Nasogastric tube depth: The 'NEX' guideline is incorrect

© 2014 MA Healthcare Ltd. Misplacing 17-23% of nasogastric (NG) tubes above the stomach (Rollins et al, 2012; Rayner, 2013) represents a serious risk in terms of aspiration, further invasive (tube) procedures, irradiation from failed X-ray confirmation, delay to feed and medication. One causal factor is that in the National Patient Safety Agency (NPSA) guidance to place a tube, length is measured from nose to ear to xiphisternum (NEX) (NSPA, 2011); NEX is incorrect because it only approximates the nose to gastro-oesophageal junction (GOJ) distance and is therefore too short. To overcome this and because the xiphisternum is more difficult to locate, local policy is to measure in the opposite direction; xiphisternum to ear to nose (XEN), then add 10 cm. The authors determined whether external body measurements can be used to estimate the NG tube length to safely reach the gastric body. This involved testing the statistical association of body length, age, sex and XEN in consecutive critically ill patients against internal anatomical landmarks determined from an electromagnetic (EM) trace of the tube path. XEN averaged 50 cm in 71 critically ill patients aged 53±20 years. Tube marking and the EM trace were used to determine mean insertion distances at pre-gastro-oesophageal junction (GOJ) (48 cm), where the tube first turns left towards the stomach and becomes shallow on the trace; gastric body (62 cm), where the tube reaches the left-most part of the stomach; and gastric antrum (73 cm) at the midline on the EM trace. Using body length, age, sex and XEN in a linear regression model, only 25% of variability was predicted, showing that external measurements cannot reliably predict the length of tube required to reach the stomach. A tube length of XEN (or NEX) is too short to guarantee gastric placement and is unsafe. XEN+10 cm or more complex measurements will reach the gastric body (mid-stomach) in most patients, but because of wide variation, external measurements often fail to predict a safe distance. Only the EM trace or possibly direct vision can show in real time whether the tip has safely reached the gastric body

Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray and tube radio-opacity

Recent evidence suggests official statistics greatly underestimate the occurrence of complications from misplaced nasogastric (NG) tubes, even when detected. Current methods of confirming tube position do not provide adequate protection from misplacement. In addition, some tubes are inadequately radio-opaque. We prospectively audited placement of Cortrak polyurethane tubes (PUTs) to determine: accuracy of the electromagnetic (EM) trace in confirming tube position, radio-opacity of PUTs compared with previously placed polyvinylchloride (PVC) Ryles tubes and whether 12 French PUTs can be used to aspirate gastric residual volumes (GRVs). A total of 127 PUTs were placed in 113 patients. EM traces accurately confirmed tube position compared with X-ray (100% agreement). A 'gastric' EM trace has been defined for future use by other operators. PUTs were adequately radio-opaque with good agreement between interpreters (>98%) whereas PVC Ryles tubes were insufficiently radio-opaque (57-73%), invisible in 23% of cases and with poor agreement between interpreters leaving risk of error. The alternative of using pH confirmation was not possible in 44%. In these cases subsequent X-ray incurred a 2-hour delay to feed and medicines. In addition, neither post-placement pH testing nor X-ray warn of lung placement and potential trauma, whereas the EM trace warned of lung placement prior to damage in 7% of placements. 12 French, single-port PUTs appear adequate to aspirate large GRVs. EM tracing may be considered a standalone method of confirming NG tube position. Corflo (Cortrak) PUTs are adequately radio-opaque. Use of PVC Ryles and other inadequately radio-opaque tubes should stop

Localized dynamics arising from multiple flat bands in a decorated photonic Lieb lattice

Photonic lattices have emerged as an ideal testbed for localizing light in space. Among others, the most promising approach is based on flat band systems and their related nondiffracting compact localized states. So far, only compact localized states arising from a single flat band have been found. Such states typically appear static, thus not allowing adaptive or evolutionary features of light localization. Here, we report on the first experimental realization of an oscillating compact localized state arising from multiple flat bands. We observe an oscillatory intensity beating during propagation in a two-dimensional photonic decorated Lieb lattice. The photonic system is realized by direct femtosecond laser writing and hosts most importantly multiple flat bands at different eigenenergies in its band structure. Our results open new avenues for evolution dynamics in the up to now static phenomenon of light localization in periodic waveguide structures and extend the current understanding of light localization in flat band systems

