Clinical praxis for assessment of dry weight in Sweden and Denmark: A mixed‐methods study

Overhydration is an independent predictor of mortality in hemodialysis (HD) patients. More than 30% of HD patients are overhydrated, motivating the development of new methods for assessing hydration status. This study surveyed clinical praxis and local guidelines for dry weight (DW) assessment in Swedish and Danish HD units, and examined if differences in routines and utilization of bioimpedance spectroscopy (BIS) and other assistive technology affected frequency of DW adjustments and blood pressure (BP) levels. Cross‐sectional information on praxis, guidelines and routines, plus treatment‐related data from 99 stratified patients were collected. Qualitative data were analyzed with content analysis and interpreted in convergence with statistical analysis of quantitative data in a mixed‐methods design. Local guidelines concerning DW existed in 54% of the units. A BIS device was present in 52%, but only half of those units used it regularly, and no correlations to frequency of DW adjustments or BP were found. HD nurses were authorized to adjust DW in 60% of the units; in these units, the frequency of DW adjustments was 1.6 times higher and systolic BP pre‐HD 8 mmHg lower. There is a wide variation in routines for DW determination, and there are indications that authorization of HD nurses to adjust DW may improve DW assessment. BIS is sparsely used; its implementation may have been delayed by uncertainty over how to manage the device and interpret measurements. Hence, better methods and guidelines for assessing DW and using BIS need to be developed.     

A fresh look at dry weight

The concept of dry weight (DW) is central to dialysis therapy. The most commonly used definition of DW is the weight below which patients become hypotensive on dialysis. However, this definition is dependent on patient symptoms. A more rigorous definition of DW is the body weight at a physiological extracellular volume (ECV) state. Overhydration is an excess in ECV above that found in healthy subjects. In healthy subjects, within extremes of salt intake, ECV may vary between 280 and 340 mL/kg lean body mass. Sodium accumulation is one of the many consequences of renal failure; it results in increased water intake and an increase in ECV, and an accompanying rise in blood pressure with its clinical sequelae, most prominently cardiovascular and cerebrovascular diseases. Recently characterized endogenous digitalis‐like factors which are released in response to ECV expansion have extended this traditional picture. Efforts to reduce a positive sodium balance include dietary counseling and avoidance of iatrogenic intradialytic sodium loading, such as dialysate sodium exceeding serum levels, sodium profiling, and intravenous saline. Excess ECV is predominantly located in the interstitial compartment and must be removed during dialysis therapy by ultrafiltration. During this process, interstitial fluid redistributes to the intravascular space via uptake in the capillary bed. In addition to that mechanism, we propose that increased lymphatic flow into the venous system contributes to plasma refilling. Both clinical and technical means are used to assess the presence of DW. Continuous segmental calf bioimpedance is a promising new technology for intradialytic DW diagnosis.     

The Neglect of Sodium Restriction in Dialysis Patients: A Short Review

In end-stage renal failure, natriuresis decreases, sodium accumulates, and extracellular volume (ECV) excess develops. In 1962, Scribner, reporting about the first maintenance hemodialysis (HD) patient, observed that ECV control using a low-salt diet and ultrafiltration led to blood pressure (BP) normalization. Thus, the concept of dry weight, the ideal postdialysis weight allowing for a stable normal BP, was born. Achieving dry weight requires a combination of negative diffusive sodium balance, adequate ultrafiltration, and a low-salt diet. Unfortunately, the low-salt diet is very often neglected today. In the late 1960s, BP control was achieved in 90% of HD patients using low-sodium dialysis and a low-salt diet. As time passed and HD duration was reduced, there was a worsening BP control and subsequent increasing in morbidity and mortality.
In recent years, interventional studies have examined the effects of reducing sodium in dialysate, in diet, or in both. All of them show that low-salt diet is essential for BP control in HD. While the healthy population is advised to eat a reasonably low-salt diet (5 g of NaCl), the K/DOQI Guidelines and the European Best Practice Guidelines surprisingly do not even mention salt restriction.
To achieve dry weight under the present conditions, with short HD duration and a frail population, it is mandatory to reduce the interdialytic weight gain. A low-salt diet is, more than ever, a necessity.     

