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A functional imaging study has shown activation of the left insula, amygdala, and cingulate when high-calorie drinks were imbibed by anorectic women (Ellison et al), but this conceivably may have reflected anxiety that the authors termed calorie fear rather than a specific biologic feature of the disease. Reports concerning the percentage of first-degree relatives of anorectic patients with manic-depressive disease are also contradictory. An increased prevalence of neurosis or alcoholism has been noted in other members of the family. However, psychiatrists seem to agree that the patient does not have symptoms that conform to any of the major neuroses or psychoses. Certainly loss of appetite, lack of self-esteem and interest in personal appearance, and self-destructive behavior- common features of anorexia nervosa- are also symptoms of depressive illness, yet most of the patients do not look or admit to being dejected. The pathologic fear of becoming fat and the obsession with weight might be interpreted as a phobic or obsessional neurosis. That anorexia nervosa is practically confined to females must figure in any acceptable explanation of the syndrome. Yet most psychiatrists do not believe anorexia nervosa to be a manifestation of hysteria. Probably important is that anorexia nervosa has its onset in relation to the menarche, at a time when the female exhibits rather large fluctuations in appetite and weight. This has suggested to some an imbalance between the satiety center, believed to lie in the ventromedial hypothalamus, and the feeding center, in the lateral hypothalamus. It is as though the appetitesatiety mechanism of the female hypothalamus were unstable. The association of anorexia with structural disease involving the appetite centers has not been established, though the cases reported by Lewin and colleagues and of White and Hain are suggestive. Martin and Reichlin, in citing these rare cases, attribute the anorexia and cachexia to lesions of the lateral hypothalamus. A rare disorder of infants has been described under the title of "diencephalic syndrome. The causative lesion has usually proved to be a low-grade astrocytoma of the anterior hypothalamus or optic nerve region (Burr et al). As weight is gained over several weeks, the patient usually becomes more normal in her attitude toward eating and will continue to recover on this regimen at home. The menses will not return until considerable weight has been gained (about 10 percent above the weight at the time of the menarche). Our colleagues report better success with such a regimen when imipramine or fluoxetine is added. Others have found these drugs to be ineffective except in patients with prominent symptoms of depression. Becker and colleagues emphasized the potentially devastating medical complications to which severely anorectic patients are prone and the need to evaluate and treat these problems at the same time that nutritional therapy is undertaken. On average, 50 percent of patients recover completely or almost completely (Steinhausen and Seidel). They either relapse after an initial period of improvement or remain chronically anorectic. Many patients are said to lapse into a chronic neurotic state characterized by a persistent preoccupation with food, weight, and dieting. It is not generally appreciated that chronic anorexia nervosa significantly shortens life; after a mean follow-up period of 12 years, 11 percent of a group of 84 patients had died (Deter and Herzog), and 15 percent after 20 years (Ratnasuriya et al). The few adolescent boys that we have seen with this syndrome have recovered on antidepressant medication. Bulimia this is a related eating disorder characterized by massive binge eating followed by the induction of vomiting or excessive use of laxatives. Insofar as the central psychologic disturbance is the pursuit of thinness at all costs, it is generally conceived as a variant of anorexia nervosa. Indeed, binge eating is a frequent manifestation of anorexia nervosa, although it also occurs as the only, or predominant, eating disorder. However, a close relationship with the menarche as well as emaciation and endocrinologic disturbances are not as evident in bulimic patients as in those with anorexia nervosa. Pope and colleagues reported considerable success in 19 of 20 bulimic patients treated with imipramine and followed for 2 years; the newer antidepressants appear to be equally effective. In general, the therapeutic benefit of these drugs is considerably greater in cases of bulimia than it is in anorexia nervosa.
