Early Insertion Research Articles

EP588 - Review of the need for Immediate Nasogastric Tube Insertion in patients with Small Bowel Obstruction: Single Centre Quality Improvement Project

Abstract Aim This QIP was conducted in a busy UK hospital. It aims to review, improve, and stress the importance of early insertion of an NG tube in patients who have clinically suspected or radiologically confirmed small bowel obstruction. Method Retrospective data collection involving 72 patients, in a period from Jan to April 2023 (50 patients) and from May to July 2023 (22 patients)Inclusion criteria: adult patients with SBO (clinically suspected or radiologically confirmed) and NGT insertion advised by the surgical teamExclusion criteria: paediatric patients, LBO, and patients not advised NGT in ED Results In the first cycle, we found that NG insertion is delayed 84% > 7 hrs. With associated morbidity of pneumonia, including aspiration in 20% of patients, ileus and sepsis in 8%, and re-admission and mortality in 6%, respectively. The following interventions were carried out. Broad communication with the ED team to highlight the importance of NG insertion for suspected patients. Provide NGT training for ED nursing staff The surgical team and admission nurses should inquire about NGT insertion before accepting patients' admission to surgical emergency wards. Circulating the QIPS recommendation Trust-wide as sharing learning point Post-intervention, we noticed a 50% delay in NGT insertion, which is a huge improvement compared to the 84% delay Conclusion Early insertion of NG for decompression in both pre and post-op periods is known to decrease associated complications, including bowel oedema, perforation, aspiration pneumonia, and post-ileus, leading to better outcomes and a significant decrease in hospital stay length.

Clinical Features of Candida Catheter-related Bloodstream Infections and Persistent Infections Associated with Early Catheter Reinsertion: A 6-year Retrospective Study

Abstract Introduction: Catheter-related persistent Candida infections (CRPCI) may develop after Candida catheter-related bloodstream infections (CRBSI) due to colonization of the newly inserted catheter. However, the optimal timing for new catheter insertion remains controversial. The aim of this study was to determine the clinical features of CRBSI due to Candida species and CRPCI. This was a retrospective study conducted in a teaching hospital in Japan. Methods: We retrospectively collected clinical information on hospitalized patients diagnosed with Candida CRBSIs by catheter tip culture from 2015 to 2020. CRPCI was defined as the growth of the same Candida species from the tip culture of a newly inserted catheter after the onset of a Candida CRBSI. The Chi-squared and Fisher’s exact tests were used to compare differences between the case and control groups. Results: Sixty-three cases of Candida CRBSI were collected. Fifty-four (85.7%) received total parenteral nutrition. CRPCI developed in 12 (48%) patients of the 25 in whom cultures of newly inserted catheters were performed. Despite antifungal therapy in these patients, persistent fungemia incidence was significantly higher (50.0% vs. 9.1%, odds ratio = 10.0, P = 0.033). The mean number of days from removal of infected catheter to reinsertion was significantly shorter for patients with CRPCI (0.27 days vs. 3.08 days, P = 0.038). Conclusions: Total parenteral nutrition may be a major risk factor in the development of Candida CRBSI. CRPCI often leads to persistent fungemia. Early insertion of a new catheter after removal of an infected catheter may be a risk factor for CRPCI.

Early Inflatable penile prosthesis implantation offers superior outcomes compared to delayed insertion following ischemic priapism: a narrative review.

