Microbiological evaluation of different reprocessing methods for cuffed and un-cuffed tracheostomy tubes in home-care and hospital setting

Background: Manufacturers’ recommendations on cleaning of tracheostomy tubes focus on general warning information and non-specific manual cleaning procedures. The aim of this experimental study was to evaluate different reprocessing methods and to determine the mechanical integrity and functionality of tracheostomy tubes following reprocessing. Methods: Sixteen cuffed or un-cuffed tracheostomy tubes obtained from hospital in-patients were reprocessed using one of the following reprocessing methods: a) manual brushing and rinsing with tap water, b) manual brushing followed by disinfection with a glutaraldehyde solution, c) manual brushing followed machine-based cleaning in a dishwasher, and d) manual brushing followed by ultrasound cleaning in a commercially available ultrasound device. Microbial burden of the tubes before and after reprocessing was assessed by measurement of microbial colony-forming units per mL (CFU/mL) of rinsing fluid. After cleaning, tracheostomy tubes were investigated for loss of functionality. Findings: Manual brushing and rinsing with tap water reduced microbial colonization in average by 102 CFU/mL, but with poor reproducibility and reliability. Complete microbial reduction was achieved only with additional chemical or machine-based thermal disinfection. Ultrasound sonification yielded no further microbial reduction after manual brushing. Conclusion: Manual brushing alone will not result in complete eradication of microorganism colonising cuffed or un-cuffed tracheostomy tubes. However, manual cleaning followed by chemical or thermal disinfection may be regarded as safe and reproducible reprocessing method. If a machine-based reprocessing method is used for cuffed tubes, the cuffs’ ventilation hose must be secured in a safe position prior to thermal disinfection

Risk regulation, trade and international law : debating the precautionary principle in and around the WTO

The precautionary principle is one of the most contested principles in international law. In the context of trade regulation in particular, it has been a source of concern to those who fear that it might help to justify existing non-tariff barriers to trade or create additional ones. Proponents of the principle, in turn, argue that it is needed to fend off unwarranted health and environmental risks in situations where scientific uncertainty prevails, even if this works against the liberalisation of trade. In these contests the question of where and when the precautionary principle should be applied is inextricably linked to the question of what it means in the first place. Starting from the observation that consensus on a precise definition is missing both in legal-political practice and in academic scholarship, the present paper is concerned precisely with those practical interpretative contests which result from the principle’s ambiguity. We focus on attempts to agree legally binding definitions in the context of international trade regulation. The core of the paper is an empirical analysis of debates on several specific aspects of the precautionary principle, which were at issue during the past decade in four different, international institutions: the WTO dispute settlement, some of the WTO’s political committees, the Codex Alimentarius Commission (in particular its Committee on General Principles), and the conference of states which negotiated the Cartagena Protocol on Biosafety. Differences and similarities among these institutions are then analysed in a comparative perspective, taking up various contested issues one by one. From our findings we derive a set of hypotheses regarding the conditions under which, and the legal or political pathways on which, the precautionary principle (and perhaps other abstract normative ideas of a similar type as well) can make a difference to the outcomes of international decision-making

Solitary routes to chimera states

We show how solitary states in a system of globally coupled FitzHugh-Nagumo oscillators can lead to the emergence of chimera states. By a numerical bifurcation analysis of a suitable reduced system in the thermodynamic limit we demonstrate how solitary states, after emerging from the synchronous state, become chaotic in a period-doubling cascade. Subsequently, states with a single chaotic oscillator give rise to states with an increasing number of incoherent chaotic oscillators. In large systems, these chimera states show extensive chaos. We demonstrate the coexistence of many of such chaotic attractors with different Lyapunov dimensions, due to different numbers of incoherent oscillators

Spectrum and amplitude equations for scalar delay-differential equations with large delay

The subject of the paper are scalar delay-differential equations with large delay. Firstly, we describe the asymptotic properties of the spectrum of linear equations. Using these properties, we classify possible types of destabilization of steady states. In the limit of large delay, this classification is similar to the one for parabolic partial differential equations. We present a derivation and error estimates for amplitude equations, which describe universally the local behavior of scalar delay-differential equations close to the destabilization threshold