Volume Control in Hemodialysis Patients

Cardiovascular disease is the main cause of the high mortality of dialysis patients and is largely due to poor control of blood pressure. Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The dry weight concept links ECV and blood pressure by a simple clinical relationship. Dry weight is the ideal postdialysis weight that allows a constantly normal blood pressure to be maintained without using antihypertensive medications. Maintenance of normal ECV requires control of salt intake to reduce interdialytic weight gain ( i.e., saline overload) combined with the diffusive and convective removal of salt and water from the body during dialysis sessions. Several problems are to be faced when using the dry weight method. Clinical evaluation must take into account the following confounding factors: weight varies with nutrition, clinical symptoms are unspecific and sometimes discordant, and there is a lag time between ECV and blood pressure changes. On the other hand, achievement of dry weight is hampered by dialysis times that are too short (and weight gains that are too high), by antihypertensive medications, and by poor heart conditions. A longer session time allows for a slower, easier, and more comfortable ultrafiltration.     

Fluid balance, dry weight, and blood pressure in dialysis

The total amount of sodium present in the body controls the extracellular volume. In advanced renal failure, sodium balance becomes positive and the extracellular volume expands. This leads to hypertension, and vascular changes that lead to adverse cardiovascular consequences in dialysis patients. Controlling the body sodium content and the extracellular volume allows one to better control hypertension and its consequences. This can be achieved by reducing the sodium input (sodium dietary restriction and reasonably low sodium dialysate) and/or by increasing the sodium output (ultrafiltration by convection). The discontinuous nature of hemodialysis causes saw-tooth volume fluctuations. This has led to the concept of dry weight (DW), a crucial component of dialysis adequacy. Assessment and achievement of DW is feasible on pure clinical grounds. But its relative lack of accuracy (and the physicians' progressive lack of interest in bedside examination) has led to several nonclinical methods of assessing DW in an effort to improve the assessment of fluid status in dialysis patients.     

Sodium,hypertension, and an explanation of the “lag phenomenon” in hemodialysis patients

Sodium balance is precisely regulated by intake and output. The kidneys are responsible for adjusting sodium excretion to maintain balance at varying intakes. Our distant ancestors were herbivores. Their diet contained little sodium, so they developed powerful mechanisms for conserving sodium and achieving low urinary excretion. About 10,000 years ago, early humans became villagers and discovered that food could be preserved in brine. This led to increased consumption of salt. High salt intake increases extracellular volume (ECV), blood volume, and cardiac output resulting in elevation of blood pressure. High ECV induces release of a digitalis‐like immunoreactive substance and other inhibitors of Na⁺‐K⁺‐ATPase. As a consequence, intracellular sodium and calcium concentrations increase in vascular smooth muscles predisposing them to contraction. Moreover, high ECV increases synthesis and decreases clearance of asymmetrical dimethyl‐l ‐arginine leading to inhibition of nitric oxide (NO) synthase. High concentration of sodium and calcium in vascular smooth muscles, and decreased synthesis of NO lead to an increase in total peripheral resistance. Restoration of normal ECV and blood pressure are attained by increased glomerular filtration and decreased sodium reabsorption. In some individuals, the kidneys have difficulty in excreting sodium, so the equilibrium is achieved at the expense of elevated blood pressure. There is some lag time between reduction of ECV and normalization of blood pressure because the normal levels of Na⁺‐K⁺‐ATPase inhibitors and asymmetrical dimethyl‐l ‐arginine are restored slowly. In dialysis patients, all mechanisms intended to increase renal sodium removal are futile but they still operate and elevate blood pressure. The sodium balance must be achieved via dialysis and ultrafiltration. Blood pressure is normalized a few weeks after ECV is returned to normal, i.e., when the patient reaches dry body weight. This is called the “lag phenomenon.”     

