Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study.

OBJECTIVES: This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs. METHODS: A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate. RESULTS: Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively). CONCLUSIONS: Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Storm-driven particulate organic matter flux connects a tidal tributary floodplain wetland, mainstem river, and estuary.

The transport of terrestrial plant matter into coastal waters is important to regional and global biogeochemical cycles, and methods for assessing and predicting fluxes in such dynamic environments are needed. We investigated the hypothesis that upon reconnection of a floodplain wetland to its mainstem river, organic matter produced in the wetland would reach other parts of the ecosystem. If so, we can infer that the organic matter would ultimately become a source for the food web in the mainstem river and estuary. To accomplish this, we adapted numerical hydrodynamic and transport modeling methods to estimate the mass of particulate organic matter (POM) derived from the annually senescent aboveground parts of herbaceous marsh plants (H-POM). The Finite-Volume Community Ocean Model (FVCOM), parameterized with flow, tide, and aboveground biomass data, simulated H-POM mobilization from fluid shear stress during tidal exchange, flooding, and variable river flow; entrainment into the water column; transport via channel and overland flow; and entrapment when wetted surfaces dry. We examined export from a recently reconnected, restoring tidal emergent marsh on the Grays River, a tributary to the Columbia River estuary. Modeling indicated that hydrologically reconnecting 65 ha at the site resulted in export of about 96 × 103  kg of H-POM, primarily during pulsed storm flooding events in autumn and early winter. This exported mass amounted to about 19% of the summer peak aboveground biomass measured at the site. Of that 19%, about 48% (47 × 103  kg) was deposited downstream in the Grays River and floodplain wetlands, and the remaining 52% (50 × 103  kg) passed the confluence of the Grays River and the mainstem estuary located about 7 km from the study site. The colonization of the restoring study site largely by nonnative Phalaris arundinacea (reed canarygrass) may have resulted in 18-28% lower H-POM mobilization than typical marsh plant communities on this floodplain, based on estimates from regional studies of marshes dominated by less recalcitrant species. We concluded that restored floodplain wetlands can contribute significant amounts of organic matter to the estuarine ecosystem and thereby contribute to the restoration of historical trophic structure.

Method development for comprehensive extraction and analysis of marine toxins: Liquid-liquid extraction and tandem liquid chromatography separations coupled to electrospray tandem mass spectrometry.

A variety of toxins are produced by marine and freshwater microorganisms that present a threat to human health. These toxins have diverse chemical properties and specifically, a range of hydrophobicity. Methods for extraction and identification of these toxins are often geared toward specific classes of toxin depending on the sample type. There is a need for a general method of toxin extraction and identification for screening samples where the likely toxin content is not known a priori. We have applied a general method for metabolite extraction to toxin containing samples. This method was coupled with a simple dual liquid chromatography approach for separating a broad range of toxins. This liquid chromatography approach was coupled to triple quadrupole and quadrupole time-of-flight MS/MS platforms. The method was testing on a fish matrix for recovery of palytoxin as well as marine corals for detection of natural mixtures of palytoxin analogues. The recovery of palytoxin was found to produce a linear response (R2 of 0.95) when spiked into the fish matrix with a limit of quantitation of 2.5 ng/µL and recovery efficiency of 73% + /- 9%. The screening of corals revealed varying amount of palytoxin, and in one case, different palytoxin structural analogues. This demonstration illustrates the potential utility of this method for toxin extraction and detection.

Eelgrass (Zostera marina L.) Restoration in Puget Sound: Development of a Site Suitability Assessment Process.

The restoration of eelgrass (Zostera marina L.) is a high priority in Puget Sound, Washington, United States. In 2011, the state set a restoration target to increase eelgrass area by 4,200 ha by 2020, a 20% increase over the 21,500 ha then present. In a region as large, dynamic and complex as Puget Sound, locating areas to restore eelgrass effectively and efficiently is challenging. To identify potential restoration sites we used simulation modeling, a geodatabase for spatial screening, and test planting. The simulation model of eelgrass biomass used time series of water properties (depth, temperature, and salinity) output from a regional hydrodynamic model and empirical water clarity data to indicate growth potential. The GIS-based analysis incorporated results from the simulation model, historical and current eelgrass area, substrate, stressors, and shoreline manager input into a geodatabase to screen sites for field reconnaissance. Finally, we planted eelgrass at test sites and monitored survival. We screened 2,630 sites and identified 6,292 ha of highly to very highly suitable conditions for eelgrass-ample area for meeting the 20% target. Test plantings indicated fine-scale data needs to improve predictive capability. We summarized the results of our analysis for the majority of the ~3,220 km of shoreline in Puget Sound on maps to support restoration site selection and planning. Our approach provides a process for identifying and testing potential restoration sites and highlights information needs and management actions to reduce stressors and increase eelgrass area to meet restoration objectives.

