Central venous catheter (CVC) maintenance is critical in administering chemotherapy, transfusions, and high-frequency laboratory draws. Although normal saline (NS) flushes have been associated with similar incidences of irreversible port occlusions as heparin among adult patients with cancer and ports, additional research is needed regarding NS efficacy in other central line maintenance within large populations with cancer.
The aim of this study was to analyze changes in reported CVC line patency via tissue plasminogen activator (tPA) administration rates in ports and other central lines because of an institutional switch from heparin to NS as preferred flushes in adult ambulatory patients with cancer.
Retrospective data were collected from patients with ports (3,706 prepolicy, 3,402 postpolicy) and nonport CVCs (816 prepolicy, 694 postpolicy).
Patients with nonport CVCs experienced similar tPA usage pre- versus postpolicy, versus an increased rate of tPA usage for ports. This policy resulted in institutional savings of $28,695.92. NS flushes are as effective as heparin for maintaining patency in ports and other CVCs for adult outpatients with cancer and address safety concerns with heparin-associated complications.

This study aimed to evaluate animal and ovarian parameters that affected fertilization and embryo development up to the morula stage. The data were combined from four studies in which cows were inseminated between 46 and 60 days in milk, following a synchronization protocol, and flushed for embryo collection five or six days later. Parity and body condition score on the day of insemination were recorded. Cyclicity, ovarian structures, and circulating hormone concentrations before and on the day of insemination were also assessed. The recovered structures were graded on a 5-point scale (excellent-good quality, fair quality, poor quality, degenerated, and not fertilized). For recovered embryos, the total number of blastomeres, the number of nonviable blastomeres, and the number of accessory spermatozoa were assessed by epifluorescence microscopy. The risk factors for fertilization and embryo quality were identified using cumulative link mixed models. A total of 418 structures from 389 lactating Holstein cows (34% primiparous and 66% multiparous) were recovered. Thirty-five percent of the recovered structures were excellent-good quality embryos, 21% were fair quality embryos, 11% were poor quality embryos, 16% were degenerated embryos, and 17% were unfertilized oocytes. Structures from primiparous cows, from those with greater progesterone concentration at insemination, and from cows with seven or less accessory spermatozoa were less likely to be fertilized or of better quality than structures from multiparous cows, from those with lower progesterone concentration in plasma, and from those with more than seven accessory spermatozoa, respectively. Embryos with more blastomeres or without nonviable blastomeres were more likely to be of better quality than embryos with fewer blastomeres or with nonviable blastomeres. The results of this analysis highlight the importance of low circulating concentrations of progesterone near artificial insemination and potential positive association with number of accessory spermatozoa reaching the embryo and improvement of embryo development up to the morula stage.

Harlequin syndrome corresponds to unilateral dysfunction of the sympathetic system, characterized by flush and unilateral hyperhidrosis associated with hypo or anhidrosis and paleness of the opposite side. It is, usually, idiopathic. Rarely, it may be associated with compressive organic processes, iatrogenic causes, and general diseases. It is a real therapeutic challenge.

The citrus leafminer, Phyllocnistis citrella Stainton, is an invasive pest of citrus whose larvae damage developing leaves, which can impact tree photosynthetic capacity and may ultimately reduce tree growth and yield. Damage is most pronounced in young trees due to their greater propensity for production of new foliage, which supports P. citrella oviposition and larval development. We studied P. citrella damage and tree growth and yield among different insecticide treatment regimes to gauge their effectiveness at protecting young citrus trees. Three levels of insecticide treatments were applied over 3 yr to \'Tango\' mandarin (Citrus reticulata Blanco) citrus trees planted in the prior summer, which were inspected regularly along with untreated trees. Leaves suitable for oviposition by P. citrella were available during all census dates, though their numbers fluctuated in the summer months. Phyllocnistis citrella were suppressed for 2-3 wk by systemic or foliar treatments of insecticides. The higher number of treatments provided more sustained suppression of larvae. Trunk diameter was unchanged and canopy volume affected by only the most aggressive treatment regime. However, citrus yield was 2-2.5 times higher following the second year of treatments and 1.2- to 1.8-fold times following the third year of treatments for trees in the treatment regimes that included systemic imidacloprid plus 2-3 or 4-5 foliar applications, respectively, relative to untreated controls. Suitable leaf flush and larval densities declined over the 3 yr of the study. These data support the use of insecticidal control of P. citrella to protect young \'Tango\' mandarin trees, but demonstrated that frequent applications are necessary to suppress populations.

