Clinically-indicated replacement versus routine replacement of peripheral venous catheters

BACKGROUND: US Centers for Disease Control guidelines recommend replacement of peripheral intravenous (IV) catheters no more frequently than every 72 to 96 hours. Routine replacement is thought to reduce the risk of phlebitis and bloodstream infection. Catheter insertion is an unpleasant experience for patients and replacement may be unnecessary if the catheter remains functional and there are no signs of inflammation. Costs associated with routine replacement may be considerable. This is an update of a review first published in 2010. OBJECTIVES: To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries. SELECTION CRITERIA: Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001). AUTHORS' CONCLUSIONS: The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present. OBJECTIVES: To assess the effects of removing peripheral IV catheters when clinically indicated compared with removing and re-siting the catheter routinely. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases (PVD) Group Trials Search Co-ordinator searched the PVD Specialised Register (December 2012) and CENTRAL (2012, Issue 11). We also searched MEDLINE (last searched October 2012) and clinical trials registries. SELECTION CRITERIA: Randomised controlled trials that compared routine removal of peripheral IV catheters with removal only when clinically indicated in hospitalised or community dwelling patients receiving continuous or intermittent infusions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. MAIN RESULTS: Seven trials with a total of 4895 patients were included in the review. Catheter-related bloodstream infection (CRBSI) was assessed in five trials (4806 patients). There was no significant between group difference in the CRBSI rate (clinically-indicated 1/2365; routine change 2/2441). The risk ratio (RR) was 0.61 but the confidence interval (CI) was wide, creating uncertainty around the estimate (95% CI 0.08 to 4.68; P = 0.64). No difference in phlebitis rates was found whether catheters were changed according to clinical indications or routinely (clinically-indicated 186/2365; 3-day change 166/2441; RR 1.14, 95% CI 0.93 to 1.39). This result was unaffected by whether infusion through the catheter was continuous or intermittent. We also analysed the data by number of device days and again no differences between groups were observed (RR 1.03, 95% CI 0.84 to 1.27; P = 0.75). One trial assessed all-cause bloodstream infection. There was no difference in this outcome between the two groups (clinically-indicated 4/1593 (0.02%); routine change 9/1690 (0.05%); P = 0.21). Cannulation costs were lower by approximately AUD 7.00 in the clinically-indicated group (mean difference (MD) -6.96, 95% CI -9.05 to -4.86; P ≤ 0.00001). AUTHORS' CONCLUSIONS: The review found no evidence to support changing catheters every 72 to 96 hours. Consequently, healthcare organisations may consider changing to a policy whereby catheters are changed only if clinically indicated. This would provide significant cost savings and would spare patients the unnecessary pain of routine re-sites in the absence of clinical indications. To minimise peripheral catheter-related complications, the insertion site should be inspected at each shift change and the catheter removed if signs of inflammation, infiltration, or blockage are present.

High rates of muscle glycogen resynthesis after exhaustive exercise when carbohydrate is coingested with caffeine

We determined the effect of coingestion of caffeine (Caff) with carbohydrate (CHO) on rates of muscle glycogen resynthesis during recovery from exhaustive exercise in seven trained subjects who completed two experimental trials in a randomized, double-blind crossover design. The evening before an experiment subjects performed intermittent exhaustive cycling and then consumed a low-CHO meal. The next morning subjects rode until volitional fatigue. On completion of this ride subjects consumed either CHO [4 g/kg body mass (BM)] or the same amount of CHO + Caff (8 mg/kg BM) during 4 h of passive recovery. Muscle biopsies and blood samples were taken at regular intervals throughout recovery. Muscle glycogen levels were similar at exhaustion [?75 mmol/kg dry wt (dw)] and increased by a similar amount (?80%) after 1 h of recovery (133 ± 37.8 vs. 149 ± 48 mmol/kg dw for CHO and Caff, respectively). After 4 h of recovery Caff resulted in higher glycogen accumulation (313 ± 69 vs. 234 ± 50 mmol/kg dw, P < 0.001). Accordingly, the overall rate of resynthesis for the 4-h recovery period was 66% higher in Caff compared with CHO (57.7 ± 18.5 vs. 38.0 ± 7.7 mmol·kg dw-1·h-1, P < 0.05). After 1 h of recovery plasma Caff levels had increased to 31 ± 11 ?M (P < 0.001) and at the end of the recovery reached 77 ± 11 ?M (P < 0.001) with Caff. Phosphorylation of CaMKThr286 was similar after exercise and after 1 h of recovery, but after 4 h CaMKThr286 phosphorylation was higher in Caff than CHO (P < 0.05). Phosphorylation of AMP-activated protein kinase (AMPK)Thr172 and AktSer473 was similar for both treatments at all time points. We provide the first evidence that in trained subjects coingestion of large amounts of Caff (8 mg/kg BM) with CHO has an additive effect on rates of postexercise muscle glycogen accumulation compared with consumption of CHO alone.

