Successful prevention of tunneled central catheter infection by antibiotic lock therapy using cefazolin and gentamicin

Catheter-related bacteremia (CRB) is one of the various complications related to hemodialysis (HD). As a result of this high rate of infection, the antibiotic lock technique (ALT) has been recommended to prevent CRB. However, adverse effects of ALT such as increased emergence of strains resistant to antibiotics and increased mechanical dysfunction catheter were poorly evaluated. We prospectively evaluated the efficacy of catheter-restricted filling using an antibiotic lock solution in preventing CRB. A total of 233 HD patients requiring 325 new tunneled catheters while waiting for placement and maturation of an arteriovenous fistula or graft were enrolled in this study. Patients with a tunneled catheter were assigned to receive either an antibiotic-heparin lock solution (antibiotic group: cefazolin 10 mg/ml, gentamicin 5 mg/ml, heparin 1,000 U/ml) or a heparin lock solution (no-antibiotic group: heparin 1,000 U/ml) as a catheter lock solution during the interdialytic period. The present study aimed to assess the efficacy of ALT using cefazolin and gentamicin in reducing CRB in patients undergoing HD with tunneled central catheter and to identify its adverse effects. CRB developed in 32.4 % of patients in the no-antibiotic group and in 13.1 % of patients in the antibiotic group. CRB rates per 1,000 catheter-days were 0.57 in the antibiotic group versus 1.74 in the no-antibiotic group (p < 0.0001). Kaplan-Meier analysis also showed that mean CRB-free catheter survival was significantly higher in the antibiotic group than in the no-antibiotic group (log-rank statistic 17.62, p < 0.0001). There was statistically significant difference between the two groups in causative organisms of CRB, with predominance of negative culture in both groups, but this prevalence was higher in ALT group (57.9 vs 90.1 %, p < 0.0001), and the two groups also were different in prevalence of gram-positive bacteria as causing organisms (ALT group 21.05 vs = 0 % in control group, p < 0.0001). There was no statistically significant difference between the two groups in drug-resistant germs. There were statistically significant differences between the two groups in the catheter removal causes, with higher rate of infectious cause in control group (12.32 vs 2.22 %, p < 0.0001) and mechanical cause in ALT group (28.26 vs 37.78 %, p < 0.0001). The results suggest that ALT may be a beneficial means of reducing the CRB rate in HD patients with tunneled catheter, without association between ALT and emergence of strains resistant. However, mechanical complications were more prevalent in antibiotic group. Further studies are required to determine the optimal drug regimen, concentrations for ALT, and its adverse effects. © 2012 Springer Science+Business Media Dordrecht.

Factores asociados con infección por catéter central en UCI Clínica San Pedro Claver de junio a diciembre de 2004.

La infección asociada a inserción de catéter vascular, es un problema cotidiano en las UCI a nivel mundial, a pesar del manejo de protocolos que se han implementado de manera independiente en las distintas instituciones para frenar este fenómeno. El estudio, de tipo observacional, analítico y cohorte concurrente, con 151 pacientes, a los cuales se insertó catéter en la UCI de la Clínica San Pedro Claver.Para el análisis se realizó estadística descriptiva, análisis de sobrevida, pruebas de asociación y regresión de Cox.

Approach to prophylactic measures for central venous catheter-related infections in hemodialysis: A critical review

Vascular access is the major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. The type of vascular access most associated with bloodstream infection is central venous catheter (CVC). The incidence of catheter-related bacteremia ranges between 0.6 and 6.5 episodes per 1000 catheter days and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter-related bacteremia, which adversely impacts morbidity and mortality rates and costs among HD patients, several prevention measures aimed at reducing the rates of CVC-related infections have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta-analyses have been conducted in order to assess the effectiveness, clinical applicability, and long-term adverse effects of such measures. In the following article, prophylactic measures against CVC-related infections in HD patients and their possible advantages and limitations will be discussed, and the more recent literature on clinical experience with prophylactic antimicrobial lock therapy in HD CVCs will be reviewed.

Nosocomial infections in dialysis access.

