Cefaly

Cefaly is a newly-FDA-approved device that prevents migraines. Users wear the plastic headband across forehead, over ears, with electrode stuck to mid-forehead for 20 minutes daily. It stimulates trigeminal nerve to prevent migraines.

It is the first TENS unit approved for use prior to pain onset. Studies indicate that it does not completely prevent migraine attacks, but those who used it had fewer headaches per month and used fewer migraine medications per month.

C-diff article

--"the development of C. difficile infection (CDI) commonly has 2 essential requirements: (1) exposure to antibiotics and (2) new acquisition of C. difficile such as that occurring via fecal-oral transmission. Although some people exposed to these two factors will develop CDI, others may only become asymptotically colonized. A third factor, related to host susceptibility of bacterial virulence, is thought to be an important determinant for developing disease.

http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

--"incubation period of C. difficile following acquisition is short (median of 2-3 days)... in contrast, the effect of antibiotics on the lower intestinal micro-biota is much longer lasting. Recent epidemiologic evidence indicates patients remain at elevated risk for CDI for 3 or more months after they have stopped antibiotic treatment."

--"In the United States, the rate of hospital discharges with CDI listed as any diagnosis increased from 3.82 per 1,000 discharges in 2000 to 8.75 per 1,000 discharges in 2008; with a disproportionate increase among persons 65 years of age and older." (That's 228%)

--"Persons 65 years of age or older have been most affected, representing over two-thirds of patients with CDI."

--"During this period of rising incidence of CDI...a greater number of severe cases associated with higher numbers of colectomies, treatment failures, and deaths were reported than ever before."

--"In 2009, 92 percent of deaths from C. difficile occurred among persons 65 years of age or older, and C. difficile was the ninteenth leading cause of death in this age group."

--Part of this change in C. difficile epidemiology has been attributed to the emergence of a hypervirulent epidemic strain of C. difficile." (BI/NAP/027-- higher toxin production compared to other strains, also has a third toxin while other strains only have 2, resistant to fluroquinolone class of ABT)

--"CDI should be suspected in any patient with diarrhea or abdominal pain and a recent history of antibiotic use, healthcare exposures, or in patients with unexplained leukocytosis. Severe CDI has also recently been reported in low risk populations—that is, people without recent antibiotic or healthcare facility exposures— therefore, CDI should be considered in any patient who has diarrhea lasting longer than 3 days and has a fever or abdominal pain"

--only patients with diarrhea should be tested, as there are lots of false-positives and false-negatives in asymptomatic patients... "Persistently positive test results at the end of treatment are not predictie of C. difficile relapse, and a 'test of cure' at the end of therapy should not be performed."

--"Routine use of repeat testing is discouraged."

--"Only watery or loose stool should be collected and tested to establish the diagnosis of CDI."

--"Most diagnostic tests involve the detection of C. difficile toxins A and B."


--C-diff spores can survive for months! (on equipment, personal items, or hard surfaces) They are highly resistant to cleaning and disinfection measures.

--spores are important for transmission, as transmission is via fecal-oral route, and spores make it possible for the bacteria to survive stomach acid; "after ingestion, the spores can germinate, produce toxins, and cause disease."

--

Midlines

Application and Use of Midlines

--Midlines measure 3-8 inches.
--They are peripheral catheters, not central, do not require x-ray
--Used for <30 days (short-term)
--May be used for blood draws
--when duration of therapy likely to >6days, use midline or PICC
--less than half infection rate of PICCs


AVERAGE DWELL TIMES:
PICC- 393 hours
Midline- 283 hours
PIV- 44 hours

Rates of infection:
highest-
non-tunneled
arterial
tunneledCVC
PICC
PIV
Midline
Implanted port
lowest

Midline:
--use for infusions appropriate for peripheral infusions
--does not require confirmation of terminal tip (x-ray)
--NOT appropriate fo rinfusions with osmolarity >600mOsm/L, or for TPN
--can be used for UP TO 29 days
--blood draws okay
--rate of occlusion 1.9-29%

PICC
--lower 1/3 of SVC (central)
--requires x-ray or EKG
--can be used for ALL infusions
--no limit on dwell time
--blood draw okay
-- rate of occlusion 25-33%

Per INS, meds appropriate for peripheral infusion have pH of 5-9
(Normal saline pH is 4.5) ??
No CDC standards

No "continuous vesicant medications and solutions"

same reimbursement code as PICC, with lower insertion costs

Deep veins of the upper arm have 5x the flow rate of the hand/forearm, which provides greater hemodilution

A vein should be 3x size of selected catheter

phlebogenic=causing phlebitis (inflammation of the vein wall)