The solitary route to chimera states

We show how solitary states in a system of globally coupled FitzHugh-Nagumo oscillators can lead to the emergence of chimera states. By a numerical bifurcation analysis of a suitable reduced system in the thermodynamic limit we demonstrate how solitary states, after emerging from the synchronous state, become chaotic in a period-doubling cascade. Subsequently, states with a single chaotic oscillator give rise to states with an increasing number of incoherent chaotic oscillators. In large systems, these chimera states show extensive chaos. We demonstrate the coexistence of many of such chaotic attractors with different Lyapunov dimensions, due to different numbers of incoherent oscillators.Comment: 4 pages, 4 figure

Inhibition of Plasma Kallikrein with Aprotinin in porcine endotoxin Shock

Activation of the contact phase of coagulation has been implicated in the pathogenesis of septic shock. We wanted to determine if inhibition of plasma kallikrein can prevent arterial hypotension and liberation of kinins from kininogen, induced by an infusion of bacterial lipopolysaccharide (LPS) in anesthetized, ventilated 20-kg pigs. The LPS was given IV in a dose of 5 [mu]g/kg/h for 8 hours. The plasma kallikrein inhibitor aprotinin, 537 [mu]mol, was given IV during 8 hours, resulting in plasma levels above 10 [mu]mol/L. Ten animals (SA) received LPS and aprotinin and ten randomized controls (SC) received LPS and saline. Kinin-containing kininogen was determined on the basis of the amount of kinin releasable in plasma samples by incubation with trypsin. Kininogen decreased to 58% +/- 4% of the baseline value without any difference between groups. This may indicate participation of other processes than degradation by plasma kallikrein in the decrease of kininogen. Arterial blood pressure was higher at 7 hours in the SA animals than in the SC group (101% +/- 11% vs. 68% +/- 8%; mean +/- SEM; p = 0.026). Fibrin monomer and C3adesArg plasma levels were attenuated by aprotinin treatment. These findings underscore the important role of the contact system in LPS shock

The antimicrobial effect of Octenidine-dihydrochloride coated polymer tracheotomy tubes on Staphylococcus aureus and Pseudomonas aeruginosa colonisation

<p>Abstract</p> <p>Background</p> <p>The surface of polymeric tracheotomy tubes is a favourable environment for biofilm formation and therefore represents a potential risk factor for the development of pneumonia after tracheotomy. The aim of this <it>in-vitro </it>study was to develop octenidine-dihydrochloride (OCT) coated polymer tracheotomy tubes and investigate any effects on <it>Staphylococcus (S.) aureus </it>and <it>Pseudomonas (P.) aeruginosa </it>colonization. Additionally the resistance of the OCT coating was tested using reprocessing procedures like brushing, rinsing and disinfection with glutaraldehyde</p> <p>Results</p> <p><it>Contamination with S. aureus</it>: Before any reprocessing, OCT coated tracheotomy tubes were colonized with 10³cfu/ml and uncoated tracheotomy tubes with 10⁵cfu/ml (P = 0.045). After reprocessing, no differences in bacterial concentration between modified and conventional tubes were observed.</p> <p><it>Contamination with P. aeruginosa</it>: Before reprocessing, OCT coated tubes were colonized with 10⁶cfu/ml and uncoated tubes with 10⁷cfu/ml (P = 0.006). After reprocessing, no significant differences were observed.</p> <p>Conclusion</p> <p>OCT coating initially inhibits <it>S. aureus </it>and <it>P. aeruginosa </it>colonisation on tracheotomy tubes. This effect, however, vanishes quickly after reprocessing of the tubes due to poor adhesive properties of the antimicrobial compound. Despite the known antimicrobial effect of OCT, its use for antimicrobial coating of tracheotomy tubes is limited unless methods are developed to allow sustained attachment to the tube.</p

What makes inpatient treatment for PTSD effective? Investigating daily therapy process factors

ObjectiveTherapeutic process factors including alliance and motivation are considered to play a key role in the treatment of post-traumatic stress disorder (PTSD). Yet, our understanding of change processes in therapy is mostly based on theoretical considerations with limited empirical evidence. In order to identify process characteristics of successful inpatient treatments of PTSD, we investigated the intraindividual, interindividual, and temporal associations of daily assessments of therapy process factors like motivation, alliance, and insight.MethodTherapy process questionnaire (TPQ) assessments were collected from 101 inpatients with PTSD over 50 days, resulting in 5050 assessments. Multilevel vector autoregressive (mlVAR) modelling was applied to investigate the networks of the TPQ factors in a subgroup with good outcome regarding PTSD symptomatology and a subgroup with less favourable outcome.ResultsThe two subgroups differed markedly in their network models, suggesting that therapy processes might be different for those with good and those with poor treatment outcomes.ConclusionsOur results suggest that good treatment outcome is linked to a specific therapy process dynamic where mindfulness and insight lead to the kind of temporary well-being required to effectively engage with problems and negative emotions, while motivation to change ensures the continuity of confronting negative emotions and problems

