Control and Performance Characteristics of Eight Different Suction Biopsy Devices

Comparison of fine-needle aspiration techniques

BACKGROUND

Fine-needle aspiration (FNA) has been reported since 1912 beginning with the use of trocars and other specialized instruments that were impractical. Since then, FNA has proven to be a successful alternative technique to excisional biopsy for some assays despite a few limitations.

METHODS

In this study, we compared four different techniques for FNA in rhesus macaques by evaluating total live cells recovered and cell viability using a standard 6 mL syringe and 1.5-inch 22-gauge needle.

RESULTS

Technique B which was the only technique in which the needle was removed from the syringe after collection of the sample to allow forced air through the needle to expel the contents into media followed by flushing of the syringe and needle resulted in the highest total cell count and second highest cell viability in recovered cells.

CONCLUSION

Based on our results, Technique B appears to be the superior method.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Aspiration in injections: should we continue or abandon the practice?

Aspiration during any kind of injection is meant to ensure that the needle tip is at the desired location during this blind procedure. While aspiration appears to be a simple procedure, it has generated a lot of controversy concerning the perceived benefits and indications. Advocates and opponents of aspiration both make logically sound claims. However, due to scarcity of available data, there is no evidence that this procedure is truly beneficial or unwarranted. Keeping in view the huge number of injections given worldwide, it is important that we draw attention to key questions regarding aspiration that, up till now, remain unanswered. In this review, we have attempted to gather and present literature on aspiration both from published and non-published sources in order to provide not only an exhaustive review of the subject, but also a starting point for further studies on more specific areas requiring clarification. A literature review was conducted using the US National Institute of Health’s PubMed service (including Medline), Google Scholar and Scopus. Guidelines provided by the World Health Organization, Safe Injection Global Network, International Council of Nursing, Center for Disease Control, US Federal Drug Agency, UK National Health Services, British Medical Association, Europe Nursing and Midwifery Council, Public Health Agency Canada, Pakistan Medical Association and International Organization of Standardization recommendations 7886 parts 1-4 for sterile hypodermics were reviewed for relevant information. In addition, curricula of several medical/nursing schools from India, Nigeria and Pakistan, the US pharmacopeia Data from the WHO Program for International Drug Monitoring network in regard to adverse events as a result of not aspirating prior to injection delivery were reviewed. Curricula of selected major medical/nursing schools in India, Nigeria and Pakistan, national therapeutic formularies, product inserts of most commonly used drugs and other possible sources of information regarding aspiration and injections were consulted as well.

Integrated Device for in Vivo Fine Needle Aspiration Biopsy and Elastic Scattering Spectroscopy in Preoperative Thyroid Nodules

Thyroid nodules are a frequent clinical finding and the most common endocrine malignancy is thyroid cancer. The standard of care in the management of a patient with a thyroid nodule is to perform a preoperative fine needle aspiration (FNA) biopsy of the suspect nodule under ultrasound imaging guidance. In a significant percentage of the cases, cytological assessment of the biopsy material yields indeterminate results, the consequence of which is diagnostic thyroidectomy. Unfortunately, 75–80% of diagnostic thyroidectomies following indeterminate cytology result in benign designation by post-surgery histopathology, indicating potentially unnecessary surgeries. Clearly, the potential exists for the improvement in patient care and the reduction of overall procedure costs if an improved preoperative diagnostic technique was developed. Elastic scattering spectroscopy (ESS) is an optical biopsy technique that is mediated by optical fiber probes and has been shown to be effective in differentiating benign from malignant thyroid tissue in ex vivo surgical tissue samples. The goal of the current research was to integrate the ESS fiber optic probes into a device that can also collect cells for cytological assessment and, thus, enable concurrent spectroscopic interrogation and biopsy of a suspect nodule with a single needle penetration. The primary challenges to designing the device included miniaturizing the standard ESS fiber optic probe to fit within an FNA needle and maintaining the needle’s aspiration functionality. We demonstrate the value of the fabricated prototype devices by assessing their preliminary performance in an on-going clinical study with >120 patients. The devices have proven to be clinically friendly, collecting both aspirated cells and optical data from the same location in thyroid nodules and with minimal disruption of clinical procedure. In the future, such integrated devices could be used to complement FNA-based cytological results and have the potential to both reduce the number of diagnostic thyroidectomies on benign nodules and improve the surgical approach for patients with thyroid malignancies, thereby, decreasing healthcare costs and improving patient outcomes.