Ischemic priapism is a urological emergency which may lead to irreversible erectile dysfunction. One of the accepted treatments is penile prosthesis implantation. Given the scarcity of studies directly comparing timing of penile prosthesis insertion after ischemic priapism, consensus remains elusive. We aim to compare different studies in the literature concerning advantages and disadvantages of early versus delayed inflatable penile prosthesis following ischemic priapism. We analyzed 8 articles that investigated immediate and delayed inflatable penile prosthesis placement after ischemic priapism. Early inflatable penile prosthesis placement is associated with better outcomes, including pain relief, priapism resolution, penile shortening prevention, and quicker sexual activity resumption. However, it still carries a high risk of complications like edema, infection, and distal perforations. Delayed inflatable penile prosthesis insertion poses surgical challenges due to the potential for extensive corporal fibrosis. Comparative analyses have shown elevated complication rates in patients with ischemic priapism who undergo delayed inflatable penile prosthesis insertion, as opposed to those with early insertion. In studies reporting complications rates, the total complication rate in the early group was 3.37%, significantly lower than the delayed group (37.23%). Most studies support the superiority of early inflatable penile prosthesis placement following ischemic priapism over delayed placement. Further research is, however, needed to establish a global consensus on timing of prosthesis insertion.

Polypyrrole polymerized by iodine oxidation for zinc[sbnd]iodine batteries with high stability

Currently, aqueous rechargeable zinc-iodine (ZnI2) batteries are recognized as promising new energy storage devices due to their significant advantages, including large theoretical capacity, rapid charging and discharging capabilities and high safety. However, the shuttle effect caused by the soluble polyiodide ions leads to low utilization of active iodine and coulombic efficiency (CE). Herein, we use a high-concentration iodine solution as the oxidizing agent to synthesize polypyrrole (PPy/I2) for the first time. Compared with the PPy polymerized by using FeCl3 as oxidant (PPy/FeCl3), the ZnI2 battery based on PPy/I2 cathode demonstrates an extended cycle life (84.2 % after 3800 cycles at 2.0 A g−1), high CE (>98 % at 1.0 A g−1), and minimal self-discharge (75 % after rest 12 h). The results based on electrochemical testing and characterization indicate that the exceptional performance of PPy/I2 is primarily attributed to the early insertion of iodine species during the preparation process. This insertion creates reserved space for polyiodide ions, and the positive charge on the main chains of PPy effectively restricts their shuttle during battery operating. Furthermore, due to the ideal shuttle inhibition of PPy/I2, the Zn corrosion caused by polyiodide ions is effectively inhibited. The detailed characterizations explore the charge storage mechanism of PPy/I2. This research has guiding significance for improving the performance of PPy-based ZnI2 batteries.

Timing and impact of percutaneous endoscopic gastrostomy insertion in patients with amyotrophic lateral sclerosis: a comprehensive analysis

Dysphagia is common in amyotrophic lateral sclerosis (ALS) patients, often requiring percutaneous endoscopic gastrostomy (PEG) for enteral nutrition. We retrospectively analyzed data from 188 Korean patients with ALS who underwent PEG tube insertion at five-time points: symptom onset (t1), diagnosis (t2), recommended time for gastrostomy (t3), PEG insertion (t4), and one-year post-insertion (t5). The recommended time point for gastrostomy (T-rec for gastrostomy) was defined as the earlier time point between a weight loss of more than 10% and advanced dysphagia indicated by the ALSFRS-R swallowing subscore of 2 or less. The T-rec for gastrostomy was reached at 22 months after symptom onset, followed by PEG insertion at 30 months, resulting in an 8-month delay. During the delay, the ALSFRS-R declined most rapidly at 1.7 points/month, compared to 0.8 points/month from symptom onset to diagnosis, 0.7 points/month from diagnosis to T-rec for gastrostomy, and 0.6 points/month after the PEG insertion. It is crucial to discuss PEG insertion before significant weight loss or severe dysphagia occurs and minimize the delay between the recommended time for gastrostomy and the actual PEG insertion. A stratified and individualized multidisciplinary team approach with careful symptom monitoring and proactive management plans, including early PEG insertion, should be prioritized to improve patient outcomes.

Early vs delayed insertion of penile prosthesis in patients with refractory priapism: a systematic review and meta-analysis.

