In Response: "Oral versus IV treatment for catheter-related bloodstream infections - by Burke A. Cunha"

In his letter Cunha suggests that oral antibiotic therapy is safer and less expensive than intravenous therapy via central venous catheters (CVCs) (1). The implication is that costs will fall and increased health benefits will be enjoyed resulting in a gain in efficiency within the healthcare system. CVCs are often used in critically ill patients to deliver antimicrobial therapy, but expose patients to a risk of catheter-related bloodstream infection (CRBSI). Our current knowledge about the efficiency (i.e. costeffectiveness) of allocating resources toward interventions that prevent CRBSI in patients requiring a CVC has already been reviewed (2). If for some patient groups antimicrobial therapy can be delivered orally, instead of through a CVC, then the costs and benefits of this alternate strategy should be evaluated...

Stabilization of experimental bioretention basins during intermittent wetting and drying

Stormwater bioretention basins are subjected to spontaneous intermittent wetting and drying, unlike water treatment filter systems that are subjected to continuous feed. Drinking water filters when constructed new or after back-wash, are subjected to a phase of stabilization. Experiments show that bioretention basins are similarly impacted by intermittent wetting and drying. The common parameter monitored in the stabilisation of filters is the concentration of total solids in the outflow. Filter media in bioretention basins however, consists of a mix of particulate organic matter and fine sand. Organic carbon and solids are therefore needed to be monitored. Four Perspex bioretention filter columns of 94 mm (ID) were packed with a filter layer (800 mm), transition layer and a gravel layer and operated with synthetic stormwater in the laboratory. The filter layer contained 8% organic material by weight. A free board of 350 mm provided detention storage and head to facilitate infiltration. Synthetic stormwater was prepared by adding NH4NO3 (ammonium nitrate) and C2H5NO2 (glycine) and a mixture of kaolinite and montmorillonite clay, to tapwater. The columns were fed with synthetic stormwater with different Antecedent Dry Days (ADD) (0 – 25 day) and constant inflow concentration (2 ppm: nitrate-nitrogen, 1.5 ppm: ammonium-nitrogen, 2.5 ppm: organic-nitrogen 100 ppm: total suspended solids and 7 ppm: organic carbon) at a feed rate of 100mL.min (85.7cm/h). Samples were collected from the outflow at different time intervals between 2 – 150 min from the start of outflow and were tested for Total Suspended Solids (TSS) and Total Organic Carbon (TOC). Both TSS and TOC concentrations in the outflow were observed to be much higher than the concentration of both the parameters in the inflow during the stabilisation period indicating a phase of wash-off (first flush) which lasted for approximately 30 min for both parameters at the beginning of each storm event. The wash-off of TSS and TOC were found to be highly variable depending on the age of the filter and the number of antecedent dry days. The duration of stabilisation phase in the experiments is significant compared with many of the stormwater events. A computational analysis on total mass of each pollutant further affirmed the significance of the first flush of an event on removal of these pollutants. Therefore, the kinetics of the first flush in the stabilisation phase needs to be considered in the performance analysis of the systems.

Effects of driver familiarity and prolonged or intermittent right-side failure on level crossing safety

This paper investigates the adverse effects of familiarity and human factors issues associated with the reliability of low-cost warning devices at level crossings. The driving simulator study featured a repetitive, low workload, monotonous driving task in which there were no failures of the level crossing (control) or prolonged or intermittent right-side failures (where the device reverts to a safe failure mode). The results of the experiment provided mixed support for the familiarity hypothesis. Four of the 23 participants collided with the train when it first appeared on trial 10 but safety margins increased from the first train to the next presentation of a train (trial 12). Contrary to expectations, the safety margins decreased with repeated right-side failure only for the intermittent condition. The limited head movement data showed that participants in the prolonged failure condition were more likely to turn their head to check for trains in the right-side failure trials than in earlier trials where there was no signal and no train. Few control participants turned their head to check for trains when no signal was presented. This research highlights the need to consider repetitive tasks and workload in experimental design and accident investigation at railway level crossings.

