Peripheral Line Research Articles

Comparison of Invasive Arterial Blood Pressure Monitoring vs. Non-Invasive Blood Pressure Monitoring in Preterm Infants < 37 Weeks in the Neonatal Intensive Care Unit- A Prospective Observational Study.

Accurate measurement of blood pressure (BP) is extremely important in the management of sick preterm newborns. The primary objective of this study was to compare non-invasive blood pressure measurement (NIBP) with invasive blood pressure measurement (IBP) using peripheral arterial cannulation (PAC) in preterm neonates < 37 weeks in the neonatal intensive care unit. Preterm neonates needing PAC were prospectively enrolled in the study. NIBP measurements were taken in the same limb as that of peripheral arterial line. Initially IBP was recorded followed by NIBP within 1 min using the same monitor. These were called as paired measurements since they are taken within 1 min of each other. Seventy-three preterm infants with 1703 paired measurements were included in the final analysis (median gestational age 32 weeks, IQR 30-34 weeks, median birth weight 1540 g, IQR 1160-2100 g). In preterm infants not receiving vasoactive agents (n = 51, 1428 paired measurements, Bland-Altman analysis for agreement between invasive mean blood pressure (MBP) and non-invasive mean BP revealed a bias of -2.9123 mmHg (SD 7.8074). The 95% limits of agreement were from -18.2157 to 12.3893 mmHg. In preterm infants with hypotension, we detected a bias of -3.9176 mmHg (SD 5.1135) between invasive MBP and non-invasive MBP. The 95% limits of agreement were from -13.9401 to 6.1048 mmHg. In normotensive preterm infants receiving vasoactive agents, we detected a bias of -0.7629 mmHg (SD 8.0539) between invasive MBP and non-invasive MBP. The 95% limits of agreement were from -16.5485 to 15.02274 mmHg. There is poor level of agreement between IBP and NIBP measurements in sick preterm neonates, leading to overestimation or underestimation of blood pressure. The bias was less for mean BP measurements as compared with systolic BP measurements and also for normotensive neonates as compared with hypotensive neonates. Hence, NIBP may be used as a screening method in haemodynamically stable preterm infants, but infants who are haemodynamically unstable and need to be commenced on vasoactive agents should have IBP monitoring.

1056. Safety and Tolerability of Dalbavancin in Vancomycin Allergic Patients – A Case Series

BackgroundVVancomycin and dalbavancin, both in the glycopeptide class of antibiotics, are used in the treatment of Gram-positive infections, including methicillin-resistant Staphylococcus aureus. Antibiotics in this class contain a heptapeptide core that has potential for cross-sensitivity. Due to this risk, dalbavancin carries a warning in the package insert for use in patients with a glycopeptide allergy. Dalbavancin, a semi-synthetic derivative of vancomycin, has lipophilic side chains which reduce the risk of cross-sensitivity to vancomycin. This case series evaluated patients with a listed vancomycin allergy in their electronic health record who received dalbavancin as an outpatient infusion.MethodsThis study was a non-randomized, retrospective chart review of adult patients who had a documented vancomycin allergy and received dalbavancin between February 2016 and February 2021 for any indication in the outpatient setting. The primary objective was to evaluate dalbavancin tolerability in patients allergic to vancomycin. Patient characteristics and the specifics of dalbavancin infusion – dose, volume, infusion rate, intravenous line access, and receipt of premedication before infusion – were collected on each patient.Results559 unique patients received dalbavancin over the time frame. Of these, ten had a documented, subjective vancomycin allergy. Patient-reported allergic reactions were rash (4), hives (3), anaphylaxis (2), red man syndrome (2), renal failure (2), and general malaise (1). Six patients had at least 1 additional subjective drug allergy. The various infections treated included cellulitis/abscess (8), osteomyelitis (1), and bacteremia (2). Most patients received 1500mg (2 received 1125mg) of dalbavancin in 300-500mL of dextrose 5% in water infused at either 600 or 1000mL/hr via a peripheral (6) or central (4) intravenous line. All patients tolerated the infusion with no adverse events reported and no receipt of premedication before administration. ConclusionDalbavancin may be a reasonable treatment option in vancomycin allergic patients, despite possible cross-sensitivity. Further investigation into cross-sensitivity between vancomycin, dalbavancin, and other glycopeptide class agents is warranted.Disclosures Kerry O. Cleveland, M.D., AbbVie (Speaker’s Bureau)Merck (Speaker’s Bureau)Pfizer (Speaker’s Bureau) Bruce M. Jones, PharmD, BCPS, Abbvie (Consultant, Advisor or Review Panel member, Speaker’s Bureau)La Jolla (Speaker’s Bureau)Melinta (Consultant)Merck (Consultant)Paratek (Consultant, Speaker’s Bureau)