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Vaccination schedules for children from birth through 18 years of age are published annually by the Centers for Disease Control and Prevention. All inactivated vaccines-whether killed whole organism or subunit, recombinant, toxoid, polysaccharide, or polysaccharide protein-conjugate-can be administered safely to individuals with altered immunocompetence. Influence of antiretroviral therapy on immunogenicity of simultaneous vaccinations against influenza, pneumococcal disease and hepatitis A and B in human immunodeficiency virus positive individuals. Response to immunization with measles, tetanus, and Haemophilus influenzae type b vaccines in children who have human immunodeficiency virus type 1 infection and are treated with highly active antiretroviral therapy. Haemophilus b conjugate vaccines for prevention of Haemophilus influenzae type b disease among infants and children two months of age and older. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Revised recommendations of the Advisory Committee on Immunization Practices to vaccinate all persons aged 11-18 Years with meningococcal conjugate vaccine. Other serious bacterial infections, including osteomyelitis, meningitis, abscess, and septic arthritis, occurred at rates <0. In a study in South African children who had not received Hib conjugate vaccine, the estimated relative annual rate of overall invasive Hib disease in children aged <1 year was 5. Diagnosis Attempted isolation of a pathogenic organism from normally sterile sites. In the absence of a laboratory isolate, differentiating viral from bacterial pneumonia using clinical criteria can be difficult. Presence of wheezing makes acute bacterial pneumonia less likely than other causes. For example, detection of Bordetella pertussis and Chlamydophila (formerly Chlamydia) pneumoniae with polymerase chain reaction assays of nasopharyngeal secretions may aid in the diagnosis of these infections. Foods and beverages that are usually safe include steaming hot foods, fruits that are peeled by the traveler, bottled (including carbonated) beverages, and water brought to a rolling boil for 1 minute. Treatment of water with iodine or chlorine may not be as effective as boiling and will not eliminate Cryptosporidia but can be used when boiling is not practical. Greater number or strength of vaccine doses are recommended in some circumstances to overcome suboptimal response. For these older children, a single dose of any Hib conjugate vaccine is recommended. Specimens for microbiologic studies should be collected before initiation of antibiotic treatment. However, in patients with suspected serious bacterial infections, therapy should be administered empirically and promptly without waiting for results of such studies; therapy can be adjusted once results become available. Factors such as response to therapy, clinical status, identification of pathogen, and need for ongoing vascular access will determine the need for and timing of catheter removal. Sinusitis in children infected with human immunodeficiency virus: clinical characteristics, risk factors, and prophylaxis. Risk factors for opportunistic illnesses in children with human immunodeficiency virus in the era of highly active antiretroviral therapy. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Active Bacterial Core Surveillance Report, Emerging Infections Program Network, Streptococcus pneumoniae, 2010. Characteristics of acute pneumonia in human immunodeficiency virusinfected children and association with long term mortality risk. National Institute of Child Health and Human Development Intravenous Immunoglobulin Clinical Trial Study Group. Increased disease burden and antibiotic resistance of bacteria causing severe community-acquired lower respiratory tract infections in human immunodeficiency virus type 1-infected children. The National Institute of Child Health and Human Developments Intravenous Immunoglobulin Study Group.
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Viral meningitis may clinically mimic bacterial meningitis, but in most cases are selflimiting. The clinical signs of acute bacterial meningitis are headache, fever, stiff neck, photophobia, and an alteration of mental status. Focal neurologic signs can occur either from ischemia of underlying brain or from damage to cranial nerves as they pass through the subarachnoid space. In a series of adults with acute bacterial meningitis,87 97% of patients had fever, 87% nuchal rigidity, and 84% headache. Nausea or vomiting was present in 55%, confusion in 56%, and a decreased level of consciousness in 51%. Papilledema was identified in only 2% of patients, although it was not tested in almost half. Seizure activity occurred in 25% of patients, but was always within 24 hours of the clinical diagnosis of acute meningitis. Over 40% of the patients had been partially treated before the diagnosis was established, so that in 30% of patients neither Gram stain nor cultures were positive. However, the classic triad of fever, nuchal rigidity, and alteration of mental status was present in only 44% of patients in a large series ofcommunity-acquiredmeningitis. Subacute or chronic meningitis runs an indolent course and may be accompanied by the same symptoms, but also may occur in the absence of fever in debilitated or immunesuppressed patients. Both acute and chronic meningitis may be characterized only by lethargy, stupor, or coma in the absence of the other common signs. However, the impairment of consciousness in each of these cases is primarily due to the immunologic processes concerned with the infection rather than structural causes (see Chapter 5). The examination should include careful evaluation of nuchal rigidity even in patients who are stuporous. Attempting to flex the neck in a patient with meningitis may lead to gri- macing and a rapid flexion of knees and hips (Brudzinski sign). If one flexes the thigh to the right angle with the axis of the trunk, the patient grimaces and resists extension of the leg on the thigh (Kernig sign). Measurement of beta-trace protein in the blood and discharge fluid is more accurate. Clinically, such children rapidly lose consciousness and develop hyperpnea disproportionate to the degree of fever. Urea, mannitol, or other hyperosmotic agents, if used properly, can prevent or reverse the full development of the ominous changes that are otherwise rapidly fatal. In elderly patients, bacterial meningitis sometimes presents as insidiously developing stupor or coma in which there may be focal neurologic signs but little evidence of severe systemic illness or stiff neck. In one series, 50% of such patients with meningitis were admitted to the hospital with another and incorrect diagnosis. They further argue that the presence of a mass lesion suggests that the neurologic signs are not a result of meningitis alone and that lumbar puncture is probably unnecessary. Finally, even in the absence of a mass lesion, obliteration of the perimesencephalic cisterns or descent of the tonsils below the foramen magnum is a major risk factor for the development of herniation after a lumbar puncture. Regardless of which approach is taken, it is critical for the diagnostic evaluation not to prevent the immediate drawing of blood cultures, followed by administration of appropriate antibiotics. A normal or low pressure raises the question of whether there has already been partial herniation of the cerebellar tonsils. Examination for bacte- rial antigens sometimes is diagnostic in the absence of a positive culture. Meropenem may turn out to be an attractive candidate for monotherapy in elderly patients.