Nosocomial infections in patients requiring renal replacement therapy have a high impact on morbidity and mortality. The most dangerous complication is bloodstream infection (BSI) associated with the vascular access, with a low BSI risk in arteriovenous fistulas or grafts and a comparatively high risk in central venous catheters. The single most important measure for preventing BSI is therefore the reduction of catheter use by means of early fistula formation. As this is not always feasible, prevention should focus on educational efforts, hand hygiene, surveillance of dialysis-associated events, and specific measures at and after the insertion of catheters. Core measures at the time of insertion include choosing the optimal site of insertion, the use of maximum sterile barrier precautions, adequate skin antisepsis, and the choice of catheter type; after insertion, access care needs to ensure hub disinfection and regular dressing changes. The application of antimicrobial locks is reserved for special situations. Evidence suggests that bundling a selection of the aforementioned measures can significantly reduce infection rates. The diagnosis of central line-associated BSI (CLABSI) is based on clinical signs and microbiological findings in blood cultures ideally drawn both peripherally and from the catheter. The prompt installation of empiric antibiotic treatment covering the most commonly encountered organisms is key regarding CLABSI treatment. Catheter removal is recommended in complicated cases or if cultures yield Staphylococcus aureus, enterococci, Pseudomonas or fungi. In other cases, guide wire exchange or catheter salvage strategies with antibiotic lock solutions may be acceptable alternatives.

A Smart Frequency Presetting Technique for Fast Lock-in LC-PLL Frequency Synthesizer

This paper proposes a smart frequency presetting technique for fast lock-in LC-PLL frequency synthesizer. The technique accurately presets the frequency of VCO with small initial frequency error and greatly reduces the lock-in time. It can automatically compensate preset frequency variation with process and temperature. A 2.4GHz synthesizer with 1MHz reference input was implemented in 0.35 mu m CMOS process. The chip core area is 0.4mm(2). Output frequency of VCO ranges from 2390 to 2600MHz. The measured results show that the typical lock-in time is 3 mu s. The phase noise is -112dBc/Hz at 600KHz offset from center frequency. The test chip consumes current of 22mA that includes the consumption of the I/O buffers.

Dynamic Lock Synchronisation for collaborative 3D applications

In a typical collaborative application, users contends for common resources by mutual exclusion. The introduction of multi-modal environment, however, introduced problems such as frequent dropping of connection or limited connectivity speed of mobile users. This paper target 3D resources which require additional considerations such as dependency of users' manipulation command. This paper introduces Dynamic Locking Synchronisation technique to enable seamless and collaborative environment for large number of user, by combining the contention-free concepts of locking mechanism and the seamless nature of lockless design.

Questionable antibiotic practices: Obtaining reliable estimates of consumer behaviours

Background: Significant recent attention has focussed on the role of antibiotic prescribing and usage with the aim of combating antibiotic resistance, a growing worldwide health concern. A significant gap in this literature concerns the consumption patterns and beliefs of consumers about antibiotics and their effects. We seek to remedy this gap by exploring a range of questionable antibiotic practices and obtaining reliable estimates of their prevalence as well as their normative status. Methods: We conducted an online survey of over 100 consumers. We used a new incentive compatible technique, the Bayesian Truth Serum (BTS), to elicit more truthful responding than standard self-report measures. We asked participants to indicate whether they engaged in a number of practices including whether they had: taken antibiotics when they are out of date and stored antibiotics at home for later use. We then sought estimates of the percentage of other patients (like them) who had engaged in each behaviour, as well as asking them among those patients who had, the percentage that would admit to having done so. We also asked about social acceptability and responsibility of the practices. Results: These results will show for each type of questionable practice how prevalent it is and whether consumers view it as both socially acceptable and socially responsible. We will gain the relative prevalence of each of these practices. Conclusion: These findings are of paramount importance in gaining a better understanding of consumers’ antibiotic consumption patterns. These will be vital for better targeting educational campaigns to lower inappropriate antibiotic consumption.

2(n)-SEMA-a robust solid state nuclear magnetic resonance experiment for measuring heteronuclear dipolar couplings in static oriented systems using effective transverse spin-lock

