Line Insertion Research Articles

Clinical Factors Associated to VTE in Multiple Myeloma Patients Treated with Daratumumab

Introduction: Hematologic malignancies, especially multiple myeloma (MM), are associated with a high risk for venous thromboembolism (VTE). In MM, multiple factors increase the risk of VTE including, but not limited to, different treatments. The most recognized therapies that increase VTE risk for MM are immunomodulator drugs (IMIDs), steroids, and carfilzomib. Monoclonal antibodies (mAbs), usually in combination with other treatments, have become the therapy of choice for transplant- and non-transplant candidates in newly diagnosed MM (NDMM) as well as those with relapsed and/or refractory disease (RRMM). Daratumumab is an anti-CD38 monoclonal antibody incorporated in several combination regimens, and its specific effect on VTE risk is not well known. Previous studies have tried to identify clinical and therapy-related factors associated with VTE risk, with limited data on VTE risk and monoclonal antibodies (Wang, J Leuk Lymphoma, 2021). This study aims to identify if an increased risk of VTE exists for patients undergoing treatment with daratumumab-based regimens in efforts to develop a future risk assessment model that incorporates mAbs. Methods: We retrospectively reviewed the medical records of consecutively identified patients who received daratumumab, registered in a data warehouse designed to study the interference of monoclonal antibodies and blood typing procedures, at MD Anderson Cancer Center (MDACC) for the treatment of MM between April 2014 and February 2021. The study was approved by the institutional review board at MDACC. Eligible patients were screened for upper and lower extremity deep venous thrombosis (DVT) and pulmonary embolism (PE) through doppler ultrasound and contrast enhanced radiology reports, respectively, within 365 days after the date of the first dose of daratumumab. A natural language processing algorithm was used to determine the likely VTE positive cases and then was confirmed with manual chart review. Patients were divided into two categories, based on the timing of VTE diagnosis relative to the first dose of daratumumab: VTE post-daratumumab versus non-VTE post-daratumumab. The co-variates of interest were derived from three previous VTE risk stratification systems (SAVED, IMPEDE-VTE, and IMWG) and the differences were compared within the two category-VTE groups. All variables of interest were analyzed using descriptive statistics. Chi-square test or Fisher exact test were used to assess the association between categorical variables, and non-parametric methods were used for continuous numeric variables. Variables with statistically significant differences between VTE-category groups (p≤ 0.05) were analyzed using a binary logistic regression to determine their effect on the VTE occurrence. Results: Out of 258 eligible patients, 32 had evidence of VTE post-daratumumab, for a VTE incidence of 12.4% at 12 months from the initiation of daratumumab. The median time to VTE from the first dose of daratumumab was 3.9 months (IQR 1.6 - 6.1 months). Of the variables tested, we identified that the presence of central venous access (PICC), surgery within the previous 90 days before the initiation of daratumumab, and the history of comorbidities (cardiac disease, CKD, acute infection, or immobilization) were more prevalent in patients with VTE (Table 1). In the logistic regression analysis, only the presence of comorbidities (p = 0.007) was significant to the risk of VTE, but PICC line insertion (p = 0.064) and surgery within the previous 90 days (p = 0.078) were not (Figure 1). The odds of having a new VTE was 3.3 (95% CI, 1.4-7.7). Conclusions: The incidence of VTE during daratumumab therapy appears to be high (>10% in 12 months). The use of concurrent chemotherapy and thalidomide-derivative agents did not appear to increase the risk of VTE in those patients. The presence of comorbidities was the only independent factor associated to the risk of VTE in that cohort. This study suggests that while the incidence of VTE in MM patients is high, the main contributing risk factors for VTE are dynamic and the interplay between those factors changes along the disease course. After validation, these findings could influence and improve current VTE risk assessment models and update primary thromboprophylaxis guidance for improved patient outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Reducing Central-Line-Associated Bloodstream Infections (CLABSI): An Improvement Project in a Specialized Tertiary Hospital.