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Deterioration continued, and 28 days after the initial anoxia he was readmitted to the hospital. His blood pressure was 170/100 mm Hg, pulse 100, respirations 24, and temperature 1018F. His extremities were flexed and rigid, his deep tendon reflexes were hyperactive, and his plantar responses extensor. Histologically, neurons in the motor cortex, hippocampus, cerebellum, and occipital lobes appeared generally well preserved, although a few sections showed minimal cytodegenerative changes and reduction of neurons. Pathologic changes were not present in blood vessels, nor was there any interstitial edema. The striking alteration was diffuse demyelination involving all lobes of the cerebral hemispheres and sparing only the arcuate fibers (the immediately subcortical portion of the cerebral white matter). The condition of delayed postanoxic cerebral demyelination observed in this patient is discussed at greater length in Chapter 5. A series of drawings illustrating levels through the brainstem at which lesions caused impairment of consciousness. For each case, the extent of the injury at each level was plotted, and the colors indicate the number of cases that involved injury to that area. The overlay illustrates the importance of damage to the dorsolateral pontine tegmentum or the paramedian midbrain in causing coma. As a result, it is no exaggeration to say that virtually any deficit due to injury of a discrete cortical area can be mimicked by injury to its thalamic relay nucleus. Hence, thalamic lesions that are sufficiently extensive can produce the same result as bilateral cortical injury. The most common cause of such lesions is the ``tip of the basilar' syndrome, in which vascular occlusion of the perforating arteries that arise from the basilar apex or the first segment of the posterior cerebral arteries can produce bilateral thalamic infarction. Other causes of primarily thalamic damage include thalamic hemorrhage, local infiltrating tumors, and rare cases of diencephalic inflammatory lesions. Examination of her brain at the time of death disclosed unexpectedly widespread thalamic neuronal loss. However, there was also extensive damage to other brain areas, including the cerebral cortex, so that the thalamic damage alone may not have caused the clinical loss of consciousness. On the other hand, thalamic injury is frequently found in patients with brain injuries who eventually enter a persistent vegetative state (Chapter 9). However, the location of the hypothalamus above the pituitary gland results in localized hypothalamic damage in cases of pituitary tumors. Patients with hypothalamic lesions often appear to be hypersomnolent rather than comatose. They may yawn, stretch, or sigh, features that are usually lacking in patients with coma due to brainstem lesions. On the other hand, we have not seen loss of consciousness with lesions confined to the medulla or the caudal pons. Twenty-five years earlier she had developed weakness and severely impaired position and vibration sense of the right arm and leg. Two years before we saw her, she developed paralysis of the right vocal cord and wasting of the right side of the tongue, followed by insidiously progressing disability with an unsteady gait and more weakness of the right limbs. Four days before coming to the hospital, she became much weaker on the right side, and 2 days later she lost the ability to swallow. When she entered the hospital she was alert and in full possession of her faculties. She had upbeat nystagmus on upward gaze and decreased appreciation of pinprick on the left side of the face. Stretch reflexes below the neck were bilaterally brisk, and the right plantar response was extensor. Position and vibratory sensations were reduced on the right side of the body and the appreciation of pinprick was reduced on the left. The next day she was still alert and responsive, but she developed difficulty in coughing and speaking and finally she ceased breathing. Later, on that third hospital day, she was still bright and alert and quickly and accurately answered questions by nodding or shaking her head. Several hypotensive crises were treated promptly with infusions of pressor agents, but no pressor drugs were needed during the last 2 weeks of life.