A novel missense mutation in TNFAIP3 causes haploinsufficiency of A20

A20, encoded by TNFAIP3, is an effective anti-inflammatory molecule that plays a crucial role in inhibiting NF-κB signal transmission and is linked to multiple inflammatory diseases. It has been reported that the haploinsufficiency of A20 (HA20) caused by multiple base mutations in TNFAIP3 shows early-onset spontaneous Behçet-like disease. However, the mechanisms by which A20 mutations involved in inflammatory disease are incompletely defined. Herein, we reported a novel TNFAIP3 (c.1804A > T, p.T602S) variation, which has not been reported before. Summarizing the patient's immunodeficiency phenotype, we aimed to delineate the underlying mechanism for regulation of inflammation and immunity. Candidate genes associated with the Behçet-like phenotypes of the patient were screened and identified by using whole-exome and sanger sequencing. Functional studies were performed in A20(c.1804A > T, p.T602S) patient-derived peripheral blood mononuclear cells (PBMCs) and THP-1 cell lines by lentivirus mediating stable over-expression of A20 and A20(c.1804A > T, p.T602S) to analyze the activity of NF-κB signaling pathway. The clinical manifestations in patients with syndrome are Behçet-like disorder, and sequencing revealed heterozygous mutation in TNFAIP3 (c.1804A > T, p.T602S). Functional tests found that the PBMCs of the patient and his family carrying this heterozygous variant stimulated by LPS, TNF-α, or IL-1β, increased the levels of inflammatory factors and induced over-activation of the canonical NF-κB signaling pathway. Similar results were also observed in the stable transduction THP-1 (A20, c.1804A＞T) cell line stimulated by LPS, TNF-α or IL-1β. The novel loss-of-function A20 variation (c.1804A > T, p.T602S) causes over-activation of the canonical NF-κB signaling pathway and fail to terminate NF-κB signaling in response to stimulation by inflammatory cytokines. The variation triggers a dominantly-inherited Behçet-like disorder caused by haploinsufficiency of the A20 protein. Identification of the novel A20 mutation attaches great importance to prenatal diagnosis and fetal therapeutic intervention, drastically reducing the risk of newborns suffering from HA20.

Comparison of the Efficacy of Simple, Partial Manual and Automated Exchange Transfusions in the Management of Sickle Cell Disease in Pediatric Patients