A study on sampling methods for chloride profiles: simulations using data from EPMA

Investigating marine concrete by determining the chloride profile is a common way for making a prediction of the remaining service life of a structure. The most common methods of sampling concrete for this purpose is dust sampling by dry drilling or sampling cores which are analyzed by profile grinding in a laboratory. Now, a similar study has been performed, by simulating different sampling techniques in data from EPMA. The results from the simulations of the concrete specimen analyzed with the EPMA, confirm the results from earlier performed dry drilling tests in laboratory and shows the same extensive variations when chloride content is presented as % by weight of concrete instead of as % by weight of calcium oxide. Comparing the results from the earlier performed sampling by dry drilling with the results from the EPMA simulations, it is seen that the dry drilling probably is afflicted with a systematic error by “movement” of dust into the sampling holes when drilling. This study also shows effects of large aggregates in small bores even though the cement content is referred to. However, no signs of “shadowing” by the aggregates was detected when the simulations where performed. Even “horizontal” drilling was simulated in order to be able to detect this possible effect of the aggregates on the chloride ingress into the concrete.     

“Smart” Surface Capsules for Delivery Devices

This review describes emerging trends, basic principles, applications, and future challenges for designing next generation responsive “smart” surface capsules. Advances and importance of “surface” capsules which are not deposited onto the surface but are built into the surface are highlighted for selective applications with specific examples of surface sponge structures formed by high intensity ultrasonic surface treatment (HIUS). Surface capsules can be adapted for biomedical applications, membrane materials, lab‐on‐chip, organ‐on‐chip, and for template synthesis. They provide attractive self‐healing anticorrosion and antifouling prospects. Nowadays delivery systems are built from inorganic, organic, hybrid, biological materials to deliver various drugs from low molecular weight substances to large protein molecules and even live cells. It is important that capsules are designed to have time prolonged release features. Available stimuli to control capsule opening are physical, chemical and biological ones. Understanding the underlying mechanisms of capsule opening by different stimuli is essential for developing new methods of encapsulation, release, and targeting. Development of “smart” surface capsules is preferable to respond to multiple stimuli. More and more often a new generation of “smart” capsules is designed by a bio‐inspired approach.     

STRUCTURAL COLLAPSE, THE FAILURE ASSESSMENT DIAGRAM AND "OFF-THE-SHELF" OPERATION

Abstract— The criteria for determining whether ferritic material exhibits fully ductile behaviour are generally based on the fracture toughness vs temperature relationship determined from standard laboratory test pieces (e.g. Charpy V Impact tests or fracture toughness specimens). This relationship defines a ductile-brittle transition region. When fully ductile, microvoid coalescence behaviour is experienced, and fracture toughness is described as being on the “upper shelf”. At “off the shelf” temperatures brittle, cleavage fracture is experienced. On the lower shelf the material is entirely brittle, exhibiting 100% crystallinity on the fracture face. As the temperature increases, initiation of tearing by microvoid coalescence occurs and some stable tearing can occur prior to the cleavage event. Material toughness increases with temperature until the upper shelf condition is achieved. The characteristics of fracture toughness tests in terms of the toughness level exhibited and the extent of ductile tearing experienced have been used as a guide to whether the structural application (e.g. a pressure vessel) will behave in a brittle or a ductile manner. This paper reports on a feasibility study where various worked examples have been performed to examine the concept of using a “cut off” on the failure assessment diagram, determined from the conditions required to cause plastic collapse of a pressure vessel, as a criterion for defining effective “ductile” operation. Fracture assessment procedures (R6 revisions 2 and 3 and PD6493 levels 2 and 3) have been utilised to determine the influence on pressure vessel performance of the behaviour of fracture toughness test specimens. The procedure of plotting a structural collapse “cut off” on a failure assessment diagram enables the assessment of whether a particular flaw geometry would result in gross deformation of the structure at failure. The use of this procedure provides an unambiguous demarcation between “fracture dominated” and “collapse controlled” conditions. This procedure facilitates judgements on the level of toughness necessary to ensure ductile operation and whether a “tearing plus toughness” requirement is necessary. It is recommended that consideration be given to including structural collapse into fracture assessment procedures carried out using R6 revision 3 or PD 6493:1991 procedures in order to determine the conditions when enhanced toughness no longer influences structural performance (i.e. when effective “upper shelf” conditions are attained).     

