Role of Antiplatelet Therapy in Hemodialysis Arteriovenous Graft Secondary Patency Following Successful Percutaneous Thrombectomy.

PURPOSE: The purpose of this study was to elicit the relationship of antiplatelet therapy (AP) in maintaining arteriovenous graft (AVG) patency after successful percutaneous pharmacomechanical thrombectomy ("declot"). MATERIALS AND METHODS: This was an institutional review board-approved retrospective review of AVG declot procedures between July 2019 and August 2020. AVG characteristics, bleeding complications, anticoagulation and antiplatelet medication regimens, and thrombosis free survival were evaluated. Recurrent time-to-event analysis was performed using a Prentice-Williams-Peterson Gap time model was performed to evaluate AVG thrombosis free survival. RESULTS: A total of 109 declots were technically successful and performed in 63 individual patients. The majority of procedures were performed in upper arm grafts (71%, n = 45). Dual antiplatelet (DAPT) was prescribed after 52 declots (48%), single antiplatelet was prescribed after 36 declots (33%), and anticoagulation was prescribed after 31 declots (28%). Median thrombosis free survival was 37 days (range 1-412 days) in the no antiplatelet group, 84 days (range 1-427 days) in the single antiplatelet group, and 93 days (range 3-407 days) in the DAPT group. Anti-platelet medications trended towards protective of AVG thrombosis in multivariate analysis (hazard ratio 0.84, 95% confidence interval 0.60-1.19); however, this did not reach statistical significance (P = 0.33). A total of 4 major and 5 minor bleeding events occurred. CONCLUSION: The results of this study support further evaluation of AP therapy in preventing secondary rethrombosis of dialysis AVG.

Single-session versus two-session placement of chest port and gastrostomy tube in patients with head and neck cancer: Is there any difference in the device-related early infection rates?

BACKGROUND: It is unknown whether placement of a chest port (port) and a gastrostomy tube (G-tube) in a single session increases the risk of the early device infections in patients with head and neck cancer (HNC) undergoing chemoradiation. PURPOSE: To compare the incidence of early (≤30 days) port and G-tube infections placed in a single session compared to two separate sessions in patients with HNC. MATERIAL AND METHODS: Between January 2012 and December 2019, 169 patients with HNC undergoing chemoradiation had a port and a G-tube placed in a single session (single-session group), while 25 had both devices placed in two separate sessions (two-session group) within 30 days of each other. The incidence of early device infections was compared between groups. Logistic regression analysis was conducted to determine if the number of sessions was a variable affecting device infections. RESULTS: A total of 6 (3%) early port infections and 13 (6.7%) early G-tube infections were identified. The two groups did not significantly differ in the incidence of early port infections (3.0%, 5/169 and 4.0%, 1/25, p = 0.59) nor early G-tube infections (7.1%, 12/169 and 4.0%, 1/25, p = 1.0). The number of sessions for device placement was not a variable affecting overall device infections in logistic regression analyses (odds ratio: 1.24, 95% confidence interval: 0.20-7.82, p = 0.82) after controlling for potential confounding variables. CONCLUSIONS: The risk of early device infections in single-session placement appeared to be the same as two-session placement in patients with HNC undergoing chemoradiation.

Risk Factors for Early Port Infections in Adult Oncologic Patients.

PURPOSE: The purpose of this study was to retrospectively investigate risk factors for chest port (port) infections within 30 days of placement (early port infections) in adult oncologic patients. MATERIALS AND METHODS: This single-institution, three-center retrospective study identified 1,714 patients (868 males, 846 females; median age 60.0 years old) who underwent port placement between January 2013 and August 2017. All patients received an intravenous antibiotic prior to port placement. The median absolute neutrophil count was 5,260 cells/µL, the median white blood cell (WBC) count was 7,700 cells/µL, and the median serum albumin was 4.00 g/dL at the time of port placement. Double-lumen ports were most commonly implanted (74.85%) more frequently in an outpatient setting (72.69%). Risk factors for early port infections were elucidated using univariate and multivariate proportional subdistribution hazard regression analyses. RESULTS: A total of 20 patients (1.2%) had early port infections; 15 patients (0.9%) had positive blood cultures. The mean time to infection was 20 days (range, 9-30 days). The port-related 30-day mortality rate was 0.2% (4 of 1,714 patients). Most bloodstream infections were attributed to Staphylococcus spp. (n = 11). In multivariate analysis, hematologic malignancy (hazard ratio [HR], 2.61; 95% confidence interval (CI), 1.15-5.92.; P = .02), hypoalbuminemia (albumin <3.5 g/dL; HR, 3.52; 95% CI: 1.48-8.36; P = .004), leukopenia (WBC <3,500 cells/µL; HR, 3.00; 95% CI: 1.11-8.09; P = .03), and diabetes mellitus (HR, 3.71; 95% CI: 1.57-8.83) remained statistically significant risk factors for early port infection. CONCLUSIONS: Hematologic malignancy, hypoalbuminemia, leukopenia, and diabetes mellitus at the time of port placement were independent risk factors for early port infections.

Conversion to Gastrojejunostomy Tubes in Developmentally Disabled Children Intolerant to Gastrostomy Tube Feeding.