Background: Chronic transfusion therapy in sickle cell disease is used to prevent complications of sickle cell disease by reducing hemoglobin S levels, most commonly used for primary or secondary stroke prophylaxis, amongst other indications. Transfusions can be completed as simple, partial manual exchange or automated exchange.Comparative evidence on the long term efficacy of simple, partial manual or automated exchange in the management of children with sickle cell disease is lacking.Methods: A retrospective study of patients aged less than 18 years with a diagnosis of sickle cell disease on a chronic transfusion program (simple top-up transfusion, partial manual exchange or automated exchange transfusion), followed at the Hospital for Sick Children, Toronto, Ontario from January 2003- July 2020.We excluded patients who received transfusions for acute complications. Data collected included: demographics, indication for transfusion, type of transfusion (simple, partial manual exchange or automated exchange), access for transfusion (peripheral intravenous (PIV), central venous line (CVL)), pre-transfusion hemoglobin and hemoglobin S values.Analysis: Exploratory data analysis was conducted where descriptive statistics were used to summarize data for both continuous and categorical variables. Continuous variables were summarized using measures of central tendency and dispersion where mean and standard deviations for normally distributed data and medians and interquartile ranges were used where the data was skewed. Chi-squared tests were employed when demonstrating relationships between two categorical variables. All statistical analyses were two-sided tests with 0.05 as the critical level of significance.Ethics: This study was approved by The Hospital of Sick Children Research Ethics Board(REB).Results: Sixty-one participants were observed between January 2003 and July 2020. Majority 38 out of (62.3%) of the participants were male. The most common indication for transfusion was primary stroke prevention (following abnormal transcranial doppler (TCD) 36 %) followed by vasculopathy 11 (%, stroke 9 % , abnormal TCD & silent infarct 8 %, and splenic sequestration 2 %) There were 744 total transfusions. 491/744 (66%) transfusions were simple transfusions, 168/744 (22.6%) were PMEs while 85/744 (11.4%) were apheresis transfusions. Average pre-transfusion hemoglobin S (HbS) was similar between the two types of access (p=0.416) and also across the three types of transfusion (p=0.158).The type of access did not appear to have an effect on the changes in HbS per transfusion(p=0.561.)The trends of pre-transfusion HbS %were similar over time between participants whose access was PIV and those whose access was CVL/ PORT.(Figure 1 below).Achievement of target HbS was similar between peripheral intravenous and central venous line access (p=0.337) and across the three types of transfusion (p=0.086).See Table 1 below.The type of transfusion had an effect on the reduction in HBS with simple transfusion having the highest percentage change of HbSS(-3.69%) followed by Apheresis (-1.32%) and PME (-0.75%), p=0.018., that is per every transfusion. The reason for this is that is the values being compared are quite different. The automated exchange values are on established patients (pre transfusion hemoglobin S had already been lowered), while the simple transfusion values are on new to transfusion patients (pre transfusion S high), the patients on partial manual exchange started off with lower HbS levels, so consequently their change was less.Conclusion: All three types of transfusion had equal efficiency in reducing HbS over time. Apheresis showed a quicker reduction in the hemoglobin S level in the initial transfusions. Simple transfusions and PME are as efficient as apheresis in achieving target HbS levels to prevent complications associated with SCD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Colonization of the central venous catheter by Stenotrophomonas maltophilia in an ICU setting: An impending outbreak managed in time

BackgroundStenotrophomonas maltophiliacauses opportunistic infections in immunocompromised and patients in intensive care units (ICUs). An outbreak of S. maltophilia in ICU is described which highlights the importance of the risk of infection from contaminated medical devices and suction fluids in ventilated patients. MethodsThe investigation of the outbreak was carried out. Environmental sampling was done. This was followed by MALDI-TOF MS typing and recA gene-based-phylogeny. ResultsIn February, S. maltophilia was reported from the central line blood of six patients from ICU within a span of two weeks. The peripheral line blood cultures were sterile in all patients. Relevant environmental sampling of the high-touch surface and fluids revealed S. maltophilia strains in normal saline used for suction and in the inspiratory circuit of two patients. The isolated strains from patients and environment (inspiratory fluid) showed a minimum of 95.41% recA gene sequence identity between each other. Strict cleaning and disinfection procedures were followed. Continuous surveillance was done and no further case of S. maltophilia was detected. Timely diagnosis and removal of central line prevented development of central-line associated blood stream infection. ConclusionThis outbreak report illustrates that environmental sources like suction fluid and normal saline could be the source of S. maltophilia in ICU patients.

Options to Minimize the Use of Central Lines: Midodrine, Peripheral Venous Lines, and Midline Catheters.

Options to Minimize the Use of Central Lines: Midodrine, Peripheral Venous Lines, and Midline Catheters.

Perioperative Antibiotic Use in Endoscopic Endonasal Skull Base Surgery.

Introduction Improved evidence-based guidelines on the optimal type and duration of antibiotics for patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) are needed. We analyze the infectious complications among a large cohort of EETS patients undergoing a standardized regimen of cefazolin for 24 hours, followed by cephalexin for 7 days after surgery (clindamycin if penicillin/cephalosporin allergic). Methods A retrospective review of 132 EETS patients from 2018 to 2020 was conducted. Patient, tumor, and surgical characteristics were collected, along with infection rates. Multivariate logistic regression determined the variable(s) independently associated with infectious outcomes. Results Nearly all patients (99%) received postoperative antibiotics with 78% receiving cefazolin, 17% receiving cephalexin, 3% receiving clindamycin, and 2% receiving other antibiotics. Fifty-three patients (40%) had an intraoperative cerebrospinal fluid (CSF) leak, and three patients (2%) developed a postoperative CSF leak requiring surgical repair. Within 30 days, no patients developed meningitis. Five patients (4%) developed sinusitis, two patients (3%) developed pneumonia, and one patient (1%) developed cellulitis at a peripheral intravenous line. Two patients (2%) developed an allergy to cephalexin, requiring conservative management. After adjustment for comorbidities and operative factors, presence of postoperative infectious complications was independently associated with increased LOS ( β = 3.7 days; p = 0.001). Conclusion Compared with reported findings in the literature, we report low rates of infectious complications and antibiotic intolerance, despite presence of a heavy burden of comorbidities and high intraoperative CSF leak rates among our cohort. These findings support our standardized 7-day perioperative antibiotic regimen.