Refractory priapism, characterized by persistent and prolonged painful erections despite initial treatment maneuvers, can significantly impair erectile function secondary to ischemia-induced corporal tissue fibrosis. These patients will likely require subsequent penile prosthesis (PP) surgery to regain sexual activity, yet consensus regarding the optimal timing of implantation remains lacking. To evaluate and compare the clinical outcomes associated with early vs delayed PP implantation in individuals with priapism-induced erectile dysfunction (ED). We included studies that focused on refractory priapism leading to ED and its management with PP implantation. We assessed cohort study bias with a risk-of-bias tool and case series bias with the modified Newcastle-Ottawa Scale. Pooled odds ratios (ORs) were calculated by a fixed-effect model. We included 9 studies, comprising 4 cohort studies and 5 case series, involving a total of 278 patients. Total complications were higher in the delayed group (OR, 4.16; 95% CI, 2.77-6.26). Fibrosis was significantly more pronounced in the delayed group (OR, 118.18; 95% CI, 20.06-696.32). The odds of erosion, infections, and penile injury did not show statistically significant differences between the groups (OR, 2.52 [95% CI, 0.67-9.49], 0.89 [0.38-2.10], 1.83 [0.79-4.26], respectively). Patients' satisfaction resulted in a pooled OR of 0.15 (95% CI, 0.04-0.49) in favor of the early PP insertion group. The results from this study favor an early approach to ED (within 30days) following ischemic priapism. However, it is important to consider patients' preferences, values, and psychological factors to make an informed decision.

(098) Does Early Implantation of Penile Prosthesis for Ischemic Priapism Associated with Decreased Complication Rate? A Systematic Review of Literature

Abstract Introduction Ischemic priapism (IP) is a prolonged undesired erection that accounts for >95% of all priapism episodes. Like compartment syndrome, it is characterized by diminished corporal blood flow and can lead to corporal fibrosis, penile shortening, and refractory erectile dysfunction. Penile prosthesis (PP) implantation is the treatment option in IP to treat the priapic episode and to preserve erectile function. However, no standardization exists regarding the optimal timing of PP implantation surgery. Objective The present review aims to systematically analyse the literature comparing early and delayed PP implantation in patients with IP. Methods A systematic search on PubMed, Scopus, and EMBASE databases were searched from inception to July 1st, 2023 and followed by hand searching. All the steps were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We assess the quality of evidence and the risk of bias in each included study. Results Three retrospective cohort studies comprising 199 subjects were included in this systematic review. All studies have different definitions of the timing of early PP implantation, ranging from within one week to ≤6 months from the onset of priapism. Despite different types of PP used, all studies agreed that early PP implantation results in lower intraoperative complications, such as corporeal perforation and urethral injury, greater preservation of penile length and girth, and a lower rate of prosthetic revision. On the other hand, the delayed insertion was linked to a longer surgical time because of challenges brought on by fibrotic tissue, with most of them also requiring a smaller cylinder. In regards to post-operative complication, the majority of studies demonstrated that delayed implantation would result in a higher rate of complication rate; however, one study demonstrated that early PP implantation had a higher likelihood of prosthesis erosion and infection, which was believed due to a higher rate of bacterial invasion during the earlier shunt surgeries. Conclusions The majority of current evidence favours early penile prosthesis insertion in term of lower complication rate for IP, especially the intraoperative complication, for IP, compared to the delayed implantation. Nevertheless, better quality evidence is still needed from RCT to determine the exact timing for early implantation, patient selection, and the best penile prosthesis types. Disclosure No.

Hearing Outcomes in Patients with Cleft Lip and Palate in a Resource Limited Setting.

