Introduction: Hemodialysis (HD) patients are hospitalized nearly twice yearly, and 35% of these patients are rehospitalized within 30-days postdischarge. We hypothesized that monitored oral nutritional supplementation (ONS) during HD treatment may decrease readmissions. Methods: A cohort of maintenance HD patients, treated at a large dialysis organization, who were hospitalized with a postdischarge albumin of <= 3.5 g/dL, without documented ONS use 90 days prior to the index hospitalization were identified. Individuals who received monitored intradialytic ONS postdischarge were compared to those without receipt of ONS. The outcome of interest was 30-day hospital readmissions. Logistic regression was used to assess the association between ONS receipt and 30-day readmission events, with adjustment for case-mix and laboratory variables. Findings: Of 5479 eligible patients, ONS was prescribed to 1420 individuals. Mean age was 64.6 +/- 14.1 (SD) years; median dialysis vintage was 3.9 years. There were 274 (19%) readmissions among ONS recipients vs. 1571 (38.7%) among controls during the 30-day follow-up period. Individuals who did not receive ONS had increased odds of readmission [OR 2.26 (95% CI 1.02, 2.53)] in 30 days, as compared to those who did receive ONS postdischarge. In sensitivity analyses using a propensity score matched cohort, the odds ratio of readmissions within 30 days postdischarge was 1.71 (95% CI: 1.42, 2.07) for individuals who did not receive ONS as compared to those who received ONS. Discussion: Consumption of ONS during HD sessions is associated with reduced hospital readmission rates among in-center maintenance HD with severe hypoalbuminemia at 30 days post-hospital discharge.

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BACKGROUND:Low serum magnesium levels in patients with kidney disease have been linked to increased mortality. This study investigated whether similar associations existed in maintenance hemodialysis (HD) patients. STUDY DESIGN:Cohort study. SETTING & PARTICIPANTS:All Fresenius Medical Care North America in-center HD patients with available serum magnesium measurements were studied. The initial exploratory study in 21,534 HD patients evaluated associations among serum magnesium level, dialysate magnesium concentration, and mortality from April 2007 through June 2008. The follow-up study in 27,544 HD patients evaluated associations between serum magnesium levels and mortality over 1 year (January through December 2008). PREDICTORS:The primary predictor was serum magnesium level, with adjustment for case-mix (age, sex, race, diabetes, and dialysis vintage and additionally for follow-up study: body surface area and vascular access) and laboratory variables (albumin, hemoglobin, phosphorus, equilibrated Kt/V, potassium, calcium, and intact parathyroid hormone values). OUTCOME:Primary outcome variable was 1-year mortality risk, evaluated using Cox proportional hazards models. RESULTS:Among 21,534 HD patients in the exploratory study, there were 3,682 deaths. Higher dialysate magnesium level was associated with higher serum magnesium level (R=0.22; P<0.001). Patients with the lowest serum magnesium levels (<1.30 mEq/L) were at highest risk for death (HR, 1.63; 95% CI, 1.30-1.96; reference serum magnesium, 1.60-<1.90 mEq/L). Among 27,544 HD patients in the follow-up study, there were 4,531 deaths. In Cox proportional hazards models, there was a linear decline in death risk from the lowest to the highest serum magnesium category, with the best survival at serum magnesium levels ≥ 2.50 mEq/L (HR, 0.68; 95% CI, 0.56-0.82). However, risk estimates were attenuated with case-mix and lab adjustment. This pattern was consistent within diabetes subgroups and for cardiovascular or noncardiovascular causes of death. LIMITATIONS:Observational study with cross-sectional serum magnesium measurements and no information for oral magnesium intake. CONCLUSIONS:Elevated serum magnesium levels > 2.10 mEq/L were associated with better survival than low serum magnesium levels < 1.30 mEq/L in HD patients. Prospective studies may determine whether manipulation of low serum magnesium levels affects survival.