This study retrospectively evaluated the safety, impact on growth, and clinical outcomes of gastrojejunostomy tubes (GJTs) converted from surgically placed gastrostomy tubes (GTs) in 44 developmentally disabled children (median age: 28 months). The total duration of GJT follow-up was 31,378 device-days (median: 643 device-days). Three major complications (aspiration pneumonia) were identified in 3 patients (6.8%), 63 minor complications in 31 patients (70.5%), and 202 tube maintenance issues (TMIs) in 41 patients (93.2%). A significantly increased average change in weight-for-age z-scores was observed at each 6-month interval that continued past 25 months. Patients above the median rate of TMIs had marginally significant lower z-scores across the study period (P = 0.06), compared with those below the median rate. GJTs were removed in 6 patients (13.6%) because of adequate oral intake at last follow-up. Conversion from GTs to GJTs was a viable option to achieve sustained growth in developmentally disabled children. Frequency of TMIs may negatively impact their growth.

Right- versus Left-Sided Chest Ports in Oncologic Patients with a History of Right-Sided Port Removal: Are There Any Differences in the Complication Rates?

PURPOSE: To compare chest port (port)-related complication rates between right- and left-sided ports placed in adult oncologic patients with a history of right-sided port removal. MATERIALS AND METHODS: A retrospective chart review identified 90 adult oncologic patients with a history of right-sided port removal. Of these, 60 patients had a second port placed on the right side (right-side group), while 30 patients had a second port placed on the left side (left-side group). Median time between first port removal and second port placement was 217 days (range, 0-3808 days). Port-related complications included infection (port-site and/or bloodstream), mechanical, thrombotic, and port-site skin complications. Complication rates between groups were compared. Proportional subdistribution hazard regression (PSHREG) was conducted to determine if laterality of the second port is an independent risk factor for port-related complications. RESULTS: The cumulative follow-up period was 34,748 catheter-days (median, 233; range, 9-2162 days). Eleven patients (18.3%) in the right-side group and 2 patients (6.7%) in the left-side group had port-related complications (P = .21), accounting for complication rates of 0.5 and 0.2/1000 catheter-days (P = .24), respectively. No statistical difference was found in the incidence of infection (9/60 vs 1/30, P = .16), mechanical (0/60 vs. 1/30, P = .33), thrombotic (1/60 vs 0/30, P = 1.0), and skin-related (1/60 vs 0/30, P = 1.0) complications between groups. In multivariate PSHREG, laterality of the second port (hazard ratio = 3.09, 95% confidence interval = 0.81-11.76, P = .10) was not a significant risk factor for port-related complications. CONCLUSIONS: In adult oncologic patients with a history of right-sided port removal, no significant differences in port-related complication rates were observed between right- and left-sided second ports.

Clinical Predictors of Port Infections in Adult Patients with Hematologic Malignancies.

PURPOSE: To identify clinical predictors of port infections in adult patients with hematologic malignancies. MATERIALS AND METHODS: A retrospective chart review identified 223 adult patients (age ≥ 18 y) with hematologic malignancies, including lymphoma (n = 163), leukemia (n = 49), and others (n = 11), who had a port placed from 2012 to 2015. Early (< 30 d after port placement) and overall port infections (bloodstream and site infections) were recorded. To elucidate clinical predictors for early and overall port infections, proportional subdistribution hazard regression (PSHREG) analyses were conducted with variables including patients' demographics, medications used, laboratory data, and port characteristics. RESULTS: Total duration of follow-up was 83,722 catheter-days (median per patient, 274 catheter-days). Early and overall port infections were identified in 8 (3.6%) and 26 (11.7%) patients, respectively. Early and overall infection rates were 1.2 and 0.3 infections/1,000 catheter-days, respectively. Backward stepwise multivariate PSHREG analyses identified hypoalbuminemia (< 3.5 mg/dL) at the time of port placement (hazard ratio = 5.03; 95% confidence interval, 1.14-22.16; P = .03) and steroid use (> 30 d cumulatively during follow-up period) (hazard ratio = 3.41; 95% confidence interval, 1.55-7.47; P = .002) as independent risk factors for early and overall port infections, respectively. CONCLUSIONS: In adult patients with hematologic malignancies, hypoalbuminemia at the time of port placement was a clinical predictor for early port infections, whereas steroid use was a clinical predictor for overall port infections.

MDHAQ/RAPID3 can provide a roadmap or agenda for all rheumatology visits when the entire MDHAQ is completed at all patient visits and reviewed by the doctor before the encounter.

The management of rheumatoid arthritis (RA) depends more on the patient history than most other chronic diseases. A patient questionnaire provides a uniform, quantitative, protocolized, "scientific" patient history, with documented prognostic significance for work disability and mortality in RA greater than radiographs and laboratory tests and capacity to distinguish active from control treatment in clinical trials and to monitor clinical care with equivalent or greater significance than joint counts or laboratory tests. Therefore, a "scientific" approach to care of a person with a rheumatic disease involves review of patient function, pain, global status, fatigue, RAPID3, review of systems, self-report joint count, and recent medical history on an MDHAQ before conversation with the patient. This practice may be viewed as analogous to a doctor reviewing blood pressure, hemoglobin A1c, viral load, or radiograph before meeting with a patient who has hypertension, diabetes, HIV, or a healing fracture to provide a roadmap or agenda for the visit. Some sites have implemented RAPID3 without the remainder of MDHAQ, a practice that is discouraged. The MDHAQ requires only 5 to 10 minutes of the patient's time and involves a single sheet of paper, which is needed for a simple RAPID3, or even a patient global estimate of status to score a DAS28 or CDAI. Completion of MDHAQ/RAPID3 by each patient at each visit in the infrastructure of care with review by the doctor helps prepare the patient for the visit, improves doctor-patient communication, saves time for the doctor, and provides a roadmap or agenda for the visit.