Free-induction-decay magnetometer with enhanced optical pumping

Spin preparation prior to a free-induction-decay (FID) measurement can be adversely affected by transverse bias fields, particularly in the geophysical field range. A strategy that enhances the spin polarization accumulated before readout is demonstrated, by synchronizing optical pumping with a magnetic field pulse that supersedes any transverse fields by over two order of magnitude. The pulsed magnetic field is generated along the optical pumping axis using a compact electromagnetic coil pair encompassing a micro-electromechanical systems (MEMS) vapor cell. The coils also resistively heat the cesium (Cs) vapor to the optimal atomic density without spurious magnetic field contributions as they are rapidly demagnetized to approximately zero field during spin readout. The demagnetization process is analyzed electronically, and directly with a FID measurement, to confirm that the residual magnetic field is minimal during detection. The sensitivity performance of this technique is compared to existing optical pumping modalities across a wide magnetic field range. A noise floor sensitivity of $238\,\mathrm{fT/\surd{Hz}}$ was achieved in a field of approximately $\mathrm{50\,\mu{T}}$, in close agreement with the Cram\'{e}r-Rao lower bound (CRLB) predicted noise density of $258\,\mathrm{fT/\surd{Hz}}$.Comment: 10 pages, 7 figure

Simulation of two-fluid flows using a Finite Element/level set method. Application to bubbles and vesicle dynamics

peer reviewe

Optical pumping enhancement of a free-induction-decay magnetometer

Spin preparation prior to a free-induction-decay (FID) measurement can be adversely affected by transverse bias fields, particularly in the geophysical field range. A strategy that enhances the spin polarization accumulated before readout is demonstrated, by synchronizing optical pumping with a magnetic field pulse that supersedes any transverse fields by over two order of magnitude. The pulsed magnetic field is generated along the optical pumping axis using a compact electromagnetic coil pair encompassing a micro-electromechanical systems (MEMS) vapor cell. The coils also resistively heat the cesium (Cs) vapor to the optimal atomic density without spurious magnetic field contributions as they are rapidly demagnetized to approximately zero field during spin readout. The demagnetization process is analyzed electronically, and directly with a FID measurement, to confirm that the residual magnetic field is minimal during detection. The sensitivity performance of this technique is compared to existing optical pumping modalities across a wide magnetic field range. A noise floor sensitivity of 238 fT/√Hz was achieved in a field of approximately 50 μT, in close agreement with the Cramér-Rao lower bound (CRLB) predicted noise density of 258 fT/√Hz

Using comparative genomics to reorder the human genome sequence into a virtual sheep genome

Using BAC-end sequences, a sparse marker map and the sequences of the human, dog and cow genomes, an accurate and detailed sub-gene level map of the sheep genome has been constructed

Free-induction-decay magnetic field imaging with a microfabricated Cs vapor cell

Magnetic field imaging is a valuable resource for signal source localization and characterization. This work reports an optically pumped magnetometer (OPM) based on the free-induction-decay (FID) protocol, that implements microfabricated cesium (Cs) vapor cell technology to visualize the magnetic field distributions resulting from various magnetic sources placed close to the cell. The slow diffusion of Cs atoms in the presence of a nitrogen (N2) buffer gas enables spatially independent measurements to be made within the same vapor cell by translating a 175 μm diameter probe beam over the sensing area. For example, the OPM was used to record temporal and spatial information to reconstruct magnetic field distributions in one and two dimensions. The optimal magnetometer sensitivity was estimated to be 0.43 pT/√Hz within a Nyquist limited bandwidth of 500 Hz. Furthermore, the sensor’s dynamic range exceeds the Earth’s field of approximately 50 μT, which provides a framework for magnetic field imaging in unshielded environments

Respiratory Dendritic Cell Subsets Differ in Their Capacity to Support the Induction of Virus-Specific Cytotoxic CD8+ T Cell Responses

Dendritic cells located at the body surfaces, e.g. skin, respiratory and gastrointestinal tract, play an essential role in the induction of adaptive immune responses to pathogens and inert antigens present at these surfaces. In the respiratory tract, multiple subsets of dendritic cells (RDC) have been identified in both the normal and inflamed lungs. While the importance of RDC in antigen transport from the inflamed or infected respiratory tract to the lymph nodes draining this site is well recognized, the contribution of individual RDC subsets to this process and the precise role of migrant RDC within the lymph nodes in antigen presentation to T cells is not clear. In this report, we demonstrate that two distinct subsets of migrant RDC - exhibiting the CD103+ and CD11bhi phenotype, respectively - are the primary DC presenting antigen to naïve CD4+ and CD8+ T lymphocytes in the draining nodes in response to respiratory influenza virus infection. Furthermore, the migrant CD103+ RDC subset preferentially drives efficient proliferation and differentiation of naive CD8+ T cells responding to infection into effector cells, and only the CD103+ RDC subset can present to naïve CD8+ T cells non-infectious viral vaccine introduced into the respiratory tract. These results identify CD103+ and CD11bhi RDC as critical regulators of the adaptive immune response to respiratory tract infection and potential targets in the design of mucosal vaccines

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707