BACKGROUND: Adequate delivery of both enteral formula and water in patients receiving enteral nutrition (EN) is critical. Pump accuracy has been identified as a factor impeding enteral formula delivery; however, rarely is enteral water delivery investigated. The purpose of this study was to explore accuracy of delivering 1 L of water by EN pumps using different flush volumes and hang heights.
METHODS: Three EN pumps were used in vitro to flush 1 L of water at 50 mL every hour for 20 hours (50 mL, 20 times per day) and 500 mL every 4 hours for 8 hours (500 mL, 2 times per day) at 0 in. and 18 in. (or 45.72 cm) hang heights. Fifteen runs were conducted at each volume and hang height per pump. Actual delivered enteral water, remaining volume in enteral feeding bags, and volume reported per pump were recorded.
RESULTS: Hang height of 18 in. delivered a mean 3.91% (95% CI, 3.25-4.57) more water than bags hung at 0 in. (P < .0005). When delivering water in 500 mL increments, 1.57% (95% CI, 0.92-2.23) more water was delivered than when delivered in 50 mL increments (P < .005).
CONCLUSIONS: Appropriate hang height recommendations improve enteral water delivery in patients receiving EN. The most accurate setting was 500 mL at 18 in., resulting in accurate water delivery in 97.8% of runs, whereas 50 mL at 0 in. delivered accurately 17.8% of the time. Appropriate bag hang height and water delivery volume is critical to maintain hydration status of patients receiving EN.

UNASSIGNED: The purpose of this study was to determine whether heparinized saline (HS) would be more effective in maintaining the patency of central venous catheters (CVCs) in dogs compared to 0.9% sodium chloride. This was a prospective randomized blinded study conducted at a University Veterinary Teaching Hospital.
UNASSIGNED: A total of 24 healthy purpose-bred dogs were randomized into two groups: a treatment and a control group. A CVC was placed in the jugular vein of each dog. Each dog in the treatment group had their CVC flushed with 10 IU/mL HS, while dogs in the control group had their CVC flushed with 0.9% sodium chloride every 6 h for 72 h. Immediately prior to flushing, each catheter was evaluated for patency by aspiration of blood. The catheter site was also evaluated for phlebitis, and a rectal temperature was obtained in each dog every 6 h. Prothrombin (PT) and activated partial thromboplastin (aPTT) times were evaluated prior to the administration of any flush solution. Results were then compared to values obtained 72 h later.
UNASSIGNED: All CVCs in both groups were patent after 72 h, which was demonstrated by aspiration of blood and ease of flushing the catheter. Two CVCs in the 0.9% sodium chloride group had a negative aspiration at hour 12 and 36, respectively. One CVC in the HS group had a negative aspiration at hour 18. Signs of phlebitis occurred in three dog: two in the 0.9% sodium chloride group and one in the HS group. No dog was hyperthermic (>103 °F). Two catheters were inadvertently removed by dogs in the HS group during the study. There were no significant differences in catheter patency, incidence of phlebitis, or incidence of negative aspirations between both groups. aPTT and PT values remained within the normal reference range for all dogs in both groups. Ultimately, 0.9% sodium chloride was as effective as 10 IU/mL HS in maintaining the patency of CVCs for up to 72 h in healthy dogs. Further evaluation in clinical patients is warranted.

IntroductionInvasive blood pressure (IBP) monitoring could be of benefit for certain prehospital patient groups such as trauma and cardiac arrest patients. However, there are disadvantages with using conventional IBP devices. These include time to prepare the transducer kit and flush system as well as the addition of long tubing connected to the patient. It has been suggested to simplify the IBP equipment by replacing the continuous flush system with a syringe and a short stopcock.HypothesisIn this study, blood pressures measured by a standard IBP (sIBP) transducer kit with continuous flush was compared to a transducer kit connected to a simplified and minimized flush system IBP (mIBP) using only a syringe.
METHODS: A mechanical, experimental model was used to create arterial pressure pulsations. Measurements were made simultaneously using a sIBP and mIBP device, respectively. This was repeated four times using different mean arterial pressure (MAP): 40, 70, 110, and 140mm Hg. For each series, 16 measurements were taken during 20 minutes. Data were analyzed using Bland-Altman plots. Measurement error greater than five percent was regarded as clinically significant.
RESULTS: Mean bias and standard deviation (SD) for systolic blood pressure (SBP), diastolic blood pressure (DBP), and MAP was -3.05 (SD = 2.07), 0.2 (SD = 0.48), and -0.3 (SD = 0.55) mmHg, respectively. Bland-Altman plots revealed that the bias and SD for systolic pressures was mainly due to an increased under-estimation of pressures in lower ranges. All MAP and 98.4% of diastolic pressure measurements had an error of less than five percent. Systolic pressures in the MAP 40 series all had an error of greater than five percent. All other systolic pressures had an error of less than five percent.
CONCLUSIONS: Thus, IBP with the mIBP flush system provides accurate measurement of MAP and DBP in a wide range of physiological pressures. For SBP, there was a tendency to under-estimate pressures, with larger error in lower pressures. Implementation of a simplified flush system could allow further development and potentially simplify the use of IBP for prehospital critical care teams. KarlssonJ, LindeJ, SvensenC, GellerforsM. Prehospital invasive arterial pressure: use of a minimized flush system. Prehosp Disaster Med. 2018;33(5):490-494.

