Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

Background

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

Aim

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

Methods

This single-center retrospective cohort study included children 0–18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018–06/01/2021.

Results

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45–3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28–3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18–0.85] p = .017).

Conclusion

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.     

Chlorhexidine cleaning of re‐usable bougies

Bougies are susceptible to becoming contaminated before or during use. Chlorhexidine wipes may have a residual antibacterial effect, potentially minimising bacterial transmission after bougie use or storage. We evaluated the decontaminant and antibacterial effectiveness of 70% alcohol/2% chlorhexidine wipes in laboratory, clinical and accelerated ageing studies, and conducted a telephone survey of normal practice. In the laboratory tests, chlorhexidine wipes were completely effective against Escherichia coli and methicillin‐resistant Staphylococcus aureus, and prevented recontamination for 24 h. Clinical introduction of chlorhexidine wipes reduced bougie contamination from 33% to 0%. Following 150 cleaning episodes, there was no physical or functional damage to the bougies. Eight out of nine hospitals in the East of England Health Region use re‐usable bougies. We recommend that following decontamination, bougies should be wiped with 70% alcohol/2% chlorhexidine wipes, to retain antimicrobial activity during handling.     

Enquête nationale sur l’utilisation du rémifentanil comme alternative à l’analgésie péridurale obstétricale dans les maternités de niveau II et III

Objectives

The last French survey on alternatives to neuraxial anaesthesia for labour pain was published in 1997. However, intravenous remifentanil has become increasingly used as an option for labour analgesia. We evaluated the use of remifentanil as an alternative to epidural analgesia in level 2 and 3 French maternities in 2009.

Study design

This was an internet-based French survey performed in 2009 including all level 2 and 3 maternities. Data recorded were maternity unit characteristic, alternatives to neuraxial analgesia used, and remifentanil administration protocols.

Results

Two hundred and forty maternity units received the survey and 103 responses were completed. A written institutional alternative analgesia protocol for labour pain was present in 78%. Alternative labour analgesia included intermittent nitrous oxide inhalation (58%), intravenous nalbuphine (52%), patient-controlled intravenous administration of remifentanil (52%) and sufentanil (46%). Pethidine administration was reported by one maternity unit (1%). The bolus dose of remifentanil scheduled, and background infusion varied widely between maternity units. The analgesic efficacy of remifentanil used for labour pain was evaluated as moderate (55%) or good (43%). Two serious adverse events were reported.

Conclusion

Intravenous administration of remifentanil was largely reported as an alternative to neuraxial anaesthesia for labour pain. Although remifentanil administration was most often based on a local written protocol, bolus dose and background infusion varied widely between maternity units.     

Does skin preparation alter suture strength characteristics? Assessing the effect of chlorhexidine and isopropyl alcohol on common skin closure suture material

Sutures are essential to approximate tissues and enable healing by first intention until a wound regains its original tensile strength. The mechanical properties of sutures are well documented, but the effects of exposing sutures to skin preparation solutions used in surgery are not. This study was performed to investigate whether 2% chlorhexidine and 70% isopropyl alcohol skin preparation, commonly used prior to incision and prior to closure, has any effect on the mechanical properties of several commonly used surgical suture types. Four suture types were soaked in either 2% chlorhexidine and 70% isopropyl alcohol or Hartmann''s solution for 5 minutes. All sutures were left to dry for 11 days before being tested to failure using an Instron 3367 tensile testing machine. Testing revealed significant differences in failure load, ultimate tensile stress, and Young''s modulus between suture types (P < .05). No significant differences in failure load (P = .98), ultimate tensile stress (P = .21), or Young''s modulus (P = .22) were observed between the test group and the control group when comparing sutures of the same type. This study demonstrates that chlorhexidine/isopropyl skin preparation solutions do not significantly change the mechanical properties of suture materials exposed to them.     

