A peripherally inserted central catheter misplacement into lateral thoracic vein: A case report

IntroductionCentral venous catheter applications and complications are closely related to the tip position. Previous studies have reported some rare cases of catheter misplacement. Here, we report a case of misplacement of a peripherally inserted central catheter into the lateral thoracic vein.Case reportA 56-year-old cancer patient underwent placement of a peripherally inserted central catheter through the left basilic vein under ultrasound-guided puncture. The catheterisation procedure was uneventful, so the catheter was believed to be in the superior vena cava. However, the post-anterior chest X-ray image revealed that after the catheter advanced towards the axilla, it turned downwards and outwards in the direction of the left lateral thoracic region, with the projection of the catheter tip giving the appearance of termination in the subcutaneous tissue of the lateral thoracic wall on the two-dimensional image. The catheter was then repositioned in the distal superior vena cava.DiscussionPeripherally inserted central catheters can be potentially misplaced into the lateral thoracic vein because these catheters can pass through the orifice of the lateral thoracic vein which flows into the axillary vein. Some pathological cases and clinical conditions can cause dilatation of the lateral thoracic vein, which increases the probability of catheter misplacement. Three principles were proposed to avoid this rare complication: a comprehensive review of the patients’ medical history, real-time image-guided catheterisation and routine radiographic identification of the tip position.     

American Orthopedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joint Scale: A Cross-Cultural Adaptation and Validation Study in the Persian Language

We evaluated the reliability and validity of the Persian translation of the American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal joint scale (AOFAS Hallux MTP-IP). The translated AOFAS Hallux MTP-IP scale form was completed for 101 patients with hallux deformities; the subjective questions were answered by the patients, whereas the orthopedic foot and ankle surgeon and his assistant answered the objective questions. The validated Persian version of the 36-Item Short Form Survey Instrument (SF-36) was used for validity assessment. Eighty-five females and 16 males with a mean age of 49 years were enrolled. Hallux valgus and hallux rigidus was the diagnosis in 73 and 28 patients, respectively. Intrarater reliability had a high level of correlation (rho >0.6) for all subscales and total score. Although the correlation between the total score of the AOFAS Hallux MTP-IP scale and role: physical subscale of SF-36 was the highest (rho = 0.47), the total score of AOFAS Hallux MTP-IP scale and the other 7 domains of SF-36 had a correlation ranging between –0.17 and 0.43. Moreover, the correlation between total score of AOFAS-Hallux MTP-IP and SF-36 physical component summary scale was 0.50, which was higher than the correlation between total score of AOFAS and SF-36 mental component summary scale (rho = 0.35). Convergent validity was approved for MTP joint motion (0.59), IP joint motion (0.51), and callus (0.56) items of AOFAS-Hallux MTP-IP. Spearman's rank correlation coefficient between all items of the functional subscale of AOFAS Hallux MTP-IP scale with its own subscales was higher than the coefficient between these items and other subscales, including pain and alignment (discriminate validity). Floor and ceiling effects were calculated as 2% and 1%, respectively. Our findings indicate that the translated Persian version of the AOFAS Hallux MTP-IP scale is a reliable instrument, but its validity is not satisfactory.     

The effectiveness of intradiscal biologic treatments for discogenic low back pain: a systematic review