Central-line-associated bloodstream infections (CLABSI) are preventable hospital-acquired infections that harm and prolong a patient's hospital stay and increase unnecessary hospital expenditure. In collaboration with infection control and hospital epidemiology, the quality management department initiated a performance improvement project to address 144 CLABSI events in 2017. The performance improvement project team used brainstorming to create change ideas presented in a driver diagram. The team then applied plan-do-study-act (PDSA) cycles to implement and monitor the improvements. Finally, the team applied a bundle of interventions that included the following: (a) policies and procedures for central line insertion, maintenance and removal processes standardization, (b) physicians training for line insertion by simulation, (c) an awareness campaign that included recognizing healthcare workers and enhancing patient engagement, (d) performing root cause analysis for the CLABSI events, and (e) automation of central line insertion, and (f) maintenance bundles documentation in the hospital information system. The CLABSI rate per 1000 patient days dropped from 1.5 per 1000 device days to 1.03 per 1000 device days. In addition, CLABSI events reduction was 24% by 2018. Then further reduction of 15% occurred by the end of 2019. Thus, the overall decrease in CLABSI events was 35% from the baseline number of events (i.e., 144 events) in 2017. Another achievement of the project is that 10 units reported zero CLABSI events in 2018 and 2019, of which four units had a high central line utilization rate, more than 40%. The implemented interventions effectively reduced the CLABSI events in the hospital. The project team will continue implementing more interventions with monitoring, aiming to achieve zero CLABSIs over time in all the hospital units.

Two Retrotransposon Elements in Intron of Porcine BMPR1B Is Associated with Phenotypic Variation.

It has been established that through binding to bone morphogenetic proteins (BMPs), bone morphogenetic protein receptor I B (BMPR1B) can mediate transforming growth factor β (TGF-β) signal transduction, and is involved in the regulation of several biological processes, such as bone and muscle formation and homeostasis, as well as folliculogenesis. Also known as FecB, BMPR1B has been reported as the major gene for sheep prolificacy. A number of previous studies have analyzed the relationship between single nucleotide polymorphisms (SNPs) in this gene and its related performance. In recent years, with the illustration of the effect of retrotransposon insertion on the expression of the proximal genes or phenotypic variation, retrotransposon insertion polymorphisms (RIPs) have been used as a novel type of molecular marker in the evaluation of evolution, population structure and breeding of plant and domestic animals. In this study, the RIPs in porcine BMPR1B gene were excavated, and thereafter verified using a comparative genome and polymerase chain reaction (PCR). The potential effects of phenotype, gene expression and functions related to RIPs were also explored. The results showed that 13 distinct RIPs were identified in introns of porcine BMPR1B. Among these, only BMPR1B-SINE-RIP9 and BMPR1B-LINE-RIP13 displayed a close relationship with the growth traits of Large White pigs. Moreover, the total number of BMPR1B-SINE+/+-RIP9 individuals born was found to be significantly higher than that of SINE−/− (p < 0.05). These two RIPs showed an obvious distribution pattern among Chinese indigenous breeds and Western commercial breeds. The expression of BMPR1B in ovaries of adult BMPR1B-SINE+/+-RIP9 Sushan pigs was found to be significantly higher in comparison to those of BMPR1B-SINE−/−-RIP9 (p < 0.05). SINE insertion of BMPR1B-SINE-RIP9 and LINE insertion of BMPR1B-LINE-RIP13 were observed to significantly increase the activity of Octamer binding transcription factor 4 (OCT4) minipromoter in CHO and C2C12 cells (p < 0.01). Therefore, these two RIPs could serve as useful molecular markers for modulating the growth or reproductive traits in assisted selection of pig breeding, while the mechanisms of the insertion function should be studied further.

Thrombosis-Related Loss of Arterial Lines in the First Wave of COVID-19 and Non-COVID-19 Intensive Care Unit Patients.