Perioperative Chlorhexidine Gluconate Wash During Joint Arthroplasty Has Equivalent Periprosthetic Joint Infection Rates in Comparison to Betadine Wash

BackgroundDilute betadine wash has been used for the prevention of prosthetic joint infection (PJI). Appropriateness for this purpose has recently come into question as the Food and Drug Administration determined that several commercial products did not pass the standards of proper sterility. The goal of this study is to determine if change in our institution’s perioperative infection protocol to sterile chlorhexidine gluconate wash affected rates of PJI.MethodsThis is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty and total hip arthroplasty. Chart review was performed to determine 90-day and 1-year readmissions and the development of PJI as per the diagnostic criteria of the Musculoskeletal Infection Society.ResultsA total of 2386 consecutive patients were included in this study. There were no significant demographic differences between the 2 groups. There was no statistically significant difference in the rate of PJI requiring a return trip to the operating room between the 2 cohorts: 4 in chlorhexidine vs 7 in betadine at 3 months (P = .61); and 9 in chlorhexidine and 14 in betadine at 1 year (P = .48, respectively). There was also no difference in the rate of wound complications between the betadine and chlorhexidine use (P = .93).ConclusionWhen comparing patients who received a betadine wash intraoperatively to those who received a chlorhexidine gluconate wash, there were no statistically significant differences in the rate of postoperative PJIs or return trips to the operating room. Although chlorhexidine gluconate and betadine have equal efficacy in the prevention of PJI, betadine is a far less expensive alternative if their sterility concerns are unwarrantedLevel of EvidenceTherapeutic Level III.     

Complications and conversions of upper tract urological laparoendoscopic single‐site surgery (LESS): multicentre experience: results from the NOTES Working Group

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? Several studies have shown the feasibility of performing both complex and reconstructive laparoendoscopic single site (LESS) surgical procedures in urology. To date, no studies have evaluated the rates of conversion to conventional laparoscopy and complications at the time of LESS procedures in urology. This study, a compilation of results from members of the NOTES working group, is the first study to address the rates of complications and conversions to conventional laparoscopy at the time of LESS surgery in urology.

OBJECTIVE

? To present complications and rates of conversion from LESS to conventional laparoscopy (CL) at the time of upper tract LESS urologic procedures.

PATIENTS AND METHODS

? Patients undergoing LESS upper tract procedures between September, 2007 and November, 2008 (n = 125) were identified at six high‐volume academic centers pioneering urologic LESS procedures. All LESS procedures were performed transperitoneally via a single umbilical incision using either adjacent conventional trocars or a dedicated single‐site access device. Reconstructive procedures incorporating a single planned 2 mm accessory needle port were included as LESS procedures and were not considered conversions. ? Patients, undergoing LESS procedures requiring conversion to CL with the placement of additional ports were identified. Conversion was defined as the placement of additional 5 or 10/12 mm ports beyond the primary incision. In each case the operative reports were reviewed, the reason for conversion was determined, and the number and types of additional ports and complications were noted.

RESULTS

? Upper tract LESS procedures were performed in 125 patients comprising 13.3% of the total 937 laparoscopic procedures performed at the participating institutions during this time period. Conversion to CL was necessary in 7 patients (5.6%) undergoing LESS requiring the addition of 2–5 ports. ? Reasons for conversion included: facilitate dissection in 3 (43%), facilitate reconstruction in 3 (43%), and control of bleeding in 1 (14%). All attempted LESS cases were completed laparoscopically without need for open conversion. ? Complications occurred in 15.2% of patients undergoing LESS surgery. Three of the 7 patients that required conversion to CL developed postoperative complications (Clavien grade II in two and IIIa in one). ? Limitations of this study included the inability to standardize LESS patient selection criteria, instrumentation and surgical technique as well as the lack of available complete data from a CL control group for comparison.

CONCLUSION

? LESS surgery is technically feasible for a variety of upper urinary tract reconstructive and ablative procedures, although it appears to be associated with higher rates of complications than in mature CL series. Conversion to CL occurs infrequently and may be a reflection of stringent patient selection.     

Comparison of Ovulation Induction Protocols After Endometrioma Resection

Background and Objectives:

The aim of this study was to compare the in vitro fertilization (IVF) outcomes of long gonadotropin-releasing hormone agonist (GnRH-a) and GnRH-antagonist (GnRH-ant) protocols in endometriosis patients who have undergone laparoscopic endometrioma resection surgery. To our knowledge, there is no study in the current literature that compares the effectiveness of long GnRH-a and GnRH-ant protocols in management of IVF cycles in endometriosis patients who underwent laparoscopic endometrioma resection surgery.