BACKGROUND CONTEXTThere are limited treatments for discogenic low back pain. Intradiscal injections of biologic agents such as platelet-rich plasma (PRP) or stem cells (SC) are theorized to have regenerative properties and have gained increasing interest as a possible treatment, but the evidence supporting their use in clinical practice is not yet well-defined.PURPOSEDetermine the effectiveness of intradiscal biologics for treating discogenic low back pain.STUDY DESIGNPRISMA-compliant systematic review.PATIENT SAMPLEPatients with discogenic low back pain confirmed by provocation discography or clinical and imaging findings consistent with discogenic pain.OUTCOME MEASURESThe primary outcome was the proportion of individuals with ≥50% pain relief after intradiscal biologic injection at 6 months. Secondary outcomes included ≥2-point pain score reduction on NRS; patient satisfaction; functional improvement; decreased use of other health care, including analgesics and surgery; and structural disc changes on MRI.METHODSComprehensive literature search performed in 2018 and updated in 2020. Interventions included were biologic therapies including mesenchymal stem cells, platelet rich plasma, microfragmented fat, amniotic membrane-based injectates, and autologous conditioned serum. Any other treatment (sham or active) was considered for comparative studies. Studies were independently reviewed.RESULTSThe literature search yielded 3,063 results, 37 studies were identified for full-text review, and 12 met established inclusion criteria for review. The quality of evidence on effectiveness of intradiscal biologics was very low. A single randomized controlled trial evaluating platelet-rich plasma reported positive outcomes but had significant methodological flaws. A single trial that evaluated mesenchymal stem cells was negative. Success rates for platelet-rich plasma injectate in aggregate were 54.8% (95% Confidence Interval: 40%–70%). For mesenchymal stem cells, the aggregate success rate at six months was 53.5% (95% Confidence Interval: 38.6%–68.4%), though using worst-case analysis this decreased to 40.7% (95% Confidence Interval: 28.1%–53.2%). Similarly, ≥30% functional improvement was achieved in 74.3% (95% Confidence Interval: 59.8%–88.7%) at six months but using worst-case analysis, this decreased to 44.1% (95% Confidence Interval: 28.1%–53.2%).CONCLUSIONLimited observational data support the use of intradiscal biologic agents for the treatment of discogenic low back pain. According to the Grades of Recommendation, Assessment, Development and Evaluation System, the evidence supporting use of intradiscal mesenchymal stem cells and platelet-rich plasma is very low quality.     

POSSUM and p-POSSUM overestimate morbidity and mortality in laparoscopic bariatric surgery

BackgroundDespite their wide use in surgical audit, the application of the Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and the Portsmouth predictor of mortality (p-POSSUM) in bariatric surgery has been limited. The aim of this study was to evaluate the usefulness of POSSUM and p-POSSUM in bariatric comparative audit.MethodsData were retrospectively collected on consecutive patients who underwent laparoscopic gastric by-pass (LRYGB) and sleeve gastrectomy (SG) at a teaching institute. POSSUM and p-POSSUM equations were applied. The observed to expected ratios for morbidity and mortality were calculated. A Student’s t test was performed to assess if a relationship could be found between the observed and the predicted outcomes.ResultsBetween 2008 and 2013, 504 patients (370 female) with a mean (range) age of 46 (17–69) years underwent LRYGB (n = 383) and SG (n = 121). The operative morbidity was 10.9% and mortality was .2%. POSSUM overpredicted morbidity (30.56%), and no relationship between morbidity risk and the development of complications was found (P = .152). There was a grouping of patients in the low-risk mortality groups for both POSSUM and p-POSSUM. Both equations overpredicted mortality (5.95% and 1.62%, respectively).ConclusionBoth POSSUM and p-POSSUM equations overpredicted morbidity and mortality in this only study in the literature of modern bariatric practice that employed a large representative patient sample receiving the commonest procedures. A multicenter study is needed to address the low incidence of events and enable modification of those equations for use in bariatric surgical audit.     

Burden of pancreatic cancer along with attributable risk factors in China from 1990 to 2019, and projections until 2030

ObjectivesUnderstanding epidemiology trends and patterns of pancreatic cancer in China from 1990 to 2019 and predicting the burden to 2030 will provide foundations for future policies development.MethodsWe collected incidence, mortality, and disability-adjusted life-years (DALYs) data of pancreatic cancer in China from 1990 to 2019 based on the Global Burden of Disease Study 2019. We calculated the estimated annual percentage change (EAPC) to depict the trends of pancreatic cancer burden and predicted the incidence and mortality in the next decade by using a Bayesian age-period-cohort analysis.ResultsThe number of incident cases sharply increased from 26.77 thousand in 1990 to 114.96 thousand in 2019, the age-standardized incidence rate (ASIR) nearly doubled from 3.17 per 100,000 in 1990 to 5.78 per 100,000 in 2019, with an EAPC of 2.32 (95% confidence interval [CI]: 2.12, 2.51). The mortality and DALYs presented a similar pattern with incidence. The dominant risk factor for pancreatic cancer was smoking, but the contribution of high body-mass index increased from 1990 to 2019. We projected that the incident cases and deaths of pancreatic cancer would increase to 218.79 thousand and 222.97 thousand, respectively, in 2030 with around 2 times growth.ConclusionsDuring the past three decades, the incidence, mortality and DALYs of pancreatic cancer gradually increased in China, and the absolute number and rate of pancreatic cancer burden would continue to rise over the next decade. Comprehensive policies and strategies need to be implemented to reduce the incidence and mortality.     