Patients with coronavirus disease 2019 (COVID-19) can present with severe respiratory distress requiring intensive care unit (ICU)-level care. Such care often requires placement of an arterial line for monitoring of pulmonary disease progression, hemodynamics, and laboratory tests. During the first wave of the COVID-19 pandemic in March 2020, experienced physicians anecdotally reported multiple attempts, decreased insertion durations, and greater need for replacement of arterial lines in patients with COVID-19 due to persistent thrombosis. Because invasive procedures in patients with COVID-19 may increase the risk for caregiver infection, better defining difficulties in maintaining arterial lines in COVID-19 patients is important. We sought to explore the association between COVID-19 infection and arterial line thrombosis in critically ill patients. In this primary exploratory analysis, a multivariable Fine-Gray subdistribution hazard model was used to retrospectively estimate the association between critically ill COVID-19 (versus sepsis/acute respiratory distress syndrome [ARDS]) patients and the risk of arterial line removal for thrombosis (with arterial line removal for any other reason treated as a competing risk). As a sensitivity analysis, we compared the number of arterial line clots per 1000 arterial line days between critically ill COVID-19 and sepsis/ARDS patients using multivariable negative binomial regression. We retrospectively identified 119 patients and 200 arterial line insertions in patients with COVID-19 and 54 patients and 68 arterial line insertions with non-COVID ARDS. Using a Fine-Gray subdistribution hazard model, we found the adjusted subdistribution hazard ratio (95% confidence interval [CI]) for arterial line clot to be 2.18 (1.06-4.46) for arterial lines placed in COVID-19 patients versus non-COVID-19 sepsis/ARDS patients ( P = .034). Patients with COVID-19 had 36.3 arterial line clots per 1000 arterial line days compared to 19.1 arterial line clots per 1000 arterial line days in patients without COVID-19 (adjusted incidence rate ratio [IRR] [95% CI], 1.78 [0.94-3.39]; P = .078). Our study suggests that arterial line complications due to thrombosis are more likely in COVID-19 patients and supports the need for further research on the association between COVID-19 and arterial line dysfunction requiring replacement.

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

PARTIAL ANOMALOUS PULMONARY VENOUS CONNECTION DIAGNOSED AFTER CENTRAL VENOUS CATHETER PLACEMENT

381 Intra-Nasal Fentanyl for Fracture Patients in the Pediatric Emergency Department

381 Intra-Nasal Fentanyl for Fracture Patients in the Pediatric Emergency Department

28 A multi-center study of peripherally inserted central venous catheters: Predictors of difficult line insertion, malfunction, and soft tissue injury

28 A multi-center study of peripherally inserted central venous catheters: Predictors of difficult line insertion, malfunction, and soft tissue injury

Association between nurse staffing levels and rotavirus infection in neonatal intensive care units: A retrospective observational study

ObjectivesTo explore the relationship between nurse staffing levels and rotavirus infection in neonatal intensive care units. Research MethodologyThis study adopted a retrospective observational design with data from the Health Insurance Review and Assessment Service (2018) database in South Korea. Participants were 35,308 infants in neonatal intensive care units. Multiple logistic regression analyses were employed to examine the association between nurse staffing levels and rotavirus infection in neonatal intensive care units after adjusting for confounding variables such as patient and hospital-related characteristics. ResultsA total of 1,514 (4.3%) infants developed rotavirus infection. Among the confounding variables, infectious disease, and being admitted from January to March and in December significantly increased the risk of rotavirus infection, whereas low birth weight, cardiovascular disorders, neonatal jaundice, receiving breastmilk, central line insertion, and ventilator usage significantly decreased the risk. Neonatal intensive care units with a grade 5 nurse staffing level (compared with grades 1–4) had a higher risk of rotavirus infection. ConclusionsThe results suggest that neonatal intensive care units with higher (vs lower) nurse staffing levels are associated with lower rotavirus infection rates among infants. High-risk infants are extremely susceptible to hospital-acquired infections, and more intensive nursing care that differs from that provided to adult or paediatric patients is required. Therefore, nurse staffing levels with less than a 2:1 patient-to-nurse ratio are needed to control and prevent rotavirus infection in neonatal intensive care units.

