CAPD bag changing with integrated disconnect system gives lower incidence of peritonitis than with UV-box system. Comparative evaluation of CAPD and PD-plus effectiveness. Prevention of peritonitis with disconnect systems in CAPD: a randomized controlled trial. The Mexican Nephrology Collaborative Study Group. A comparison of two types of catheters for continuous ambulatory peritoneal dialysis (CAPD). Twin- versus single-bag disconnect systems: infection rates and cost of continuous ambulatory peritoneal dialysis. Does catheter immobilization reduce exit-site infections in CAPD patients? Randomized study comparing combined pulmonary vein-left atrial junction disconnection and cavotricuspid isthmus ablation versus pulmonary vein-left atrial junction disconnection alone in patients presenting with typical atrial flutter and atrial fibrillation. A controlled investigation of in-field attenuation performance of selected insert, earmuff, and canal cap hearing protectors. Plasma exchange in polyneuropathy associated with monoclonal gammopathy of undetermined significance.
The use of a UV-box disconnect system reduces the incidence of peritonitis as compared with manual exchanges. An integrated disconnect system (IDS) also gives good results. See Figure 1. From 1988-1991, we prospectively compared two groups of patients using either a UV-box disconnect system (Baxter, n = 18, mean age 64, range 28-75 yrs) or an IDS (Baxter, n = 25, mean age 53, range 30-78). The Tenckhoff catheter had been inserted by the same technique in all patients, and the training program and nursing care were also identical. Since many younger patients preferred IDS and refused randomization, age was significantly lower in the IDS group. All peritonitis episodes (PER) were registered. Excluded from calculations of PER were episodes most probably not due to failure in connective device: PER after incidental penetration of the dialysis bags, deep penetrating tunnel infections and in the direct course of abdominal surgery. Results: There were significantly fewer months with PER (one month = 1 PER; Chi-2 = 6.45, p < 0.05) in patients using the IDS (3 PER/269 months) compared with those using the UV-box system (15 PER/355 months). The IDS was requested mainly by younger patients, while some older patients found it to be too complicated. Conclusion: The integrated disconnect system is especially acceptable by younger patients, and patients using the IDS show a low incidence of peritonitis. Decline in residual renal function in CAPD patients often leads to reduced overall solute clearances. Inadequate dialysis has been linked to malnutrition and increased morbidity and mortality rates. Achieving dialysis adequacy targets is often difficult by the conventional method of increasing CAPD exchange volumes. In comparison, substantial increases in solute clearances can be achieved with the use of automated peritoneal dialysis with large fill volumes and an extra daytime exchange. Recently, disconnect systems for CAPD that are associated with a reduced frequency of peritonitis have been introduced. Our objective was to compare the incidence of peritonitis using three current CAPD systems in a high-risk population with low educational and socioeconomic levels, and high prevalence of malnutrition.
                In a prospective controlled trial, 147 patients commencing CAPD were randomly assigned to one of three groups: 29 to the conventional, 57 to the Y-set, and 61 to the twin bag systems. The number of peritonitis episodes was registered, and patients were followed up for an average of 11.3 months.
                The average peritonitis-free interval for the conventional group was 6.1 months, for the Y system was 12.0 months, and for the twin bag was 24.8 months (P < 0.001). By multivariate analysis, the only factor associated with peritonitis was the CAPD system. Peritonitis-related hospitalization was 5.3 +/- 2.0, 2.7 +/- 1.0, and 1.5 +/- 0.9 days/patient/year in the conventional, Y system, and twin bag groups, respectively. The cost per bag was similar for the conventional and Y system, but higher for the twin bag. However, the total costs of treatment (pesos/patient/year) were lower for twin bag (62,159 for the conventional, 70,275 for the Y system, and 54,387 for the twin bag), due to the lower peritonitis incidence and associated hospitalizations.
                Y system and twin bag use was associated with a reduction of 50 and 75% peritonitis incidence, respectively, in patients on CAPD. The cost of the twin bag was actually lower, because of savings from a decreased usage of antibiotics and fewer hospitalizations. This study was undertaken to critically examine the value of the curled Tenckhoff catheter for continuous ambulatory peritoneal dialysis (CAPD) access with respect to the incidence of catheter-related complications. In the setting of a prospective, randomised, double-blind comparison, we were unable to demonstrate any advantage of the curled Tenckhoff catheter over the conventional straight type. Although twin-bag disconnect fluid-transfer systems for continuous ambulatory peritoneal dialysis (CAPD) have a lower rate of catheter-related infection than single-bag systems, their greater monetary purchase cost has prevented universal adoption. Therefore, a single-center randomized study was performed in 63 adult patients to compare the efficiency and total cost of Freeline Solo (FS, twin-bag) and Basic Y (BY, single-bag) systems. Patients were new to CAPD (N = 39), or had a new CAPD catheter, or had had no episodes of peritonitis or exit-site infection in the previous 12 months (N = 24). Total follow-up was 631 patient months (pt.mon), and 53 patients were still on the trial at its termination. Patients rated FS as easier to use than BY (P < 0.001). Peritonitis occurred on 23 occasions in 12 out of 30 patients using BY, and on seven occasions in five of 33 patients using FS. Time to first infection was less with BY than FS (hazard ratio, 2.4; 95% confidence interval (CI), 1.0 to 5.3; P < 0.04). Cumulative incidence of peritonitis was 1 per 14.0 pt.mon with BY and 1 per 46.5 pt.mon with FS (odds ratio, 3.6; 95% CI 1.5 to 8.5; P = 0.004). Length of hospitalization for peritonitis or exit-site infection was 98 days in six patients with BY, versus 17 days in two patients with FS. With BY, four catheters were removed because of infection, but none with FS (P < 0.05). With BY, the total cost of infection was $AUD127,079 ($5033 per pt.yr) versus $19,250 ($704 per pt.yr) with FS, which offset the higher purchase cost of FS. The total cost of CAPD was $AUD956 per pt.yr less with FS than BY. In conclusion, the higher purchase cost of the FS twin-bag system is more than offset by savings from its lower incidence of peritonitis. This study was undertaken to ascertain the effectiveness of an immobilization device in reducing exit site infections (ESI) in CAPD patients, and whether immuno-suppressive therapy, diabetes, disconnect system and Staphylococcus aureus nasal carriage had any bearing on the incidence of ESI. Sixty-six patients having a Tenckhoff catheter placement were randomly allocated into one of three groups; immobilizer, tape and non-immobilized group. The groups were monitored for the incidence of ESI over a total period of 347 patient months. The results show no significant difference in infection rates between the three groups, nor do the factors mentioned have any bearing on ESI rate. Whilst immobilization is important, the ineffectiveness of this device was probably related to its design problem. Atrial flutter (AFL) and atrial fibrillation (AF) frequently coexist in the same patient. Recently it has been demonstrated that the triggers for both AF and AFL may originate in the pulmonary veins (PVs). We hypothesized that in patients with both AF and typical AFL, pulmonary vein-left atrial junction (PV-LAJ) disconnection may eliminate both arrhythmias.