Adverse effects of perioperative paracetamol,NSAIDs, glucocorticoids,gabapentinoids and their combinations: a topical review

Post‐operative pain affects millions of patients worldwide and the post‐operative period has high rates of morbidity and mortality. Some of this morbidity may be related to analgesics. The aim of this review was to provide an update of current knowledge of adverse events (AE) associated with the most common perioperative non‐opioid analgesics: paracetamol, non‐steroidal anti‐inflammatory drugs (NSAIDs), glucocorticoids (GCCs), gabapentinoids and their combinations. The review is based on data from systematic reviews with meta‐analyses of analgesic efficacy and/or adverse effects of perioperative non‐opioid analgesics, and randomised trials and cohort/retrospective studies. Generally, data on AE are sparse and related to the immediate post‐operative period. For paracetamol, the incidence of AEs appears trivial. Data are inconclusive regarding an association of NSAIDs with mortality, cardiovascular events, surgical bleeding and renal impairment. Anastomotic leakage may be associated with NSAID usage. No firm evidence exists for an association of NSAIDs with impaired bone healing. Single‐dose GCCs were not significantly related to increased infection rates or delayed wound healing. Gabapentinoid treatment was associated with increased sedation, dizziness and visual disturbances, but the clinical relevance needs clarification. Importantly, data on AEs of combinations of the above analgesics are sparse and inconclusive. Despite the potential adverse events associated with the most commonly applied non‐opioid analgesics, including their combinations, reporting of such events is sparse and confined to the immediate perioperative period. Knowledge of benefit and harm related to multimodal pain treatment is deficient and needs clarification in large trials with prolonged observation.     

Evaluation of the Caring Ahead: Preparing for End-of-Life With Dementia Questionnaire

ObjectivesFamily caregivers of persons with dementia rarely feel prepared for end of life although preparedness predicts outcomes in bereavement. The Caring Ahead: Preparing for End-of-Life With Dementia questionnaire was developed to measure family caregiver death preparedness. The aim of this study was to evaluate questionnaire psychometrics and refine the Caring Ahead questionnaire.DesignA quantitative cross-sectional reliability study design was used to evaluate the questionnaire.Setting/ParticipantsData were collected by mail from 134 English-speaking family caregivers of persons with dementia recruited from more than 50 congregate living facilities in Canada. Thirty-two participants completed a test-retest.MethodsAnalysis of psychometrics included exploratory factor analysis, calculation of correlation with a single-global preparedness item, Cronbach alpha, intraclass correlation coefficient (ICC) over time.ResultsA 4-factor model with 20 items emerged through exploratory factor analysis with principal factors extraction and promax rotation. The revised questionnaire includes 4 factor subscales: Actions (7 items), Dementia Knowledge (5 items), Communication (4 items), and Emotions and Support Needs (4 items). Evidence was demonstrated for concurrent validity (0.44-0.55, P < .001), internal consistency (alpha > 0.7), and reliability (ICCs > 0.7). Lower levels of preparedness were reported for “knowing what the dying process with dementia may be like” and “discussing end-of-life care and preferences with health care providers.”Conclusions and ImplicationsPreliminary evidence for validity and reliability of the refined 20-item Caring Ahead questionnaire suggests the questionnaire may be useful to clinicians and researchers seeking to assess caregivers’ feelings of preparedness, identify specific areas for intervention, and evaluate the effectiveness of caregiver interventions. Additional testing is needed to evaluate predictive validity.