Methods:

Eighty-six patients with stage III to IV endometriosis who had undergone laparoscopic resection surgery for endometrioma were divided into 2 groups: those who had ovarian stimulation with a long GnRH-a protocol (n = 44), and those who had ovarian stimulation with a GnRH-ant protocol (n = 42).

Results:

The number of follicles on human chorionic gonadotropin injection day, duration of hyperstimulation, number of retrieved metaphase II oocytes, and total number of grade 1 embryos were statically significantly higher in the long GnRH-a protocol. There were no significant differences in positive β-human chorionic gonadotropin pregnancy rates (25% vs 21.4%; P = .269) and ongoing pregnancy rates per patient (20.5% vs 19.1%; P = .302) between the 2 protocols.

Conclusions:

Long GnRH-a and GnRH-ant protocols both present similar IVF outcomes in patients with endometriosis who have undergone laparoscopic endometrioma resection surgery. A long GnRH-a protocol may lead to a higher number of embryos that can be cryopreserved, providing the possibility of additional embryo transfers without having to go through the process of ovarian stimulation again.     

Intraperitoneal and intravenous lidocaine for effective pain relief after laparoscopic appendectomy: a prospective, randomized, double-blind, placebo-controlled study

Background  

The preemptive intravenous and intraperitoneal application of local anesthetics is known to improve the postoperative outcome in abdominal surgery. The aim of this study was to compare the analgesic effect of intravenous lidocaine injection to that of intraperitoneal lidocaine instillation in patients who were undergoing laparoscopic appendectomy (LA).     

Effectiveness of chlorhexidine versus povidone-iodine for preventing surgical site wound infection: A meta-analysis

A systematic evaluation was conducted to assess the efficacy of two disinfectants, chlorhexidine and povidone-iodine, as primary components in preventing surgical site infection (SSI). A comprehensive computerised search was performed in the PubMed, EMBASE, Web of Science, Cochrane Library, CNKI and Wanfang databases for randomised controlled trials (RCTs) on chlorhexidine and povidone-iodine disinfection for the prevention of SSI from inception until July 2023. Two independent researchers completed literature screening, data extraction and quality assessment of the included studies. The meta-analysis was conducted using RevMan 5.4 software. Ultimately, 20 RCTs were included, which included 13 133 patients, with 6460 patients in the chlorhexidine group and 6673 patients in the povidone-iodine group. The meta-analysis results revealed that the incidence rate of surgical site wound infections [odds ratio (OR): 0.67, 95% confidence interval (CI): 0.58–0.78, p < 0.001)], superficial SSI rate (OR: 0.59, 95% CI: 0.46–0.75, p < 0.001) and deep SSI rate (OR: 0.49, 95% CI: 0.31–0.79, p = 0.003) were all lower in patients subjected to chlorhexidine disinfection compared to those patients receiving povidone-iodine disinfection. Existing evidence suggests that chlorhexidine is more effective than povidone-iodine at preventing SSI. However, owing to the potential quality limitations of the included studies, further validation through high-quality large-scale RCTs is warranted.     

Treatment of lateral epicondilitis using three different local injection modalities: a randomized prospective clinical trial

Background  To determine the effectiveness of three different local injection modalities in the treatment of lateral epicondilitis. Methods  In a prospective randomized study on lateral epicondilitis, 75 patients were divided into three equal groups A, B and C (n = 25) and were treated using three different method of local injection. The patients in group A were treated with local injection of a steroid (1 mL triamcinolone) combined with local anaesthetic (1 mL lidocaine), those in group B were treated with injection of local anaesthetic (1 mL lidocaine) combined with peppering technique and those in group C with local injection of a steroid (1 mL triamcinolone) combined with local anaesthetic (1 mL lidocaine) and peppering technique. The outcome was defined by measuring the elbow pain during the activity using a 10-cm visual analogue scale (VAS) and satisfaction with the treatment using a scoring system based on the criteria of the Verhaar et al. at 3 weeks and 6 months after the injection and compared with the pre-treatment condition. Results  There were significant (P = 0.006) differences in the successful outcomes between the three groups at 6 months. In group C in which local steroid + peppering injection technique were used; excellent results were obtained in 84% of patients comparing to 36% and 48% for patients in groups A and B, respectively. The successful outcomes were statistically higher in group C comparing to group A (P = 0.002) and group B (P = 0.011). In all groups, there was a significantly lower pain (VAS) at the 3-week and 6-month follow-ups comparing to the pre-treatment condition. VAS measured at 6-month follow-up were significantly lower in group C comparing to other groups (P = 0.002). Conclusion  In the treatment of lateral epicondilitis, combination of corticosteroid injections with peppering is more effective than corticosteroid injections or peppering injections alone and produces better clinical results.     