Incidence of fertility preservation procedures in prepubertal individuals with cancer

Fertility Preservation (FP) for children and adolescents with cancer is underutilized. In prepubertal individuals, ovarian and testicular tissue can be frozen; however, this is still considered largely experimental. Our objective was to identify trends of FP in prepubertal individuals. We performed a retrospective study of prepubertal children with cancer identified through the Pediatric Health Information System from 2011 to 2020. Children who underwent a testicular or ovarian biopsy were included. Any patients with testicular or ovarian malignancy, or other diagnoses which may have required a gonadal biopsy were excluded. A total of 418 boys under 13 and 333 girls under 12 who underwent a gonadal biopsy were identified. There was a total of 66,929 new cancer diagnoses in girls and 86,001 new cancer diagnoses in boys during this time. The most common cancer diagnosis was hematologic in both boys (50.96%) and girls (36.64%). A concurrent procedure at time of gonadal biopsy was performed in 84% of boys and 62% of girls, with line insertion being the most common. The only predictive variable of receiving a gonadal biopsy was increasing year. Overall, only 0.04% of children had a gonadal biopsy for FP during this time period. Gonadal biopsy rates have increased in prepubertal children with cancer, presumably for FP. While recent international guidelines support FP in this group, our findings highlight the need to establish protocols and tracking for FP procedures in the US.

Mechanical complications of weekly care and maintenance versus once every 10 days of the peripherally inserted central catheter line insertion site in newborns: A propensity score-matched cohort study in Mexico

PurposeTo evaluate the mechanical complications of weekly care and maintenance versus once every 10 days of the peripherally inserted central catheter (PICC) line insertion site versus once every 10 days in newborns. Design and methodsProspective propensity score matched cohort study. Care and maintenance of the PICC line insertion site were performed on days 7 and 10 during January 2018 to December 2019. To compare mechanical complications, propensity score matching was performed. Propensity scores were used to determine the relative risks and hazard ratios by using logistic regressions with log-link function and Cox regressions, respectively. ResultsWe included 175 newborns hospitalized in the neonatal intensive care unit (NICU) who underwent insertion of a PICC line. Ninety-six received weekly care and maintenance, and 79 received care and maintenance every 10 days. Weekly care and maintenance were associated with more breakage (RR 1.98, 95% CI 1.68–2.34); occlusions (RR 0.81, 95% CI 0.46–1.42) and accidental withdrawals (RR 1.31, 95% CI 0.93–1.84) were not different between care and maintenance every 7 and 10 days. A survival analysis was performed, showing that weekly care and maintenance are a risk factor for removal for mechanical complications (HR 7.61, 95% CI 3.05–19.01). ConclusionWe concluded that care and maintenance of the PICC in newborns every 10 days have fewer complications than when performing care and maintenance every 7 days. Practice implicationsNewborns requiring intravenous therapy will benefit from care and maintenance every 10 days, and this practice could potentially spread to other NICUs.

Current practice, education and recommendations for training of central line insertion for trainees and fellows in adult intensive care units across Australia and New Zealand.

Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. A prospective cross-sectional web-based survey was sent through email and CICM e-newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post-hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty-five percent of the participants inserted 0-5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1-year period. Two-thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU.

Clinical outcomes and characteristics of acute myocardial infarction patients with developing fever after percutaneous coronary intervention

The incidence of fever complicating percutaneous coronary intervention (PCI) is rare. However, little is known regarding the cause of fever after PCI. Therefore, this study aimed to determine the clinical characteristics of patients with acute myocardial infarction (AMI), with or without fever, after PCI. We enrolled a total of 926 AMI patients who underwent PCI. Body temperature (BT) was measured every 4 hours or 8 hours for 5 days after PCI. Patients were divided into two groups according to BT as follows: BT&lt;37.7°C (no-fever group) and BT ≥37.7°C (fever group). The 2 years clinical outcomes were compared subsequently. Fever after PCI was associated with higher incidence of major adverse cardiac events (MACE) (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.07-2.28; &lt;i&gt;P&lt;/i&gt;=0.021), all-cause death (HR, 2.32; 95% CI, 1.18-4.45; &lt;i&gt;P&lt;/i&gt;=0.014), cardiac death (CD) (HR, 2.57; 95% CI, 1.02-6.76; &lt;i&gt;P&lt;/i&gt;=0.049), and any revascularization (HR, 1.69; 95% CI, 1.02-2.81; &lt;i&gt;P&lt;/i&gt;=0.044) than without fever. In women, prior chronic kidney disease, lower left ventricular (LV) ejection fraction, higher LV wall motion score index, white blood cell count, peak creatine kinase-myocardial band level, and longer PCI duration were associated with fever after PCI. Procedures such as an intra-aortic balloon pump, extracorporeal membrane oxygenation, continuous renal replacement therapy, central and arterial line insertion, and cardiopulmonary resuscitation were related to fever after PCI. Fever after PCI in patients with AMI was associated with a higher incidence of MACE, all-cause death, CD, and any revascularization at the 2 years mark than in those without fever.