To compare hearing outcomes of early versus late tympanostomy tube insertion in patients with cleft lip and palate in a resource limited setting Retrospective cohort study. Conducted at Queen Sirikit National Institute of Child Health, a tertiary care hospital in Bangkok, Thailand. Included 76 patients under 18 with cleft anomalies undergoing tympanostomy tube insertion between January 2018 and July 2022, categorized into early ( n = 11) and late ( n = 65) tympanostomy groups. Early tympanostomy tube placement at ≤ 3 months old, coordinated with cleft lip repair, following failed transitory evoked otoacoustic emission (TEOAE) and Type B tympanogram. Late tympanostomy tube placement preceded by a diagnosis of middle ear effusion and typically a failed TEOAE and subsequent level of testing. Primary outcomes: normal hearing rates and age at normal hearing. Secondary outcomes: repeated tympanostomy tube placement rate, postoperative complications, and length of hospital stays. Early tympanostomy tube placement was associated with higher rates of normal hearing (100% vs. 75%. P = .103) and significantly younger age at normal hearing (11 vs. 19 months, P = .036). Time to normal hearing was shorter in the early group. Postoperative complications, including otorrhea, occurred more frequently in the early group, but differences were not significant. Early tympanostomy tube insertion improves hearing outcomes in pediatric patients with cleft lip and palate, achieving normal hearing at a significantly younger age. This approach offers a valuable alternative in resource-limited settings with constrained audiological services. Further research on long-term speech outcomes and cost-effectiveness is warranted.

Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury.

Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. We pooled individual patient data for all relevant harmonizable variables from the Erythropoietin in Traumatic Brain Injury (EPO-TBI) and Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomized control trials, and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Core Study version 3.0 and Australia-Europe NeuroTrauma Effectiveness Research in TBI (Oz-ENTER) prospective observational studies to create a combined dataset. The Glasgow Coma Scale (GCS) score was used to define TBI severity and we included all patients admitted to an intensive care unit with a GCS ≤12, who were 15 years or older and underwent EVD placement within 7 days of injury. We used hierarchical multi-variable logistic regression models to study the association between EVD insertion within 24 h of injury (early) compared with EVD insertion more than 24 h after injury (late) and 6-month functional neurological outcome measured using the Glasgow Outcome Score Extended (GOSE). In total, 2536 patients were assessed. Of these, 502 (20%) underwent early EVD insertion and 145 (6%) underwent late EVD insertion. Following adjustment for the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) score extended (Core + CT), sex, injury severity score, study and treatment site, patients receiving a late EVD had higher odds of death or severe disability (GOSE 1-4) at 6 months follow-up than those receiving an early EVD adjusted odds ratio; 95% confidence interval, 2.14; 1.22-3.76; p = 0.008. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area.

Possible effects of left pulmonary artery stenting in single ventricle patients on bronchial area, lung volume and lung function.

Left pulmonary artery (LPA) stenting is often required in single ventricle (SV) patients. Due to their close anatomical relationship an LPA stent could potentially compress the left main bronchus (LMB). We assessed the impact of LPA stenting on bronchial size, pulmonary volumes, and lung function in a cohort of SV patients. Forty-nine patients underwent cardiovascular magnetic resonance (CMR) and 36 spirometry 11 (8-15) years after Fontan. All patients were free of respiratory symptoms. LPA stents were inserted in 17 (35%) patients at 8.8 (3.4-12.6) years. Area/shape of the main bronchi (n = 46) and lung volumes (n = 47) were calculated from CMR-ZTE images for each lung and transformed in right-to-left (r/l) ratio and indexed for BSA. The effect of early stent insertion (prior to stage III) was analyzed. Patients with LPA stent had larger r/l ratio for main bronchus area (p < 0.001) and r/l ratio difference for lung volumes was slightly larger in patients with early stenting. A trend toward a deformation of LMB shape in patients with LPA stent and toward a higher prevalence of abnormal spirometry in patients with early stent implantation was observed. In this cohort of patients, early insertion of LPA stents seems to relate with smaller LMB sizes and a trend toward smaller left lung volume and higher prevalence of impaired lung function. Whether these findings are caused by the stent or, at least to a certain degree, present prior to the implantation needs to be verified.

