Line Removal Research Articles

Protein Aggregation and Particle Formation in Prefilled Glass Syringes

The stability of therapeutic proteins formulated in prefilled syringes (PFS) may be negatively impacted by the exposure of protein molecules to silicone oil-water interfaces and air-water interfaces. In addition, agitation, such as that experienced during transportation, may increase the detrimental effects (i.e., protein aggregation and particle formation) of protein interactions with interfaces. In this study, surfactant-free formulations containing either a monoclonal antibody or lysozyme were incubated in PFS, where they were exposed to silicone oil-water interfaces (siliconized syringe walls), air-water interfaces (air bubbles), and agitation stress (occurring during end-over-end rotation). Using flow microscopy, particles (≥2 μm diameter) were detected under all conditions. The highest particle concentrations were found in agitated, siliconized syringes containing an air bubble. The particles formed in this condition consisted of silicone oil droplets and aggregated protein, as well as agglomerates of protein aggregates and silicone oil. We propose an interfacial mechanism of particle generation in PFS in which capillary forces at the three-phase (silicone oil-water-air) contact line remove silicone oil and gelled protein aggregates from the interface and transport them into the bulk. This mechanism explains the synergistic effects of silicone oil-water interfaces, air-water interfaces, and agitation in the generation of particles in protein formulations.

Accuracies of Optimal Transmission Switching Heuristics Based on DCOPF and ACOPF

This paper considers optimal transmission switching (OTS) to reduce generation cost by removing lines from service. A mixed integer program (MIP) has been proposed to solve the OTS problem, based on the linear direct current optimal power flow (DCOPF) model. Because of excessive computation times for large, real systems, the MIP model has been followed by some heuristics, also based on the DCOPF, to obtain near-optimal solutions quickly. However, the approximations in the DCOPF model may lead to poor choices of lines to remove from service. We assess the quality of line removal recommendations that rely on a previously published, DCOPF-based heuristic, by estimating actual cost reduction with the exact ACOPF model, using the IEEE 118-bus and 300-bus test systems with several demand levels. We also extend this heuristic to be based on the ACOPF and compare the quality of its recommendations to those of the DCOPF-based heuristic. The DCOPF-based heuristic performs very poorly in several cases, even leading to cost increases sometimes. There is a need for approximations to the ACOPF which are accurate enough to produce reliably good results for OTS heuristics, but fast enough for practical use.

Research on Uyghur Handwriting Identification Technology Based on Stroke Statistical Features

The automatic handwriting identification is a hot topic in pattern recognition that it has been extensively studied in many languages. A Uyghur handwriting identification technique based on the stroke statistical features is proposed in this paper. Firstly, the handwriting image is preprocessed taking modified methods of grid line removal, noise reduction and thinning. Then novel stroke statistical features are extracted based on the structural character and writing styles of Uyghur handwriting. And this approach respectively achieves a top 1 and top 2 identification rates of 98.66% and 99.78% on the Uyghur handwriting data set from 224 different people. Finally, Comparison analysis of different stroke length and distance measurement method has been conducted through three different kinds of experiments, the optimal stroke length and distance measurement method is determined, and its effectiveness and stability are tested. The stroke statistical features can capture the structural character and writing style of Uyghur handwriting efficiently, and it is suitable for any languages theoretically.

Implementing Six Sigma to Reduce Online Petitions on the E-petition System in Taiwan Power Company

This study presents a case study demonstrating the application of Six Sigma (DMAIC) to successfully reduce the number of online petitions on the e-petition system in Taiwan Power Company (TPC). First, in the define (D) stage, a total of 1,292 petitions for the year 2010 in TPC are received and divided into 9 categories. In the measure (M) stage, the category that received the most petition letters is line removal, which accounts for 29.3% of the total petitions. The analyze (A) stage indicates that TPC did not provide relevant application procedures for line removal service. In the improve (I) stage, this study presents three approaches to speed up the line removal application process. Finally, a well-organized standard of procedure and workflow control charts has been developed in order to monitor the overall application and construction processes in the control (C) stage. After implementing Six Sigma (DMAIC), the number of petitions for line removal decreased by 66% from 379 in 2010 to 129 in 2011.