The role of routine chest radiography after implantable venous access port catheter insertion under the guide of ultrasonography and fluoroscopy

BackgroundThe objective of this study is the evaluation of routine chest radiography following the placement of Implantable venous access port catheter (IVAPC) central lines using combined ultrasound and fluoroscopic guidance by a vascular surgeon in the operating room.Material and methodA prospective study of 189 consecutive patients who underwent IVAPC central line insertion in the vascular surgery operating room from 2016 to 2019. Venipuncture was performed with an 18-gauge needle under the guidance of sonography in each case, and the access site was noted. The line position was confirmed by fluoroscopy following the procedure. Multiple tries for puncture and patients under 18 were excluded from our study. Routine radiography of chest was performed for all patients and pneumothorax, hemothorax, and catheter malposition were evaluated in each case.ResultsThere were 2 cases of asymptomatic pneumothorax, no cases of hemothorax, and all catheter tip positions were optimal or acceptable. The annual cost of chest radiography was 33,000,000IRR, 220 h of hospital and staff time, and 1.1 mSv radiation.ConclusionIn conclusion, when imaging guidance is used for IVAPC insertion by an experienced surgeon in a high-volume center, performing post-procedure routine chest radiography shows little benefit.

Severity and Extent of Lead-Related Venous Obstruction in More Than 3000 Patients Undergoing Transvenous Lead Extraction.

BackgroundLead-related venous stenosis/obstruction (LRVSO) may be a major challenge in patients with cardiac implantable electronic devices (CIED) when device upgrade, insertion of central lines, or creation of an arteriovenous fistula for hemodialysis is indicated. The aim of this study was to evaluate the extent and severity of LRVSO.MethodsWe performed a retrospective analysis of 3002 venograms from patients awaiting transvenous lead extraction (TLE) to assess the occurrence, severity, and extent of LRVSO.ResultsMild LRVSO occurred in 19.9%, moderate in 20.7%, severe in 19.9% and total venous occlusion in 22.5% of the patients. Moderate/severe stenosis or total occlusion of the subclavian and brachiocephalic veins was found in 38.2% and 22.5% of the patients, respectively. LRSVO was not detected in 16.9% of the patients. Moderate and severe superior vena cava (SVC) obstruction and total SVC occlusion were rare (0.4%, 0.3%, and 0.3%, respectively). Lead insertion on the left side of the chest contributed to an increased risk of LRVSO compared to right-sided implantation. Major thoracic veins on the opposite side may be narrowed in varying degrees.ConclusionA total of 60% of the patients with pacemaker or high-voltage leads have an advanced form of LRVSO. Any attempt to insert new pacing leads, central lines, venous ports, or catheters for hemodialysis, or to create dialysis fistula on the same side as the existing lead should be preceded by venography. Furthermore, venography may provide useful information, if it is planned to implant the lead or the catheter on the opposite side of the chest.