Co-occurrence of severe PTSD, Somatic Symptoms and Dissociation in a large sample of childhood trauma inpatients: A Network Analysis

Co-occurrence of mental disorders including severe PTSD, somatic symptoms, and dissociation in the aftermath of trauma is common and sometimes associated with poor treatment outcomes. However, the interrelationships between these conditions at symptom-level are not well understood. In the present study, we aimed to explore direct connections between PTSD, somatic symptoms, and dissociation to gain a deeper insight into the pathological processes underlying their comorbidity that can inform future treatment plans. In a sample of 655 adult inpatients with a diagnosis of severe PTSD following childhood abuse (85.6% female; mean age = 47.57), we assessed symptoms of PTSD, somatization, and dissociation. We analyzed the comorbidity structure using a partial correlation network with regularization. Mostly positive associations between symptoms characterized the network structure. Muscle or joint pain was among the most central symptoms. Physiological reactivation was central in the full network and together with concentrations problems acted as bridge between symptoms of PTSD and somatic symptoms. Headaches connected somatic symptoms with others and derealization connected dissociative symptoms with others in the network. Exposure to traumatic events has a severe and detrimental effect on mental and physical health and these consequences worsen each other trans-diagnostically on a symptom-level. Strong connections between physiological reactivation and pain with other symptoms could inform treatment target prioritization. We recommend a dynamic, modular approach to treatment that should combine evidence-based interventions for PTSD and comorbid conditions which is informed by symptom prominence, readiness to address these symptoms and preference

Psychometric Evaluation of the German Version of the Demoralization Scale-II and the Association Between Demoralization, Sociodemographic, Disease- and Treatment-Related Factors in Patients With Cancer

Objective: To test the psychometric properties, internal consistency, dimensional structure, and convergent validity of the German version of the Demoralization Scale- II (DS-II), and to examine the association between demoralization, sociodemographic, disease- and treatment-related variables in patients with cancer. Methods: We recruited adult patients with cancer at a Psychosocial Counseling Center and at oncological wards. Participants completed the 16-item DS-II, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder Screener-2 (GAD-2), Distress Thermometer (DT), and Body Image Scale (BIS). We analyzed internal consistency of the DS-II using Cronbach‘s Alpha (a). We tested the dimensional structure of the DS-II with Confirmatory Factor Analyses (CFA). Convergent validity was expressed through correlation coefficients with established measures of psychological distress. The associations between demoralization, sociodemographic, disease- and treatmentrelated variables were examined with ANOVAs. Results: Out of 942 eligible patients, 620 participated. The average DS-II total score was M = 5.78, SD = 6.34, the Meaning and Purpose subscale M = 2.20, SD = 3.20, and the Distress and Coping Ability subscale M = 3.58, SD = 3.45. Internal consistency ranged from high to excellent with a = 0.93 for the DS-II total scale, a = 0.90 for the Meaning and Purpose subscale, and a = 0.87 for the Distress and Coping Ability subscale. The one-factor and the two-factor model yielded similar model fits, with CFI and TLI ranging between 0.910 and 0.933, SRMR < 0.05. The DS-II correlated significantly with depression (PHQ-9: r = 0.69), anxiety (GAD-2: r = 0.72), mental distress (DT: r = 0.36), and body image disturbance (BIS: r = 0.58). High levels of demoralization were reported by patients aged between 18 and 49 years (M = 7.77, SD = 6.26), patients who were divorced/separated (M = 7.64, SD = 7.29), lung cancer patients (M = 9.29, SD = 8.20), and those receiving no radiotherapy (M = 7.46, SD = 6.60). Conclusion: The DS-II has very good psychometric properties and can be recommended as a reliable tool for assessing demoralization in patients with cancer. The results support the implementation of a screening for demoralization in specific risk groups due to significantly increased demoralization scores