ALL SUGARS ARE NOT SWEET

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Extravasation of vesicants occurs when there is leakage from a vessel into the surrounding area, with the potential to cause tissue necrosis. Common vesicants include vasopressors, alkylating chemotherapeutic agents, hyper-osmolar or hypo-osmolar agents, and certain antibiotics (vancomycin). Dextrose, at concentrations greater than 10% (D10), is also considered a vesicant, with rates of extravasation from 50% dextrose (D50) varying between 10-30% (1). CASE PRESENTATION: A cachectic 48-year-old with a history of HIV and alcohol and IV drug use, presented with lethargy. Upon initial assessment, she had track marks on her arms and was only responsive to sternal rub, with her exam otherwise unremarkable. She briefly improved with intravenous naloxone but ultimately required intensive care unit admission following intubation for airway protection. The toxicology screen was positive for methadone, opioids, and alcohol. Initial labs revealed ALT of 118 units/L, AST of 94 units/L, hemoglobin of 9.5 g/dL, and albumin of 2.3 g/dL. She was started on thiamine, multivitamin, and folate supplements. Despite starting tube feeds, fingerstick (FS) glucose was consistently low, dropping to 35 mg/dL. She received 2 ampules of 50 mL (25 g) 50% dextrose through a 22-gauge antecubital peripheral IV line, with FS improving to 220 mg/dL after 10 minutes. Two hours later, extensive swelling and fluid-filled blisters were noted throughout the forearm and hand, with Doppler ultrasound revealing the absence of a radial pulse. Her arm was elevated, a cold compress was applied, and a local subcutaneous injection of hyaluronidase was administered. Compartment pressures remained within normal limits, and a repeat Doppler ultrasound after an hour showed reappearance of a right radial pulse. The patient's swelling and blisters improved over the next few days. DISCUSSION: To the best of our knowledge, there are only three published cases on D50 extravasation so far, where D50 was administered by initial paramedic responders, in the field, in an emergent setting (1,2,3). D10 has a similar median time to recovery and post-treatment Glasgow Coma Scale, but with a decreased risk of rebound hyperglycemia. In our case, as the hypoglycemia incident occurred in an intensive care unit, administering D10 would have been a better option, as frequent FS monitoring would have been possible to assess response. Fortunately, close monitoring allowed for early recognition, prompt treatment, and good outcome. CONCLUSIONS: Hypoglycemia is a frequently encountered complication in a critical care setting. This case emphasizes the importance of early detection and treatment when suspecting extravasation of D50 to prevent the development of serious complications. D10 is now emerging as a safer and equally effective alternative to D50 and could become the standard of care for hypoglycemia management. REFERENCE #1: Wiegand R, Brown J. Hyaluronidase for the management of dextrose extravasation. Am J Emerg Med. 2010 Feb;28(2):257.e1-2. doi: 10.1016/j.ajem.2009.06.010. PMID: 20159411. REFERENCE #2: Chinn M, Colella MR. Prehospital Dextrose Extravasation Causing Forearm Compartment Syndrome: A Case Report. Prehosp Emerg Care. 2017 Jan-Feb;21(1):79-82. doi: 10.1080/10903127.2016.1209263. Epub 2016 Sep 6. PMID: 27598324. REFERENCE #3: Lawson SL, Brady W, Mahmoud A. Identification of highly concentrated dextrose solution (50% dextrose) extravasation and treatment--a clinical report. Am J Emerg Med. 2013 May;31(5):886.e3-5. doi: 10.1016/j.ajem.2012.12.010. Epub 2013 Apr 18. PMID: 23602753. DISCLOSURES: No relevant relationships by Natasha Garg, source=Web Response No relevant relationships by Archana Pattupara, source=Web Response No relevant relationships by Adam Rothman, source=Web Response No relevant relationships by DISHANT SHAH, source=Web Response