While hyperglycemia is central to the pathogenesis and management of diabetes mellitus, hypoglycemia and glucose variability also contribute to outcomes. We previously reported on the relationship of glycemic control to outcomes in a large population of diabetic end-stage renal disease (ESRD) patients. Recognizing that ESRD is a risk factor for severe hypoglycemia, we have now analyzed the association between glycosylated hemoglobin A1c (HgbA1c) levels and glycemic variability in those with hypoglycemia. This is a retrospective study of patients with diabetes enrolled in a large hemodialysis program. Hypoglycemia was identified from hospital discharge diagnostic codes. Glycemic variability was assessed by the standard deviation of HgbA1c and glucose levels over time. Hypoglycemia as a discharge diagnosis was documented in 4.1% of patients. Higher baseline HgbA1c was associated with greater risk for hypoglycemia hospitalization, a finding confirmed by time-lagged HgbA1c levels drawn a quarter earlier. Higher baseline HgbA1c categories were also associated with greater variability in HgbA1c levels during the analysis period. Similarly, greater glucose variability was associated with higher mean glucose levels by trend analysis. High, not low, HgbA1c levels are associated with greater risk of severe hypoglycemia, which may derive from glucose variability in the setting of treatment for hyperglycemia. High HgbA1c and glycemic variability are associated with increased risk of hypoglycemia in individuals with diabetes and ESRD.

BACKGROUND:The prevalence of central venous catheters (CVCs) for hemodialysis remains high and, despite infection-control protocols, predisposes to bloodstream infections (BSIs).STUDY DESIGN:Stratified, cluster-randomized, quality improvement initiative.SETTING & PARTICIPANTS:All in-center patients with a CVC within 211 facility pairs matched by region, facility size, and rate of positive blood cultures (January to March 2011) at Fresenius Medical Care, North America.QUALITY IMPROVEMENT PLAN:Incorporate the use of 2% chlorhexidine with 70% alcohol swab sticks for exit-site care and 70% alcohol pads to perform "scrub the hubs" in dialysis-related CVC care procedures compared to usual care.OUTCOME:The primary outcome was positive blood cultures for estimating BSI rates.MEASUREMENTS:Comparison of 3-month baseline period from April 1 to June 30 and follow-up period from August 1 to October 30, 2011.RESULTS:Baseline BSI rates were similar (0.85 vs 0.86/1,000 CVC-days), but follow-up rates differed at 0.81/1,000 CVC-days in intervention facilities versus 1.04/1,000 CVC-days in controls (P = 0.02). Intravenous antibiotic starts during the follow-up period also were lower, at 2.53/1,000 CVC-days versus 3.15/1,000 CVC-days in controls (P < 0.001). Cluster-adjusted Poisson regression confirmed 21%-22% reductions in both (P < 0.001). Extended follow-up for 3 successive quarters demonstrated a sustained reduction of bacteremia rates for patients in intervention facilities, at 0.50/1,000 CVC-days (41% reduction; P < 0.001). Hospitalizations due to sepsis during 1-year extended follow-up were 0.19/1,000 CVC-days (0.069/CVC-year) versus 0.26/1,000 CVC-days (0.095/CVC-year) in controls (∼27% difference; P < 0.05).LIMITATIONS:Inability to capture results from blood cultures sent to external laboratories, underestimation of sepsis-specific hospitalizations, and potential crossover adoption of the intervention protocol in control facilities.CONCLUSIONS:Adoption of the new catheter care procedure (consistent with Centers for Disease Control and Prevention recommendations) resulted in a 20% lower rate of BSIs and intravenous antibiotic starts, which were sustained over time and associated with a lower rate of hospitalizations due to sepsis.

In this study we improve the capacity of the polishing process of silicon reclaim wafer by applying the six sigma approach and the five steps of DMAIC. Based on the Taguchi experiment approach, a four-factor three-level experiment is designed by experimental design method using the existing polishing parameters, in particular such processing conditions as the cylinder head down force of the main process section, the PP rpm, LP rpm, and the flow of polishing slurry. The four factors are as follows: cylinder head down force, PP rpm, LP rpm, and the slurry flow. By studying the correlation between various parameters in the polishing process and the polishing result, the polishing factors’ effect on the material removal rate (MRR) and wafer’s total thickness variation (TTV) after the polishing process is analyzed, to obtain the optimized parameters for the improvement of the quality of polishing process and enhancement of process yield rate.