                Consecutive patients with documented symptomatic AF and typical AFL were randomly assigned to have PV-LAJ disconnection combined with cavotricuspid isthmus (CTI) ablation (group 1, n=49) or PV-LAJ disconnection alone (group 2, n=59). Within the first 8 weeks after ablation, 32 of the group 2 patients had typical AFL documented, whereas none was seen in group 1. Twenty of these 32 converted to sinus rhythm after initiating antiarrhythmic drugs (AADs). Twelve were cardioverted, and AADs were started. After 8 weeks, all AADS were stopped, and only 3 patients continued to have recurrent sustained typical AFL that was eliminated by CTI ablation. Beyond 8 weeks of follow-up, 7 patients in group 1 and 6 patients in group 2 (14% and 11%, respectively) continued to have AF. Ten of these 13 patients underwent a repeat PV-LAJ disconnection procedure and were cured. The remaining 3 remained in normal sinus rhythm while taking AADs.
                In patients with both AFL and AF, PV-LAJ disconnection alone may be sufficient to control both arrhythmias. CTI block reduced early postablation recurrence of arrhythmias, which in the majority of patients reflects a short-term clinical problem. A field study assessed the actual spectral noise attenuation achieved by 40 industrial workers wearing four different hearing protection devices (HPDs) while on the job. The effect of two different HPD fitting procedures (subject fit vs. trained fit) on attenuation performance over two three-week periods of protector use was determined. Subjects were retrieved from their workplaces without prior knowledge of when they were to be tested and were not permitted to readjust the fit of their HPDs. Attenuation data were then collected using psychophysical procedures testing real ear attenuation at threshold. Statistical analyses indicated that the earplugs' attenuation significantly improved when training for proper fitting was used, whereas the earmuff and the ear canal cap were relatively insensitive to the training effect. The training was most effective for a slow-recovery foam plug over the three-week period. Results confirmed that laboratory protocols designed to simulate workplace influences on attenuation may not be relied on to yield reasonable estimates of field protection performance of HPDs, particularly for earplugs; however, the laboratory results were much better predictors of field protection for the earmuff. This study also demonstrated that the labeled manufacturers' noise reduction ratings (NRRs) substantially overestimated the actual field attenuation performance. Polyneuropathy associated with monoclonal gammopathy of undetermined significance (MGUS) has been treated with plasma exchange, intravenous immune globulin, and chemotherapy, but the effectiveness of these treatments remains uncertain.
                We randomly assigned 39 patients with stable or worsening neuropathy and MGUS of the IgG, IgA, or IgM type to receive either plasma exchange twice weekly for three weeks or sham plasma exchange, in a double-blind trial. The patients who initially underwent sham plasma exchange subsequently underwent plasma exchange in an open trial.
                In the double-blind trial, the average neuropathy disability score improved by 2 points from base line (from 62.5 to 60.5) in the sham-exchange group and by 12 points (from 58.3 to 46.3) in the plasma-exchange group (P = 0.06). A similar difference was observed in the weakness score, a component of the neuropathy disability score (improvement, 1 and 10 points, respectively; P = 0.07). After treatment the summed compound muscle action potentials of motor nerves were 1.2 mV lower (worse) than at base line in the sham-exchange group and 0.4 mV higher (better) in the plasma-exchange group (P = 0.07). The greater degree of improvement with plasma exchange was equal in magnitude to or greater than the difference between not being able to walk on the heels or toes and being able to perform these activities. Changes in the vibratory detection threshold, summed motor-nerve conduction velocity, and sensory-nerve action potentials did not differ significantly between the treatment groups. In the open trial, in which patients who initially underwent sham exchange were treated with plasma exchange, the neuropathy disability score (P = 0.04), weakness score (P = 0.07), and summed compound muscle action potentials (P = 0.07) improved more with plasma exchange than they had with sham exchange. In both the double-blind and the open trial, those with IgG or IgA gammopathy had a better response to plasma exchange than those with IgM gammopathy.
                Plasma exchange appears to be efficacious in neuropathy associated with MGUS, especially of the IgG or IgA type.
Disconnect systems should be the preferred exchange systems in CAPD.