Flushing tap water is promoted as a low cost approach to reducing water lead exposures. This study evaluated lead reduction when prevailing flush guidelines (30 s⁻2 min) are implemented in a city compliant with lead-associated water regulations (New Orleans, LA, USA). Water samples (n = 1497) collected from a convenience sample of 376 residential sites (2015⁻2017) were analyzed for lead. Samples were collected at (1) first draw (n = 375) and after incremental flushes of (2) 30⁻45 s (n = 375); (3) 2.5⁻3 min (n = 373), and (4) 5.5⁻6 min (n = 218). There was a small but significant increase in water lead after the 30 s flush (vs. first draw lead). There was no significant lead reduction until the 6 min flush (p < 0.05); but of these samples, 52% still had detectable lead (≥1 ppb). Older homes (pre-1950) and low occupancy sites had significantly higher water lead (p < 0.05). Each sample type had health-based standard exceedances in over 50% of sites sampled (max: 58 ppb). While flushing may be an effective short-term approach to remediate high lead, prevailing flush recommendations are an inconsistently effective exposure prevention measure that may inadvertently increase exposures. Public health messages should be modified to ensure appropriate application of flushing, while acknowledging its short-comings and practical limitations.

Toilets contaminated with infectious organisms are a recognized contact disease transmission hazard. Previous studies indicate that toilet bowl water can remain contaminated for several flushes after the contamination occurs. This study characterized contamination persistence over an extended series of flushes using both indicator particles and viable bacteria. For this study, toilets were seeded with microbe-size microbial surrogates and with Pseudomonas fluorescens or Clostridium difficile bacteria and flushed up to 24 times. Bowl water samples collected after seeding and after each flush indicated the clearance per flush and residual bowl water contaminant concentration. Toilets exhibited 3 + log10 contaminant reductions with the first flush, only 1-2 logs with the second flush, and less than 1 log thereafter. Contamination still was present 24 flushes post contamination. Clearance was modeled accurately by a two-stage exponential decay process. This study shows that toilet bowl water will remain contaminated many flushes after initial contamination, posing a risk of recurring environmental contamination and associated infection incidence.

BACKGROUND: The failure rate of free flaps is approximately 5%, mostly due to thrombosis of microvascular anastomosis. A number of pharmacological agents have been tested in order to enhance the patency of microvascular anastomosis and so to as extend the survival of free flaps. One of them is heparin, a very commonly used anticoagulant. However, there exists no consensus on its use in microsurgery as concerns time of introduction (pre-, intra- or post-operative), recommended dosage, or duration of utilization. The aim of this study was to determine whether or not the use of intra-operative heparin, in its systemic or topical forms, can bring about improved survival of free flaps, and if and when it should be recommended in microsurgery.
METHODS: A systematic review on the PUBMED database enabled us to identify articles evaluating the benefits of intra-operative heparin with regard to free-flap survival. All in all, fifteen articles in animal and human research were selected.
RESULTS: As far as animal research is concerned, 9 studies out of 11 showed the superiority of topical intra-operative heparin compared to saline in improving free-flap survival rates through improved patency of the anastomosis. As regards systemic intra-operative heparin, on the other hand, only two trials out of four yielded favorable results. In clinical research in humans, there has been no prospective randomized trial studying the action of topical intra-operative heparin in vessel irrigation of ex-vivo free flaps before vascular repermeabilisation. However, the preliminary results of four trials seem to provide positive arguments for this practice.
CONCLUSIONS: The use of systemic per-operative heparin (intravenous injection) does not improve the survival of free flaps in either animal models or humans. In animal models, however, the use of topical intra-operative heparin (vessel irrigation) has been shown to improve the free-flap survival rate by avoiding thrombosis of microvascular anastomosis. Finally, in clinical studies concerning humans, as of now no prospective randomized trial has proven that use of topical intra-operative heparin to ensure vessel irrigation in ex-vivo flaps is likely to increase free-flap survival. Studies should be conducted to decide whether or not to validate a rather ritualistic practice that consists in irrigating the relevant vessels before anastomosis; does it or does it not improve the patency rate?