Critical Appraisal of 'Computed Tomography Frequency and Power Injection Utilization for a Cohort Cancer Patients with Arm Ports'

This critical appraisal examines the article 'Computed Tomography Frequency and Power Injection Utilization for a Cohort Cancer Patients with Arm Ports' by Bixler et al. (2018) in Clinical Infectious Diseases. The appraisal analyzes the study design, research objectives, literature review, methods, results, and discussion of the article. The study aims to determine the CT follow-up frequency and power injection utilization in a cohort of breast and colon cancer patients with arm ports. The authors use a prospective review of randomized clinical trials and analyze the data using statistical analysis. The results show a higher CT follow-up frequency in colon cancer patients compared to breast cancer patients. The discussion highlights the strengths and limitations of the study and suggests further research in this area.

A Critical Appraisal of the article:
‘Computed tomography frequency and
power injection utilization for a cohort
cancer patients with arm ports’ Bixler et
al. (2018), Clinical Infectious Diseases,
68(6), 956-963
Student’s Name:
University:
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Table of contents:
Abstract 4
Introduction: 4
Research Objectives/Questions: 5
Literature Review: 5
Study Design: 6
Ethical Concern: 6
Methods: 7
Sampling: 7
Bias and confounding: 7
Collection of Data and Analysis 7
Statistical Analysis 7
Results: 8
Discussion: 9
Conclusion: 10
References: 11
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Abstract
The major role of an abstract in critical appraisal is to explain the major aims and objectives of
the study, summarizing the content, and delivering appropriate article elements of the study to
make it interesting. In the context of this study the authors have provided the major goals of the
study of following a cohort of breast and colon malignant patients for the determination of the
CT follow-up frequency as well as the power injection of arm port in computed tomography
within a year. They further explained that the most required characteristic for a patient requiring
intravenous agents for computed tomography is the power injection potentiality of access devices
of veins. The prospective review RCTs study is the perfect study design, and the patients are
enrolled with cancer agency and their images of CT were kept in PACS. The total number of
patients, outcome measurements, statistical analysis, results and conclusion are also mentioned in
the abstract. However, the abstract was unable to provide background information of the study.
The authors were not able to vividly mention the research questions, rationale and the hypothesis
of the study. In the following study, the authors failed to explain the background as well as the
concepts on which the study is based to give credibility to the study. The authors should have
provided sufficient information on the background of the study to understand the aims behind the
study.
Introduction:
Research plays an important part in all fields, specifically in health care it is considered as the
base of advancements. The following paper will critically examine the study by Burbridge
Adams & Burbridge (2018) “Computed tomography frequency and power injection utilization
for a cohort cancer patient with arm ports”. The JBI Critical appraisal tools (CAT), 2017 will be
used for critiquing this study (Tufanaru et al. 2017). The appraisal would help to answer
questions to check if the process of research is constitutively followed or not. The research steps
consist of study design, size of the sample, ethical approval as well as concern, statistical
analysis and methods of data collection. The following critical appraisal will tend to examine the
strengths and limitations of the use of computed tomography frequency follow-up within a
specific group of malignant patients (Herts et al., 2001, pp.48). The major robust evidence form
is provided by randomized clinical trials (i.e., RCTs) in terms of efforts as they suggest evidence
associated with the condition of presence or absence of existing causal relation between an
intervention which have been stated or a particular measurable outcome as well as the direction
and implications of the association. The researchers have stated that computed tomography is
used in following known malignancy patients. However, for examining CT a contrast media is
used in which intravenous iodination occurs for assessing the anatomy of the patient (Haggag et
al. 2016, pp.113).
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The title of the study by Burbridge Adams & Burbridge (2018) have provided an explanation to
what the study relates to and why clearly and precisely. The title tend to help the reader to
understand the major aims of the study in a specific and interesting manner. However, a title
should provide a summarization of the content and should be specific with the objectives free
from any equivocation. The keywords of the study have provided a lead regarding the major
parts of the study such as ‘arm ports’, ‘power injection’, ‘CT’, ‘cancer imaging’, ‘port access’,
‘arm vein port’, ‘colon and breast cancer’, ‘power injection’, and ‘intravenous contrast agents’.
Research Objectives/Questions:
The objectives/research questions of the study were formulated according to the JBI Critical
Appraisal Tool (CAT) and it consists of the following:
1. Was true randomization used for assigning participants to groups of treatment?
2. Any similarity among treatment groups?
3. Were participants analyzed in the groups to which they were randomized?
4. Was outcome measurement done in a reliable manner?
5. Any appropriate use of statistical analysis?
Literature Review:
The review of literature section in the study was not clearly defined by the researchers and they
haven’t explained this section in a particular manner. However, a small section have been
provided in the introduction section regarding the absence of any published article on the use of
power injections access port in veins among malignant patients. The authors have failed to
demonstrate the current and appropriate evidence associated with the research statement (Altman
2001, pp.63). Furthermore, they also failed to outline the variable and their relation with each
other. The authors tend to focus on the different venous access ports useful for contrast media
power injection and have suggested that for improving the CT images, an implantable venous
access power injection device which in turn improves the contrast injection result rate as well as
reduction in risk of extravasation (Marcy et al., 2007, pp.33). However, the statements were not
supported by relevant studies. The article was not able to explain the theoretical framework and
the major concepts of the research was not defined clearly.