Substance identification based on transmission THz spectra using library search

Over recent years terahertz spectroscopy has become a new tool for the characterization of solid materials, in particular for investigating polymorphism and crystallinity in pharmaceutics. Search strategies have been tested for THz spectra of various organic compounds with their spectra taken from the Riken database (http://www.riken.jp), using the GRAMS spectroscopy software. A subset of the entire database was used, which had been processed by removal of atmospheric water vapour lines and smoothing applied based on Savitzky-Golay convolution or time domain filtering. The spectral range available for all library substances was restricted to an interval from 0.9 to 4.5 THz (30–150cm−1). The number of vibrational bands within this spectral range is much reduced compared with mid-infrared or Raman spectra. The appropriateness of spectral pre-treatment is demonstrated with regard to reliability and robustness of the search methods. In particular, time-domain filters for smoothing and pre-treatment by the removal of water lines and etalon effects have been successfully tested in combination with least squares and correlation methods. With these insights, applications for substance identification, especially for the pharmaceutical industry, may be enlarged.

Let's change our behaviors: From bed rest and heavy sedation to awake, spontaneously breathing and early mobilized Intensive Care Unit patients.

Let's change our behaviors: From bed rest and heavy sedation to awake, spontaneously breathing and early mobilized Intensive Care Unit patients.

Central line associated blood stream infection rate after intervention and comparing outcome with national healthcare safety network and international nosocomial infection control consortium data.

Background:Benchmarking of central line associated blood stream infection (CLABSI) rates remains a problem in developing countries due to the variations in surveillance practices and/or infection risk as non-availability of national data.Aim:The aim of the following study was to find out the CLABSI rate before and after central line (CL) bundle intervention and compare the outcome with international surveillance data.Subjects and Methods:This prospective longitudinal cohort study on adult intensive care unit patients was conducted at Hera General Hospital, Makkah Saudi Arabia from January 1 to December 31, 2012. Five key components of bundle were selected; hand hygiene, maximal barrier precautions upon insertion, skin antisepsis, optimum site selection and daily review of line necessity with prompt removal of unnecessary lines. Post-intervention CLABSI rate was compared with National Healthcare Safety Network (NHSN) and International Nosocomial Infection Control Consortium (INICC) rates. Statistical Package for the Social Sciences (SPSS) 14.0 software (SPSS Inc., 233 South Wacker Drive, 11th floor Chicago, USA) was used for statistical analysis included regression analysis for correlation. Statistical significance was set at P < 0.05.Results:CLABSI rate was reduced from 10.1 to 6.5 per 1000 CL days after interventions and had significant correlation with overall bundle compliance rate 87.6% (P = 0.02) On benchmarking, CLABSI rate after the intervention was similar to mean pool value of INICC (6.8) while higher than NHSN (3.1). The most common microorganisms isolated were; methicillin-resistant Staphylococcus aureus (30.8%), Acinetobacter baumanii (23.3%) and Enterococcus faecalis (15.4%).Conclusion:We found that INICC data was a better benchmarking tool comparative to NHSN because it represents the countries that are developing the surveillance system. A multicenter national study is recommended.

Removal of Arterial Lines and Devices from the Ascending Aorta in Cardiac Surgery Patients

The use of monitoring or device lines through the ascending aorta may be necessary for a variety of clinical situations. The technique provided in this article allows percutaneous closure of these entry sites with a closed chest.

Removal of Arterial Lines and Devices from the Ascending Aorta in Cardiac Surgery Patients

Removal of Arterial Lines and Devices from the Ascending Aorta in Cardiac Surgery Patients

Board 192 - Program Innovations Abstract Using Standardized Patients to Teach Central Line Catheter Removal (Submission #700)