Sensitive Detection of Carcinoembryonic Antigen Using Stability‐Limited Few‐Layer Black Phosphorus as an Electron Donor and a Reservoir

The instability of few‐layer black phosphorus (FL‐BP) hampers its further applications. Here, it can be demonstrated that the instability of FL‐BP can also be the advantage for application in biosensor. First, gold nanoparticle/FL‐BP (BP‐Au) hybrid is facilely synthesized by mixing Au precursor with FL‐BP. BP‐Au shows outstanding catalytic activity (K = 1120 s^?1 g^?1) and low activation energy (17.53 kJ mol^?1) for reducing 4‐nitrophenol, which is attributed to the electron‐reservoir and electron‐donor properties of FL‐BP, and synergistic interaction of Au nanoparticles and FL‐BP. Oxidation of FL‐BP after catalytic reaction is further confirmed by transmission electron microscope, X‐ray photoelectron spectroscopy, and zeta potentials. Second, the catalytic activity of BP‐Au can be reversibly switched from “inactive” to “active” upon treatment with antibody and antigen in solution, thus providing a versatile platform for label‐free colorimetric detection of biomarkers. The sensor shows a wide detection range (1 pg mL^?1 to –10 µg mL^?1), high sensitivity (0.20 pg mL^?1), and selectivity for detecting carcinoembryonic antigen (CEA). Finally, the biosensor has been used to detect CEA in colon and breast cancer clinical samples with satisfactory results. Therefore, the instability of BP can also be the advantage for application in detecting cancer biomarker in clinic.     

Extracellular Volume Changes and Blood Pressure Levels in Hemodialysis Patients

Background: Despite the use of highly efficient antihypertensive drugs (AHD), blood pressure (BP) is poorly controlled in the vast majority of hemodialysis (HD) patients. Many of them show no reduction in nocturnal BP, a finding that is associated with left ventricular hypertrophy. The aim of the study was to investigate the effect of the removal of a fluid overload on BP by monitoring the ambulatory BP during 48 hours in 16 hypertensive HD patients treated with AHD. Our aim was to obtain a gradual reduction in post‐HD body weight (BW) over a period of 3 to 4 months. Methods: During a period of 3–4 months, the postdialysis BW was reduced as the minimal tolerable BW was gradually achieved by slightly increasing the ultrafiltration volume. The Na concentration in the dialysate was reduced from 143–141 mmol/L to 139–138 mmol/L. Extracellular volume (ECV) was measured with a multiple‐frequency bioimpedance analyzer (Xitron 4000B, Xitron Technologies Inc., San Diego, CA, USA). Based on the change in ECV, the patients were subdivided into two groups: group 1 with a reduction in ECV (n = 10), and group 2 with no reduction (n = 6). At the start of the study, BW, BP, and AHD in group 1 and group 2 were virtually identical. Results: Group 1 showed a significant reduction during the entire 48‐hour period in systolic (156 ± 16 mmHg vs. 140 ± 14 mmHg, P = 0.030) and diastolic BP (97 ± 12 mmHg vs. 87 ± 9 mmHg, P = 0.026) as well as in mean arterial pressure (MAP, 117 ± 13 vs. 105 ± 10 mmHg, P = 0.027). This reduction was more marked during the night (systolic BP 156 ± 15 mmHg vs. 138 ± 14 mmHg, P = 0.007; diastolic BP 97 ± 12 mmHg vs. 85 ± 9 mmHg, P = 0.009) than during the day (157 ± 18 mmHg vs. 142 ± 15 mmHg, P = 0.067; diastolic BP 97 ± 13 mmHg vs. 90 ± 9 mmHg, P = 0.126). A significant reduction in systolic load also occurred during the entire 48‐hour period (76 ± 24% vs. 46 ± 28%, P = 0.043) as well as in night systolic load (75 ± 21% vs. 41 ± 30%, P = 0.015) and night diastolic load (67 ± 32% vs. 39 ± 31%, P = 0.030). AHD were stopped in eight and reduced in two patients. There were no significant reductions in BP and AHD in group 2. Conclusions: The removal of excess fluid is necessary for adequate BP control and especially for the reduction in elevated BP during the night.     