Acute caval thrombosis leading to obstructive shock in the early post insertion period of an inferior vena cava filter: a case report and literature review

BackgroundObstructive shock is extremely rare in clinical practice and is caused by acute blood flow obstruction in the central vessels of either the systemic or pulmonary circulation. Utilizing inferior vena cava filters (IVCFs) to prevent pulmonary embolism (PE) is associated with some potential complications, such as inferior vena cava thrombosis (IVCT). Shock as a direct result of IVCT is rare. We present a case of obstructive shock secondary to extensive IVCT caused by inadequate anticoagulant therapy after the placement of an IVCF.Case presentationA 63-year-old male patient with a traffic accident injury presented orthopaedic trauma and lower limb deep vein thrombosis (DVT). He experienced sudden and severe abdominal pain with hypotension, tachycardia, tachypnea, oliguria and peripheral oedema 5 days after IVCF placement and 3 days after cessation of anticoagulant therapy. Considering that empirical anti-shock treatment lasted for a while and the curative effect was poor, we finally recognized the affected vessels and focused on the reason for obstructive shock through imaging findings—inferior vena cava thrombosis and occlusion. The shock state immediately resolved after thrombus aspiration. The same type of shock occurred again 6 days later during transfer from the ICU to general wards and the same treatment was administered. The patient recovered smoothly in the later stage, and the postoperative follow-up at 1, 3, and 12 months showed good results.ConclusionThis case alerts clinicians that it is crucial to ensure adequate anticoagulation therapy after IVCF placement, and when a patient presents with symptoms such as hypotension, tachycardia, and lower limb and scrotal oedema postoperatively, immediate consideration should be given to the possibility of obstructive shock, and prompt intervention should be based on the underlying cause.

Type 2 biliary perforation successfully managed with early insertion of self-expandable metal stent

Perforations after endoscopic retrograde colangiopancreatography (ERCP) are divided into four types. Type 1 refers to the duodenum, type 2 the periampullary region, type 3 the bile duct itself, and type 4 the observation of retroperitoneal free air on cross-sectional imaging. The treatment of type 2 biliary perforations remains debatable. We present a patient who was successfully treated with a self-expandable metal stent (SEMS) without the need for surgery or any complications.

Impact of ventilation tube insertion on long-term language outcomes at 6 and 10 years of age: A prospective pregnancy cohort study.

Investigating the impact of early childhood ventilation tube insertion (VTI) on long-term language outcomes. Longitudinal cohort study. A total of 2900 pregnant women participated in the Raine Study between 1989 and 1991 in Western Australia, and 2868 children have been followed up. Based on parental reports, 314 children had a history of recurrent otitis media but did not undergo VTI (rOM group); another 94 received VTI (VTI group); while 1735 had no history of rOM (reference group) in the first 3 years of childhood. Children with data on outcomes and confounders were included in analyses of PPVT-R at ages 6 (n = 1567) and 10 years (n = 1313) and CELF-III at 10 years (n = 1410) (approximately 5% in the VTI group and 15% in the rOM group). Peabody Picture Vocabulary Test-Revised edition and Clinical Evaluation of Language Fundamentals® Preschool-3. At 6 years, mean PPVT-R scores were significantly lower in the VTI group than the reference group (β = -3.3; 95% CI [-6.5 to -0.04], p = .047). At 10 years, while the difference between the VTI and reference groups was less pronounced for PPVT-R scores, there was a small but consistent trend of lower measures, on average, across CELF-III scores (expressive: β = -3.4 [-7.1 to 0.27], p = .069; receptive: β = -4.1 [-7.9 to -0.34], p = .033; total: β = -3.9 [-7.5 to -0.21], p = .038). There was no evidence to suggest that language outcomes in the rOM group differed from the reference group. Lower scores of language outcomes in school-aged children who received VTI in early childhood may suggest a long-term risk which should be considered alongside the potential benefits of VTI.