Failure to repeatedly supercompensate muscle glycogen stores in highly trained men

Purpose: It is not known whether it is possible to repeatedly supercompensate muscle glycogen stores after exhaustive exercise bouts undertaken within several days. Methods: We evaluated the effect of repeated exercise-diet manipulation on muscle glycogen and triacylglycerol (IMTG) metabolism and exercise capacity in six well-trained subjects who completed an intermittent, exhaustive cycling protocol (EX) on three occasions separated by 48 h (i.e., days 1, 3, and 5) in a 5-d period. Twenty-four hours before day 1, subjects consumed a moderate (6 g·kg-1)-carbohydrate (CHO) diet, followed by 5 d of a high (12 g·kg-1·d -1)-CHO diet. Muscle biopsies were taken at rest, immediately post-EX on days 1, 3, and 5, and after 3 h of recovery on days 1 and 3. Results: Compared with day 1, resting muscle [glycogen] was elevated on day 3 but not day 5 (435 ± 57 vs 713 ± 60 vs 409 ± 40 mmol·kg -1, P < 0.001). [IMTG] was reduced by 28% (P < 0.05) after EX on day 1, but post-EX levels on days 3 and 5 were similar to rest. EX was enhanced on days 3 and 5 compared with day 1 (31.9 ± 2.5 and 35.4 ± 3.8 vs 24.1 ± 1.4 kJ·kg-1, P < 0.05). Glycogen synthase activity at rest and immediately post-EX was similar between trials. Additionally, the rates of muscle glycogen accumulation were similar during the 3-h recovery period on days 1 and 3. Conclusion: We show that well-trained men cannot repeatedly supercompensate muscle [glycogen] after glycogen-depleting exercise and 2 d of a high-CHO diet, suggesting that the mechanisms responsible for glycogen accumulation are attenuated as a consequence of successive days of glycogen-depleting exercise.

Phase III study of matrix metalloproteinase inhibitor prinomastat in non-small-cell lung cancer

Purpose: Matrix metalloproteinases (MMPs) degrade extracellular proteins and facilitate tumor growth, invasion, metastasis, and angiogenesis. This trial was undertaken to determine the effect of prinomastat, an inhibitor of selected MMPs, on the survival of patients with advanced non-small-cell lung cancer (NSCLC), when given in combination with gemcitabine-cisplatin chemotherapy. Patients and Methods: Chemotherapy-naive patients were randomly assigned to receive prinomastat 15 mg or placebo twice daily orally continuously, in combination with gemcitabine 1,250 mg/m2 days 1 and 8 plus cisplatin 75 mg/m2 day 1, every 21 days for up to six cycles. The planned sample size was 420 patients. Results: Study results at an interim analysis and lack of efficacy in another phase III trial prompted early closure of this study. There were 362 patients randomized (181 on prinomastat and 181 on placebo). One hundred thirty-four patients had stage IIIB disease with T4 primary tumor, 193 had stage IV disease, and 34 had recurrent disease (one enrolled patient was ineligible with stage IIIA disease). Overall response rates for the two treatment arms were similar (27% for prinomastat v 26% for placebo; P = .81). There was no difference in overall survival or time to progression; for prinomastat versus placebo patients, the median overall survival times were 11.5 versus 10.8 months (P = .82), 1-year survival rates were 43% v 38% (P = .45), and progression-free survival times were 6.1 v 5.5 months (P = .11), respectively. The toxicities of prinomastat were arthralgia, stiffness, and joint swelling. Treatment interruption was required in 38% of prinomastat patients and 12% of placebo patients. Conclusion: Prinomastat does not improve the outcome of chemotherapy in advanced NSCLC. © 2005 by American Society of Clinical Oncology.