744 THE USE OF IMMUNOFLUORESCENCE TO EVALUATE THE PERFUSION OF THE GASTRIC PLASTY DURING OESOPHAGECTOMY.

Abstract Anastomotic leakage in oesophageal cancer surgery is one of the most serious complications and occurs mainly at the cervical level between 10–30% according to series. The use of immunofluorescence could help to select a better vascularized area in which to perform the anastomosis more safely. We present the initial experience (between July and December 2020) of our group. Methods Prospective and descriptive study of patients with oesophageal neoplasia who underwent a 3 stage oesophagectomy with cervical anastomosis using immunofluorescence with indocyanine green (dose: 7,5 mg) for quick evaluation of vascularization in the theoretical anastomosis zone in gastric plasty. Intravenous injection of the indocyanine green dilution was performed intraoperatively in a peripheral line, once the plasty was positioned in place to perform the anastomosis. The route of ascent was transmediastinal in all cases. 9 patients with a mean age of 61 ± 7.6 years were included in the study. Results The mean heart rate was 83 ± 16 bpm, the mean systolic blood pressure was 111 ± 17 mmHg. The time and mean speed it took for the fluorescence to reach the marked area to perform the anastomosis was 30 ± 28 seconds and 1.83 cm/sec; and at the apex of the plasty it was 93 ± 79 seconds and 0.75 cm/sec. In all patients in whom the anastomosis was performed in the area where ICG arrived between 30 and 90 seconds, there was no leakage. In two patients, due to anatomical needs, the anastomosis was performed in areas where ICG took more than 100 seconds and in the postoperative period leaked. Conclusion Immunofluorescence is a technique that allows an immediate visual image to evaluate the vascularization of the gastric plasty during an esophagectomy. It allows characterizing the adequate vascularization of the future anastomotic area, being able to help decide the best place to carry out the anastomosis. Studies with a larger number of cases are needed to be able to define the range in which to establish the anastomosis or change the surgical strategy.

Measuring Activated Clotting Time during Cardiac Catheterization and PCI: The Effect of the Sampling Site.

Results In 100 patients (mean age 67.1, 65% male), no significant differences were observed in ACT values obtained from the guiding catheter and arterial sheath (mean difference (MD) −18.3 s; standard deviation (SD) 96 s; P=0.067). Contrarily, ACT values obtained from the intravenous line were significantly lower as compared to values obtained from the guiding catheter (MD 25.7 s; SD 75.5; P=0.003) and arterial sheath (MD 39 s; SD 102.8; P < 0.001). Furthermore, ACT measurements from the arterial sheath showed a statistically significant proportional bias when compared to the other sampling sites (sheath vs. catheter, r = 0.761, P=0.001; sheath vs. IVL, r = 1.013, P < 0.001). Conclusions The present study shows statistical significance and possibly clinically relevant variations between ACT measurements from different sample sites. Bias in ACT measurements may be minimized by using uniform protocols for ACT measurement during cardiac catheterization.

Inter-element variation in the bone histology ofAnteosaurus(Dinocephalia, Anteosauridae) from theTapinocephalusAssemblage Zone of the Karoo Basin of South Africa