Chlorhexidine (di)gluconate locking device for central line infection prevention in intensive care unit patients: a multi-unit, pilot randomized controlled trial

Intensive care unit (ICU) patients are at risk for central line-associated bloodstream infection (CLABSI) with significant attributable mortality and increased hospital length of stay, readmissions, and costs. Chlorhexidine (di)gluconate (CHG) is used as a disinfectant for central line insertion; however, the feasibility and efficacy of using CHG as a locking solution is unknown. Patients with a central venous access device (CVAD) in situ were randomized to standard care or a CHG lock solution (CHGLS) within 72 hours of ICU admission. The CHG solution was instilled in the lumen of venous catheters not actively infusing. CVAD blood cultures were taken at baseline and every 48 hours. The primary outcome was feasibility including recruitment rate, consent rate, protocol adherence, and staff uptake. Secondary outcomes included CVAD colonization, bacteraemia, and clinical endpoints. Of 3,848 patients screened, 122 were eligible for the study and consent was obtained from 82.0% of the patients or substitute decision makers approached. Fifty participants were allocated to each group. Tracking logs indicated that the CHGLS was used per protocol 408 times. Most nurses felt comfortable using the CHGLS. The proportion of central line colonization was significantly higher in the standard care group with 40 (29%) versus 26 (18.7%) in the CHGLS group (P=0.009). Using a device that delivers CHG into CVADs was feasible in the ICU. Findings from this trial will inform a full-scale randomized controlled trial and provide preliminary data on the effectiveness of CHGLS. ClinicalTrials.gov Identifier NCT03309137, registered on October 13, 2017.

Transthoracic intracardiac lines-A double edged sword.

Routine use of central venous access is needed in children undergoing open heart surgery for pressure monitoring and inotrope infusion. We sought to evaluate the efficiency and safety of routine use of transthoracic intracardiac lines (ICLs) in patients undergoing cardiac surgery and to compare them to patients who have been previously treated with traditional central venous lines (non-ICLs). Retrospective review of charts of all patients who underwent cardiac surgery and had an ICL inserted in the operating room. Case control matching was done with similar patient in which ICL was not inserted. Patients characteristics, diagnosis, operative, and intensive care datawere collected for each patient and analyzed. A total number of 376 patient records were reviewed (198 ICL patientsand 178 non-ICL patients). Umbilical line and non-ICL durations were longer in the non-ICL group. ICL duration was the longest of all lines, averaging 12.87 ± 10.82 days. The necessity for multiple line insertions (˃2 insertions) was significantly higher in the non-ICL group, with a relative risk ratio of 3.24 (95% confidence interval: 1.617-6.428). There was no statistical difference of infections rate and line complications between the two groups. ICLs are safe in infants undergoing cardiac surgery and can be kept in place for a long period of time with a low rate of line complications and infection. Routine use of ICLs reduces the number of central venous catheter placement in this complex patient population.

Common Emergency Department Procedures: Competency, Knowledge, and Frequency of Performance by Emergency Medicine Trainees

BACKGROUND Trainees ought to master specific procedural skills throughout the course of the emergency residency programme they are enrolled in. AIMS We aim to assess the level of exposure to procedures, the confidence towards performing such procedures during each level of training, and an estimate of the minimum number of procedures required to influence trainee confidence and knowledge. METHODS The authors constructed a survey that was distributed using a snowball sampling method, targeting a sample of emergency trainees at nine training hospitals in Riyadh, Saudi Arabia. Participants were asked to answer multiple questions related to 6 different emergency procedures, including the amount of times the procedure had previously been performed and a personal assessment of confidence level related to each procedure using a five-point scale. The mean levels of knowledge and confidence were calculated and used as parameters to reflect on the training of participants. RESULTS The survey was completed by a total of 104 participants and revealed that the most common overall procedure performed was endotracheal intubation with the least common being vaginal delivery. A significant difference was noted between senior trainees and trainees at junior levels in the mean knowledge score for procedures [F(3,100)= 6.03, p= 0.001]. A positive correlation was found between the number of procedures performed and the confidence level. The minimum number of procedures according to the survey revealed the need for more than 15 intubation attempts, 6-10 central line insertions, 1-5 chest tube placements, 1-5 shoulder reductions and 6-10 lumbar punctures to build confidence in trainees. CONCLUSION Procedures that are less frequently performed in specific settings should be noted and attempts should be made to broaden exposure through simulations or rotations at other centres with higher procedural exposure rates.

Risk factors for early PICC removal: A retrospective study of adult inpatients at an academic medical center.