Kidney Transplantation Across a Positive Crossmatch: A Single-Center Experience

Background

Kidney transplantation is the treatment of choice for end-stage renal disease, with improved mortality and quality of life compared with dialysis. Desensitization protocols have allowed kidney transplantation of highly sensitized patients, who have a lower probability to receive a matching kidney from a deceased or living donor. The aim of this work was to analyze the post-transplantation period of highly HLA-sensitized patients with positive flow cytometry crossmatch against donor cells.

Methods

Following an observational, retrospective design, we investigated 16 highly sensitized patients who underwent kidney or kidney-pancreas transplantation, assessing the impact of desensitization protocols and investigating treatment-related complications, graft function, antibody-mediated rejection (AMR) rate, and graft and patient survivals.

Results

We studied 16 patients with positive flow cytometry crossmatch, who were divided into 2 groups based on whether they were submitted to a desensitization protocol or not. Patients who were desensitized underwent transplantation in later years, had higher immunologic risk (panel reactive antibody peak 62% vs 33%; P = .038), higher percentage of 2nd kidney transplant (75% vs 25%; P = .066), and higher percentage of donor-specific anti-HLA antibodies identified (P = .028). A majority of patients were desensitized with high-dose intravenous immunoglobulin and plasmapheresis, and 5 patients received rituximab. Acute AMR rate was of 38%, and rituximab was associated with fewer episodes of AMR. Only 1 patient had graft failure, due to chronic humoral rejection, and the remaining maintained good graft function (mean serum creatinine value of 1.33 mg/dL). No patient died and few complications related to immunossupression were observed.

Conclusions

Desensitization protocols were safe and allowed kidney transplantation in highly sensitized patients that probably would never undergo transplantation and gave the opportunity of living-donor transplant to patients with anti-HLA antibodies against the donor.     

Botulinum toxin injection vs topical nitrates for chronic anal fissure: an updated systematic review and meta‐analysis of randomized controlled trials

Aim

Chronic anal fissures (CAFs) are frequently encountered in coloproctology clinics. Chemical sphincterotomy with pharmacological agents is recommended as first‐line therapy. Topical nitrates (TN) heal CAF effectively but recurrences are common. An alternative treatment modality is injection of botulinum toxin (BT) into the anal sphincter. We aimed to perform an updated systematic review and meta‐analysis to compare the effectiveness of BT and TN in the management of CAF.

Method

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until March 2017. All randomized controlled trials (RCTs) that reported direct comparisons of BT and TN were included. Two independent reviewers performed methodological assessment and data extraction. Random effects models were used to calculate pooled effect size estimates.

Results

Six RCTs describing 393 patients (194 BT, 199 TN) were included. There was significant heterogeneity among the trials. On random effects analysis there were no significant differences in incomplete fissure healing (OR = 0.47, 95% CI 0.13–1.68, P = 0.24) or recurrence (OR = 0.70, 95% CI 0.39–1.25, P = 0.22) between BT and TN, respectively. BT was associated with a higher rate of transient anal incontinence (OR = 2.53, 95% CI 0.98–6.57, P = 0.06) but significantly fewer total side effects (OR = 0.12, 95% CI 0.02–0.63, P = 0.01) and headache (OR = 0.10, 95% CI 0.02–0.60, P = 0.01) compared with TN.

Conclusion

BT is associated with fewer side effects than TN but there is no difference in fissure healing or recurrence. Patients need to be warned regarding the risk of transient anal incontinence associated with BT.     

Microwave coagulation therapy and drug injection to treat splenic injury

Background

The present study compares the efficacy of 915- and 2450-MHz contrast-enhanced ultrasound (CEUS)–guided percutaneous microwave coagulation with that of CEUS-guided thrombin injection for the treatment of trauma-induced spleen hemorrhage.

