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Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n = 84) in 2016 and a post-intervention audit (n = 84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "The formulation and introduction of a can't intubate, can't ventilate algorithm into clinical practice," by A. M. B. Heard and colleagues, in a previous issue, proposing an adjunct to the scalpel-bougie cricothyroidotomy technique.

A letter to the editor is presented which compares two new rigid indirect laryngoscopes such as Airtraq® from Prodol Meditec SA in Vizcaya, Spain and Airway Scope® AWS-S100 from Pentax Corp. in Tokyo, Japan.

Background: To offer vaginal birth after cesarean (VBAC) in a hospital setting is recommended in international guidelines, but offering VBAC in out-of-hospital settings is considered controversial. This study describes neonatal and maternal outcomes in mothers who started labor in German out-of-hospital settings., Method: In a retrospective analysis of German out-of-hospital data from 2005 to 2011, included were 24,545 parae II with a singleton pregnancy in a cephalic presentation at term (1,927 with a prior cesarean and 22,618 with a prior vaginal birth)., Result: The overall VBAC rate was 77.8 percent. The intrapartum transfer rate to hospital was 38.3 percent (prior cesarean) versus 4.6 percent (prior vaginal) (p < 0.05), and the 10-minute Apgar < 7 rate was 0.6 versus 0.2 percent (p < 0.05), and the nonemergency intrapartum transfer rate was 91.5 versus 85.0 percent (p < 0.05). Prolonged first stage of labor was the most common reason for intrapartum transfer in both groups. The leading reason for postpartum transfer was retained placenta., Discussion: There was a high rate of successful VBAC in this study. The high nonemergency transfer rate for women with VBAC might mean that midwives are more cautious when attending women with a prior cesarean in out-of-hospital settings. Further studies are necessary to evaluate which women are suitable for VBAC in out-of-hospital settings., (© 2014 Wiley Periodicals, Inc.)

Previous studies have suggested an important role for the Janus kinase-signal transducer and activator of transcription (JAK-STAT) signalling pathway in tumour development. Therefore, we explored genetic variants in JAK-STAT pathway associated genes with lymphoma risk. In samples of the EpiLymph case-control study we genotyped 1536 single nucleotide polymorphisms (SNPs) using GoldenGate BeadArray™ Technology (Illumina, San Diego, CA, USA). Here, we report the associations between selected SNPs and haplotypes of the JAK-STAT pathway and risk of Hodgkin lymphoma (HL), B-cell non-Hodgkin lymphoma (B-NHL) and most frequent B-NHL subtypes. Among 210 relevant JAK-STAT pathway-related SNPs, polymorphisms in nine genes (BMF, IFNG, IL12A, SOCS1, STAT1, STAT3, STAT5A, STAT6, TP63) were significantly associated with lymphoma risk. At a study-wise significance level, we obtained a risk reduction of 28% among carriers of the heterozygous genotype of the STAT3 variant (rs1053023) for B-NHL. For six other variants within the STAT3 gene we observed an inverse association with different lymphoma subtypes. A reduced risk for HL was observed for the heterozygous genotype of the STAT6 SNP (rs324011). This is an explorative investigation to examine associations between JAK-STAT signalling related genes and lymphoma risk. The results implicate a relevant role of certain pathway-related genes in lymphomagenesis, but still need to be approved by independent studies., (© 2011 Blackwell Publishing Ltd.)