Outcomes and cost-effectiveness of carpal tunnel injections using sonographic needle guidance

This randomized controlled study addressed whether sonographic needle guidance affected the outcomes of corticosteroid injection for symptomatic carpal tunnel syndrome. Seventy-seven symptomatic carpal tunnels were randomized to injection by either (1) conventional anatomic landmark palpation-guided injection or (2) sonographic image-guided injection, each using a two-step technique where 3 ml of 1% lidocaine was first injected to hydrodissect and hydrodisplace critical intra-carpal tunnel structures followed by injection with 80 mg of triamcinolone acetonide (2 ml). Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, total cost, and cost per responder were determined. There were no complications in either treatment group. Relative to conventional anatomic landmark palpation-guided methods, sonographic guidance for injection of the carpal tunnel resulted in 77.1% reduction in injection pain (p<0.01), a 63.3% reduction in pain scores at outcome (p<0.014), 93.5% increase in the responder rate (p<0.001), 84.6% reduction in the non-responder rate (p<0.001), a 71.0% increase in therapeutic duration (p<0.001), and a 59.3% ($150) reduction in cost/responder/year for a hospital outpatient (p<0.001). However, despite improved outcomes, cost per patient per year was significantly increased for an outpatient in a physician's office and was neutral for a hospital outpatient. Sonographic needle guidance significantly improves the performance and clinical outcomes of injection of the carpal tunnel and is cost-effective for a hospital-based practice, but based on current reimbursements, it significantly increases overall costs for medical care delivered in a non-hospital-based physician practice.

Autoaspiration versus manual aspiration in transbronchial needle aspiration in diagnosis of intrathoracic lymphadenopathy

BACKGROUND

Traditionally, aspiration with high negative pressure is recommended to obtain a specimen in transbronchial needle aspiration (TBNA). Undeniably, however, the assistant experiences difficulty in the generation of the negative pressure and precise control of the syringe while performing the procedure.

OBJECTIVE

To evaluate the effectiveness of the autoaspiration method created by our plunger lock in comparison with the conventional manual aspiration in the diagnosis of intrathoracic lymphadenopathy by TBNA.

METHODS

A prospective study was conducted on all patients referred for diagnostic TBNA of enlarged intrathoracic lymph nodes. Both automatic and manual aspiration techniques were performed after the needle had been completely inserted into the nodes. The diagnostic yield and the numbers of diagnostic cells or benign lymphoid cells obtained by each technique were compared in the same node.

RESULTS

A total of 31 intrathoracic lymph nodes in 24 patients were prospectively studied. Twenty-four nodes (77.4%) were malignancies whereas 7 nodes (22.6%) were benign disease. Adequate lymph node samples were obtained in 30 targets (96.8%), and TBNA revealed definite diagnosis for 25 nodes (80.6%). Both aspiration techniques showed exactly the same diagnostic yield. However, the autoaspiration technique provided significantly more adequate samples than manual aspiration techniques did (P=0.003).

CONCLUSION

The autoaspiration method using our plunger lock was superior to the manual method in obtaining the numbers of adequate samples in TBNA procedures.

New device technologies for subcutaneous fat biopsy

PURPOSE

Subcutaneous fat biopsy is useful for the evaluation of amyloidosis, environmental contaminants, lipid metabolism, genetic studies and diabetes research. The present study examined new technologies for fat biopsy.

METHODS

Subcutaneous fat biopsy in 10 high-risk individuals was randomized to (i) a 10 ml reciprocating procedure device (RPD) mechanical syringe or (ii) a 60 ml vacuum syringe. Outcome measures included pain by the 10 cm Visual Analogue Pain Scale (VAS), adequacy of biopsied tissue, complications and diagnosis. The operator's ability to control syringes was quantitatively measured by the linear displacement method.

RESULTS

Both syringes permitted facile aspiration of subcutaneous fat with adequate sample without complications. The mechanical and the vacuum syringes enhanced control of the needle compared to conventional syringes, reducing unintended forward penetration by 75% (3.6 ± 0.5 mm) and 87% (12.0 ± 1.4 mm), respectively (p < 0.0001). Free adipose cells were obtained in abundance as well as columnar biopsies containing intact blood vessels and connective tissue septa permitting precise microhistological examination. One case of primary AL amyloidosis (κ light chain disease) was diagnosed in each group.

CONCLUSIONS

Subcutaneous fat biopsy by needle aspiration can be facilely achieved with new aspiration syringe technologies with improved needle control and enhanced patient safety.

A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee

OBJECTIVE

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee.

METHODS

Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

RESULTS

Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001).

CONCLUSIONS

Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.

Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?

OBJECTIVE

The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance.

METHODS

Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks.

RESULTS

Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 ± 3.0 cm, US-guided: 3.0 ± 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 ± 10 mL, US-guided: 34 ± 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 ± 2.4 cm, US-guided: 1.5 ± 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures.