Fischer rats consume 20% ethanol in a long-term intermittent-access two-bottle-choice paradigm

The 20% ethanol intermittent-access (IAE) two-bottle-choice drinking procedure has been shown to produce high voluntary ethanol consumption in a number of rat strains. For this study, we applied this procedure to male Fischer (F344) rats, a strain previously reported to exhibit low levels of ethanol consumption. We also subjected these animals to a two-week ethanoldeprivation- period to see if they would exhibit an alcohol deprivation effect (ADE) signified by a transient increase in alcohol consumption following deprivation. Our data show a separation between high and low consuming animals within this strain, with high-consumers exhibiting an escalation in consumption. In contrast, Fischer rats did not show a significant separation between high and low consumers or any significant escalation in consumption, using the 20% ethanol continuous-access two-bottle-choice drinking protocol. Following the two-week deprivation period, animals in the high (but not the low) IAE group exhibited the transient increase in ethanol consumption and preference typically associated with an ADE. Together, the data suggest that the intermittent access protocol is a useful protocol for increasing ethanol consumption.

Ramipril - improving exercise tolerance in intermittent claudication?

Peripheral artery disease (PAD) is one of the most common manifestations of systemic atherosclerosis. It is estimated that 10-15% of the general population is affected by PAD, whereby the narrowed arteries lead to reduced blood flow to the extremeties - particularly the legs. While many people have mild or no systems with PAD, approximately one-third of people experience intermittent claudication (IC).

Dynamics of nitrogen and suspended solids removal in experimental stormwater biofilters under intermittent wetting and drying

This research study comprehensively analyses the dynamics of nitrogen and suspended solids removal in stormwater biofilters. The study focuses on pollutant removal during an event with time, rather than the conventional event-mean analysis. Antecedent dry days (number of days in between rainfall) during which biofilters remain dry and the inflow concentration of pollutants were two other important variables analysed in this study. The research outcome highlights the significance of dry-phase processes and the process of stabilization on filter performance and sets a paradigm shift from the current approach towards an innovative way of performance analysis of biofilters.

Modelling intermittent microwave convective drying (IMCD) of food materials

This thesis develops comprehensive mathematical models for an advanced drying technology Intermittent Microwave Convective Drying (IMCD). The models provide an improved physical understanding of the heat and mass transport during the drying process, which will help to improve the quality of dried food and energy efficiency of the process, as well as will increase the ability of automation and optimization. The final model in this thesis represents the most comprehensive fundamental multiphase model for IMCD that considers 3D electromagnetics coupled with multiphase porous media transport processes. The 3D electromagnetics considers Maxwell's equation and multiphase transport model considers three different phases: solid matrix, liquid water and gas consisting water vapour and air. The multiphase transport includes pressure-driven flow, capillary diffusion, binary diffusion, and evaporation. The models developed in this thesis were validated with extensive experimental investigations.

A time and motion study of peripheral venous catheter flushing practice using manually prepared and prefilled flush syringes

Peripheral venous catheters (PVCs) are the simplest and most frequently used method for drug, fluid, and blood product administration in the hospital setting. It is estimated that up to 90% of patients in acute care hospitals require a PVC; however, PVCs are associated with inherent complications, which can be mechanical or infectious. There have been a range of strategies to prevent or reduce PVC-related complications that include optimizing patency through the use of flushing. Little is known about the current status of flushing practice. This observational study quantified preparation and administration time and identified adherence to principles of Aseptic Non-Touch Technique and organizational protocol on PVC flushing by using both manually prepared and prefilled syringes.

A mathematical model for intermittent microwave convective (IMCD) drying of food materials

Intermittent microwave convective drying (IMCD) is an advanced technology that improves both energy efficiency and food quality in drying. Modelling of IMCD is essential to understand the physics of this advanced drying process and to optimize the microwave power level and intermittency during drying. However, there is still a lack of modelling studies dedicated to IMCD. In this study, a mathematical model for IMCD was developed and validated with experimental data. The model showed that the interior temperature of the material was higher than the surface in IMCD, and that the temperatures fluctuated and redistributed due to the intermittency of the microwave power. This redistribution of temperature could significantly contribute to the improvement of product quality during IMCD. Limitations when using Lambert's Law for microwave heat generation were identified and discussed.