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This change persisted for the remainder of the mission without noticeable improvement or progression. The astronaut did not complain of transient visual obscurations, headaches, diplopia, pulsatile tinnitus, or visual changes during eye movement. Postflight fundoscopic images revealed choroidal folds and a cotton wool spot (Figure 3). In the years since the mission his vision has been stable with optical correction but has not returned to his pre-mission refractive status. The astronaut had additional postflight lumbar punctures with documented opening pressures of 26, 22, and 23 cm H2O at 17, 19, and 60 months, respectively. Fundoscopic images showing choroidal folds (white arrows) in the papillomacular bundle area in the right eye and left eye and a cotton-wool spot (bottom arrow) at the inferior arcade in the left eye. Upon return to Earth, no eye issues were reported by the astronaut (C3) at landing. Astronaut C3 had the most pronounced optic disc edema of all the astronauts reported to date, with a 0. The fourth case of visual changes on orbit was significant because the individual (C4) had previously undergone transsphenoidal hypophysectomy surgery for macroadenoma. Yellow: Borderline, with values outside 95% but within 99% confidence interval of the normal distribution (. Red: Outside normal limits, with values outside 99% confidence interval of the normal distribution. Astronaut C4 reported no transient visual obscurations, headaches, diplopia, pulsatile tinnitus, or vision changes during eye movement. During the mission the astronaut used a topical corticosteroid and oral ketoconazole for a facial rash, occasionally took vitamin D supplements, and took promethazine to treat symptoms of space adaptation syndrome. Preflight eye examination of astronaut C4 revealed a cycloplegic refraction of -0. Ten days after he returned from space, astronaut C4 had a visual acuity that was correctable to 20/15 with a cycloplegic refraction of +0. He never experienced losses in subjective bestcorrected acuity, color vision, or stereopsis. The remotely guided ultrasound eye examinations of astronauts C4 and C5 demonstrated posterior flattening of the globe, dilated optic nerve sheaths, bilaterally distended jugular veins, and a raised right optic disc in the astronaut C4 (Figure 6 and Figure 7). Image files of a near and far acuity chart and an Amsler grid were uploaded and printed on orbit. D S 12 mm Figure 7 On-orbit ultrasound of optic nerves of the fourth case of visual changes from long-duration spaceflight. Three weeks after the ultrasound examination and Amlser grid testing, reading glasses (2. The astronauts took turns being the operator and subject during these examinations and were given their preflight fundoscopic images to use as references. Consultants agreed that no treatment was indicated at that time and that these images would serve as a baseline for follow up examinations throughout the rest of the mission. Monthly remotely-guided ocular ultrasound, dilated video fundoscopic, and visual acuity exams were performed for the duration of the mission. These images allowed experts on the ground to make a diagnosis of mild optic disc edema in the right eye. Postflight fundus examination revealed mild, nasal optic disc edema (Frisen grade 1) of the right eye with choroidal folds extending from the disc into the macula. Greater increase is noted in the right eye inferior sector consistent with postflight optic disc photography. The right optic sheath diameter measures 10 to 11 mm (b and c); and the left optic sheath diameter measured 8 mm.