CONCLUSIONS

US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.

Safety syringes and anti-needlestick devices in orthopaedic surgery

BACKGROUND

The American Academy of Orthopaedic Surgery (AAOS), The Joint Commission, the Occupational Safety and Health Administration (OSHA), and the Needlestick Safety and Prevention Act encourage the integration of safety-engineered devices to prevent needlestick injuries to health-care workers and patients. We hypothesized that safety syringes and needles could be used in outpatient orthopaedic injection and aspiration procedures.

METHODS

The study investigated the orthopaedic uses and procedural idiosyncrasies of safety-engineered devices, including (1) four safety needles (Eclipse, SafetyGlide, SurGuard, and Magellan), (2) a mechanical safety syringe (RPD), (3) two automatic retractable syringes (Integra, VanishPoint), (4) three manual retractable syringes (Procedur-SF, Baksnap, Invirosnap), and (5) three shielded syringes (Safety-Lok, Monoject, and Digitally Activated Shielded [DAS] Syringe). The devices were first tested ex vivo, and then 1300 devices were used for 425 subjects undergoing outpatient arthrocentesis, intra-articular injections, local anesthesia, aspiration biopsy, and ultrasound-guided procedures.

RESULTS

During the clinical observation, there were no accidental needlesticks (0 needlesticks per 1300 devices). Safety needles could be successfully used on a Luer syringe but were limited to ≤1.5 in (≤3.81 cm) in length and the shield could interfere with sonography. The mechanical safety syringes functioned well in all orthopaedic procedures. Automatic retractable syringes were too small for arthrocentesis of the knee, and the plunger blew out and prematurely collapsed with high-pressure injections. The manual retractable syringes and shielded syringes could be used with conventional needles for most orthopaedic procedures.

CONCLUSIONS

The most effective and reliable safety devices for orthopaedic syringe procedures are shielded safety needles, mechanical syringes, manual retractable syringes, and shielded syringes, but not automatic retractable syringes. Even when adopting safety-engineered devices for an orthopaedic clinic, conventional syringes larger than 20 mL and conventional needles longer than 1.5 in (3.8 cm) are necessary.

Pressure generated by syringes: implications for hydrodissection and injection of dense connective tissue lesions

OBJECTIVE

Hydrodissection and high-pressure injection are important for the treatment of dense connective tissue lesions including rheumatoid nodules, Dupuytren's contracture, and trigger finger. The present study determined the optimal syringes for high-pressure injection of dense connective tissue lesions.

METHODS

Different sizes (1, 3, 5, 10, 20, and 60 mL) of a mechanical syringe (reciprocating procedure device) with a luer-lock fitting were studied. Twenty operators generated maximum pressure with each mechanical syringe size, and pressure was measured in pounds per square inch (psi). Subsequently, 223 dense connective tissue lesions were injected with different sizes of syringes (1, 3, or 10 mL). Outcomes included (i) successful intralesional injection and (ii) clinical response at 2 weeks.

RESULTS

Smaller syringes generated significantly more injection pressure than did larger syringes: 1 mL (363 ± 197 psi), 3 mL (177 ± 96 psi), 5 mL (73 ± 40 psi), 10 mL (53 ± 29 psi), 20 mL (32 ± 18 psi), and 60 mL (19 ± 12 psi). Similarly, smaller syringes were superior to larger syringes for intralesional injection success: 10 mL: 34% (15/44) vs. 1 mL: 100% (70/70) (p < 0.001) and 3 mL: 91% (99/109) (p < 0.001).

CONCLUSION

Smaller syringes (≤ 3 mL) are superior to larger syringes (≥ 5 mL) for successful hydrodissection and high-pressure intralesional injection of dense connective tissue lesions.

The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% ($35 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction ($26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.

Sonographically guided hydrodissection and corticosteroid injection for scleroderma hand