Despite its abundance in the Permian fossil record of South Africa, little is known about the life history of Anteosaurus. Here we examine the bone microstructure of multiple skeletal elements of Anteosaurus from the Tapinocephalus Assemblage Zone of the Karoo Basin. The bone histology of Anteosaurus magnificus reveals that the cortex is composed of highly vascularized, uninterrupted fibrolamellar bone tissue surrounding the inner spongy medullary region. However, the histology of two ribs and a previously described femur of another Anteosaurus taxon revealed an interrupted growth pattern with lines of arrested growth and peripheral rest lines occurring in the compacta, indicating periodic pauses in growth possibly linked to the slowing down of growth during maturity. Given that the fibula of the same individual has well-vascularised fibrolamellar bone tissue without any growth marks in the cortex; this suggests variation in skeletal growth. Based on our histological results, three growth dynamic stages are deduced for the genus Anteosaurus: (i) the earliest growth stage is represented by the predominance of highly vascularized, uninterrupted fibrolamellar bone tissue in the inner cortex, which suggests rapid periosteal bone deposition during early ontogeny; (ii) the next stage of growth shows periodic interruptions in the bone deposition as indicated by the deposition of lines of arrested growth; (iii) the third stage shows the development of lamellar bone tissue with rest lines in the peripheral part of the cortex suggesting a slowing down of growth prior to death. Most of the skeletal elements are characterized by thick bone walls, extensive secondary reconstruction and the complete infilling of the medullary cavity. However, the radius and a previously studied femur have open medullary cavities with struts of bony trabeculae. Based on histologic structures and comparisons with extant taxa, it is likely that Anteosaurus may have been more terrestrial as its osteology point towards terrestriality, but it may have occasionally inhabited ephemeral pools like modern semi-aquatic Hippopotamus.

Novel method for selecting slices of the same cross-sectional view from digital tomosynthesis for monitoring posterior spinal instrumentation

BackgroundA method to evaluate pedicle screw loosening on digital tomosynthesis images is yet to be established owing to lack of methods for selecting slices of the same cross-sectional view. We aimed to develop an objective method for selecting slices of the same cross-sectional view on digital tomosynthesis images. MethodsFirst, an objective method of pixel selection was developed by measuring the size of glass disk and titanium alloy screw on digital tomosynthesis images followed by comparison with the actual sizes. Second, a method for selecting slices of the same cross-sectional view was explored on a bone model with posterior spinal instrumentation using the screw centerline and rod curvature as indicators of the same cross section. The angle between the screw centerline and rod was calculated to verify the accuracy in obtaining the same cross-sectional view. Third, the method for selecting slices of the same cross-sectional view was applied to six patients after posterior lumbar spinal instrumentation. ResultsThe pixel selection method enabled objective determination of a pixel on the peripheral lines of objects with an error as low as 200 μm in distance measurements on titanium alloy and glass. The mean differences of rod-screw angles between two slices were less than 1° and were not statistically significant in the bone model and patient images. ConclusionA method for selecting slices of the same cross-sectional view on digital tomosynthesis images was successfully developed. This method can enable objective and quantitative evaluations of pedicle screw loosening.

New Shunosaurus (Dinosauria: Sauropoda) material from the middle Jurassic lower Shaximiao Formation of Yunyang, Chongqing, China

ABSTRACT Shunosaurus is a small eusauropod from China. It is characterised by solid cervical and dorsal vertebral centra without complicated pneumatic structures, platycoelous or amphicoelous middle and posterior vertebrae and a lack of pubic foramen in adult individuals. Although many Shunosaurus individuals have been discovered, the ontogenetic characteristics of its long bones and bone tissues are not very clear and the existing description of the postcranial skeleton is relatively rudimentary. The new well-preserved and the smallest Shunosaurus specimen discovered in Yunyang, Chongqing, China, provides good material for solving these problems. The radial distal breadth is more than twice the minimum midshaft breadth, and the fibular distal end is twice as wide as the midshaft, while these ratios are all smaller in adult specimens. The lateral trochanter is undeveloped. This individual does show a pubic foramen. The degree of vascularisation of the bone tissue in the juvenile bone tissue is higher for adults. There are no arrested growth lines and peripheral rest lines in the compact bone, indicating that body size still increases slowly after maturity. The discovery of this new material expands the distribution range of Shunosaurus in China.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit.

Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications. The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU). A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period. Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period. The development of a dedicated, local team played a key role in improving vascular access in the NICU. Proximity of specialized teams provides a solution to address gaps in care in the NICU.

The Toxicity of Universal Dental Adhesives: An In Vitro Study.