Materials and methods

In a canine splenic artery hemorrhage model with two levels of arterial diameter (A, <1 mm and B, between 1 and 2 mm), hemostatic therapy was performed using 915- and 2450-MHz microwaves and drug injection. Therapy efficacy was measured by comparing bleeding rate, hemostatic time, bleeding index, bleeding volume, and pathology.

Results

The most efficient technique was CEUS-guided 915-MHz percutaneous microwave coagulation therapy in terms of action time and total blood loss. The success rate of the 915-MHz microwave group was higher than that of the 2450-MHz microwave and the drug injection groups (except A level, P < 0.05). Hemostatic time, bleeding index, and bleeding volume were significantly less in the 915-MHz microwave group than those in the 2450-MHz microwave and drug injection groups (P < 0.05). Obvious degeneration and necrosis of parenchyma and large intravascular thrombosis were observed in the cavity of larger vessels in the 915-MHz microwave group, but pathologic changes of light injury could be seen in the other groups.

Conclusions

The present study provides evidence that microwave coagulation therapy is more efficient than thrombin injection for the treatment of splenic hemorrhage. Furthermore, treatment with 915-MHz microwaves stops bleeding more rapidly and generates a wider cauterization zone than does treatment with 2450-MHz microwaves.     

In-use efficacy of a chlorhexidine in alcohol surgical rub: a comparative study

BACKGROUND: Although full surgical scrubs are performed prior to each case on an operating list, optimum regimens for hand cleaning have yet to be determined, and in-use efficacy evaluations are very limited. METHODS: A crossover study was undertaken comparing a chlorhexidine in detergent/alcohol regimen with povidine-iodine detergent scrub, within an orthopaedic operating environment. Depending on the skin asepsis regimen used, five surgical team members scrubbed or rubbed prior to each case for a complete operating list. Bactericidal efficacy was measured using the 'glove-juice' technique before and after hand asepsis, and at the completion of each case. RESULTS: The chlorhexidine regimen caused substantial and sustained reductions in hand bacterial counts (>50-fold prior to case 1) during surgical cases. Application of alcoholic chlorhexidine prior to each subsequent case reduced bacterial counts to the same level as the original scrub. In contrast, the povidine-iodine scrub reduced counts <3-fold prior to the first case and <2-fold in subsequent cases. The chlorhexidine regimen also resulted in persistent bactericidal effects between cases, as counts prior to application of cases 2 and higher were significantly lower than prior to case 1 (>7-fold for case 2 vs case 1). CONCLUSIONS: The chlorhexidine regimen demonstrated excellent bactericidal efficacy throughout an operating list, and was superior to povidine-iodine scrubbing in all aspects. The alcoholic chlorhexidine regimen is simpler and should have wide surgical application.     

Weekly nab-paclitaxel is safe and effective in ≥65 years old patients with metastatic breast cancer: a post-hoc analysis

Purpose

This post-hoc analysis of 2 studies investigated the safety and efficacy of weekly and every-3-week (q3w) nanoparticle albumin-bound paclitaxel (nab-paclitaxel) in older patients with metastatic breast cancer (MBC) compared with q3w solvent-based paclitaxel and docetaxel.

Results

Patients ≥65 years (median: 69) were analyzed. In phase 2 (n = 52), overall response rates (ORR) for weekly nab-paclitaxel were 60–64% vs 22% for q3w nab-paclitaxel and 32% for docetaxel. In phase 3 (n = 62), ORRs were 27% for q3w nab-paclitaxel and 19% for solvent-based paclitaxel. In phase 2, median progression-free survival (PFS) was 18.9 months for 150 mg/m² weekly nab-paclitaxel vs 8.5–13.8 months for all other regimens. In phase 3, median PFS for q3w nab-paclitaxel and solvent-based paclitaxel were 5.6 months and 3.5 months, respectively. Weekly nab-paclitaxel resulted in less serious adverse events compared with all other regimens.

Conclusions

Weekly nab-paclitaxel was safe and more efficacious compared with the q3w schedule and with solvent-based taxanes in older patients with MBC.     

Peripheral nerve-blocks and associations with length of stay and readmissions in fast-track total hip and knee arthroplasty

Background

Peripheral nerve blocks (PNB) have recently been recommended in total hip (THA) and knee (TKA) arthroplasty as they may reduce pain, morphine consumption, length of stay (LOS) and complications. However, whether PNBs are associated with early discharge within an enhanced recovery protocol including multimodal analgesia is uncertain.