Educational interventions for preventing vascular catheter bloodstream infections in critical care: Evidence map, systematic review and economic evaluation

Background Bloodstream infections resulting from intravascular catheters (catheter-BSI) in critical care increase patients' length of stay, morbidity and mortality, and the management of these infections and their complications has been estimated to cost the NHS annually £19.1–36.2M. Catheter-BSI are thought to be largely preventable using educational interventions, but guidance as to which types of intervention might be most clinically effective is lacking. Objective To assess the effectiveness and cost-effectiveness of educational interventions for preventing catheter-BSI in critical care units in England. Data sources Sixteen electronic bibliographic databases – including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health Literature (CINAHL), NHS Economic Evaluation Database (NHS EED), EMBASE and The Cochrane Library databases – were searched from database inception to February 2011, with searches updated in March 2012. Bibliographies of systematic reviews and related papers were screened and experts contacted to identify any additional references. Review methods References were screened independently by two reviewers using a priori selection criteria. A descriptive map was created to summarise the characteristics of relevant studies. Further selection criteria developed in consultation with the project Advisory Group were used to prioritise a subset of studies relevant to NHS practice and policy for systematic review. A decision-analytic economic model was developed to investigate the cost-effectiveness of educational interventions for preventing catheter-BSI. Results Seventy-four studies were included in the descriptive map, of which 24 were prioritised for systematic review. Studies have predominantly been conducted in the USA, using single-cohort before-and-after study designs. Diverse types of educational intervention appear effective at reducing the incidence density of catheter-BSI (risk ratios statistically significantly < 1.0), but single lectures were not effective. The economic model showed that implementing an educational intervention in critical care units in England would be cost-effective and potentially cost-saving, with incremental cost-effectiveness ratios under worst-case sensitivity analyses of < £5000/quality-adjusted life-year. Limitations Low-quality primary studies cannot definitively prove that the planned interventions were responsible for observed changes in catheter-BSI incidence. Poor reporting gave unclear estimates of risk of bias. Some model parameters were sourced from other locations owing to a lack of UK data. Conclusions Our results suggest that it would be cost-effective and may be cost-saving for the NHS to implement educational interventions in critical care units. However, more robust primary studies are needed to exclude the possible influence of secular trends on observed reductions in catheter-BSI.

Intermittent Dynamics, Stochastic Resonance and Dynamical Heterogeneity in Supercooled Liquid Water

Here we find through computer simulations and theoretical analysis that the low temperature thermodynamic anomalies of liquid water arises from the intermittent fluctuation between its high density and low density forms, consisting largely of 5-coordinated and 4-coordinated water molecules, respectively. The fluctuations exhibit strong dynamic heterogeneity (defined by the four point time correlation function), accompanied by a divergence like growth of the dynamic correlation length, of the type encountered in fragile supercooled liquids. The intermittency has been explained by invoking a two state model often employed to understand stochastic resonance, with the relevant periodic perturbation provided here by the fluctuation of the total volume of the system.

Comparison of Radiation Doses for Catheter Ablation Procedures for Atrial Fibrillation with Percutaneous Coronary Intervention Cases

Background: Catheter ablation procedures for atrial fibrillation (AF) may frequently require long fluoroscopic times. We sought to undertake a review of radiation safety practice in our Cardiac Electrophysiology Laboratory and implement changes to minimize fluoroscopic doses. We also sought to compare the results with radiation doses for percutaneous coronary intervention (PCI) cases performed in our hospital. Methods: Fluoroscopic times and doses for AF ablation procedures performed by a single operator on a Philips Integris H3000 image-intensifier were analysed for 11-month period. Results were compared with all PCI procedures performed over a similar period by multiple operators on a Philips Integris Allura FD system. Comprehensive review of radiation practice in the Electrophysiology laboratory identified the potential to reduce pulse frame rates and doses, and to narrow the field of interest without impacting the performance of the procedure. These changes were implemented and results analysed after a further 11 months. Results: In the pre-intervention period 50 AF catheter ablations had a mean fluoroscopic time of 86.4 min and mean fluoroscopic dose 68.4 Gy/cm2. Post-intervention 75 procedures had a mean fluorosocopic time of 68.9 min (p < 0.0001) and mean dose of 14.3 Gy/cm2 (p < 0.0001) 128 PCI procedures had a mean combined fluoroscopic and image acquisition time of 10.0 min and mean total dose 38.8 Gy/cm2. Conclusions: Catheter ablation procedures for AF may require lengthy use of fluoroscopy but simple modifications to radiation practice can result in marked reductions in radiation dose that compare favourably with PCI case doses