Low cost localisation for agricultural robotics

This paper presents a pose estimation approach that is resilient to typical sensor failure and suitable for low cost agricultural robots. Guiding large agricultural machinery with highly accurate GPS/INS systems has become standard practice, however these systems are inappropriate for smaller, lower-cost robots. Our positioning system estimates pose by fusing data from a low-cost global positioning sensor, low-cost inertial sensors and a new technique for vision-based row tracking. The results first demonstrate that our positioning system will accurately guide a robot to perform a coverage task across a 6 hectare field. The results then demonstrate that our vision-based row tracking algorithm improves the performance of the positioning system despite long periods of precision correction signal dropout and intermittent dropouts of the entire GPS sensor.

Voltage unbalance reduction in low voltage feeders by dynamic switching of residential customers among three phases

Low voltage distribution feeders with large numbers of single phase residential loads experience severe current unbalance that often causes voltage unbalance problems. The addition of intermittent generation and new loads in the form of roof top photovoltaic generation and electric vehicles makes these problems even more acute. In this paper, an intelligent dynamic residential load transfer scheme is proposed. Residential loads can be transferred from one phase to another phase to minimize the voltage unbalance along the feeder. Each house is supplied through a static transfer switch with three-phase input and single-phase output connection. The main controller, installed at the transformer will observe the power consumption in each load and determine which house(s) should be transferred from one phase to another in order to keep the voltage unbalance in the feeder at a minimum. The efficacy of the proposed load transfer scheme is verified through MATLAB and PSCAD/EMTDC simulations.

Impacts of climatic factors on evolution of molecular diversity and the natural distribution of wild stocks of the giant freshwater prawn (Macrobrachium rosenbergii)

Natural distributions of most freshwater taxa are restricted geographically, a pattern that reflects dispersal limitation. Macrobrachium rosenbergii is unusual because it occurs naturally in rivers from near Pakistan in the west, across India and Bangladesh to the Malay Peninsula, and across the Sunda Shelf and Indonesian archipelago to western Java. Individuals cannot tolerate full marine conditions, so dispersal between river drainage basins must occur at limited geographical scales when ecological or climatic factors are favorable. We examined molecular diversity in wild populations of M. rosenbergii across its complete natural range to document patterns of diversity and to relate them to factors that have driven evolution of diversity in this species. We found 3 clades in the mitochondrial deoxyribonucleic acid (mtDNA) data set that corresponded geographically with eastern, central, and western sets of haplotypes that last shared a common ancestor 1 × 106 y ago. The eastern clade was closest to the common ancestor of all 3 clades and to the common ancestor with its congener, Macrobrachium spinipes, distributed east of Huxley's Line. Macrobrachium rosenbergii could have evolved in the western Indonesian archipelago and spread westward during the early to mid-Pleistocene to India and Sri Lanka. Additional groups identified in the nuclear DNA data set in the central and western clades probably indicate secondary contact via dispersal between regions and modern introductions that have mixed nuclear and mtDNA genes. Pleistocene sea-level fluctuations can explain dispersal across the Indonesian archipelago and parts of mainland southeastern Asia via changing river drainage connections in shallow seas on wide continental shelves. At the western end of the modern distribution where continental shelves are smaller, intermittent freshwater plumes from large rivers probably permitted larval dispersal across inshore areas of lowered salinity.

First full-scale trials of pebble matrix filtration

Protecting slow sand filters from high turbidity waters by pre-treatment using Pebble Matrix Filtration (PMF) has been studied in the laboratory at University College London followed by pilot field trials in Papua New Guinea and Serbia. Subsequently, the construction of two full-scale PMF units, one out of concrete (4.8m x4.8m x 3.0m high) and the other using pre-cast Ferro-cement panels (900mm x 1600mm x 20mm thick) with an effective diameter of 4.7m and 3m height, and the combined effective plan area of 40 m2 was completed to protect an existing Slow Sand Filter system at the National Water Supply Drainage Board (NWSDB) in Sri Lanka. Although the plant was completed in April 2008 due to some major repairs to address some leaks and other construction defects in both filters, monitoring was intermittent until November 2008. The results on the plant performance are presented here along with some of the construction problems encountered during the project.

