Explore the vast range of titles available.

With the growth of ultrasound-guided regional anesthesia, so has the requirement for training tools to practice needle guidance skills and evaluate echogenic needles. Ethically, skills in ultrasound-guided needle placement should be gained in a phantom before performance of nerve blocks on patients in clinical practice. However, phantom technology is varied, and critical evaluation of the images is needed to understand their application to clinical use. Needle visibility depends on the echogenicity of the needle relative to the echogenicity of the tissue adjacent the needle. We demonstrate this point using images of echogenic and nonechogenic needles in 5 different phantoms at both shallow angles (20 degrees) and steep angles (45 degrees). The echogenicity of phantoms varies enormously, and this impacts on how needles are visualized. Water is anechoic, making all needles highly visible, but does not fix the needle to allow practice placement. Gelatin phantoms and Blue Phantoms provide tactile feedback but have very low background echogenicity, which greatly exaggerates needle visibility. This makes skill acquisition easier but can lead to false confidence in regard to clinical ability. Fresh-frozen cadavers retain much of the textural feel of live human tissue and are nearly as echogenic. Similar to clinical practice, this makes needles inserted at steep angles practically invisible, unless they are highly echogenic. This review describes the uses and pitfalls of phantoms that have been described or commercially produced.

Needle tip visualization is fundamental to the safety and efficacy of ultrasound-guided regional anesthesia (UGRA). It can be extremely challenging especially at steep insertion angles. We assessed whether an echogenic needle improved tip visibility during UGRA by anesthesiologists performing their normal in-plane technique. The visibility of the Pajunk Sonoplex (echogenic) and the Pajunk Uniplex (control) needle were compared during 60 nerve blocks (30 femoral, 30 sciatic) in this randomized controlled trial. All ultrasound imaging was recorded for analysis. The anesthesiologist subjectively estimated the percentage time they had visualized the needle tip (5-point scale: 1 [0%-20%], 2 [20%-40%], 3 [40%-60%], 4 [60%-80%], 5 [80%-100%]). The actual time the tip was in view, angle of needle insertion, target depth, and procedure time were subsequently measured objectively by a single investigator. The Sonoplex group had both subjectively and objectively better tip visibility (P = 0.002), despite having larger mean body mass index (29.0 vs 25.0 kg/m2, P = 0.01) and steeper mean insertion angle (31 vs 22 degrees, P = 0.03). Objective percentage tip visibility, during in-plane UGRA, reduced by 12% for every 10-degree increase in insertion angle with the control. Tip visibility with the Sonoplex was independent of insertion angle over the range studied (0-57 degrees, P = 0.95). This finding occurred when nonexpert anesthesiologists performed their standard UGRA technique. A needle that is visible for a greater percentage of time has potential safety and efficacy implications.

Background and Objectives:Needle visibility using ultrasound remains problematic at steep insertion angles. Despite modified techniques, steep approaches are still needed, particularly in the obese, neuraxial anesthesia or pain blocks around the spine. We describe a novel technique for objective assessment of needle-tip identification and present data on a new needle.Methods:Five needles were compared for accuracy of tip position identification. Pajunk facet-tipped, Tuohy-tipped, Polymedic Ultrasound, Hakko EchoStim, and a new intermittently textured needle (T). Static ultrasound images were obtained of the needles in first-thaw, unembalmed cadavers at shallow, moderate and steep angles. Actual tip position was defined. Images were presented in blinded, random order to 10 experienced and 10 novice anesthetists who estimated tip position. Distance between true tip position and estimated position was measured (\"tip error\"). Secondary objectives included subjective measures of visibility and differences between needles at shallower insertion angles and between novice and expert observers.Results:At steep angles, study needles varied significantly with regard to tip error (P < 0.0001). Needle T scored highest for confidence and subjective visibility at moderate and steep angles. There was no significant difference between novice and experienced anesthetists for tip error or visibility. Experts were more confident in their estimates.Conclusions:Needle T demonstrated good properties even at steep insertion angles. Tip location was accurate, and observers rated it highly visible. Ability to identify needle-tip position can be objectively assessed.

