Implantable central venous access devices in children with metabolic disease

Incidence and Risk Factors for Totally Implantable Venous Access Device Infections in Pediatric Patients With Cancer: A Study of 25,954 Device-Days

BACKGROUND

Totally implantable venous access devices (TIVADs) are frequently used in pediatric patients with cancer owing to their multiple benefits. Despite occasional infections with TIVADs, knowledge of the incidence and risk factors is limited.

METHODS

This retrospective study included pediatric patients with cancer who received TIVAD at Chungbuk National University Hospital from 2001 to 2021. We collected data on demographics, diagnosis, duration of TIVAD use, pathogens, and other risk factors.

RESULTS

During the study period, 55 TIVADs with 25,954 device-days were applied in 49 patients. There were 15 TIVAD infections (15/55, 27.3%), with an infection rate of 0.21 infections per TIVAD per year (0.58 cases/1,000 device-days). TIVAD infections occurred at a median of 5 months (range, 8 days-30 months) after insertion. The most common causative microorganisms were methicillin-resistant coagulase-negative staphylococci (n = 8, 53.3%) followed by Escherichia coli (n = 3, 20.0%). Infection-free TIVAD survival was higher in the group with normal platelet count at insertion (platelet counts ≥ 150,000/μL) than in the group with thrombocytopenia at insertion (platelet counts < 150,000/μL) (81.3% vs. 32.1%, P = 0.004). Device removal was the mainstay of treatment (11/15, 73.3%).

CONCLUSION

TIVAD infection may be related to thrombocytopenia at the time of device insertion. Further studies are needed to identify preventive factors against TIVAD infections in children with cancer.

Implantable central venous access device in infants: Long-term results

BACKGROUND

The management of central venous access device (CVAD) is extremely difficult in babies and small infants (BSI). We therefore compared the long-term results and complications of CVAD in BSI with those in children.

METHODS

One hundred and twenty patients were divided into two groups as follows: age <1 year or weight <10 kg (group A; 25 patients); and age ≧1 year and weight ≧10 kg (group B; 95 patients). The clinical results were retrospectively compared between the groups.

RESULTS

Mean age and weight were 12.5 ± 5.9 months and 8.2 ± 1.2 kg in group A, and 78.8 ± 58.9 months and 20.9 ± 13.6 kg in group B. Operation time was 57 ± 29 min in group A and 52 ± 21 min in group B (P = 0.38). The catheter was advanced with difficulty into the central vein in five and in 16 patients (P = 0.77), and surgical complications occurred in one and in seven patients in groups A and B, respectively (P > 0.99). The CVAD remained in place for 627 ± 494 and 550 ± 414 days (P = 0.47) and was removed before treatment completion in five and in 14 patients in groups A and B, respectively (P = 0.54).

CONCLUSION

The clinical results for CVAD in BSI did not differ from those in children. CVAD are useful and safe for the treatment of BSI with serious diseases.

Complications of chemoport in children with cancer: Experience of 54,100 catheter days from a tertiary cancer center of Southern India

BACKGROUND

Chemoport is an essential part of the management of children with cancer and provides long-term venous access. There are few studies from resource poor countries reporting complications of chemoport.

AIMS

This study was aimed at describing the complications of chemoport in patients with cancer.

MATERIALS AND METHODS

This retrospective observational study analyzed 200 patients <15 years of age who underwent chemoport insertion. The medical records of these patients were reviewed for the patient characteristics, diagnosis, nature of port use, port-related complications and their management.

RESULTS

A total of 209 ports were implanted in 200 patients and 24 ports were removed due to port-related complications. There were 122 boys and 78 girls whose ages ranged from 4 months to 13 years (median age 2.5 years). About72% of patients were <2 years old. The cumulative duration of catheterization was 54,100 days. Of 209 ports, there were 36 complications that led to the removal of 21 ports. Port-related infection was the most common infection observed in our study (0.66/1000 catheter days and 11.9%). Mechanical complications were seen in 9 patients. Venous thrombosis and skin necrosis occurred in one patient each.

CONCLUSIONS

Use of chemoport is safe and is a boon for children with cancer in developing countries with incidence of complications similar to Western countries. Although use of chemoport is associated with complications, they are easily managed. With stringent catheter care by trained personnel, some complications can be prevented.