Early labor insertion in Latin America: A perspective from business sector needs

Early labor insertion in Latin America: A perspective from business sector needs

Refugees and asylum seekers in informal and precarious jobs: early labour market insertion from the perspectives of professionals and volunteers

PurposeThis article aims to explore the engagement of refugees and asylum seekers (RAS) in informal and precarious jobs from a civil society actors' perspective. Despite a burgeoning literature on refugee integration and a focus on institutional integration programmes, little is known about the early insertion of RAS into informal and precarious employment as an alternative to subsidised integration programmes, when these are available.Design/methodology/approachThis article draws on rich qualitative data collected through in-depth interviews with social workers, volunteers and other professionals supporting migrants.FindingsData analysis shows that migrants' insertion in informal jobs and their rejection of integration programmes may be the result of people's need to access financial capital to cover actual and future needs. Although such an engagement may be criticised for hampering RAS’ integration, it can be seen as an important source of agency against insecurity surrounding one's legal status.Originality/valueThis article highlights the importance of legal status precarity in shaping informal workers' agency and perceptions of them, opening up a debate on the relevance of informal work in terms of long-term integration and future migration trajectories.

The incidence of aspiration pneumonia in acute ischemic stroke patients in relation to early insertion of nasogastric tube feeding

Background Stroke is the acute onset of cerebral ischemia. Dysphagia with difficult swallowing is one of the common complications during the course of acute stroke, its incidence varies between 29–67%. Pneumonia is the second most common cause of death during the acute phase of stroke, with up to 20% mortality rate. In patient with risk of dysphagia or deficient oral intake, enteral feeding will be recommended. Objective Study the effect of early insertion of nasogastric tube for feeding on incidence of aspiration pneumonia in acute ischemic stroke patients with abnormal water swallow test. Methods The study was carried out in Alexandria Main University Hospital on 40 patients with acute ischemic stroke. Patients with abnormal water swallow test were classified into two groups: Group A: Insertion of nasogastric tube on admission after diagnosis. Group B: Giving intravenous fluids, minerals and traces for the first 48 h then inserting nasogastric tube on the third day. Results By comparing the patients in both groups, there was no statistical significant difference between them as regards; age, gender, comorbidities, and APACHE II score on admission. There was a statistical significant difference between both groups regarding fever, CRP level, WBCs, hypoxic index and the length of hospital stay. Conclusion Inserting Nasogastric tube insertion on admission in acute stroke patients may increase the incidence of aspiration pneumonia than being non-oral for 48 h before insertion on the third day as it affects the duration of ICU and hospital stay.

Impact of early external ventricular drainage on functional outcome after traumatic brain injury: a bicentric retrospective cohort analysis

PurposeSeveral studies have confirmed that external ventricular drain decreases intracranial pressure (ICP) after traumatic brain injury (TBI). Considering its impact on ICP control and cerebral waste metabolites clearance, timing of external ventricular drain (EVD) insertion could improve CSF drainage efficiency. The aim of the study was to evaluate the impact of early EVD versus a later one on the 3-month outcome. MethodsFor this retrospective cohort study conducted in two regional trauma-center (Caen CHU Côte de Nacre and Beaujon Hospital) between May 2011 and March 2019, all patients with intracranial hypertension following TBI and treated with EVD were included. We defined the early EVD by drainage within the 24 h of the hospital admission and the late EVD insertion by drainage beyond 24 h. A poor outcome was defined as a Glasgow Outcome Scale of one or two at 3 months. ResultsAmong the cohort of 671 patients, we analyzed 127 patients. Sixty-one (48.0%) patients had an early insertion of EVD. In the early EVD group, the mean time to insertion was 10 h versus 55 h in the late EVD group. Among the analyzed patients, 69 (54.3%) had a poor outcome including 39 (63.9%) in the early group and 30 (45.5%) in the later one. After adjustment on prognostic factors, early EVD insertion was not associated with a decrease in a poor outcome at 3-months (OR = 1.80 [0.73–4.53]). ConclusionEarly insertion of EVD (<24 h) for intracranial hypertension after TBI was not associated with improved outcome at 3 months.

Intrauterine Tamponade Balloon for Management of Severe Postpartum Haemorrhage: Does Early Insertion Change the Outcome? A Retrospective Study on Blood Loss.