Background and Objectives:Anesthesiologists often find that patients would prefer a general anesthetic (GA) to a regional anesthetic (RA) for surgery. We surveyed patients' attitudes to RA in an Australian tertiary-care hospital, hoping to understand the reasons for acceptance or refusal. We explored how 3 main factors influence the patient's choice for subsequent RA: gender, type of anesthetic on the day of surgery, and perioperative concerns.Methods:Consecutive patients at a single institution were interviewed on the first postoperative day by a research nurse, either as a face-to-face interview or by telephone after ambulatory surgery. A short description of RA and GA was given, and preferences for future anesthesia and concerns were recorded.Results:Complete data were obtained from 1000 patients. More women preferred GA compared with men (76.3% vs 69.0%). Patients who received only RA during their surgery on the previous day were almost 3 times more likely to express a future preference for RA compared with those who received any GA, using hypothetical examples of arm or hip surgery (83.2% vs 21.1%, P = 0.00001). Patients expressed more concerns about hearing or seeing the surgery than experiencing a complication, and 84% preferred sedation.Conclusions:More patients, especially females, may accept RA if reassured appropriately about not hearing or seeing the surgery. Once patients have experienced RA, they are more likely to choose it in future. Modification of our discussion and consent process may increase the uptake of RA techniques.

The reliability of Anaesthetists' Non-Technical Skills (ANTS) has been investigated using videos of simulated conduct of anaesthesia, with the assessed raters being anaesthetists involved in either training or assessment of anaesthesia trainees. While different forms of assessment have been used for many years, assessment in the workplace is thought to be the most meaningful. The challenge is to create and test tools that will be robust enough to perform high stakes assessments. During the initial evaluation of ANTS by the Scottish team, feedback from experts and calibration were deliberately excluded from rater training to isolate the impact of these on inter-rater agreement. The audio-visual department made a number of posters which were displayed in the clinic where patients undergo pre-operative assessment. Video production commenced in January 2007 and took seven months. The videos were produced by the audio-visual department at Sir Charles Gairdner Hospital. The video taken was of anaesthetists' real-time performance.

Dr Graham Hocking, consultant in anaesthesia, Oxford Radcliffe Hospitals NHS Trust

The bacterium Vibrio parahaemolyticus is ubiquitous in tropical and temperate waters throughout the world and causes infections in humans resulting from water exposure and from ingestion of contaminated raw or undercooked seafood, such as oysters. We describe a nationwide outbreak of enteric infections caused by Vibrio parahaemolyticus in Australia during September 2021-January 2022. A total of 268 persons were linked with the outbreak, 97% of whom reported consuming Australia-grown oysters. Cases were reported from all states and territories of Australia. The outbreak comprised 2 distinct strains of V. parahaemolyticus, sequence types 417 and 50. We traced oysters with V. parahaemolyticus proliferation back to a common growing region within the state of South Australia. The outbreak prompted a national recall of oysters and subsequent improvements in postharvest processing of the shellfish.

Sustainable land management encompasses a range of activity that balance land use requirements with wider conservation and ecosystem impact considerations. Perennial invasive alien plants (IAPs), such as Japanese knotweed, cause severe ecological and socio-economic impacts, and methods to control their spread also come at a cost. Synthetic herbicides are generally viewed as less sustainable and more ecologically damaging than alternative approaches. Here we used a comparative Life Cycle Assessment to evaluate the sustainability of herbicide-based management approaches and physical alternatives, using a large-scale Japanese knotweed field study as a model IAP system. Glyphosate-based methods elicited the lowest environmental impacts and economic costs during production. Geomembrane covering and integrated physiochemical methods were the costliest and imposed the greatest impacts. We discuss the costs and benefits of chemical and physical approaches for the sustainable management of invaded land and question how sustainable environmental stewardship is defined for the control of IAPs.