title: A randomized trial comparing buttonhole with rope ladder needling in conventional hemodialysis patients.
abstract: OBJECTIVE
  Buttonhole needling is reported to be associated with less pain than standard needling. The purpose of this study was to compare patient perceived pain and fistula complications in buttonhole and standard needling.
  
  
  METHODS
  In this study, 140 conventional hemodialysis patients were randomly assigned to buttonhole or standard needling. The primary outcome was patient perceived pain with needling at 8 weeks. Fistula complications of hematoma, bleeding postdialysis, and infection were tracked.
  
  
  RESULTS
  Median pain score at 8 weeks using a visual analog scale from 0 to 10 cm was similar for standard and buttonhole needling (1.2 [0.4-2.4] versus 1.5 [0.5-3.4]; P=0.57). Rate of hematoma formation in standard needling was higher (436 versus 295 of 1000 hemodialysis sessions; P=0.03). Rate of no bleeding postdialysis was 23.6 and 28.3 per 1000 in standard and buttonhole needling, respectively (P=0.40). Rate of localized signs of infection in standard versus buttonhole needling was 22.4 versus 50 per 1000 (P=0.003). There was one episode of Staphylococcal aureus bacteremia during the 8 weeks with buttonhole needling and no episodes with standard needling (P=1.00). Within 12 months of follow-up, another two buttonhole needling episodes developed S. aureus bacteremia, and nine buttonhole needling episodes had needling site abscesses requiring intravenous antibiotics versus zero standard needling episodes (P=0.003).
  
  
  CONCLUSIONS
  Patients had no difference in pain between buttonhole and standard needling. Although fewer buttonhole needling patients developed a hematoma, there was an increased risk of bacteremia and localized signs of infection. Routine use of buttonhole needling is associated with increased infection risk.
authors: Faculty of Medicine, Division of Nephrology, University of Calgary, Calgary, Alberta, Canada. Jennifer.macrae@albertahealthservices.ca
authors: Jennifer M
authors: JM
authors: MacRae
authors: Sofia B
authors: SB
authors: Ahmed
authors: Rajneet
authors: R
authors: Atkar
authors: Brenda R
authors: BR
authors: Hemmelgarn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001166:Arteriovenous Shunt, Surgical / Q000009:adverse effects; D016009:Chi-Square Distribution; D005260:Female; D006406:Hematoma / Q000209:etiology; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000175:diagnosis / Q000209:etiology; D010147:Pain Measurement; D011677:Punctures / Q000009:adverse effects; D006435:Renal Dialysis / Q000009:adverse effects / Q000379:methods*; D012307:Risk Factors; D013203:Staphylococcal Infections / Q000188:drug therapy / Q000382:microbiology; D013211:Staphylococcus aureus / Q000302:isolation & purification; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents