The stuck catheter: a case report.

Complications after the use of central venous catheters have become more frequent as their use in therapy has increased. As a result, the recognition and management of central venous catheters must be emphasized. We describe a unique problem, that of the "stuck catheter," and its safe and simple solution.

Peripherally inserted central catheters in general medicine.

OBJECTIVE: To report the success rate and complications associated with peripherally inserted central venous catheters (PICCs) and to compare costs between PICCs and centrally inserted central catheters. MATERIAL AND METHODS: We undertook a cohort study of the first 1,000 patients referred to the PICC service of a large tertiary-care, university-affiliated, community hospital. The data were analyzed for insertion success rate, insertion mode, complication rate, successful completion, insertion costs, and applicability of PICCs in "high-risk" groups (transplant, human immunodeficiency virus-infected, intensive-care unit, and pediatric populations). RESULTS: Of 1,000 consecutive PICC attempts, 963 (96.3%) were successful. Cutdown procedures were necessary in 141 insertions (14.6%). Complications of PICC placement occurred in 170 cases (17.7%). Among the major complications were a need for multiple attempts at insertion in 92 cases, malpositioning in 56, mechanical phlebitis in 37, clotting in 37, and bleeding in 5. The rate for completion of therapy was 68.9%. Frequent reasons for early termination were dislodgment (in 85 cases) and infection (in 72-37 confirmed and 35 potential cases). The rate of confirmed infection was 11 per 10,000 catheter days. The costs of PICC insertion were less than those associated with centrally inserted central catheters. CONCLUSIONS: PICCs can satisfy long-term vascular needs and are safe in many patient populations. The infection rate did not depend on insertion mode, lumen number, or patient's immune status. Use of total parenteral nutrition was the most important risk factor in all patient subsets. Cost and safety considerations strongly favor PICCs as alternatives to other vascular access devices.

Rapid identification of group A streptococcus as the cause of necrotizing fasciitis.

Group A beta-hemolytic Streptococcus pyogenes (GAS) causes a spectrum of highly aggressive, invasive infections. We report two cases of necrotizing fasciitis in which GAS was identified as the presumptive causative organism with the use of the standard rapid streptococcal diagnostic kit. We believe the rapid test kits may be a useful adjunct in the diagnosis and treatment of this catastrophic illness and may play a role in limiting the spread of infection.

Peripherally inserted central catheters in the intensive care unit.

We report the success rate and complications of peripherally inserted central catheters (PICCs) in patients hospitalized in an intensive care unit (ICU). We performed a cohort study in the ICU of a large tertiary care, university-affiliated community hospital. All ICU patients for whom their attending physicians requested a PICC service consultation were included. Main outcome measurements included (1) the success rate for initial PICC placement, (2) the placement complication rate, and (3) the overall success and complication rate. Of the 91 consecutive attempts at PICC placement, 89 (97.8%) were successful: of the 89 successful placements, 25 (28%) required cutdown procedures. There were 20 complications of initial placement and 8 delayed complications, which occurred in 19 PICCs. Complications included recatheterization after first attempt was unsuccessful (10), catheter malposition (7), palpitations or catheter clotting (3 each), heavy bleeding or mechanical phlebitis (2 each), and arterial puncture (1). The overall success rate for completion of therapy using the PICC was 74.7%. The most frequent reasons for failure to complete therapy were catheter dislodgment in 8 patients and "infection" in 9 patients. Of these 9 patients with "infections," 8 catheters were discontinued due to potential infection, and only 1 was removed due to confirmed infection. The confirmed infection rate was 6/10,000 patient days. The PICC appears to be a reasonable alternative to other approaches to peripheral and central venous access. The initial and overall success rates from this preliminary study justify further evaluation of the PICC in critically ill patients.

Constant time delay with discrete responses: a review of effectiveness and demographic, procedural, and methodological parameters.

Constant time delay, a variation of progressive time delay, is a response prompting strategy designed to provide and remove prompts in a systematic manner on a time dimension. Constant time delay has two defining characteristics: (a) initial trials involve presentation of the target stimulus followed immediately by delivery of a controlling prompt; and (b) on all subsequent trials, the target stimulus is presented, a response interval of a fixed duration is delivered, the controlling prompt is provided, and a second response interval is delivered as needed. Reports of 36 studies using the constant time delay procedure with discrete behaviors were identified and analyzed. The results are described in terms of demographic variables (i.e., the types of subjects, settings, behaviors, instructors, and instructional arrangements), and the procedural parameters of the strategy. The effectiveness of the strategy and the outcome measures are summarized. Finally, the methodological adequacy of the constant time delay research is examined. Implications for practice and for further research are presented.

Assessing the acquisition of incidental information by secondary-age students with mental retardation: comparison of response prompting strategies.

The effectiveness and efficiency of four response prompting conditions (progressive time delay, progressive time delay with a descriptive consequent event, system of least prompts, and system of least prompts with a descriptive consequent event) were compared. Students with moderate to severe mental retardation were taught to read functional recipe words. Maintenance and students' acquisition of incidental information were assessed when it was (a) embedded in the prompts of the system of least prompts procedure, (b) included in the descriptive praise statements following correct performance with the progressive time delay and system of least prompts procedures, and (c) not presented. A multiple probe design across behaviors, replicated across subjects, was used. Results indicated that (a) each of the procedures produced criterion level responding: (b) efficiency data on traditional measures were roughly equal; (c) maintenance checks showed no differential effects related to the instructional condition; and (d) incidental information was acquired, although it was not directly targeted for instruction.

Comparison of constant time delay and the system of least prompts in teaching preschoolers with developmental delays.

This investigation compared the effectiveness and efficiency (sessions, errors, percent of errors, and minutes of instructional time through criterion) of constant time delay and the system of least prompts in teaching sight words to developmentally delayed preschoolers. Maintenance of sight words and generalization across instructors and materials were assessed. Also, students' acquisition of relationships between the target behavior and previously learned information were assessed. Two sessions were conducted each day in their classroom, one with each procedure. Two of the children were taught 16 words and one child learned 12 words. The parallel treatments design was used to assess the effectiveness of the two instructional strategies. The results indicated that (a) both strategies produced criterion level responding in the instructional setting, (b) constant time delay resulted in fewer total trials, errors, percent of errors, and minutes of direct instructional time through criterion than the system of least prompts, (c) both strategies produced criterion-level responding that maintained in 1-, 3- and 5-week follow-up probes, (d) both strategies resulted in generalization across instructors and materials, and (e) both strategies resulted in cross-modal generalization from expressive to receptive, receptive and expressive identification of the words' function or action, and matching the written word to a photograph of its referent.

Absence of hepatitis B surface antigenemia after vaccination.

Vaccination against hepatitis B is readily available and provides safe and effective immunization for individuals at increased risk for this disease. However, since the available vaccines employ a protein consisting of hepatitis B surface antigen, the question has arisen whether a detectable surface antigenemia might occur in recently vaccinated individuals. Employing two current immunoassays for hepatitis B surface antigen, we could not detect this marker in individuals either 1 hour or 24 hours after vaccination. We therefore conclude that the presence of surface antigen in the blood cannot be attributed to recent vaccination.

Review of comparative studies in the instruction of students with moderate and severe handicaps.

Systematic instructional strategies that investigators have used with students who display moderate to severe handicaps were identified and defined. The investigations which directly compared two or more strategies were analyzed, and summary statements/recommendations about the relative effectiveness and efficiency of the strategies were made. Analyzing the effectiveness of the procedures involved determining which strategies successfully taught skills to subjects. The efficiency of the strategies was analyzed on measures which indicated the skills were taught in a productive and timely manner (i.e., trials to criterion, sessions to criterion, errors to criterion, direct instruction time). Recommendations for future research and practice include (a) conduct more studies comparing the effectiveness and efficiency of instructional strategies, (b) conduct investigations of the specific variables of single strategies to identify the most efficient use of each procedure, (c) expand the efficiency measures to assess whether students learn information not directly targeted for instruction, and (d) conduct research to determine which strategy is best to use with given types of students and skills.