β-Arrestin2 regulates RANKL and Ephrins gene expression in response to bone remodeling in mice

PTH-stimulated intracellular signaling is regulated by the cytoplasmic adaptor molecule barrestin. We reported that the response of cancellous bone to intermittent PTH is reduced in b-arrestin22/2 mice and suggested that b-arrestins could influence the bone mineral balance by controlling RANKL and osteoprotegerin (OPG) gene expression. Here, we study the role of b-arrestin2 on the in vitro development and activity of bone marrow (BM) osteoclasts (OCs) and Ephrins ligand (Efn), and receptor (Eph) mRNA levels in bone in response to PTH and the changes of bone microarchitecture in wildtype (WT) and barrestin2 2/2 mice in models of bone remodeling: a low calcium diet (LoCa) and ovariectomy (OVX). The number of PTH-stimulated OCs was higher in BM cultures from b-arrestin22/2 compared with WT, because of a higher RANKL/OPG mRNA and protein ratio, without directly influencing osteoclast activity. In vivo, high PTH levels induced by LoCa led to greater changes in TRACP5b levels in b-arrestin22/2 compared with WT. LoCa caused a loss of BMD and bone microarchitecture, which was most prominent in b-arrestin22/2. PTH downregulated Efn and Eph genes in b-arrestin22/2, but not WT. After OVX, vertebral trabecular bone volume fraction and trabecular number were lower in b-arrestin22/2 compared with WT. Histomorphometry showed that OC number was higher in OVX-b-arrestin22/2 compared with WT. These results indicate that b-arrestin2 inhibits osteoclastogenesis in vitro, which resulted in decreased bone resorption in vivo by regulating RANKL/OPG production and ephrins mRNAs. As such, b-arrestins should be considered an important mechanism for the control of bone remodeling in response to PTH and estrogen deprivation.

Evidence based physical activity for school-age youth

Objectives To review the effects of physical activity on health and behavior outcomes and develop evidence-based recommendations for physical activity in youth. Study design A systematic literature review identified 850 articles; additional papers were identified by the expert panelists. Articles in the identified outcome areas were reviewed, evaluated and summarized by an expert panelist. The strength of the evidence, conclusions, key issues, and gaps in the evidence were abstracted in a standardized format and presented and discussed by panelists and organizational representatives. Results Most intervention studies used supervised programs of moderate to vigorous physical activity of 30 to 45 minutes duration 3 to 5 days per week. The panel believed that a greater amount of physical activity would be necessary to achieve similar beneficial effects on health and behavioral outcomes in ordinary daily circumstances (typically intermittent and unsupervised activity). Conclusion School-age youth should participate daily in 60 minutes or more of moderate to vigorous physical activity that is developmentally appropriate, enjoyable, and involves a variety of activities.

The use of uniaxial and triaxial accelerometers to measure children's "free-play" physical activity

In order to effectively measure the physical activity of children, objective monitoring devices must be able to quantify the intermittent and nonlinear movement of free play. The purpose of this study was to investigate the validity of the Computer Science and Applications (CSA) uniaxial accelerometer and the TriTrac-R3D triaxial accelerometer with respect to their ability to measure 8 "free-play" activities of different intensity. The activities ranged from light to very vigorous in intensity and included activities such as throwing and catching, hopscotch, and basketball. Twenty-eight children, ages 9 to 11, wore a CSA and a heart rate monitor while performing the activities. Sixteen children also wore a Tritrac. Counts from the CSA, Tritrac, and heart rates corresponding to the last 3 min of the 5 min spent at each activity were averaged and used in correlation analyses. Across all 8 activities, Tritrac counts were significantly correlated with predicted MET level (r= 0.69) and heart rate (r= 0.73). Correlations between CSA output, predicted MET level (0.43), and heart rate (0.64) were also significant but were lower than those observed for the Tritrac. These data indicate that accelerometers are an appropriate methodology for measuring children's free-play physical activities.