Scleroderma is associated with intractable hand pain from vasospasm, digital ischemia, tenosynovitis, and nerve entrapment. This study investigated the effect of hydrodissection of the carpal tunnel followed by corticosteroid injection for the painful scleroderma hand. Twenty-six consecutive subjects [12 with painful scleroderma hand and 14 with rheumatoid arthritis and carpal tunnel syndrome (RA/CTS)] underwent sonographically observed carpal tunnel hydrodissection with 3 ml of 1% lidocaine administered with a 25-gauge 1-in. needle on a 3-ml RPD mechanical syringe (reciprocating procedure device). After hydrodissection, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected. Baseline pain, procedural pain, pain at outcome, responders, therapeutic duration, and reinjection interval were determined. Hydrodissection and injection with corticosteroid significantly reduced pain scores by 67% in scleroderma (p < 0.001) and by 47% in RA/CT (p < 0.001). Scleroderma and RA/CTS were similar in outcome measures: injection pain (p = 0.47), pain scores at outcome (p = 0.13), responders (scleroderma, 83.3%; RA/CTS, 57.1%, p = 0.15), pain at 6 months (p = 0.15), and therapeutic duration (p = 0.07). Scleroderma patients responded better in time to next injection (scleroderma, 8.5 ± 3.0 months; RA/CTS, 5.2 ± 3.1 months, p = 0.03). Reduced Raynaud's attacks and healing of digital ulcers occurred in 83% of subjects. There were no complications. Hydrodissection with lidocaine followed by injection of triamcinolone reduces pain and vasomotor changes in the scleroderma hand. The mechanism may be a combination of hydrodissection-mediated mechanical freeing of entrapped arteries, nerves, and tendinous structures and corticosteroid-induced reduction of inflammatory vasospasm.

A Randomized Controlled Trial of the Cost-Effectiveness of Ultrasound-Guided Intraarticular Injection of Inflammatory Arthritis

Objective.

We studied whether sonographic needle guidance affected the outcomes of intraarticular (IA) injection for inflammatory arthritis.

Methods.

Joints with inflammatory arthritis (n = 244; 76% rheumatoid arthritis, 3% small joints, 51% intermediate, and 46% large) were randomized to injection by conventional palpation-guided anatomic injection (120 joints) or sonographic image-guided injection enhanced with a 1-handed reciprocating procedure device mechanical syringe (124 joints). A 1-needle, 2-syringe technique was used. After IA placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and triamcinolone acetonide was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

Results.

Relative to conventional palpation-guided methods, sonographic guidance for injection of inflammatory arthritis resulted in an 81% reduction in injection pain (p < 0.001), 35% reduction in pain scores at outcome (p < 0.02), 38% increase in the responder rate (p < 0.003), 34% reduction in the non-responder rate (p < 0.003), 32% increase in therapeutic duration (p = 0.01), 8% reduction ($7) in cost/patient/year, and a 33% ($64) reduction in cost/responder/year for a hospital outpatient (p < 0.001).

Conclusion.

Sonographic needle guidance improves the performance, clinical outcomes, and cost-effectiveness of IA injections for inflammatory arthritis. (Clinical Trial Identifier NCT00651625)

Image-directed fine-needle aspiration biopsy of the thyroid with safety-engineered devices

PURPOSE

The purpose of the present study was to integrate safety-engineered devices into outpatient fine-needle aspiration (FNA) biopsy of the thyroid in an interventional radiology practice.

MATERIALS AND METHODS

The practice center is a tertiary referral center for image-directed FNA thyroid biopsies in difficult patients referred by the primary care physician, endocrinologist, or otolaryngologist. As a departmental quality of care and safety improvement program, we instituted integration of safety devices into our thyroid biopsy procedures and determined the effect on outcome (procedural pain, diagnostic biopsies, inadequate samples, complications, needlesticks to operator, and physician satisfaction) before institution of safety devices (54 patients) and after institution of safety device implementation (56 patients). Safety devices included a patient safety technology-the mechanical aspirating syringe (reciprocating procedure device), and a health care worker safety technology (antineedlestick safety needle).

RESULTS

FNA of thyroid could be readily performed with the safety devices. Safety-engineered devices resulted in a 49% reduction in procedural pain scores (P < 0.0001), a 56% reduction in significant pain (P < 0.002), a 21% increase in operator satisfaction (P < 0.0001), and a 5% increase in diagnostic specimens (P = 0.5). No needlesticks to health care workers or patient injuries occurred during the study.

CONCLUSIONS

Safety-engineered devices to improve both patient and health care worker safety can be successfully integrated into diagnostic FNA of the thyroid while maintaining outcomes and improving safety.

Syringe and needle size, syringe type, vacuum generation, and needle control in aspiration procedures

PURPOSE

Syringes are used for diagnostic fluid aspiration and fine-needle aspiration biopsy in interventional procedures. We determined the benefits, disadvantages, and patient safety implications of syringe and needle size on vacuum generation, hand force requirements, biopsy/fluid yield, and needle control during aspiration procedures.

MATERIALS AND METHODS

Different sizes (1, 3, 5, 10, and 20 ml) of the conventional syringe and aspirating mechanical safety syringe, the reciprocating procedure device, were studied. Twenty operators performed aspiration procedures with the following outcomes measured: (1) vacuum (torr), (2) time to vacuum (s), (3) hand force to generate vacuum (torr-cm2), (4) operator difficulty during aspiration, (5) biopsy yield (mg), and (6) operator control of the needle tip position (mm).