Structural reliability assessment of cracked pipes: The role of probability of detection data

The structural reliability of industrial pipes, including those in the nuclear, oil, and gas industries, has a significant impact on the safety of people and the environment. This work aims to develop a computational structural reliability model method in conjunction with the failure assessment diagram method and the user‐defined probability of detection curves of non‐destructive testing are used. The concept of “reliability factor of a repair” is proposed. Then, the effects of the pipe inspection considering different user‐defined probability of detection curves and different values of the reliability factor of a repair on probability of failure are discussed. The main results include the identification of cases where performing repairs do not guarantee an improved reliability, as well as the consequences of considering the repair as a “perfect process” which result in non‐conservative assessments.     

Stimulus Responsive 3D Assembly for Spatially Resolved Bifunctional Sensors

3D electronic/optoelectronic devices have shown great potentials for various applications due to their unique properties inherited not only from functional materials, but also from 3D architectures. Although a variety of fabrication methods including mechanically guided assembly have been reported, the resulting 3D devices show no stimuli‐responsive functions or are not free standing, thereby limiting their applications. Herein, the stimulus responsive assembly of complex 3D structures driven by temperature‐responsive hydrogels is demonstrated for applications in 3D multifunctional sensors. The assembly driving force, compressive buckling, arises from the volume shrinkage of the responsive hydrogel substrates when they are heated above the lower critical solution temperature. Driven by the compressive buckling force, the 2D‐formed membrane materials, which are pre‐defined and selectively bonded to the substrates, are then assembled to 3D structures. They include “tent,” “tower,” “two‐floor pavilion,” “dome,” “basket,” and “nested‐cages” with delicate geometries. Moreover, the demonstrated 3D bifunctional sensors based on laser induced graphene show capability of spatially resolved tactile sensing and temperature sensing. These multifunctional 3D sensors would open new applications in soft robotics, bioelectronics, micro‐electromechanical systems, and others.     

An Exact Asymptotically Efficient Confidence Bound for Reliability in the Case of the Weibull Distribution

This paper presents a simple method for obtaining exact lower confidence bounds for reliabilities (tail probabilities) for items whose life times follow a Weibull distribution where both the “shape” and “scale” parameters are unknown. These confidence bounds are obtained both for the censored and non-censored cases and are asymptotically efficient. They are exact even for small sample sizes in that they attain the desired confidence level precisely. The case of an additional unknown “location” or “shift” parameter is also discussed in the large sample case. Tables are given of exact and asymptotic lower confidence bounds for the reliability for sample sizes of 10, 15, 20, 30, 50 and 100 for various censoring fractions.     

Length of Dialysis Session Is More Important Than Large Kt/V in Hemodialysis

Long, slow hemodialysis (3 × 8 hours/week) has been used without significant modification in Tassin, France, for 30 years with excellent morbidity and mortality rates. A long dialysis session easily provides high Kt/V_urea and allows for good control of nutrition and correction of anemia with a limited need for erythropoietin (EPO). Control of serum phosphate and potassium is usually achieved with low-dose medication. The good survival achieved by long hemodialysis sessions is essentially due to lower cardiovascular morbidity and mortality than in short dialysis sessions. This, in turn, is mainly explained by good blood pressure (BP) control without the need for antihypertensive medication. Normotension in this setting is due to the gentle but powerful ultrafiltration provided by the long sessions, associated with a low salt diet and moderate interdialytic weight gains. These allow for adequate control of extracellular volume (dry weight) in most patients without important intradialytic morbidity. Therefore, increasing the length of the dialysis session seems to be the best way of achieving satisfactory long-term clinical results.     