Separated local field (SLF) spectroscopy is a powerful technique to measure heteronuclear dipolar couplings. The method provides site-specific dipolar couplings for oriented samples such as membrane proteins oriented in lipid bilayers and liquid crystals. A majority of the SLF techniques utilize the well-known Polarization Inversion Spin Exchange at Magic Angle (PISEMA) pulse scheme which employs spin exchange at the magic angle under Hartmann-Hahn match. Though PISEMA provides a relatively large scaling factor for the heteronuclear dipolar coupling and a better resolution along the dipolar dimension, it has a few shortcomings. One of the major problems with PISEMA is that the sequence is very much sensitive to proton carrier offset and the measured dipolar coupling changes dramatically with the change in the carrier frequency. The study presented here focuses on modified PISEMA sequences which are relatively insensitive to proton offsets over a large range. In the proposed sequences, the proton magnetization is cycled through two quadrants while the effective field is cycled through either two or four quadrants. The modified sequences have been named as 2(n)-SEMA where n represents the number of quadrants the effective field is cycled through. Experiments carried out on a liquid crystal and a single crystal of a model peptide demonstrate the usefulness of the modified sequences. A systematic study under various offsets and Hartmann-Hahn mismatch conditions has been carried out and the performance is compared with PISEMA under similar conditions.

Lock Acquisition and Sensitivity Analysis of Advanced LIGO Interferometers

Laser interferometer gravitational wave observatory (LIGO) consists of two complex large-scale laser interferometers designed for direct detection of gravitational waves from distant astrophysical sources in the frequency range 10Hz - 5kHz. Direct detection of space-time ripples will support Einstein's general theory of relativity and provide invaluable information and new insight into physics of the Universe.

Initial phase of LIGO started in 2002, and since then data was collected during six science runs. Instrument sensitivity was improving from run to run due to the effort of commissioning team. Initial LIGO has reached designed sensitivity during the last science run, which ended in October 2010.

In parallel with commissioning and data analysis with the initial detector, LIGO group worked on research and development of the next generation detectors. Major instrument upgrade from initial to advanced LIGO started in 2010 and lasted till 2014.

This thesis describes results of commissioning work done at LIGO Livingston site from 2013 until 2015 in parallel with and after the installation of the instrument. This thesis also discusses new techniques and tools developed at the 40m prototype including adaptive filtering, estimation of quantization noise in digital filters and design of isolation kits for ground seismometers.

The first part of this thesis is devoted to the description of methods for bringing interferometer to the linear regime when collection of data becomes possible. States of longitudinal and angular controls of interferometer degrees of freedom during lock acquisition process and in low noise configuration are discussed in details.

Once interferometer is locked and transitioned to low noise regime, instrument produces astrophysics data that should be calibrated to units of meters or strain. The second part of this thesis describes online calibration technique set up in both observatories to monitor the quality of the collected data in real time. Sensitivity analysis was done to understand and eliminate noise sources of the instrument.

Coupling of noise sources to gravitational wave channel can be reduced if robust feedforward and optimal feedback control loops are implemented. The last part of this thesis describes static and adaptive feedforward noise cancellation techniques applied to Advanced LIGO interferometers and tested at the 40m prototype. Applications of optimal time domain feedback control techniques and estimators to aLIGO control loops are also discussed.

Commissioning work is still ongoing at the sites. First science run of advanced LIGO is planned for September 2015 and will last for 3-4 months. This run will be followed by a set of small instrument upgrades that will be installed on a time scale of few months. Second science run will start in spring 2016 and last for about 6 months. Since current sensitivity of advanced LIGO is already more than factor of 3 higher compared to initial detectors and keeps improving on a monthly basis, upcoming science runs have a good chance for the first direct detection of gravitational waves.

High-precision digital lock-in measurements of critical current and AC loss in HTS 2G-Tapes

Application of High Temperature Superconducting (HTS) has been increasingly popular since the new superconducting materials were discovered. This paper presents a new high-precision digital lock-in measurement technique which is used for measuring critical current and AC loss of the 2nd Generation HTS tape. Using a lock-in amplifier and nano-voltage meter, we can resolve signals at nano-volt level, while using a specially designed compensation coil we can cancel out inductive by adjusting the coil inductance. Furthermore, a finer correction for the inductive component can be achieved by adjusting the reference phase of the lock-in amplifier. The critical current and AC loss measurement algorithms and hardware layout are described and analyzed, and results for both numerical and experimental data under varieties of frequencies are presented. © 2008 SICE.

