Intrathecal catheterisation after observed accidental dural puncture in labouring women: update of a meta-analysis and a trial-sequential analysis

BackgroundOur meta-analysis from 2013 showed that inserting a catheter intrathecally after an observed accidental dural puncture can reduce the need for epidural blood patch in labouring women requesting epidural analgesia. We updated our conventional meta-analysis and added a trial-sequential analysis (TSA).MethodsA systematic literature search was conducted to identify studies that compared inserting the catheter intrathecally with an epidural catheter re-site or with no intervention. The extracted data were pooled and the risk ratio (RR) and 95% confidence interval (95%CI) for the incidence of post-dural puncture headache (PDPH) was calculated, using the random effects model. A contour-enhanced funnel plot was constructed. A TSA was performed and the cumulative Z score, monitoring and futility boundaries were constructed.ResultsOur search identified 13 studies, reporting on 1653 patients, with a low risk of bias. The RR for the incidence of PDPH was 0.82 (95%CI 0.71 to 0.95) and the RR for the need for epidural blood patch was 0.62 (95%CI 0.49 to 0.79); heterogeneity of both analyses was high. The TSA showed that the monitoring or futility boundaries were not crossed, indicating insufficient data to exclude a type I error of statistical analysis. Contour-enhanced funnel plots were symmetric, suggesting no publication bias.ConclusionsConventional meta-analyses showed for the first time that intrathecal catheterisation can reduce the incidence of PDPH. However, TSA did not corroborate this finding. Despite increasing use in clinical practice there is no firm evidence on which to base a definite conclusion.     

Dural puncture epidural versus conventional epidural block for labor analgesia: a systematic review of randomized controlled trials

IntroductionDural puncture epidural (DPE) analgesia is a modification of conventional epidural analgesia that involves the intentional puncture of the dura with a spinal needle through the needle placed in the epidural space, without a medication being injected intrathecally. There have been contradictory findings regarding better analgesia and better block quality.MethodsA systematic literature search was done to identify randomized controlled trials (RCT) comparing DPE with epidural analgesia. The risk of bias was assessed with the Cochrane tool. Risk ratio and 95% confidence intervals were calculated.ResultsFive RCTs including 581 patients were identified. One RCT on caesarean section was excluded. Single studies suggested slightly better analgesia by finding a median time to achieve sufficient analgesia of two minutes less in the DPE group, a higher number of women having a pain score <10/100 at 20 min, a reduction in the number of epidural top-ups and better sacral spread. The studies did not show a difference between DPE and epidural analgesia for catheter replacement or manipulation rates, the incidence of intravascular placement or unilateral block.ConclusionThere is a lack of clear evidence on either the benefits or the risks of the DPE technique, such that a recommendation for or against its routine use is premature. Two of the three studies showing a beneficial effect of DPE came from the same institution and replication of the findings by other groups is warranted.     

腰椎穿刺术后头痛与卧床时间的关系

目的探讨腰椎穿刺术后平卧时间30min、2h对头痛的影响。方法对794例具有腰椎穿刺术适应证而无禁忌证并排除有关因素的患者，随机分为30min组、2h组。分别观察术后头痛发生率。结果30min组头痛发生率为（8／460）1．74％，2h组为（7／334）2.10％，两组组间比较均无显著性差异（P〉0．05）。结论本研究说明腰穿后卧床时间长短（30min～2h），对腰穿后头痛的发生率无影响，可缩短至30min，没有必要卧床2h，更没有必要卧床4～6h。     

自发性气胸的临床特点与治疗对策

目的通过对多种自发性气胸的临床表现采用不同的治疗方法,达到治愈。方法根据不同临床表现及气胸压缩程度采取人工抽气、闭式引流术、胸膜粘连术等检测效果。结论96例病人中治愈90例,说明采用适用的方法可有效地治疗自发性气胸。     

带手套穿刺对留置套管针一次成功率的影响

为探讨戴手套与不戴手套穿刺对留置静脉套管针一次成功率的影响 ,为护理人员的自身防护提供科学依据 ,选取冠状动脉搭桥术病人 12 0例 ,随机分为实验组和对照组 ,实验组采用戴手套穿刺法 ,对照组采用常规洗手后不戴手套穿刺法。结果两组一次穿刺成功率经χ2 检验 ,无统计学意义( χ2 =0 .5 6 3,P >0 .0 5 )。说明戴手套留置套管针并不影响一次穿刺成功率。     

Large colloid cyst in lateral ventricle simulating brain tumour

Summary This case report describes a patient presenting with symptoms of increased intracranial pressure, whose computerized tomographic (CT) scan was highly suggestive of a large low-grade glioma invading the basal ganglia. Magnetic resonance imaging (MRI) revealed a well-demarcated space-occupying mass of increased intensity in the left lateral ventricle and adjacent white matter. Following stereotactic biopsy, which yielded a homogeneous jelly-like material, the mass was removed microsurgically and was found to be most like a colloid cyst on histological examination. Discussion focusses on the clinical and differential diagnostic implications of this very unusual combination of findings.     