Myeloperoxidase (MPO) plays important roles in disease by increasing oxidative and nitrosative stress and oxidizing lipoproteins. Here we report N-acetyl lysyltyrosylcysteine amide (KYC) is an effective inhibitor of MPO activity. We show KYC inhibits MPO-mediated hypochlorous acid (HOCl) formation and nitration/oxidation of LDL. Disulfide is the major product of MPO-mediated KYC oxidation. KYC (⩽4,000 μM) does not induce cytotoxicity in bovine aortic endothelial cells (BAECs). KYC inhibits HOCl generation by phorbol myristate acetate (PMA)-stimulated neutrophils and human promyelocytic leukemia (HL-60) cells but not superoxide generation by PMA-stimulated HL-60 cells. KYC inhibits MPO-mediated HOCl formation in BAEC culture and protects BAECs from MPO-induced injury. KYC inhibits MPO-mediated lipid peroxidation of LDL whereas tyrosine (Tyr) and tryptophan (Trp) enhance oxidation. KYC is unique as its isomers do not inhibit MPO activity, or are much less effective. Ultraviolet-visible spectral studies indicate KYC binds to the active site of MPO and reacts with compounds I and II. Docking studies show the Tyr of KYC rests just above the heme of MPO. Interestingly, KYC increases MPO-dependent H2O2 consumption. These data indicate KYC is a novel and specific inhibitor of MPO activity that is nontoxic to endothelial cell cultures. Accordingly, KYC may be useful for treating MPO-mediated vascular disease.

Management of equipment parts readiness for process setup adjustment to meet variable order requirements in a semiconductor packaging plant is crucial to the health of production lines and downtime avoidance. In order to improve the current equipment parts readiness management system, which is exercised by periodical manual verification, this paper propose a RFID-enabled equipment parts readiness management system REPR-MS to take advantage of RFID technology in real-time monitor and track the equipment parts readiness flow. To validate the design, four tests of hypotheses were developed to compare the before and after introducing REPR-MS on four different parts flow impacted areas. The hypotheses were tested using survey data originated from a semiconductor packaging plant. This paper studies against the combined pilot run data based on the equipment parts readiness management operation proposed under REPR-MS. Moreover, this paper investigates the production time saving of individual station of the assembly line in the studied plant and the affected rate of average time of each operating step of equipment parts readiness management after introducing REPR-MS. The results show significant potential and promising efficiency for performance improvement and cost saving after adopting REPR-MS.

BACKGROUND AND OBJECTIVE:Calcific uremic arteriolopathy (CUA) is an often fatal condition with no effective treatment. Multiple case reports and case series have described intravenous sodium thiosulfate (STS) administration in CUA, but no studies have systematically evaluated this treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:This study included 172 patients undergoing maintenance hemodialysis who had CUA and were treated with STS between August 2006 and June 2009 at Fresenius Medical Care North America. Of these, 85% completed STS therapy. Clinical, laboratory, and mortality data were abstracted from clinical information systems. Responses to survey questionnaires sent to treating physicians regarding patient-level outcomes were available for 53 patients. Effect on CUA lesions and mortality were summarized as CUA outcomes. Relevant laboratory measures, weight (using pairwise comparisons of values before, during, and after STS), and adverse events were summarized as safety parameters. RESULTS:Mean age of the cohort was 55 years, and 74% of patients were women. Median STS dose was 25 g, and median number of doses was 38. Among surveyed patients, CUA completely resolved in 26.4%, markedly improved in 18.9%, improved in 28.3%, and did not improve in 5.7%; in the remaining patients (20.8%), the response was unknown. One-year mortality in patients treated with STS was 35%. Adverse events, laboratory abnormalities, and weight-related changes were mild. Significant reductions in serum phosphorous (P=0.02) and parathyroid hormone (P=0.01) were noted during STS treatment in patients who completed the therapy. CONCLUSIONS:Although conclusive evidence regarding its efficacy is lacking, a majority of patients who received STS demonstrated clinical improvement in this study.