Methods

An observational multicenter study from January to August 2017 in six Danish Arthroplasty Centers with established fast-track protocols. Prospective recording of preoperative characteristics and information on PNB, LOS and readmissions through the Danish National Patient Registry and medical records. Multiple logistic regression was used to investigate associations between PNB and a LOS >1 day, LOS >4 days, and 30-days readmissions. We also reported on mobilization, pain, opioid and fall-related complications leading to LOS >4 days or readmissions.

Results

A total of 2027 (58.6%) THA and 1432 (41.4%) TKAs with a median LOS of 1 day (IQR 1–2) and 5.3% (CI:4.6–6.1) 30-days readmission rate were identified. PNB was used in 40.7% (CI:38.2–43.3) of TKA and 2.7% (CI:2.0–3.5) of THA, but with considerable interdepartmental variation (0.0–89.0% for TKA). There was no association between PNB and LOS >1 day (OR:1.19 CI:0.82–1.72; p = .354), LOS >4 days (OR:1.4 CI:0.68–2.89; p = .359) or 30-days readmissions (OR:1.02 CI:0.63–1.65; p = .935) in TKA. Logistic regression in THA was not possible due to limited use of PNB. In TKA there were 12 (2.1% CI:1.2–3.6) with and 1 (0.1% CI:0.02–0.7) without a PNB, who had mobilization, pain or opioid-related complications, and 5 (0.9% CI:0.4–2.0) versus 4 (0.5% CI:0.2–1.2) who fell. Correspondingly, 2 (3.7% CI:1.0–12.6) and 11 (0.6% CI:0.3–1.0) of THA patients had these complications, while 0 (0.0% CI:0.0–6.6) and 17 (0.8% CI:0.5–1.3) fell.

Conclusion

Routine use of peripheral nerve blocks was not associated with early discharge or 30-days readmissions in fast-track THA and TKA. Future studies should focus on benefits of PNB in high-risk patients.     

Burden of complications from needle penetration of plastic ports in children

Background

Complications of totally implanted venous access ports are well documented. A concerning mechanical complication we have encountered is posterior penetration of plastic ports with the access needle. The purpose of this study is to investigate the burden of posterior penetrations.

Methods

We performed a retrospective review of all ports placed between November 2007 and December 2011 at a single institution.

Results

There were 247 children who received a port. 117 children (47%) received a port with a plastic posterior wall, 95 children (38%) received a port with a metal posterior wall, and 35 children (14%) had ports that were unable to be identified as plastic or metal. Posterior port penetrations occurred 8 times (3.2% overall, 6.8% of plastic ports). All perforations occurred in plastic ports of a single brand and product code. Average time from port insertion to penetration was 11.2 ± 21.3 months (range 0.3 to 63.4 months). Other complications included catheter malfunction (14), infection (9), pain (2), inability to draw/aspirate (4), leak (3), port migration (2), and malfunctioning not otherwise specified (15).

Conclusions

There is an unacceptably high risk of needle penetration of the posterior wall of plastic ports. We recommend utilizing ports with metal backing to avoid this complication.     

Pre-operative peripheral intravenous cannula insertion failure at the first attempt in adults: Development of the VENSCORE predictive scale and identification of risk factors

Study objectiveOur objective was to develop a clinical scale (the VENSCORE) to predict pre-operative peripheral intravenous cannula (PIVC) insertion failure at the first attempt in adults.DesignThis was a prospective multicenter cohort study that included internal validation with bootstrapping.SettingThe operating rooms of 14 hospitals in southern France from June 2016 to June 2018.PatientsConsecutive adult patients aged 18 years or older were recruited upon arrival to the operating room, regardless of American Society of Anaesthesiology (ASA) physical status.InterventionsPIVC insertion on arrival to the OR.MeasurementsPIVC insertion failure at the first attempt was the outcome of interest. Data collected included the number of PIVC insertion attempts and potential predictors of the risk of failure (including pre-operative patient characteristics and data relative to the procedure). Uni- and multivariable logistic analyses were performed. Based on these results, the VENSCORE scale was developed to predict the risk of failure of the first PIVC insertion.Main resultsIn total, 3394 patients were included, and 27 were excluded because of protocol violations. The PIVC insertion failure rate at the first attempt was 20.3%. Based on multivariable analysis, a history of difficult PIVC insertions, high-risk surgery, poor vein visibility, and moderate to poor vein palpability were identified as risk factors for insertion failure at the first attempt. The area under the curve of the predictive model was 0.82 (95% confidence interval: 0.80–0.84). A VENSCORE value of 0 points was associated with a failure rate of 7%, versus 97% for a score of 6.ConclusionsThe four-item VENSCORE scale could be useful for prospectively identifying adults at risk of first PIVC insertion attempt failure.     