Introduction/Background In 2011, The Patient Safety/Risk Management Committee at UIC determined there was a need for additional training in performing the removal of central venous catheters to improve technique and reduce the number of associated complications. Our Central Line Removal workshop was developed to provide them with didactic and hands on practice to better equip them for performing this procedure. Methods Checklists were developed for the time out protocol and the removal of central line catheters, then reviewed and validated by the hospital Best Practices Committee. These are specifically meant to guide removal of internal jugular, subclavian, or femoral lines and not for peripherally inserted central catheters (PICC). The checklists are available on our website to allow review at any time, and are referenced during both the didactic and practical training portion of the program. The didactic portion of the workshop includes review of personnel requirements per UIC policy, possible complications and specific indications/contraindications to the timing of catheter removal to reduce the chance of infection. Senior residents in each discipline are trained as trainers for the other residents within their program and function as the clinical experts during didactic review. Practical training consists of the residents utilizing task trainers and skin pads with checklist prompting from qualified instructors. Residents are encouraged to practice both the timevout and removal until they are comfortable with the procedures and are ready to report for assessment. The senior residents are present to give useful feedback on technique and clinical significance throughout the practical training but may not deviate from the checklist steps. For the removal assessment, we replace the skin pads and task trainers with a standardized patient (SP). An instructor from the clinical performance center marks the checklist. Residents are asked to treat the simulation as a real case by communicating with the patient as they would in the medical center. In using SPs for this procedure we can arrange for residents to be better prepared to perform a central line removal, determine whether the patient understands instructions given in preparation of removal and be prepared to handle a complication if one should occur. SPs are trained in the removal procedure and how to respond from a patient’s view as well as what to expect from medical personnel during the removal process. To create a realistic experience for the residents, silicone neck skins are created for each SP with a catheter and sutures already in place. SPs may be instructed to simulate a complication during or immediately after the procedure. In addition, some catheters will have been broken or missing tips to ensure residents are checking for these complications. The SP provides feedback immediately regarding verbal communication with the patient, body language ensuring the patient understands and when necessary, provides suggestions for improvement in the future. Residents are deemed successful once achieving 100% on the checklists. Those who missed few steps may immediately reattempt assessment up to three times until meeting the standard. Those requiring additional practice are referred back to the training stations and may retest once the senior resident determines it appropriate. This remediation process is also followed if any critical actions are missed on the first assessment attempt. Results: Conclusion With conscious patients having an active role during the removal of a central line, the use of SPs appears to be an excellent means for residents to practice. Senior residents have shown to need less practice, however, at a teaching facility the less experienced residents are expected to perform this procedure making the practice time more critical. Residents are receptive to the feedback especially with communication requiring patient participation and instructions for the patient post procedure. Disclosures None.

Bilateral pleural effusion complicating umbilical venous catheterization

Umbilical venous lines are sometimes complicated with pleural and or pericardial effusion, often due to line migration. Bilateral chylous pleural effusion without pericardial effusion in a 28 weeks, extremely low birth infant who was on total parenteral nutrition. Investigations including chest x ray and 2D echocardiogram showed bilateral chylous pleural effusions but appropriate tip position of the umbilical venous line. Removal of the umbilical venous line and cessation of total parenteral nutrition resulted in complete resolution of the pleural effusion. In any newborn with central venous catheter in situ, acute deteriorations specially, those related to pleural and pericardial effusions should alert the clinicians to remove the catheter and should not be misguided by apparently appearing normal correct catheter position by x-ray or 2D echocardiogram.

Reducing Central Line–Associated Bloodstream Infections in North Carolina NICUs

Central lines in NICUs have long dwell times. Success in reducing central line-associated bloodstream infections (CLABSIs) requires a multidisciplinary team approach to line maintenance and insertion. The Perinatal Quality Collaborative of North Carolina (PQCNC) CLABSI project supported the development of NICU teams including parents, the implementation of an action plan with unique bundle elements and a rigorous reporting schedule. The goal was to reduce CLABSI rates by 75%. Thirteen NICUs participated in an initiative developed over 3 months and deployed over 9 months. Teams participated in monthly webinars and quarterly face-to-face learning sessions. NICUs reported on bundle compliance and National Health Surveillance Network infection rates at baseline, during the intervention, and 3 and 12 months after the intervention. Process and outcome indicators were analyzed using statistical process control methods (SPC). Near-daily maintenance observations were requested for all lines with a 68% response rate. SPC analysis revealed a trend to an increase in bundle compliance. We also report significant adoption of a new maintenance bundle element, central line removal when enteral feedings reached 120 ml/kg per day. The PQCNC CLABSI rate decreased 71%, from 3.94 infections per 1000 line days to 1.16 infections per 1000 line days with sustainment 1 year later (P = .01). A collaborative structure targeting team development, family partnership, unique bundle elements and strict reporting on line care produced the largest reduction in CLABSI rates for any multiinstitutional NICU collaborative.