Multivariate statistical analysis of hydrochemical data to assess alluvial aquifer–stream connectivity during drought and flood : Cressbrook Creek, southeast Queensland, Australia

A catchment-scale multivariate statistical analysis of hydrochemistry enabled assessment of interactions between alluvial groundwater and Cressbrook Creek, an intermittent drainage system in southeast Queensland, Australia. Hierarchical cluster analyses and principal component analysis were applied to time-series data to evaluate the hydrochemical evolution of groundwater during periods of extreme drought and severe flooding. A simple three-dimensional geological model was developed to conceptualise the catchment morphology and the stratigraphic framework of the alluvium. The alluvium forms a two-layer system with a basal coarse-grained layer overlain by a clay-rich low-permeability unit. In the upper and middle catchment, alluvial groundwater is chemically similar to streamwater, particularly near the creek (reflected by high HCO3/Cl and K/Na ratios and low salinities), indicating a high degree of connectivity. In the lower catchment, groundwater is more saline with lower HCO3/Cl and K/Na ratios, notably during dry periods. Groundwater salinity substantially decreased following severe flooding in 2011, notably in the lower catchment, confirming that flooding is an important mechanism for both recharge and maintaining groundwater quality. The integrated approach used in this study enabled effective interpretation of hydrological processes and can be applied to a variety of hydrological settings to synthesise and evaluate large hydrochemical datasets.

Non-square-well potential profile and suppression of blinking in compositionally graded Cd1−xZnxSe/CdxZn1−xSe nanocrystals

Random blinking is a major problem on the way to successful applications of semiconducting nanocrystals in optoelectronics and photonics, which until recently had neither a practical solution nor a theoretical interpretation. An experimental breakthrough has recently been made by fabricating non-blinking Cd1-xZnxSe/ZnSe graded nanocrystals [Wang et al., Nature, 2009, 459, 686]. Here, we (1) report an unequivocal and detailed theoretical investigation to understand the properties (e.g., profile) of the potential-well and the distribution of Zn content with respect to the nanocrystal radius and (2) develop a strategy to find the relationship between the photoluminescence (PL) energy peaks and the potential-well due to Zn distribution in nanocrystals. It is demonstrated that the non-square-well potential can be varied in such a way that one can indeed control the PL intensity and the energy-level difference (PL energy peaks) accurately. This implies that one can either suppress the blinking altogether, or alternatively, manipulate the PL energy peaks and intensities systematically to achieve a controlled non-random intermittent luminescence. The approach developed here is based on the ionization energy approximation and as such is generic and can be applied to any non-free-electron nanocrystals.

Controller design for variable-speed permanent magnet wind turbine generators interfaced with Z-source inverter

Increased awareness of environmental concerns has caused greater interest in developing power sources based on renewable technologies, such as wind. Due to the intermittent nature of the wind speed, output voltage and frequency of the direct driven permanent magnet synchronous generators (PMSG) are normally unsteady. Recently proposed Z-source inverter has been considered as a potential solution for grid interfacing wind power generators, thanks to buck-boost function that the single stage Z-source inverter can offer. Two control methodologies, namely unified controller for isolated operation and a multi-loop controller for grid interfaced operation are investigated in this paper. Theoretical analysis of these two control schemes is presented and experimental results to verify the effectiveness of the control method are also included.

Improving voltage profile of residential distribution systems using rooftop PVs and Battery Energy Storage systems

Large number of rooftop Photovoltaics (PVs) have turned traditional passive networks into active networks with intermittent and bidirectional power flow. A community based distribution network grid reinforcement process is proposed to address technical challenges associated with large integration of rooftop PVs. Probabilistic estimation of intermittent PV generation is considered. Depending on the network parameters such as the R/X ratio of distribution feeder, either reactive control from PVs or coordinated control of PVs and Battery Energy Storage (BES) has been proposed. Determination of BES capacity is one of the significant outcomes from the proposed method and several factors such as variation in PV installed capacity as well as participation from community members are analyzed. The proposed approach is convenient for the community members providing them flexibility of managing their integrated PV and BES systems