There is no consensus in the literature regarding the potential toxicity of universal dental adhesives (UDA). Being used in close proximity to the pulp, their biocompatibility should be an important factor in dental research. The aim of the present study was to evaluate the biocompatibility of UDA in an in vitro model. The study was performed using a monocyte/macrophage peripheral blood SC cell line (ATCC CRL-9855) on four specific UDA, namely: All-Bond Universal (Bisco); CLEARFIL Universal Bond Quick (Kuraray); G-Premio BOND (GC); Single Bond Universal (3M ESPE). The cytotoxicity of the investigated UDA was measured using the XTT colorimetric assay. The genotoxicity of the analyzed compounds was evaluated using an alkaline version of the comet assay. Furthermore, flow cytometry (FC) apoptosis detection was performed using the FITC Annexin V Apoptosis Detection Kit I. FC cell-cycle arrest assessment was performed using propidium iodide staining. The study observed significant differences in the toxicity of the UDA that were tested, as G-Premio BOND showed significant in vitro toxicity in all of the tests performed, while All-Bond Universal, CLEARFIL Universal Bond Quick and Single Bond Universal did not present any significant toxic effects toward SC cell line. The in vitro toxicity of UDA should be taken into consideration prior to in vivo and clinical studies. The flow cytometry could improve the accuracy of dental materials research and should be incorporated into the standardization criteria.

Reliability of Capillary Complete Blood Count in Children With Acute Gastroenteritis.

Background: To assess the reliability of complete blood count (CBC) in the capillary blood of children with acute gastroenteritis (AGE), with a focus on leukocytes.Methods: This was a retrospective cross-sectional study. Complete blood count was compared between the capillary and venous blood in children admitted to a pediatric gastroenterology department with primary diagnosis of AGE (ICD-10 A09, A08.0, A08.2). Capillary blood was obtained in the emergency room and venous blood was sampled in the ward shortly thereafter during peripheral intravenous line placement.Results: One hundred and forty children were included. The mean (±SD) age and weight of patients were 3.0 ± 2.9 years and 16 ± 9 kg; 26% had leukocytosis. The mean difference between obtaining results of capillary and venous blood tests was 2 ± 1 h. Area under the receiver operating characteristic curve (AUC) for the identification of leukocytosis using the capillary blood was 0.98 (95% CI 0.96–1.0). The sensitivity and specificity were 86 and 98%, respectively (accuracy 95%). The positive and negative predictive values were 94 and 95%, respectively. The intraclass correlation coefficient revealed high concordance between capillary and venous CBC measurements (leukocyte count 0.94, hemoglobin 0.88, erythrocyte count 0.77, hematocrit 0.79, platelet count 0.90). Matched pairs comparisons revealed marginally higher erythrocytes (difference of medians: 0.2 T/L), hemoglobin (0.3 g/dL), hematocrit (1.0%), and platelets (9 G/L) in the capillary blood.Conclusion: Capillary CBC is useful in detecting leukocytosis in children with AGE.

Bacterial profile, antimicrobial susceptibility patterns, and associated factors among bloodstream infection suspected patients attending Arba Minch General Hospital, Ethiopia

Bacterial bloodstream infections are of great concern globally. Of late, the emergence of drug resistant bacteria worsen the related morbidity and mortality. This study was aimed to determine the bacterial profile, antimicrobial susceptibility patterns, and associated factors among the blood stream infection (BSI) suspected patients attending the Arba Minch General Hospital (AMGH), southern Ethiopia, from 01 June through 31st August, 2020. A cross-sectional study was conducted among 225 BSI suspected patients. Systematic random sampling method was used to select patients. Blood culture was done to isolate bacterial pathogens. Antimicrobial susceptibility test was performed by employing the Kirby-Bauer disc diffusion method. Descriptive statistics and multivariable logistic regression analysis were done by Statistical Package for Social Service (SPSS) version 22. The rate of prevalence of bacteriologically confirmed cases was 22/225 (9.8%). Majority of BSI were caused by Gram-positive cocci, 13/22 (59.1%), particularly the isolates of S. aureus, 7/22 (31.8%) followed by Enterococci species, 4/22 (18.2%) and coagulase-negative Staphylococci (CoNS), 2/22 (9.1%). Among the Gram-negative bacteria 9/22 (41.1%), Klebsiella species 4/22 (18.2%) was the prominent one followed by Escherichia coli 2/22 (9.1%), Pseudomonas aeruginosa 2/22 (9.1%), and Enterobacter species 1/22 (4.5%). All the isolates of Gram-negative bacteria were susceptible to meropenem whereas 69.2% of the isolates of Gram-positive counterparts were susceptible to erythromycin. Slightly above two third (68.2%) of the total isolates were multidrug resistant. Insertion of a peripheral intravenous line was significantly associated with BSI [p = 0.03; Adjusted Odds Ratio = 4.82; (Confidence Interval: 1.08–21.46)]. Overall results revealed that eventhough the prevalence of BSI in Arba Minch is comparatively lower (9.8%), multidrug resistance is alarmingly on the rise, which is to be addressed through effective surveillance and control strategies.