RESULTS

Vacuum increased tissue biopsy yield at all needle diameters (P<0.002). Twenty-milliliter syringes achieved a vacuum of -517 torr but required far more strength to aspirate, and resulted in significant loss of needle control (P<0.002). The 10-ml syringe generated only 15% less vacuum (-435 torr) than the 20-ml device and required much less hand strength. The mechanical syringe generated identical vacuum at all syringe sizes with less hand force (P<0.002) and provided significantly enhanced needle control (P<0.002).

CONCLUSIONS

To optimize patient safety and control of the needle, and to maximize fluid and tissue yield during aspiration procedures, a two-handed technique and the smallest syringe size adequate for the procedure should be used. If precise needle control or one-handed operation is required, a mechanical safety syringe should be considered.

Does sonographic needle guidance affect the clinical outcome of intraarticular injections?

OBJECTIVE

This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections.

METHODS

In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0-10 cm visual analog pain scale (VAS).

RESULTS

Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score > or = 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score > or = 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%.

CONCLUSION

Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Reciprocating procedure device for thyroid cyst aspiration and ablative sclerotherapy

Most thyroid cysts are benign; however, they require aspiration if symptomatic or atypical on ultrasound scanning, and ablation with ethanol injection if recurrent. We have systematically studied the use of new safety technologies for surgical procedures, which protect both the surgeon and the patient. Here, we describe the use of one such technology, the reciprocating procedure device, which enables simpler, safer, more efficient and less painful thyroid cyst aspiration and therapeutic ablation.

Integration of patient safety technologies into sclerotherapy for varicose veins

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

Integration of new safety technologies for needle aspiration of breast cysts

INTRODUCTION

National and international regulatory agencies and professional societies mandate systematic improvements in both the safety of patients and heath care workers (HCW), including the integration of safety technologies into the procedures of obstetrics and gynecology (Ob-Gyn).

MATERIALS AND METHODS

Using national resources for patient safety and literature review, these safety technologies were identified: (1) a safety needle to reduce needle sticks to HCW, and (2) the reciprocating procedure device (RPD) to reduce injuries to patients. These technologies were introduced in a trial fashion into routine breast cyst aspiration, and physician responses were determined.

RESULTS

The safety needle presented a number of difficulties associated with the safety sheath, but could be used efficiently for breast cyst aspiration. The RPD safety device functioned well for breast aspiration procedures and was well accepted by physicians.

CONCLUSIONS

New safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during outpatient breast procedures. Since these technologies have been demonstrated to decrease injuries to patients and HCW by 60-70%, serious efforts should be undertaken to systematically integrate safety technologies into the routine practice, including aspiration of breast cysts.

Reduced Pain of Intraarticular Hyaluronate Injection With the Reciprocating Procedure Device

BACKGROUND

Greater than 50% of patients report significant pain with intraarticular injection of hyaluronate. The reciprocating procedure device (RPD), also known the reciprocating syringe, has 2 plungers that reciprocate with each other, permitting one-handed operation. The RPD increases physician control of the needle and is proposed to reduce patient pain during syringe procedures.

OBJECTIVES

To determine in a randomized controlled trial whether the RPD induces less pain than the traditional syringe during intraarticular hyaluronate therapy for the knee.

METHODS

Eighty intraarticular injection procedures of the knee were randomized to either the conventional syringe or the RPD using hyaluronate sodium derivative (Hylan G-F-20). Outcome measures included physician's estimate of pain, patient pain (Visual Analogue Pain Scale [VAPS]), procedure duration, operator satisfaction, complications, and response to the injected medication.

RESULTS

Patients reported 85% more pain than physicians estimated. Fifty-one percent (19/37) of subjects experienced moderate to severe pain with the conventional syringe, while only 14% (6/43) experienced pain with the RPD. The RPD reduced pain scores (RPD VAPS score: 2.12 +/- 2.15; conventional syringe VAPS score: 4.22 +/- 3.25; P < 0.001), reduced procedure time (RPD: 1.34 +/- 1.09, conventional syringe: 1.90 +/- 1.35 minutes, P < 0.001), and improved physician satisfaction (RPD VASS Score: 9.02 +/- 0.80, conventional syringe 5.69 +/- 1.33, P < 0.001).

CONCLUSIONS

Patients have considerably more pain with intraarticular needle introduction and injectable hyaluronate therapy than physicians estimate. The RPD reduces patient pain, reduces procedure time, and improves needle introduction compared with the conventional syringe for hyaluronate injection therapy for the knee.