To evaluate the role of the timing of IUTB insertion and to assess the correlation between the time of insertion and outcome. A retrospective study in two tertiary care centres, including patients transferred for severe PPH management. A total of 81 patients were included: 52 patients with IUTB inserted before 15 min (group 1) and 29 patients with IUTB inserted after 15 min (group 2). The mean volume of blood loss in the group of patients with IUTB inserted before 15 min was significantly lower than in group of patients with IUTB set after 15 min. An IUTB could be inserted simultaneously with a uterotonic agent, within 15 min and not after 15 min as suggested by local guidelines, but further prospective studies are required to confirm this.

The clinical topography of peripherally inserted central catheter-related thrombosis in cancer patients: A prospective and longitudinal observational study based on ultrasound scans every two days

AimsTo delineate the clinical topography of peripherally inserted central catheter (PICC)-related thrombosis in cancer patients. BackgroundMost of the clinical features of PICC-related thrombosis are based on a single follow-up, which is insufficient to reflect the full topography of a thrombosis. DesignThis is an observational study conducted at West China Hospital, according to the STROBE guidelines. MethodsCancer patients scheduled for PICC placement were potentially eligible; patients with contraindications to PICC placement or existing diseases affecting blood flow were excluded; and those who later withdrew or did not reply to our contact request during the follow-up period were eliminated from this study. Ultrasound was used to detect thrombosis from the insertion site, proximal insertion site, axillary vein to the subclavian vein once every two days for two weeks post insertion. The thrombosis and its involved venous segments, onset time and symptoms and signs were recorded. ResultsAmong the 173 included patients, 126 (72.8 %) were identified as having thrombosis. Specifically, 113 and 126 patients were identified as having thrombosis within the first three days and the first week post insertion, respectively. In the 126 patients, thrombosis occurred at the insertion site (72.8 %) concurrently with thrombosis at the proximal insertion site (n = 120, 69.4 %), thrombosis in the axillary vein (n = 94, 54.3 %), and/or thrombosis in the subclavian vein (n = 41, 23.7 %). The log-rank test demonstrated that thrombosis in these four venous segments decreased significantly from the distal to the proximal central vein (log-rank test = 117.128, P < .001). Of 31 patients (17.9 %) who presented symptomatic thrombosis, only five patients experienced obvious swelling in the upper arm, and the other 26 patients exhibited atypical symptoms, such as soreness, tightness, numbness, tingling, or other discomforts in the palm, arm, armpit, and/or shoulder. In some thrombotic cases, ultrasonic assessment of PICC-related thrombosis did not parallel clinical symptoms and signs. ConclusionPICC-related thrombosis is common and can occur very early post insertion in cancer patients, and most thromboses present atypical symptoms. More than half of the cases with thrombosis evaluated involve multiple venous segments, and the farther the venous segments are from the central vein, the higher the incidence of thrombosis tend to be and the earlier the onset time are. Relevance to clinical practiceThe results highlight the importance that medical staff pay particular attention to patients with catheters in the first week post insertion and be alert to thrombosis presenting atypical symptoms while keeping in mind that clinical symptoms and signs are not reliable for diagnosing thrombosis. Clinical regestrationClinical Trials ChiCTR1900024890.

Modified feeding plate for a one-month-old infant with Pierre Robin sequence: A case report

Pierre robin sequence is characterized by the triad of mandibular micrognathia, ‘U’ shaped cleft palate, and glossoptosis. Infants with this condition usually present with airway obstruction and feeding difficulties. This in turn leads to low weight and nutritional deficiencies which might delay the surgical intervention for the same. This case report describes a one-month-old infant with Pierre Robin sequence presenting with feeding difficulty and nasal regurgitation due to a ‘U’ shaped cleft palate. Elastomeric impression followed by fabrication of feeding plate with auto-polymerizing resin was done. Additional ‘S-shaped’ retentive arms were provided from the intra-oral to extra-oral side wire to provide additional retention and to prevent injury to both the child and parent while feeding. Early insertion of a feeding plate helps to prevent nasal regurgitation, to gain weight, and to guide the growth of the mandible in a child with Pierre Robin Sequence.