Domoic acid toxicokinetics in Dungeness crabs: new insights into mechanisms that regulate bioaccumulation.

Domoic acid (DA) is an excitatory neurotoxic amino acid produced by several marine algal species and is the causative agent of amnesic shellfish poisoning. Profound differences in the toxicokinetics of DA have been identified in a wide variety of shellfish. We characterized the toxicokinetics of DA in Dungeness crabs (Metacarcinus magister) after oral and intravascular dosing (IV) using a variety of doses ranging from 0.1 to 20mg/kg. After a 1mg/kg oral dose, DA disappeared from the foregut within 2h and largely accumulated in the hepatopancreas, with hemolymph and other tissues having 100-1000 times lower concentrations. After IV dosing, hemolymph concentrations of DA were unexpectedly high and toxicokinetic analysis indicated the steady-state volume of distribution (Vss) was 123-197 ml/kg, which is well below the hemolymph volume of 350 ml/kg for crabs. This indicated only limited extravascular distribution of DA was occurring after IV injection, which is surprising considering the capacity of the hepatopancreas to sequester DA after oral dosing. Additional studies measured the partitioning of DA in hepatopancreas cellular and subcellular fractions. The subcellular distribution of DA was primarily associated with the S8 fraction and could be filtered through a 30,000 MW cut-off filter, indicating DA was not appreciably bound to macromolecules. Interestingly, very little (<0.4%) of the total hepatopancreas DA tissue content was associated with the cellular fraction isolated after dissociation and separation from tissue fragments. The in vivo and in vitro results led us to hypothesize that DA uptake and distribution is regulated by crustacean orthologs of ATP-binding cassette (ABC) type transporters. We tested this hypothesis by co-exposing crabs to DA and known inhibitors of ABC transporters (verapamil, cyclosporine A and MK-571) and through in vitro studies using isolated hepatopancreas tissue and mixed cell suspensions prepared from hepatopancreas tissue. The in vivo results were inconclusive in that the toxicokinetics of DA was not consistently altered by co-administration of the inhibitors. Two exceptions were MK-571, which significantly increased the total body clearance of DA and co-administration of verapamil, which significantly increased the hepatopancreas tissue content of DA 24h after IV injection. Isolated pieces of hepatopancreas tissue were able to readily absorb DA from incubation media, but mixed cell suspensions did not. The absorption of DA or lack thereof was largely unaffected by co-incubation with verapamil although cell suspensions appeared to accumulate small quantities of DA in the presence of verapamil. Collectively, the results of this study suggest DA accumulates in the extracellular spaces of the hepatopancreas, such as the tubular lumen. Under natural circumstances, crabs feeding on contaminated shellfish would be expected to readily absorb DA, which is then stored and slowly eliminated in urine. If the DA exposure level exceeds the storage capacity of the tissue (as occurred with the 20mg/kg dose), breakthrough occurs resulting in much higher systemic exposure and potential for DA toxicity.

Domoic acid excretion in dungeness crabs, razor clams and mussels.

Domoic acid (DA) is a neurotoxic amino acid produced by several marine algal species of the Pseudo-nitzschia (PN) genus. We studied the elimination of DA from hemolymph after intravascular (IV) injection in razor clams (Siliqua patula), mussels (Mytilus edulis) and Dungeness crabs (Cancer magister). Crabs were also injected with two other organic acids, dichloroacetic acid (DCAA) and kainic acid (KA). For IV dosing, hemolymph was repetitively sampled and DA concentrations measured by HPLC-UV. Toxicokinetic analysis of DA in crabs suggested most of the injected dose remained within hemolymph compartment with little extravascular distribution. This observation is in sharp contrast to results obtained from clams and mussels which exhibited similarly large apparent volumes of distribution despite large differences in overall clearance. These findings suggest fundamentally different storage and elimination processes are occurring for DA between bivalves and crabs.