Inexact Schwarz‐algebraic multigrid preconditioners for crack problems modeled by extended finite element methods

Traditional algebraic multigrid (AMG) preconditioners are not well suited for crack problems modeled by extended finite element methods (XFEM). This is mainly because of the unique XFEM formulations, which embed discontinuous fields in the linear system by addition of special degrees of freedom. These degrees of freedom are not properly handled by the AMG coarsening process and lead to slow convergence. In this paper, we proposed a simple domain decomposition approach that retains the AMG advantages on well‐behaved domains by avoiding the coarsening of enriched degrees of freedom. The idea was to employ a multiplicative Schwarz preconditioner where the physical domain was partitioned into “healthy” (or unfractured) and “cracked” subdomains. First, the “healthy” subdomain containing only standard degrees of freedom, was solved approximately by one AMG V‐cycle, followed by concurrent direct solves of “cracked” subdomains. This strategy alleviated the need to redesign special AMG coarsening strategies that can handle XFEM discretizations. Numerical examples on various crack problems clearly illustrated the superior performance of this approach over a brute force AMG preconditioner applied to the linear system. Copyright © 2011 John Wiley & Sons, Ltd.     

基于紫外/可见光谱技术的李子硬度无损检测

目的探究采用紫外/可见光谱技术结合化学计量学预测李子硬度的可行性。方法以“红”李子和“青”李子为研究对象,采用光谱采集系统获取李子样本的平均光谱;采用标准正态变换对原始光谱数据进行预处理,并利用连续投影算法(SPA)和竞争性自适应重加权算法(CARS)从全光谱的1024个波长中分别提取2个(513.04 nm和636.72 nm)和10个(230.01,244.67,274.71,287.66,290.90,300.59,311.78,423.08,515.39,631.31 nm)特征波长;分别建立基于全光谱和提取的特征波长预测李子硬度的误差反向传播(BP)网络模型。结果将采用SPA和CARS特征波长选择方法提取的特征变量作为BP网络输入,明显提升了BP网络模型的运行效率,且SPA-BP网络模型具有相对较好的李子硬度预测能力(rp=0.695,预测样本集均方根误差为1.610 kg/cm2)。结论采用紫外/可见光谱技术结合特征波长提取方法可实现李子硬度的快速无损检测。     

不同配比Ni-Cr系涂层非线性动力学系统的抗腐蚀性能研究

采用非线性动力学系统的BP数据网络进行管材涂层腐蚀性能预测。首先采用增重法获取9种腐蚀工况下的增重数据,将获取的数据用于构建BP神经网络模型,通过传输和反演操作设置拓扑结构为6×15×1的BP神经网络,然后基于90组实验数据用于验证和评价BP神经网络预测模型,最后通过对优选出的涂层进行Ni-Cr系涂层的机理分析,从而解决生物质电站锅炉"四管"的腐蚀问题,研发的抗腐蚀涂层具有较好的经济性和实用性。     

Organic Nanowire Fabrication and Device Applications

Organic nanowires (ONWs) are flexible, stretchable, and have good electrical properties, and therefore have great potential for use in next‐generation textile and wearable electronics. Analysis of trends in ONWs supports their great potential for various stretchable and flexible electronic applications such as flexible displays and flexible photovoltaics. Numerous methods can be used to prepare ONWs, but the practical industrial application of ONWs has not been achieved because of the lack of reliable techniques for controlling and patterning of individual nanowires. Therefore, an “individually controllable” technique to fabricate ONWs is essential for practical device applications. In this paper, three types of fabrication methods of ONWs are reviewed: non‐alignment methods, massive‐alignment methods, and individual‐alignment methods. Recent research on electronic and photonic device applications of ONWs is then reviewed. Finally, suggestions for future research are put forward.     

Welding mechanics for advanced component safety assessment

Numerical methods are nowadays a useful tool for the calculation of distortion and residual stresses as a result from the welding process. Modern finite element codes not only allow for calculation of deformations and stresses due to the welding process but also take into account the change of microstructure due to different heating and cooling rates. As an extension to the pure welding simulation, the field of welding mechanics combines the mechanics and the material behaviour from the welding process with the assessment of service behaviour of welded components. In the paper, new results of experimental and numerical work in the field of welding mechanics are described. Through examples from automotive, nuclear and pipe-line applications it is demonstrated that an equilibrated treatment and a close interaction of “process”, “properties” and “defects” are necessary to come up with an advanced fitness-for-service assessment of welded components.