural biopsy) and time elapsed between RTs and the number of eosinophils present in pleural fluid samples., Methods: We reviewed retrospectively 273 pleural fluid samples belonging to 120 patients (79 males, 41 females), attended in our institution from 1992 to 2000, whose clinical management had required RTs. Apart from the anthropometric and clinical data of each patient, we included the following variables in the analysis: number of thoracenteses performed in each individual, number of pleural biopsies carried out at each thoracentesis and time between consecutive thoracenteses. We also recorded the total (and differential) leukocyte count, red blood cell count, as well as the main biochemical, microbiological and histological data of both the pleural fluid and peripheral blood samples., Results: We did not observe any significant change in the percentage of eosinophils in relation to the number of thoracenteses performed per patient. This lack of relationship was also observed in the subgroup of patients who required one (or more) pleural biopsies (n = 111) (regardless of the number of biopsies). Our results suggest that RTs are not an important risk factor for the development of EPE, regardless of the time elapsed between two thoracenteses., Conclusion: We believe, therefore, that multiple punctures should not longer be considered a prevalent cause of pleural eosinophilia., (Copyright 2003 S. Karger AG, Basel)

Objective: Study of the complications occurring during the weak after carrying out evacuatory paracentesis at home. To assess the viability of using this technique in primary care (PC)., Design: A retrospective observation study., Setting: Home Hospital Unit of the Marqués de Valdecilla University Hospital (Santander)., Patients and Other Participants: 14 patients with chronic hepatopathy or cirrhosis admitted to our unit between 1984 and 1994 and who required evacuatory paracentesis to control their ascites., Measurements and Main Results: Only in 17 of the 90 paracentesis performed was there any kind of complication: 12 cases of high digestive haemorrhage, 10 of hepatic encephalopathy, 3 of spontaneous bacterial peritonitis and 2 acute renal failures. There were no complications in 81.11% (73). We found no significant differences between creatinine and sodium in blood pre-paracentesis (1.60 +/- 0.65 mg/dl and 133.07 +/- 4.47 mEq/ml) and post-paracentesis (1.79 +/- 0.83 mg/dl and 132 +/- 4.57 mEq/ml)., Conclusions: Evacuatory paracentesis is a safe and simple procedure that can be performed in the home and could be assumed by primary-care teams as a part of their scheduled home visits.

During the XXII Congress of the Spanish Association for the Study of the Liver a questionnaire was distributed with the aim of describing the current therapeutic attitude of those attending the meeting, concerning two of the most frequent complications of cirrhosis: ascites and spontaneous bacterial peritonitis (SBP). One hundred twelve of the 135 physicians who answered the questionnaire (83%) use to treat tense ascites by therapeutic paracentesis, while 86 physicians (63.7%) managed moderate ascites with diuretics, with spironolactone being the drug most commonly used (n = 117; 87.3%). The most used diuretic schedule for the treatment of ascites was the isolated administration of spironolactone. Frusemide was associated with spironolactone only when moderate or high doses of the latter were found to be insufficient for increasing urinary sodium excretion and eliminating ascites. Following therapeutic paracentesis however, 79 of those surveyed (58.3%) administered a combination of both diuretics on initiation to avoid reaccumulation of ascitic fluid. Sixty-eight of the physicians (50.3%) used transhepatic intrajugular portosystemic shunt in the treatment of refractory ascites. Cefotaxime was the antibiotic most widely used in the treatment of SBP (n = 119; 88%). Most of the physicians surveyed performed prophylaxis of this infection (generally by the oral administration of norfloxacin) in patients with a previous history of SBP (n = 125; 92.6%) or an episode of gastrointestinal hemorrhage (n = 108; 80%) but not in those patients with no previous history of SBP and with low protein concentrations in the ascitic fluid (n = 40; 29.6%). On the appearance of SBP in patients undergoing prophylactic treatment, cefotaxime remained the antibiotic of choice (n = 104; 79%).