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Some clinicians have suggested that catheter placement be checked by chest x-ray every three months (Aitken & Minton, 1984; Gallieni et al. Users in training must be supervised closely by qualified personnel to ensure their technical expertise before independent perfor- mance of these procedures. Ongoing monitoring of experienced trainees should be undertaken to ensure continued competence. Except in emergencies, catheterization should be performed with full aseptic technique, which includes hand washing, sterile gloves, mask, hat, gown, drapes, and proper skin antiseptic (Pratt et al. Therefore, users should read all manufacturer labels, instructions, and warnings because they contain important and useful information for the safe and effective use of the catheter. The potential exists for complications, such as shearing the catheter or reintroducing infectious organisms. Symptoms of pinch-off: Difficulty infusing fluids or withdrawing blood, able to infuse or withdraw with patient repositioned such as raising arms or changes in shoulder position, lying supine Symptoms of fracture: Arrhythmia, extra heart sound, palpitations, extravasation, shortness of breath, unable to draw blood Diagnostic tests Figure 8. This places the catheter inside the subclavian vein, instead of next to the vein, through the clavicle and first rib. No studies confirm frequency of surveillance or the type of imaging study to be performed. Image courtesy of the Carole and Ray Neag Comprehensive Cancer Center, University of Connecticut Health Center. Currently, routine use of systemic anticoagulation is not recommended (Geerts et al. Catheter With Fibrin Tail Fibrin tail with "initial" attachment on the outside of catheter, allowing for "trap door" effect and demonstration of partial withdraw occlusion; ability to flush easily but no blood return when attempting to aspirate. Fibrin tail with attachment on the inner aspect of catheter; however, this is a triple-lumen catheter, and it demonstrates that close proximity of lumens can be occluded with single fibrin buildup. Fibrin tail and the extent of "clot burden" extend approximately 4 cm inside the catheter. With more research, these agents may be alternative treatments for catheter clearance (Liu, Jain, Shields, & Heilbrun, 2004). Urokinase is an enzyme produced by the kidneys and found in the urine that converts plasminogen to plasmin. This action degrades fibrin clots as well as fibrinogen and other plasma proteins. Maintenance use has been shown to decrease the rate of occlusion from fibrin buildup (Molinari et al. Urokinase currently is being marketed in large vials only and is indicated for pulmonary emboli. Immunocompromised patients may not demonstrate symptoms of infection because of a decrease in the number of white blood cells. If infection is suspected in a port, it is recommended not to access it because of the potential to introduce microorganisms into the bloodstream. However, it may be necessary to access a suspicious port to obtain blood cultures upon a physician order (Camp-Sorrell, 2007). One culture is drawn from the catheter, and one culture is drawn from a peripheral venipuncture site and labeled accordingly (Krzywda & Edmiston, 2002). Care should be given to use strict aseptic technique, as one contaminant can produce a falsepositive result. If the infusate or solution within the internal lumen of the catheter is thought to be contaminated, no blood should be discarded. It may be necessary to access it to determine the organism within the port system. For multilumen catheters, rotate the lumens for antibiotic administration to ensure that all of the lumens are treated. However, some reports exist of successful management of tunneled catheters by guidewire exchange (Casey et al.
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Several studies have found Emergency Department ultrasound to have a sensitivity in excess of 92% and a specificity approaching 100% in the detection of hemothorax. Free fluid in the peritoneal or thoracic cavities in a hypotensive patient in whom a history of trauma is present or suspected should initially be presumed to be blood, leading to a diagnosis of hemorrhagic shock. Although a history of trauma is commonly elicited in such cases, the trauma may be occult or minor, making diagnosis sometimes difficult. One circumstance of occult trauma is a delayed splenic rupture resulting from an enlarged and more fragile spleen, such as in a patient with infectious mononucleosis. Although rare, this entity may occur several days following a minor trauma, and may thus be easily overlooked by both patient and clinician. Ruptured ectopic pregnancy and hemorrhagic corpus luteum cyst are 2 diagnoses that should not be overlooked in women of childbearing age. In an elderly patient, an abdominal aortic aneurysm may occasionally rupture into the peritoneal cavity and thoracic aneurysms may rupture into the chest cavity. Once the diagnosis of hemorrhagic shock is made, treatment should be directed toward transfusion of blood products and surgical or angiographic intervention. In the nontrauma patient, ascites and pleural effusions will appear as dark, or anechoic, fluid collections, similar to blood. Parapneumonic inflammation may cause considerable pleural effusions and/or empyema. Differentiating blood from other fluids can be suggested from the history, clinical examination, and chest radiograph. There may occasionally be some signature sonographic findings that help make a diagnosis. In hemorrhagic conditions, blood often has a mixed appearance, with areas of both anechoic fresh blood and more echogenic blood clot present. In an infectious parapneumonic pleural effusion, gas bubbles may be seen within the fluid. In cases of uncertainty, a diagnostic thoracentesis or paracentesis (under ultrasound guidance) will most accurately evaluate the nature of the fluid. Although chest radiography reveals characteristic findings in tension pneumothorax, therapy should not be delayed while awaiting radiographic studies. With bedside ultrasound, the diagnosis of tension pneumothorax can be accomplished within seconds. Pneumothorax