Hepatitis C Virus Maintains Infectivity for Weeks After Drying on Inanimate Surfaces at Room Temperature: Implications for Risks of Transmission

Healthcare workers may come into contact with fomites that contain infectious hepatitis C virus (HCV) during preparation of plasma or following placement or removal of venous lines. Similarly, injection drugs users may come into contact with fomites. Hypothesizing that prolonged viability of HCV in fomites may contribute significantly to incidence, we determined the longevity of virus infectivity and the effectiveness of antiseptics. We determined the volume of drops misplaced during transfer of serum or plasma. Aliquots equivalent to the maximum drop volume of plasma spiked with the 2a HCV reporter virus were loaded into 24-well plates. Plates were stored uncovered at 3 temperatures: 4°C, 22°C, and 37°C for up to 6 weeks before viral infectivity was determined in a microculture assay. The mean volume of an accidental drop was 29 µL (min-max of 20-33 µL). At storage temperatures 4°C and 22°C, we recovered viable HCV from the low-titer spots for up to 6 weeks of storage. The rank order of HCV virucidal activity of commonly used antiseptics was bleach (1:10) > cavicide (1:10) > ethanol (70%). The hypothesis of potential transmission from fomites was supported by the experimental results. The anti-HCV activity of commercial antiseptics varied.

Thromboembolic and Hemorrhagic Complications In Adult Patients With Acute Lymphoblastic Leukemia (ALL) Treated With Asparaginase-Containing Combination Chemotherapy: A Single Center Experience

BackgroundL-asparaginase (LASP) depletion of asparagine reduces antithrombin (AT) and fibrinogen and is associated with thromboembolic (TE) and hemorrhagic events (HE). AT replacement in pediatric ALL patients demonstrated safety and potential benefit as thromboprophylaxis in a prospective, randomized trial.(Mitchell et al, 2003) Current consensus supports AT replacement when AT activity is below 60%.(Stock et al, 2011) The incidence of TE and HE in adults receiving AT repletion during LASP or pegylated asparaginase (PEGASP) requires further investigation. MethodsThis single center, retrospective, observational study was approved by the Mayo Clinic Institutional Review Board. Consecutive adult patients with a confirmed diagnosis of ALL receiving LASP or PEGASP containing chemotherapy regimens between January 2000 and October 2012 were evaluated. Patients with documented thrombophilia and pre-existing TE or HE were excluded. Patients receiving AT concentrate (ATC) compared to those that did not and were evaluated up to 60 days after the last LASP or PEGASP dose for objectively confirmed TE and HE. ResultsOf the 74 patients screened, 54 (73%) met inclusion criteria. Forty-seven (87%) received ATC and were evaluable. The remaining 7 (13%) did not meet follow up duration and were excluded from further analysis. Twenty-three (49%) patients received LASP, 20 (42%) received PEGASP and 4 (9%) received both. Distribution per treatment protocols was; CALGB 9111 (n=16 (34%), Larson et al, 1998), E2993 (n=12 (25%), Goldstone et al, 2008), C10403 (n=8 (17%), NLM: NCT00558519), CCG 1941 (n=6 (13%), Gaynon et al, 2006) and Augmented HyperCVAD (n=5 (11%), Faderl et al, 2011). A total of 1465 AT activity levels were analyzed, resulting in 378 doses of ATC. Ten patients (21%) experienced a clinical event, with all events occurring during cycle 1 of chemotherapy (table 1). Median time from last LASP or PEGASP dose to TE was 13 days (range 3-56) with a median of 4 days (range 3-13) from last ATC dose to TE. Median AT activity level at time of TE was 56% (range 47-72). Thrombotic events included; line-related deep vein thrombosis (LRDVT, n=7), cerebral venous sinus thrombosis (CVST, n=1) and pulmonary embolism (PE, n=1). One patient with cerebral hemorrhage constituted the only HE. All LRDVT occurred in central venous catheters and management included; line removal (n=3), anticoagulation (n=1), line removal and anticoagulation (n=2) and no intervention (n=1). The single case of PE was managed with anticoagulation. Two patients had a recurrent LRDVT in different locations during subsequent chemotherapy in spite of ongoing ATC supplementation. ConclusionsThe incidence of TE in adult ALL patients receiving LASP or PEGASP during induction chemotherapy with AT thromboprophylaxis was 19%. LRDVT was the most common TE with a comparable incidence to adult ALL patients not receiving ATC (15%) (Grace et al 2011). There was a small incidence of non-LRDVT (4%) and HE (2%). As induction-phase chemotherapy and placement of central lines are independent risk factors for thrombosis, the cost-effectiveness of AT replacement for prevention of TE during adult ALL treatment requires prospective evaluation. Disclosures:No relevant conflicts of interest to declare.