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Study Design:
In the following RCT study a quantitative method have been used in which the patients were
registered in a potential RCT of a power injectable device/port against a non-power injectable
device i.e., TIVAD for the determination of the long distance as well as problematic profile. The
quantitative method is relevant due to the requirement of quantification of the issue as well as
understanding its prevalence. Such approach also helps in studying the relationship between both
the dependent and independent variable. The data is utilized in quantitative approach for the
determination of link between cause and effect, which is used to make predictions. The study has
included a total number of 209 patients under treatment for 19 types of tumors out of which total
152 are breast and colon malignancy patients. This help the researchers to recognize the potential
research subjects. The population size was found to be appropriate, however, the use of power
analysis for the estimation of population size was not found to be stated. The authors have
further reviewed the malignant patients for CT utilization excluding 17 different types of tumor
due to small sample size from the statistical analysis. Out of 209 patients 109 were fulfilling the
data analysis eligibility criteria for assessing the use of power injectable characteristic of the
ports (Busch et al., 2012, pp.49).
Randomised clinical trials are used in the evaluation of the effectiveness of the new treatment for
the patients. It consists of random allocation of patients to treatment group to create a
comparison between them. A proper design of RCT helps in reducing risk of bias, variables as
well as results (Kanin & Young 2013, pp.29). However, poorly conducted RCTs are found to be
vulnerable to bias while producing information that misleads as well as overstated effects of the
treatment (Moher et al. 2003). The study followed a random allocation of patients to treatment
group (Chopra Anand & Hickner 2014, pp.53).
Ethical Concern:
The authors of the study have obtained the ethical approval from the local University Research
Ethics Committee. The participants were all vulnerable and due to their illness they were
registered in the study with the ClinicalTrials.gov. All the participants of the study have provided
consent to participate in the research trial as well as the venous access port clinical implantation
to get treated. However, ethical principles are found to be reiterated on the significance of
requesting informed consent from the subjects of the research before permitting them to
participate in the research (Moher 2001).
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Methods:
Sampling:
In the study the participants included are not allocated to control or treatment groups randomly
hence, a risk is created in terms of allocation which have been influenced by the known features
of the patients causing distortion in the group similarity. The study followed a random allocation
of patients to the treatment groups as the patients were selected purely on being treated for
different types of tumors. A computer-generated list of random numbers has been used in the
study as the review of the computed tomography imaging of the patients was performed after
their implantation. The performed CT images was reviewed for the determination of the patients
which have the injected port for the examination (Fallouh et al. 2015, pp.23).
Bias and confounding:
Collection of Data and Analysis
If the patients have known about their allocation to the treatment group, it usually creates a risk
that they might behave in a different way as well as in their response to the clinical implication in
comparison with the situations when the patients are devoid of any allocation to the treatment
groups hence, distorting the results. Blinding of the patients is required for minimizing such risk.
In the study, the patients were aware about their allocation to the treatment groups at the time of
their consent. Hence, the study was not able to follow the blinding of patients which was not able
to prevent the patients to know about their allocation (Delluc et al. 2015, pp.01).
Statistical Analysis
The study makes use of statistical analysis with the help of SPSS Statistics version 24.0. The
statistical method was employed consisting of descriptive analysis such as means and standard
deviations in order to determine the variables, frequency as well as portions in terms of
categorized variables (Jack et al., 2010, pp.62). Furthermore, the study has made comparisons of
categorized variables with the help of Fisher’s exact test. For analyzing the continuous variables,
the authors have also utilized t-test/ANOVA in combination with confirmatory testing which is
non-parametric. A significance value was kept for the analysis i.e., a p- value of <0.05 (Bhandari
Godin & Dhillon 2011).
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Results:
Any differentiation among the patients provided threat to the validity of the study. Selection bias
will appear if differences appear among the participants. However, no bias appeared in the
following study in terms of selection as the the patients belonging to 2 tumor groups i.e., the
breast (22) and colon cancer (26) patients deprived of the data of CT utilization follow-up were
therefore, not appropriate to disadvantaged as there was no asymmetrical data loss of data in any
group. The participants from the treatment groups were found similar in terms of the features
which tend to elaborate the effect in the absence of the follow-up period of the CT which was
found to be higher in colon cancer patients than breast cancer patients (i.e., the number of scans
3.06 vs. 1.08/patients and the p value was found to be less than 0.001) (Scheffel 2009). However,
the total number of CT performed tend to increase with the first and fourth stage of the cancer,
which was found to be in a range of 0.22-2.13/patient and p-value less than 0.001, while the CT
performed for colon cancer stages (first and fourth) fall in a range of 0.67-3.23/patient and is
statistically significant with parametric testing (where the p-value is equals to 0.03), and not
significant with non-parametric testing (where the p-value is equals to 0.052) (Jean-François
2008, pp.16).