We report the hospitalization risk among participants and non-participants in a Fresenius Medical Care North America program offering monitored intradialytic oral nutritional supplements (ONS) for chronic hemodialysis patients with low serum albumin. All ONS program-eligible patients with albumin <= 3.5 g/dL in Q4-2009 without ONS in the prior 90-days and did not receive any ONS external to the program were eligible. Participants initiated ONS within Q4-2009 while controls did not receive ONS at anytime during the follow-up period. In addition to the full study cohort, a 1: 1 geographic region and propensity score matched study population (utilizing case-mix, labs, access type, 30-day prior hospitalization, incident patient status) was followed for hospitalization until 12/31/2010. The sensitivity analysis restricted eligible control patients to 30+ day survivors after qualifying for participation, providing sufficient "lag" period for the opportunity to be offered ONS. Hospitalization was less in the ONS cohort at 2.5 vs. 2.7 episodes/patient-year and corresponding 19.2 vs. 20.4 hospital days/patient-year (both p<0.001) as well as a lower observed death rate of 29.4% vs. 36.6%. Hazard ratios for 1st hospitalization with ONS were 0.93 (0.90, 0.96) for the entire cohort, 0.97 (0.92, 1.02) in the matched cohort, and 0.90 (0.86, 0.95) in the matched "lag" cohort - all adjusted for case-mix, prior hospitalization within 30 days of study entry, SMR and laboratory results. Chronic hemodialysis patients with albumin <= 3.5 g/dL who received monitored intradialytic ONS exhibited significantly lower hospitalization risk than similar, matched patient controls. These results require confirmation in prospective clinical trials.

Use of intradialytic oral nutritional supplements (ONS) improve nutritional biomarkers but an association with survival has not been proven. We evaluated mortality, comparing patients with serum albumin ≤3.5 g/dL who received monitored ONS (at no patient cost) during chronic outpatient hemodialysis (HD) as part of a standardized national program in Fresenius Medical Care, North America facilities, with eligible patients who did not receive ONS (controls). Participation was promoted but not mandatory. Study enrolment covered Q4‐2009 and follow‐up was until 12/31/10. Patients who received ONS outside of the program or started during 2010 were excluded. Two protein bars and two liquid formulations of ONS options were offered, which were available until albumin was ≥ 4.0 g/dL. Crude mortality in the ONS group (N= 7,264) was 29.4% vs. 36.6% for controls (N= 13,853), p<0.001. Compared to controls, the unadjusted mortality hazard ratio for ONS was 0.70 (0.67, 0.74) and after adjustment for baseline case‐mix and 5 quality indicators was 0.68 (0.64, 0.71). Although limited by the observational design, these results indicate favorable survival associated with ONS use in malnourished chronic HD patients with albumin ≤3.5 g/dL.

Radio Frequency Identification (RFID) application are becoming increasingly popular such as access control, location tracking, industrial automation, and as a replacement for barcodes in consumer products. There are a lot of system components suppliers available, system integrators put the components or subsystems into a complete system, and then how to assess or predict the reliability of integrated RFID system is the major focus in this research. A passive RFID tag tracking system of management is adopted as the experimental platform for this study. The fault tree analysis attempts to model and analyze the failures processes of RFID system, this research highlights the subsystem or components such as electronic tags, readers, middleware, and database server. The component importance analysis also performed to identify weaknesses in RFID system, such as subsystem with higher failure rate which effects system reliability. The database built in this prototype framework will enable the enterprise to monitor and obtain the reliability of RFID system, which also offer valuable reference to the researchers for future work.