Patient patience.

Today is my third day in the ED. I feel more comfortable here, and I know my way around. You want a flush, the ultrasound machine, even some fresh linens? I'm your guy. I feel more confident in other ways, too. I watched several ultrasound-guided IV placements during the past couple days and I'm running over the steps in my head-I can definitely do this. A stellar physician's assistant walks me through the steps one more time, encourages me, brings me to the bedside of a patient who needs a peripheral line placed, and he patiently supervises my work. I introduce myself as a third-year medical student and explain what I'm going to do in detail, for the patient's sake and for my own.

Peripheral Arterial Lines in Extremely Preterm Neonates: A Potential Alternative to Umbilical Arterial Catheters.

Arterial catheterization is a routine procedure in extremely preterm neonates. Umbilical arterial catheters (UACs) are typically used for this purpose, but life-threatening complications have been described. Peripheral arterial lines (PALs) might offer a valuable alternative, but their feasibility in extremely preterm newborns is unclear. To investigate efficacy and complications of PALs in extremely preterm neonates. Retrospective analysis of patients born below 26 weeks of gestation in 2011-2014 (cohort 1, UAC as primary arterial access) and 2015-2019 (cohort 2, PAL as primary arterial access). Arterial line placement during their first 14 days of life, duration of arterial access, reasons for discontinuation, and long-term complications were recorded from health records. In total, 161 of 202 newborns had an arterial line during their first 14 days of life. In cohort 2, the life span of a PAL was significantly longer than that in cohort 1. Signs of dysfunction were the primary reason to discontinue a PAL. Signs of peripheral ischemia were present in 36 of 105 cases (34%) when the PAL was removed but persisted in only 2 patients. UAC-associated persistent ischemic damage occurred in 2 of 97 patients. PALs are a valuable alternative to UACs even in preterm newborns below 26 weeks of gestational age. A special focus on ischemic complications is warranted. Prospective, multicenter studies to verify safety and efficacy of arterial line management and complications in extremely preterm infants are warranted.

Ecological stability evaluation of tidal flat in coastal estuary: A case study of Liaohe estuary wetland, China

The tidal flat, located at the forefront of the coastal estuary wetland, serves as a peripheral defense line to maintain the stable ecological function of the estuary wetland. Therefore, the accurate identification of the stable state of a tidal flat is rendered as the decision-making basis for the restoration and management of estuary wetland ecosystems. Conducted at the tidal flat of the Liaohe Estuary Wetland, the study established a comprehensive evaluation index of tidal flat ecological stability (ECO-CSI) based on the Pressure-State-Response model and Rough Set theory. The driving factors and threshold values which affected the stability of the tidal flat were identified. The results showed that the average ECO-CSI value of the tidal flat during the past 30 years was 0.44 indicating, in general, a relatively stable state of the tidal flat. On the other hand, in 2017 the ECO-CSI value was 0.25, pointing that the tidal flat is in an unstable state currently. Among the factors affecting the tidal flat ecological stability, the artificial development activities were the major driving factors, and the urbanization and the traffic road scale were the key driving factors leading to the instability of the tidal flat. Of the natural factors, the sediment discharge, the flow in flood season, and the precipitation in the upstreams were the key guarantee factors for maintaining the material supply of the tidal flat. The threshold values for maintaining the ecological stability of the tidal flat in the Liaohe Estuary wetland were determined that the sediment discharge of the Liaohe River should be not less than 792.91 × 104t⋅y-1 and the scale of traffic roads in the tidal flat should be less than or equal to 770.9244 hm2. Hence, in the development and utilization of tidal flats and coastal wetlands, unreasonable human development activities should be minimized to avoid damage to the integrity and natural dispositions of the tidal flat. In this way, the stability of the tidal flat could be improved, contributing to the ecological security for the overall stability of the estuary wetland ecosystem.