腹腔镜卵巢穿刺内凝治疗多囊卵巢不孕症的临床研究

目的探讨腹腔镜卵巢穿刺内凝对多囊卵巢不孕症的治疗价值。方法１５１例腹腔镜卵巢穿刺内凝术（实验组）和１５１例开腹卵巢楔切术（对照组）治疗多囊卵巢不孕症配对对比研究。结果实验组的手术时间３３．１±７．２ｍｉｎ，术中失血１５．６±４．７ｍｌ，总排卵率９２．０５％，总妊娠率４９．６７％，均优于对照组（Ｐ＜０．０１）；术后雄激素、ＬＨ／ＦＳＨ下降幅度小于对照组（Ｐ＜０．０１）。随时间推移，两组术后排卵巢、妊娠率均有下降倾向，而术后雄激素、ＬＨ／ＦＳＨ则有逐渐回升的倾向。结论腹腔镜卵巢穿刺内凝术对多囊卵巢不孕症有较好的治疗效果     

Incidence of post-lumbar puncture syndrome reduced by reinserting the stylet: a randomized prospective study of 600 patients

The post-lumbar puncture syndrome (PLPS) can best be explained by prolonged spinal fluid leakage owing to delayed closure of a dural defect. Its incidence after spinal anaesthesia is much lower than after diagnostic lumbar puncture (LP). This difference could be caused by a strand of arachnoid, which might enter the needle with the outflowing cerebrospinal fluid (CSF) during diagnostic LP and upon removal of the needle be threaded back through the dura to produce prolonged CSF leakage. To find a technique that further reduces the incidence of PLPS, this hypothesis was tested by evaluating the effect that reinserting the stylet before removing the needle had on the incidence of PLPS. By reinserting the stylet to the tip of the needle, the hypothesized strand would be pushed out, thereby reducing the frequency of PLPS. Sprotte’s “atraumatic needle” (21 gauge) was used for LP. A total of 600 patients participated in the prospective study. They were randomized into two groups and questioned about their complaints every day for up to 7 days after the LP. All LPs were performed by two experienced neurologists (T.B., M.S.). In 300 patients, the stylet was reinserted to the tip of the needle; in the other 300 it was not reinserted. Whereas 49 of the 300 patients without reinsertion developed PLPS, only 15 of the 300 patients with reinsertion did. This significant difference (16.3 vs 5.0%, P < 0.005, chi square test) supports our hypothesis. On the basis of our results, we recommend reinserting the stylet before removing the needle in order to reduce the incidence of PLPS. Received: 30 September 1997 Received in revised form: 9 March 1998 Accepted: 20 March 1998     

Lumbar Puncture Ordering and Results in the Pediatric Population: A Promising Data Source for Surveillance Systems

Background: The Centers for Disease Control and Prevention is incorporating laboratory data into real-time surveillance systems. When normal patterns of laboratory test orders and results are modeled, aberrations can be detected. Because many test orders are available electronically well before results, atypical patterns of test ordering may signal outbreaks.
Objectives: The authors sought to characterize baseline patterns in the ordering and early results of lumbar punctures, motivated by the possibility of using these data for real-time surveillance for early detection of meningitis or encephalitis outbreaks.
Methods: Retrospective cohorts of pediatric emergency department patients at a single hospital (1993–2003) and from the National Hospital and Ambulatory Medical Care Survey (1992–2000) were used for analysis.
Results: Test ordering exhibits seasonal patterns, with monthly peaks in January and August (p < 0.0001). For the hospital cohort, the rate of cerebrospinal fluid pleocytosis exhibits seasonal patterns (p < 0.0001), with a peak from August to October. This is strongly associated with the rate and pattern of clinical neurologic disease (p < 0.0001). A long-term secular decline in daily test ordering is evident, dropping from 5.3 to 2.9 in the hospital sample, and from 371.8 to 185.3 in the national sample (p < 0.001). The long-term rate of pleocytosis has declined (p < 0.0001), though the yield of testing for pleocytosis has improved (p = 0.0104).
Conclusions: Laboratory test patterns correspond with those of clinical disease and are a promising source of surveillance data. Using such data for real-time monitoring requires specific adjustments for patient age, periodicities, and secular trends.     

经皮肾穿气压弹道碎石联合体外冲击波碎石治疗上尿路结石

目的 探讨提高上尿路结石碎石成功率的微创治疗方法。方法 采用经皮肾穿微造瘘输尿管镜气压弹道碎石，术中放置双J管，术后配合体外冲击波碎石术(ESWL)治疗上尿路结石48例。结果 结石总排净率为89．1％，结石最小排净率79．2％，无严重并发症发生。结论 该方法结石排净率高，创伤较小，手术并发症少，是上尿路结石较为理想的微创治疗方法。