Gene expression in cell lines from propionic acidemia patients, carrier parents, and controls

Propionic acidemia (PA) is an inborn of metabolism which usually presents with metabolic acidosis and accumulation of 3-hydroxypropionate among other toxins. Examining the gene expression in lymphoblastoid cell lines (LCLs) from PA patients, their carrier parents and age/sex-matched controls at normal glucose and low glucose growth conditions demonstrated differences among and between these groups. Using three-way ANOVA analysis, four DAVID clusters of response were identified of which three of the four clusters showed that LCLs from carrier parents had an intermediate response between healthy controls and PA patients. These differences included changes in expression of cell cycle regulatory genes, mitochondrial related genes, and transcriptional regulation. In addition, differences also were observed in expression of genes involved in transendothelial migration and focal adhesion at normal growth conditions when comparing the LCLs from PA patients and controls. These studies demonstrate transcriptional differences between LCLs from PA patients, their parents and biochemically normal controls.

Proposed guidelines for the diagnosis and management of methylmalonic and propionic acidemia

Methylmalonic and propionic acidemia (MMA/PA) are inborn errors of metabolism characterized by accumulation of propionic acid and/or methylmalonic acid due to deficiency of methylmalonyl-CoA mutase (MUT) or propionyl-CoA carboxylase (PCC). MMA has an estimated incidence of ~ 1: 50,000 and PA of ~ 1:100’000 -150,000. Patients present either shortly after birth with acute deterioration, metabolic acidosis and hyperammonemia or later at any age with a more heterogeneous clinical picture, leading to early death or to severe neurological handicap in many survivors. Mental outcome tends to be worse in PA and late complications include chronic kidney disease almost exclusively in MMA and cardiomyopathy mainly in PA. Except for vitamin B₁₂ responsive forms of MMA the outcome remains poor despite the existence of apparently effective therapy with a low protein diet and carnitine. This may be related to under recognition and delayed diagnosis due to nonspecific clinical presentation and insufficient awareness of health care professionals because of disease rarity.

These guidelines aim to provide a trans-European consensus to guide practitioners, set standards of care and to help to raise awareness. To achieve these goals, the guidelines were developed using the SIGN methodology by having professionals on MMA/PA across twelve European countries and the U.S. gather all the existing evidence, score it according to the SIGN evidence level system and make a series of conclusive statements supported by an associated level of evidence. Although the degree of evidence rarely exceeds level C (evidence from non-analytical studies like case reports and series), the guideline should provide a firm and critical basis to guide practice on both acute and chronic presentations, and to address diagnosis, management, monitoring, outcomes, and psychosocial and ethical issues. Furthermore, these guidelines highlight gaps in knowledge that must be filled by future research. We consider that these guidelines will help to harmonize practice, set common standards and spread good practices, with a positive impact on the outcomes of MMA/PA patients.

Chronic management and health supervision of individuals with propionic acidemia

Propionic acidemia is a relatively rare inborn error of metabolism. Individuals with propionic acidemia often have life-threatening episodes of hyperammonemia and metabolic acidosis, as well as intellectual disability. There are many reports of additional problems, including poor growth, stroke-like episodes of the basal ganglia, seizures, cardiomyopathy, long QTc syndrome, immune defects, pancreatitis and optic neuropathy; however, there is little information about the incidence of these problems in this rare disease. Additionally, there are no clear guidelines for medical or surgical management of individuals with propionic acidemia. Through a comprehensive and systematic review of the current medical literature and survey of expert opinion, we have developed practice guidelines for the chronic management of individuals with propionic acidemia, including dietary therapy, use of medications, laboratory monitoring, chronic health supervision, use of gastrostomy tubes and liver transplantation.

Port-A-Cath infections in children with cancer

Implanted subcutaneous (s.c.) central venous port accesses including Port-A-Cath (PAC) facilitate the administration of chemotherapy or blood products and are frequently used in children with cancer. The incidence of PAC-related infections was determined in 155 consecutive paediatric cancer patients with PAC followed for a total of 134,773 days (median, 738; range, 25-2080). Overall, 48 bloodstream infections occurred in 26 patients. 12 (25%) of these infections and 3 local infections at the insertion site were treatment-resistant and demanded removal of the PAC. Coagulase-negative staphylococci were involved in 12 of these 15 episodes. The rate of clearly PAC-related infections in this so far largest reported series was 0.11 episodes per 1000 PAC days, one of the lowest in the literature. Although catheter-related infections demanded PAC removal in 8% of our patients, the long periods PAC were in use and their benefits argue for continued PAC use in the paediatric cancer population.