The incidence of emergence delirium and risk factors following sevoflurane use in pediatric patients for day case surgery, Kingston, Jamaica

Background and objectivesEmergence delirium is a distressing complication of the use of sevoflurane for general anesthesia. This study sought to determine the incidence of emergence delirium and risk factors in patients at a specialist pediatric hospital in Kingston, Jamaica. MethodsThis was a cross-sectional, observational study including pediatric patients aged 3–10 years, ASA I and II, undergoing general anesthesia with sevoflurane for elective day-case procedures. Data collected included patients’ level of anxiety pre-operatively using the modified Yale Preoperative Anxiety Scale, surgery performed, anesthetic duration and analgesics administered. Postoperatively, patients were assessed for emergence delirium, defined as agitation with non-purposeful movement, restlessness or thrashing; inconsolability and unresponsiveness to nursing and/or parental presence. The need for pharmacological treatment and post-operative complications related to emergence delirium episodes were also noted. ResultsOne hundred and forty-five (145) children were included, with emergence delirium occurring in 28 (19.3%). Emergence delirium episodes had a mean duration of 6.9±7.8min, required pharmacologic intervention in 19 (67.8%) children and were associated with a prolonged recovery time (49.4±11.9 versus 29.7±10.8min for non-agitated children; p<0.001). Factors positively associated with emergence delirium included younger age (p=0.01, OR 3.3, 95% CI 1.2–8.6) and moderate and severe anxiety prior to induction (p<0.001, OR 5.6, 95% CI 2.3–13.0). Complications of emergence delirium included intravenous line removal (n=1), and surgical site bleeding (n=3). ConclusionChildren of younger age with greater preoperative anxiety are at increased risk of developing emergence delirium following general anesthesia with sevoflurane. The overall incidence of emergence delirium was 19%.

Surgical site infections and bloodstream infections in infants after cardiac surgery

Few recent studies have assessed the epidemiology of and risk factors for surgical site infections (SSIs) and bloodstream infections (BSIs) in infants after cardiac surgery. We hypothesized that infants younger than 30 days old and those with higher Risk Adjustment in Congenital Heart Surgery-1 scores would have an increased risk of SSIs, but not an increased risk of BSIs after surgery. We performed a retrospective cohort study of infants younger than 1 year of age undergoing cardiac surgery from January 2010 to December 2011 to determine the rates of SSIs and BSIs occurring within 3 months of surgery, risk factors associated with these infections, and causative pathogens. Multivariable associations using Cox proportional hazard modeling assessed potential risk factors for BSIs or SSIs. Overall, 8.7% (48 of 552) of surgical procedures were complicated by SSIs (n=19) or BSIs (n=29). Thus, SSIs and BSIs occurred after 3.4% and 5.3% of procedures, respectively. Multivariate models found age younger than 30 days, incorrect timing of preoperative antibiotics, and excessive bleeding within 24 hours of surgery to be significant predictors for SSIs, and duration of use of arterial lines to be a significant predictor for BSIs. Gram-positive bacteria caused 75% of SSIs and BSIs and methicillin-susceptible Staphylococcus aureus caused 63% of SSIs. We identified some potential strategies to reduce risk, including closer monitoring of timing of preoperative antimicrobial prophylaxis and enhanced efforts to achieve intraoperative hemostasis and earlier removal of arterial lines. SSIs and BSIs remain important complications after cardiac surgery in infants.