BACKGROUNDInsufficient clinical data exist to determine whether provision of oral nutritional supplements during dialysis can improve survival in hypoalbuminemic maintenance hemodialysis patients.STUDY DESIGNRetrospective matched-cohort study.SETTING & PARTICIPANTSAll oral nutritional supplement program-eligible in-center maintenance hemodialysis patients with albumin level ≤3.5 g/dL in quarter 4 of 2009 without oral nutritional supplements in the prior 90 days at Fresenius Medical Care, North America facilities.QUALITY IMPROVEMENT PLANMonitored intradialytic oral nutritional supplements were provided to eligible maintenance hemodialysis patients upon physician order, to continue for a year or until serum albumin level was ≥4.0 g/dL.OUTCOMEMortality (including deaths and withdrawals), followed up until December 31, 2010.MEASUREMENTSBoth an intention-to-treat (ITT) and an as-treated analysis was performed using a 1:1 geographic region and propensity score-matched study population (using case-mix, laboratory test, access type, 30-day prior hospitalization, and incident patient status) comparing patients treated with intradialytic oral nutritional supplements with usual-care patients. Cox models were constructed, unadjusted and adjusted for facility standardized mortality ratio and case-mix and laboratory variables.RESULTSThe ITT and as-treated analyses both showed lower mortality in the oral nutritional supplement group. The conservative ITT models with 5,227 matched pairs had 40% of controls subsequently receiving oral nutritional supplements after January 1, 2010 (because many physicians delayed participation), with comparative death rates of 30.1% versus 30.4%. The corresponding as-treated (excluding crossovers) death rates for 4,289 matched pairs were 30.9% versus 37.3%. The unadjusted ITT mortality HR for oral nutritional supplement use was 0.95 (95% CI, 0.88-1.01), and the adjusted HR was 0.91 (95% CI, 0.85-0.98); the corresponding as-treated HRs were 0.71 (95% CI, 0.66-0.76) and 0.66 (95% CI, 0.61-0.71) before and after adjustment, respectively.LIMITATIONSLimited capture of oral nutritional supplement intake outside the facility and potential residual confounding from unmeasured variables, such as dietary intake.CONCLUSIONSMaintenance hemodialysis patients with albumin levels ≤3.5 g/dL who received monitored intradialytic oral nutritional supplements showed survival significantly better than similar matched patient controls, with the as-treated analysis highlighting the potentially large effect of this strategy in clinical practice.

For preventing RFID from signal collision as well as enhancing the efficiency of RFID readers, a new algorithm, which combines meridian ideas to prevent RFID from signal collision, is proposed in this study. For human bodies, bad circulation is likely to result in illnesses that the most painful area is normally caused by Chinese Qi obstruction. Similar to a RFID reader reading several tags and simultaneously receiving numerous signals, the signal obstruction would result in failure or incomplete data reading and further reduce the reading efficiency. With meridian theory, this study proposes an algorithm to solve such a problem.

Use of intradialytic oral nutritional supplements (ONS) improve nutritional biomarkers but an association with hospitalization risk is unexplored. We evaluated hospitalization events from all causes (HOS), comparing patients with serum albumin ≤3.5 g/dL who received monitored ONS (at no patient cost) during chronic outpatient hemodialysis (HD) as part of a standardized national program in Fresenius Medical Care, North America facilities, with eligible patients who did not receive ONS (controls). Study enrolment covered Q4‐2009 and follow‐up was until 12/31/10. Patients who received ONS outside of the program or started during 2010 were excluded. Two protein bars and two liquid formulations of ONS options were offered – – which were available until albumin was ≥ 4.0 g/dL. Overall, HOS was lower in the ONS group (N= 7,264) at 2.5 vs. 2.7 episodes/pt‐year for controls (N= 13,853), p<0.001. The unadjusted time to 1st HOS hazard ratio for ONS was 0.92 (0.88, 0.95) and after adjustment for baseline case‐mix, HOS 30‐days prior to study entry, and 5 HD quality indicators was 0.93 (0.90, 0.96). Although limited by the observational design, these results indicate lower HOS associated with ONS use in malnourished chronic HD patients with albumin ≤3.5 g/dL.