Use of PICCs has been rising since 2001. They are used when long-term intravenous access is needed and for blood draws in patients with difficult venous access. To determine which risk factors contribute to inappropriate PICC line insertion defined as removal of a PICC within five days of insertion for reasons other than a PICC complication. Retrospective, observational study. Tertiary-care, Level 1 trauma center. Adult patients with a PICC removed 1/1/2017 to 5/4/2020. Frequency of PICC removal within five days of insertion and associated risk factors for early removal. Between 1/1/2017 and 5/4/2020, 995 of 5348 PICCs inserted by the IV nursing team were removed within five days (19%). In 2017, 5 of 429 PICCs developed a central line-associated infection (1.2%) and 29 of 429 PICCs developed symptomatic venous thromboembolism (6.7%). Patients with PICCs whose primary service was in an ICU were independently at higher risk of early removal (OR 1.44, 95% CI 1.14, 1.83); weekday insertion was independently associated with a lower likelihood of early removal compared to weekend insertion (OR 0.60; 95% CI 0.49, 0.75). PICC removal after discharge was not assessed and paper records were likely incomplete and biased. Nearly one in five PICCs were removed within five days. Patients whose primary team was in an ICU and PICCs ordered on weekends were at independently higher risk of early removal.

Geriatricians' knowledge of terminal care in patients with advanced dementia

Objective: To learn about the disagreements among geriatricians from a Latin American country (Peru) as to the palliative therapy for dementia. Materials and methods: A descriptive and cross-sectional study. The population consisted of Peruvian geriatricians and geriatrics residents surveyed during August 2019. A non-probability convenience sampling was used. Considering a total population of 277 geriatricians in Peru and a design effect of 1.0, the minimum sample size was 162 geriatricians. The survey included different questions focused on geriatricians’ decisions on the daily clinical practice of terminal care in dementia. To ensure a better understanding of the answers, a typical case of the disease was presented. Results: One hundred sixty-two (162) doctors were surveyed, most of whom were geriatricians (81.48 %). Regarding the global level of attitudes and knowledge of palliative care, 89.61 % considered dementia as a non-oncological terminal illness, and 69.18 % considered laboratory sample collection, peripheral intravenous line insertion, urinary catheterization and nasogastric tube insertion as invasive measures. Conclusions: The survey showed a moderate level in attitudes and knowledge of palliative care. The weakest points were the practical perspective and suitability in decision-making. Therefore, training programs aimed at making adequate prognoses and improving decision-making of physicians involved in the care and support of older adults with late-stage dementia should be conducted to avoid implementing measures that will not generate a positive impact to and will harm the patient's quality of life.

Disjunção do Anel Mitral: Modalidades Diagnósticas, Implicações Clínicas e Evolução Prognóstica

Mitral annulus disjunction (MAD) is an abnormal insertion of the flexion line of the mitral annulus into the atrial wall. The annulus presents a separation (disjunction) between the posterior leaflet–atrial wall junction and the left ventricular myocardial crest.1 MAD was first described more than 30 years ago in an autopsy study and is reportedly related to mitral valve prolapse (MVP) in 92% of cases.2 Since then, several studies have been conducted, and reports on the prevalence of MAD in patients with MVP have varied. Ultimately, it may or may not be associated with mitral regurgitation. Transthoracic echocardiography is part of initial MVP assessment, allowing its diagnosis and the assessment of related complications. As new diagnostic methods emerged, cardiac magnetic resonance imaging and transesophageal echocardiography improved the assessment of this pathology in terms of its diagnosis, extension, and location. However, the phenotypic characteristics of MVP that are more closely associated with MAD remain uncertain mainly due to the limited number of patients in classic studies on the subject. Patients with MAD may develop symptoms related to ventricular arrhythmias, configuring the MAD arrhythmic syndrome, which may progress to sudden death. The literature presents conflicting prognostic data among several studies on the subject from clear diagnostic criteria and best imaging method to be used to treatment and prognosis. This review describes MAD characteristics associated (or not) with valve prolapse to improve the diagnosis and management of this important pathology.