Patency of neck veins following ultrasound-guided percutaneous Hickman line insertion

Venous occlusion following permanent central venous catheter (CVC) insertion by open cutdown or the landmark percutaneous technique has been reported between up to 25 %. However, there are no published data on the equivalent rate following ultrasound-guided percutaneous CVC insertion. The purpose of this study was to document the rate of venous occlusion associated with ultrasound-guided percutaneous CVC insertion in children. From 1 April 2010 to 1 December 2011, all children having elective or emergency removal of a Hickman line by the vascular access team had a Doppler ultrasound of their neck veins. Only Hickman lines inserted by the ultrasound-guided percutaneous route were included. Internal jugular, innominate and subclavian veins were scanned and recorded as patent, reduced or absent. We identified 100 consecutive children. Median age was 6 years (range 21 days to 16 years). Indication for insertion was chemotherapy (60), parenteral nutrition (15), blood products (12), renal replacement (3) and other indications (10). Three children had absent flow at the time of line removal (median age 4 months, range 3-6 months), with 2 out of 3 requiring removal for infection. The venous occlusion rate following ultrasound-guided insertion of CVC is 3 % in our study. We conclude that (1) complete venous occlusion is associated with younger age and CVC infection. (2) In our study, the venous occlusion rate of 3 % is significantly lower than the published series of either open cutdown or the landmark technique.

Assessment of branch outage contingencies using the continuation method

This paper provides a contribution to the contingency analysis of electric power systems under steady state conditions. An alternative methodology is presented for static contingency analyses that only use continuation methods and thus provides an accurate determination of the loading margin. Rather than starting from the base case operating point, the proposed continuation power flow obtains the post-contingency loading margins starting from the maximum loading and using a bus voltage magnitude as a parameter. The branch selected for the contingency evaluation is parameterised using a scaling factor, which allows its gradual removal and assures the continuation power flow convergence for the cases where the method would diverge for the complete transmission line or transformer removal. The applicability and effectiveness of the proposed methodology have been investigated on IEEE test systems (14, 57 and 118 buses) and compared with the continuation power flow, which obtains the post-contingency loading margin starting from the base case solution. In general, for most of the analysed contingencies, few iterations are necessary to determine the post-contingency maximum loading point. Thus, a significant reduction in the global number of iterations is achieved. Therefore, the proposed methodology can be used as an alternative technique to verify and even to obtain the list of critical contingencies supplied by the electric power systems security analysis function.

Staff Line Removal Algorithm and Research Based on Run-Length Graph Slice and Topological Structure of Music

Staff line removal is a key step before segmentation and recognition of music image and plays an important role in OMR (Optical Music Recognition) research, the result of staff line removal directly influences the performance and function of the whole OMR system. However, over-removal and under-removal often occurs in the processing and leads to the low efficiency of music recognition rate. So, in order to solve the arduous problem, an approach based on run-length graph slice and topological structure of music is put forward by careful analysis of staff line and music notation structure. Experience results show the validity and practicality of the presented algorithm fast and effectively.

Counteracting geometrical attacks on robust image watermarking by constructing a deformable pyramid transform

Counteracting geometrical attacks remains one of the most challenging problems in robust watermarking. In this paper, we resist rotation, scaling, and translation (RST) by constructing a kind of deformable pyramid transform (DPT) that is shift-invariant, steerable, and scalable. The DPT is extended from a closed-form polar-separable steerable pyramid transform (SPT). The radial component of the SPT's basis filters is taken as the kernel of the scalable basis filters, and the angular component is used for the steerable basis filters. The shift-invariance is inherited from the SPT by retaining undecimated high-pass and band-pass subbands. Based on the designed DPT, we theoretically derive interpolation functions for steerability and scalability and synchronization mechanisms for translation, rotation, and scaling. By exploiting the preferable characteristics of DPT, we develop a new template-based robust image watermarking scheme that is resilient to RST. Translation invariance is achieved by taking the Fourier magnitude of the cover image as the DPT's input. The resilience to rotation and scaling is obtained using the synchronization mechanisms for rotation and scaling, for which an efficient template-matching algorithm has been devised. Extensive simulations show that the proposed scheme is highly robust to geometrical attacks, such as RST, cropping, and row/column line removal, as well as common signal processing attacks such as JPEG compression, additive white Gaussian noise, and median filtering.