BACKGROUND Hemodialysis (HD) access is considered a critical and actionable determinant of morbidity, with a growing literature suggesting that initial HD access type is an important marker of long-term outcomes. Accordingly, we examined HD access during the incident dialysis period, focusing on infection risk and successful fistula creation during the first dialysis year. STUDY DESIGN Longitudinal cohort. SETTING & PARTICIPANTS All US adults admitted to Fresenius Medical Care North America facilities within 15 days of first maintenance dialysis session between January 1 and December 31, 2007. PREDICTOR Vascular access type at HD therapy initiation. OUTCOMES Vascular access type at 90 days and at the end of the first year on HD therapy, bloodstream infection within the first year by access type, and catheter complication rate. RESULTS Of 25,003 incident dialysis patients studied, 19,622 (78.5%) initiated dialysis with a catheter; 4,151 (16.6%), with a fistula; and 1,230 (4.9%), with a graft. At 90 days, 14,105 (69.7%) had a catheter, 4,432 (21.9%) had a fistula, and 1,705 (8.4%) had a graft. Functioning fistulas and grafts at dialysis therapy initiation had first-year failure rates of 10% and 15%, respectively. Grafts were seldom replaced by fistulas (3%), whereas 7,064 (47.6%) of all patients who initiated with a catheter alone still had only a catheter at 1 year. Overall, 3,327 (13.3%) patients had at least one positive blood culture during follow-up, with the risk being similar between the fistula and graft groups, but approximately 3-fold higher in patients with a catheter (P<0.001 for either comparison). Nearly 1 in 3 catheters (32.5%) will require tissue plasminogen activator use by a median of 41 days, with 59% requiring more than one tissue plasminogen activator administration. LIMITATIONS Potential underestimation of bacteremia because follow-up blood culture results did not include samples sent to local laboratories. CONCLUSIONS In a large and representative population of incident US dialysis patients, catheter use remains very high during the first year of HD care and is associated with high mechanical complication and bloodstream infection rates.

This paper represents a novel memristor based chaotic circuit, which is obtained by replacing the Chua's diode with a flux-controlled active memristor in a hyperchaotic circuit. Some characteristics of this proposed system are analyzed in detail. Analysis results show that the memristor circuit has an equilibrium set and the special phenomenon of transient chaos and state transfer, and exhibits a complex topological structure of the attractor. Moreover, a method for overcoming the transient chaos and generating continuous chaos is proposed for the engineering applications of memristor based chaotic circuits.

BACKGROUND:Patients' education about transplant, hemodialysis (HD), peritoneal dialysis (PD), and conservative care often is provided by nephrologists as needed and occurs as time allows.STUDY DESIGN:Quality improvement report.SETTING & PARTICIPANTS:Attendees of a national treatment options program (TOPs) who initiated long-term dialysis therapy (median, 3.4 months) at Fresenius Medical Care, North America facilities throughout 2008 were compared with period-prevalent incident patients receiving usual care.QUALITY IMPROVEMENT PLAN:Standardized predialysis treatment options education.OUTCOMES:Rates of opting for PD modality, arteriovenous HD access at initiation, and early (90-day) mortality risk.MEASUREMENTS:Logistic regression (for choice of PD and HD access type) and Cox models (for early mortality) were constructed, including a 1:1 matched cohort. A post hoc sensitivity analysis also compared a propensity score-matched cohort.RESULTS:3,165 TOPs attendees (10.5% of 30,217 incident patients admitted between January 1 and December 31, 2008), were younger, more likely to be white, and had slightly larger body surface area. The unadjusted OR for TOPs attendees for selecting PD therapy was 8.45 (95% CI, 7.63-9.37) with a case-mix plus laboratory-adjusted OR of 5.13 (95% CI, 3.58-7.35). For patients who opted for in-center HD therapy, the OR was 2.14 (95% CI, 1.96-2.33) and adjusted OR was 2.06 (95% CI, 1.88-2.26) for starting with a fistula or graft. The unadjusted early mortality HR was 0.51 (95% CI, 0.43-0.60) and case-mix plus laboratory-adjusted adjusted HR was 0.61 (95% CI, 0.50-0.74) for TOPs attendees (all outcomes, P < 0.001). These results were consistent in the 1:1 matched analysis and propensity score-matched analysis.LIMITATIONS:It is possible that physicians who referred to these programs were more likely to prescribe PD therapy or place arteriovenous accesses. Motivated, treatment-adherent patients (who would have better outcomes) may have self-selected to attend education sessions.CONCLUSION:Attending an options class predialysis was associated with more frequent selection of home dialysis, fewer tunneled HD catheters, and lower mortality risk during the first 90 days of dialysis therapy.

Radio Frequency Identification (RFID) has been widely applied and the implementations of RFID Real-time Location Systems (RTLS) have been increasing. This study proposes an RFID RTLS based on Received Signal Strength (RSS) without increasing the equipment cost and changing location algorithms. The proposed system uses optimal combination of RFID calibration parameters and Taguchi parameter design to provide low cost and effective solutions with improved location accuracy.