This inquiry is about the intention-to-treat (ITT) examination. There are diverse statistical
analysis techniques accessible for the data analysis from RCTs such as intent-to-treat analysis,
pre-convention analysis, and astreated investigation. In the ITT investigation the members are
assessed in the groups to which they were randomized, paying little respect to whether they
really took part or not in those groups for the whole length of the RCT, got the exploratory
intercession or control mediation as arranged or whether they were consistent or not with the
arranged trial mediation or control mediation (Raslich & Onady 2007). The ITT investigation
thinks about the results for members from the underlying groups made by the underlying random
allocation of patients to those groups. In the following study, the ITT analysis was reported. The
power injectable arm device has been used in the study for acquiring contrasting increased
images in 114 patients accounting for forty seven percent. However, the portion of that made use
of power injectable arm device for contrast managing was found to be same among patients
suffering from breast or colon cancer accounting for sixty vs. forty eight percent and the reported
p-value is 0.22. CT studies that were performed in the study at 6 rural or urban places, in which
43 studies were performed at rural places accounting 17.8 percent, while 198 studies were
carried out at urban places accounting for 82.2 percent (Buccheri & Sharifi 2017, pp.6). The
power injectable arm port was used in 114 studies out of 198 studies accounting 57.6 percent at
urban site with a p-value of less than 0.001. The patients were assessed in the treatment groups
for which they were randomised, despite of their participation in the groups and them being
really receiving interventions (Somers et al. 2019).
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Discussion:
The discussion relates to the fact that the vein got to for catheter inclusion identified with a
power-injectable port should be bigger because of the bigger catheter measure. Embeddings
bigger catheters into fringe veins has been demonstrated to build the danger of venous
thrombosis. Smith found the accompanying rates of venous thrombosis identified with fringe
venous catheters 5F – 6.6 percent, 6F – 9.8 percent (Smith 2008, pp.10). The power injectable
catheter utilized in this examination was 6.6F in breadth versus 5F for the non-control injectable
port. Therefore, if a bigger catheter measure isn't clinically required, a port with a small distance
across the catheter might be justified (Syha et al. 2016). An extra test for catheter measure
related venous thrombosis is the absence of a settled upon methodology for prophylactic
anticoagulation for upper appendage veins (Kumar et al. 2014, pp.22). The role control infusion
plays in device related complexities stays unsure as clashing reports have been distributed
proposing both a relationship with expanded difficulties and no clear affiliation (Kaseda et al.
2016, pp.75). Power injectable ports are marginally bigger in size and this outcomes in a gadget
that requires a bigger inclusion site skin entry point and causes a more detectable skin swell than
a small non-power injectable alternative. This may have an unfriendly effect upon self-
perception. The outcomes measurements bolster the supposition that patients with colon
malignancy have follow-up CT performed more generally than those with breast cancer disease.
Therefore, stating that the study has a reliability measure. The uniqueness for CT use was
likewise measurably clear for those with increasingly ideal illness organizing for the two
malignancies with this being very discernible for breast cancer patients. It was evident that there
was no convincing need to embed a power injectable port for all patients requiring chemotherapy
dependent on CT usage (Nemtsova 2007). On the off chance that a discretionary cut-off of in
excess of two power infused CT checks/quiet/year was connected to legitimize a power
injectable port, this dimension of use was met by those patients with stage 4 cancer malignancy
and stages 3 and 4 colon disease. It would appear to be sensible to propose that for patients with
progressively great arranging of these infections, a power injectable port isn't required because of
the for the most part low use of CT for follow-up. In any case, tolerant dread of venipuncture
ought to be taken in to thought while deciding whether a power injectable port is justified. The
study has maintained its validity in terms of reliability of outcome measurements of statistical
relationship (Rosengarten & Savransky 2018, pp.82).
The researchers of the study have used an appropriate statistical analysis resulting in avoiding of
errors caused due to statistical inference in terms the existence and the magnitude of the CT and
injection which have to be determined through the treatment. In this paper, some limitations of
the study are also acknowledged such as in terms of scope, and the researchers had no control on
the presence and absence of patients.
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Conclusion:
The critical appraisal of the study Burbridge Adams & Burbridge (2018) “Computed tomography
frequency and power injection utilization for a cohort cancer patient with arm ports” using the
JBI Critical appraisal tools (CAT), 2017. The appraisal would help to answer questions to check
if the process of research is constitutively followed or not. Bigger catheters in fringe veins have
an expanded danger of venous thrombosis. While sending an arm port for venous access thought
ought to be taken regarding whether the potential expanded hazard related with bigger catheter
measure is justified dependent on threat type and the phase of the harm. Restricting the effect of
catheter distance across may help decrease gadget related confusions. The accessibility of faculty
prepared to get to and use control infusion is a goal. On the off chance that there is an absence of
prepared faculty in CT the power injectable port will be of no advantage. Accordingly, the
personalization of the determination procedure for an arm port may limit potential complexities
and improve tolerant consideration.
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