Realization of a Scanning Photoacoustic Technique: Thermal properties of Bulk and Film Samples

Among the large number of photothcrmal techniques available, photoacoustics assumes a very significant place because of its essential simplicity and the variety of applications it finds in science and technology. The photoacoustic (PA) effect is the generation of an acoustic signal when a sample, kept inside an enclosed volume, is irradiated by an intensity modulated beam of radiation. The radiation absorbed by the sample is converted into thermal waves by nonradiative de-excitation processes. The propagating thermal waves cause a corresponding expansion and contraction of the gas medium surrounding the sample, which in tum can be detected as sound waves by a sensitive microphone. These sound waves have the same frequency as the initial modulation frequency of light. Lock-in detection method enables one to have a sufficiently high signal to noise ratio for the detected signal. The PA signal amplitude depends on the optical absorption coefficient of the sample and its thermal properties. The PA signal phase is a function of the thermal diffusivity of the sample.Measurement of the PA amplitude and phase enables one to get valuable information about the thermal and optical properties of the sample. Since the PA signal depends on the optical and thennal properties of the sample, their variation will get reflected in the PA signal. Therefore, if the PA signal is collected from various points on a sample surface it will give a profile of the variations in the optical/thennal properties across the sample surface. Since the optical and thermal properties are affected by the presence of defects, interfaces, change of material etc. these will get reflected in the PA signal. By varying the modulation frequency, we can get information about the subsurface features also. This is the basic principle of PA imaging or PA depth profiling. It is a quickly expanding field with potential applications in thin film technology, chemical engineering, biology, medical diagnosis etc. Since it is a non-destructive method, PA imaging has added advantages over some of the other imaging techniques. A major part of the work presented in this thesis is concemed with the development of a PA imaging setup that can be used to detect the presence of surface and subsmface defects in solid samples.Determination of thermal transport properties such as thermal diffusivity, effusivity, conductivity and heat capacity of materials is another application of photothennal effect. There are various methods, depending on the nature of the sample, to determine these properties. However, there are only a few methods developed to determine all these properties simultaneously. Even though a few techniques to determine the above thermal properties individually for a coating can be found in literature, no technique is available for the simultaneous measurement of these parameters for a coating. We have developed a scanning photoacoustic technique that can be used to determine all the above thermal transport properties simultaneously in the case of opaque coatings such as paints. Another work that we have presented in this thesis is the determination of thermal effusivity of many bulk solids by a scanning photoacoustic technique. This is one of the very few methods developed to determine thermal effiisivity directly.

Phase-Locked loops lock-in range in Frequency Modulated-Atomic Force Microscope nonlinear control system

Since the mid 1980s the Atomic Force Microscope is one the most powerful tools to perform surface investigation, and since 1995 Non-Contact AFM achieved true atomic resolution. The Frequency-Modulated Atomic Force Microscope (FM-AFM) operates in the dynamic mode, which means that the control system of the FM-AFM must force the micro-cantilever to oscillate with constant amplitude and frequency. However, tip-sample interaction forces cause modulations in the microcantilever motion. A Phase-Locked loop (PLL) is used to demodulate the tip-sample interaction forces from the microcantilever motion. The demodulated signal is used as the feedback signal to the control system, and to generate both topographic and dissipation images. As a consequence, a proper design of the PLL is vital to the FM-AFM performance. In this work, using bifurcation analysis, the lock-in range of the PLL is determined as a function of the frequency shift (Q) of the microcantilever and of the other design parameters, providing a technique to properly design the PLL in the FM-AFM system. (C) 2011 Elsevier B.V. All rights reserved.

Experimental model for transanal endorectal pull-through surgery. Technique of de la Torre and Ortega

Background: We describe an experimental model for transanal endorectal pull-through surgery using the method of de]a Torre and Ortega that can be used for training purposes in experimental laboratories.Methods: Ten rabbits were submitted to the transanal endorectal pull-through technique of de la Torre and Ortega. Animals were randomly selected in the Botucatu School of Medicine experimental laboratory. Animals weighted between 2800 and 4400 g. Colons were not prepared, and antibiotic therapy was not used; dipyrone(1) was administered postoperatively for analgesic purposes. We standardized resected segment size, recorded surgical time, and observed Survival and possible complications for 1 month.Results: All animals survived the initial follow-up period without infection. Bowel movements returned quickly, and all animals were evacuating regularly within the first 24 hours. Mean surgical time was 48.6 minutes.Conclusions: the experimental model proposed in this study is very useful for training and improving surgical techniques using the method of de la Torre and Ortega. The rabbit is an excellent animal for this surgery because of its size and postoperative resistance. (c) 2005 Elsevier B.V. All rights reserved.