detection with ultrasound relies on the fact that free air (pneumothorax) is lighter than normal aerated lung tissue, and thus will accumulate in the nondependent areas of the thoracic cavity. Therefore, in a supine patient a pneumothorax will be found anteriorly, while in an upright patient a pneumothorax will be found superiorly at the lung apex. Multiple studies have shown ultrasound to be more sensitive than supine chest radiography for the detection of pneumothorax. A study by Zhang and colleagues71 that focused on trauma victims found the sensitivity of ultrasound for pneumothorax was 86% versus 27% for chest radiography; furthermore, this same study reported the average time to obtain ultrasound was 2. Position a high-frequency linear array or a phased-array transducer in the mid-clavicular line at approximately the third through fifth intercostal spaces to identify the pleural line. This line appears as an echogenic horizontal line located approximately half a centimeter deep to the ribs. The pleural line consists of both the visceral and parietal pleura closely apposed to one another. In the normal lung, the visceral and parietal pleura can be seen to slide against each other, with a glistening or shimmering appearance, as the patient breathes. A normal image will depict ``waves on the beach,' with no motion of the chest wall anteriorly, represented as linear ``waves,' and the motion of the lung posteriorly, representing ``the beach'. When a pneumothorax is present, air gathers between the parietal and visceral pleura, preventing the ultrasound beam from detecting lung sliding. In pneumothorax, the pleural line seen consists only of the parietal layer, seen as a stationary line. M-mode Doppler through the chest will show only repeating horizontal linear lines, demonstrating a lack of lung sliding or absence of the ``beach' (see. The clinician can examine through several more intercostal spaces, moving the transducer more inferiorly and lateral, to increase the utility of the test. This maneuver may also help identify the lung point, or the area where an incomplete pneumothorax interfaces with the chest wall, as visualized by the presence of lung sliding on one side and the lack of lung sliding on the other.
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Ongoing meetings and engagement from a wide variety of stakeholders have been used not only to establish appropriate targets and metrics, but also to improve surveillance and monitor results. Expert committees made up of varied stakeholders, including patients, participate in the standard development process. Nursing care structure is affected by the supply of nursing staff, the skill level of the nursing staff, and the education of nursing staff. Process indicators measure aspects of nursing care, such as assessment, intervention, and registered nurse job satisfaction. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care. With the Deficit Reduction Act of 2005, the federal government began looking to improve healthcare quality and reduce healthcare spending by limiting Medicare payments for certain adverse impacts. Funding for incentive payments comes from across-the-board reductions of base-operating diagnosis-related group payments for all hospitals. Higher scores indicate worse performance and the 25 percent of hospitals with the highest score will be subject to the 1-percent reduction in Medicare reimbursement. Inpatient costs, mortality and 30-day re-admission in patients with central line-associated bloodstream infections. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the associated mortality and costs. Reduction in central line-associated bloodstream infections among patients in intensive care units-Pennsylvania, April 2001-March 2005. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study. This represents up to 6,000 lives saved and $414 million in potential excess healthcare costs in 2009, and approximately $1. Other clinical conditions associated with catheter use include mycotic aneurysms and suppurative thromboembolism. In both cases the catheter causes inflammation or damage to the vessel wall that eventually leads to infection. Shortly after insertion, intravascular catheters are coated with the polymeric matrix which consists of fibrin, plasma proteins, and cellular elements, such as platelets and red blood cells. Microbes interact with the conditioning film, resulting in colonization of the catheter. Formation of these sessile communities and their inherent resistance to antimicrobial agents are at the root of many persistent and chronic bacterial infections and often prompt the removal of central lines when organisms are cultured. Although biofilms occur naturally, the current increased association between biofilms and disease reflects changes in medical practices. Biofilms are the preferred method used by microorganisms for survival, especially when environmental selective pressures are present. For example, naturally occurring biofilms are found in drinking water lines, urban water systems, oil recovery equipment, food processing areas, ship hulls, and at any interface between a solid and nonsolid surface. The increased impact of biofilms in medicine is a result of the explosive growth in the past decade or so in the use of both simple and complex indwelling medical devices. However, there is no absolute method for mitigating the risk; all indwelling medical devices are associated with biofilm formation. Various experiments have been conducted to eliminate intraluminal biofilms through the use of antibiotics, ethanol, and thrombolytics, but no best practice for "catheter salvage" has yet been identified. Venous Thrombosis Increasing attention is being paid to the risk of deep vein thrombosis associated with central venous access. Infection prevention practices seek to minimize the risk for the routes of spread. Hematogenous Spread Organisms can be carried hematogenously to the indwelling catheter from remote sources of local infection, such as pneumonia. Hematogenously spread flora from a distant site, such as the urinary tract, are thought of in theory rather than in fact when looking for a source of catheter infection.