Combined intrathymic and intravenous injection of mesenchymal stem cells can prolong the survival of rat cardiac allograft associated with decrease in miR-155 expression

Background

Mesenchymal stem cells (MSCs) have the potential to improve graft outcomes and promote allograft tolerance. In this study, we examined the effects and mechanism of combined intrathymic (IT) and intravenous (IV) injection of MSCs on the survival of transplanted hearts in a rat allograft model.

Methods

Recipient Sprague-Dawley rats were transplanted with hearts from Wistar rats. Wistar rat MSCs were infused via IT or IV or combined IT and IV (IT/IV) injection at designated intervals. In vitro mixed lymphocyte reaction assays were performed to assess the immunosuppressive capacity of MSCs. Mesenchymal stem cell surface markers and CD4+, CD25+, and Foxp3+ T-cells in the peripheral blood were detected using flow cytometry analysis. The expression of microRNAs and cytokines in graft infiltrating lymphocytes was analyzed by real-time polymerase chain reaction.

Results

The MSCs cultured in vitro had multipotential differentiation capacity. Mixed lymphocyte reaction assays showed that donor-derived MSCs could not stimulate a proliferative response of recipient lymphocytes and could markedly suppress T-cell responses. Survival of the allografts was significantly prolonged by administration of IT/IV injection of MSCs compared with controls, with a mean survival of 32.2 versus 6.5 d, respectively. Compared with the syngeneic groups posttransplant, miR-155 expression was significantly increased in the allogeneic group, and could be restored by injection of MSCs, especially IT/IV injection of MSCs. Moreover, IT/IV injection of MSCs decreased the level of interleukin (IL)-2 and interferon-gamma, but increased the levels of IL-4 and IL-10 in the allogeneic group. More important, IT/IV injection of MSCs was the best way to increase the percentage of CD4+, CD25+, and Foxp3+ T-cell peripheral blood.

Conclusions

Our results indicated that IT/IV injection of MSCs can prolong the survival of rat cardiac allograft, which may be associated with down-regulating miR-155 expression, a shift in the Th1/Th2 balance, and up-regulation of Treg cells expression.     

Acute diverticulitis in immunosuppressed patients: a 12-year management experience

Background

Diverticular disease of the colon occurs commonly in developed countries. Immunosuppressed patients are thought to be more at risk of developing acute diverticulitis, worse disease, and higher complications secondary to therapy. This study aimed to assess outcomes for immunosuppressed patients with acute diverticulitis.

Method

A retrospective single-centre review was conducted of all patients presenting with acute diverticulitis at a major tertiary Australian hospital from 2006 to 2018.

Result

A total of 751 patients, comprising of 46 immunosuppressed patients, were included. Immunosuppressed patients were found to be older (62.25 versus 55.96, p = 0.016), have more comorbidities (median Charlson Index 3 versus 1, P < 0.001), and undergo more operative management (13.3% versus 5.1%, P = 0.020). Immunosuppressed patients with paracolic/pelvic abscesses (Modified Hinchey 1b/2) were more likely to undergo surgery (56% versus 24%, P = 0.046), while in patients with uncomplicated diverticulitis, there was no difference in immunosuppressed patients undergoing surgery (6.1% versus 5.1% P = 0.815). Immunosuppressed patients were more likely to have Grade III-IV Clavien-Dindo complication (P < 0.001).

Conclusion

Immunosuppressed patients with uncomplicated diverticulitis can be treated safely with non-operative management. Immunosuppressed patients were more likely to have operative management for Hinchey 1b/II and more likely to have grade III/IV complications.