Under-mask beard covers achieve an adequate seal with tight-fitting disposable respirators using quantitative fit testing.

BACKGROUND: Tight-fitting respirators are a critical component of respiratory protection against airborne diseases for health workers. However, they are not recommended for health workers with facial hair. Some health workers are unable to shave for religious or medical reasons. Under-mask beard covers have been proposed as a solution to allow health workers with facial hair to wear tight-fitting respirators. However, studies to date have been limited by their predominant reliance on qualitative rather than quantitative fit testing techniques. AIM: To assess the efficacy of under-mask beard covers in achieving an adequate seal with tight-fitting disposable P2/N95 respirators using quantitative fit testing. METHODS: Bearded adult males underwent quantitative fit testing with an under-mask beard cover using either a TSI PortaCount Respirator Fit Tester 8038 or an AccuFit 9000 PRO fit testing device on up to five disposable P2/N95 respirators (3M 1860, 3M 1870+, BYD N95 Healthcare Particulate Respirator, BSN Medical ProShield N-95 Medium and Trident RTCFFP2). The primary outcome was the proportion of subjects that passed or failed quantitative fit testing with an under-mask beard cover. FINDINGS: Thirty subjects were assessed; of these, 24 (80%) passed quantitative fit testing with at least one tight-fitting P2/N95 disposable respirator. Among these subjects, the median best-achieved fit factor was 200 (interquartile range 178-200). None of the subjects had an adverse reaction to the under-mask beard cover. CONCLUSION: The under-mask beard cover technique may be used to achieve a satisfactory seal with tight-fitting P2/N95 respirators in health workers with facial hair who cannot shave.

Hypoxia Inducible Factor 1: A Urinary Biomarker of Kidney Disease.

Identifying noninvasive biomarkers of kidney disease is valuable for diagnostic and therapeutic purposes. Hypoxia inducible factor 1 (HIF-1) expression is known to be elevated in the kidneys in several renal disease pathologies. We hypothesized that the urinary HIF-1a mRNA level may be a suitable biomarker for expression of this protein in chronic kidney disease (CKD). We compared HIF-1a mRNA levels from urine pellets of CKD and healthy subjects. To ensure that urinary HIF-1a mRNA is of kidney origin, we examined colocalization of HIF-1a mRNA with two kidney specific markers in urine cells. We found that HIF-1a mRNA is readily quantifiable in urine pellets and its expression was significantly higher in CKD patients compared with healthy adults. We also showed that the urinary HIF-1a mRNA comes primarily from cells of renal origin. Our data suggest that urinary HIF-1a mRNA is a potential biomarker in CKD and can be noninvasively assessed in patients.

Dissecting multi-photon resonances at the large hadron collider.

We examine the phenomenology of the production, at the 13 TeV Large Hadron Collider (LHC), of a heavy resonance X, which decays via other new on-shell particles n into multi-(i.e. three or more) photon final states. In the limit that n has a much smaller mass than X, the multi-photon final state may dominantly appear as a two-photon final state because the γ s from the n decay are highly collinear and remain unresolved. We discuss how to discriminate this scenario from X → γ γ : rather than discarding non-isolated photons, it is better to relax the isolation criteria and instead form photon jets substructure variables. The spins of X and n leave their imprint upon the distribution of pseudo-rapidity gap Δ Î· between the apparent two-photon states. Depending on the total integrated luminosity, this can be used in many cases to claim discrimination between the possible spin choices of X and n, although the case where X and n are both scalar particles cannot be discriminated from the direct X → γ γ decay in this manner. Information on the mass of n can be gained by considering the mass of each photon jet.

An unusual cause of meningitis.

A 57 year old man patient presented with fever and frontal headache. He had a background history of sero-positive rheumatoid arthritis which was well controlled on immunomodulatory disease modifying anti-rheumatoid drugs (DMARDS) including methotrexate and lef lunomide. Six months earlier he had returned from Massachussetts in the USA after a one year period of residence there. On examination his vital signs were within normal limits and he was afebrile with a temperature of 36.1oC. His left elbow joint was warm, tender and swollen; examination was otherwise normal.

Immediate coronary artery bypass surgery after platelet inhibition with eptifibatide: results from PURSUIT. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrelin Therapy.

BACKGROUND: The platelet GP IIb/IIIa inhibitor eptifibatide improves outcomes in patients with acute coronary syndromes. Patients requiring emergent coronary artery bypass grafting, however, may be at increased risk for bleeding if exposed to eptifibatide. Data from the PURSUIT trial were reviewed to assess this risk in patients undergoing coronary surgery immediately after exposure to eptifibatide. METHODS: In PURSUIT, 10,948 patients who presented with non-ST segment elevation acute coronary syndromes were prospectively randomized to receive eptifibatide (180 microg/kg bolus plus 2 microg/kg/min infusion) or placebo. A total of 78 patients underwent immediate coronary artery bypass surgery within 2 hours of cessation of study drug (placebo, n = 46; eptifibatide, n = 32). Clinical outcome, bleeding, and transfusion requirements within this subset were examined. RESULTS: Major bleeding was not different between groups, occurring in 64% of patients receiving placebo and 63% of patients receiving eptifibatide. The incidence of blood transfusion was similar as well (57% vs 59%). Postoperative thrombocytopenia occurred less often after eptifibatide exposure. Perioperative myocardial infarction was significantly reduced in patients who received eptifibatide (46% vs 22%, p < 0.05). There was no difference in perioperative stroke (2.2% vs 6.3%) or mortality (6.3% vs 6.5%). CONCLUSIONS: Patients may safely undergo coronary artery bypass surgery within 2 hours of discontinuation of eptifibatide. Eptifibatide infusion in the immediate preoperative period had no adverse clinical effects, but did significantly decrease the incidence of perioperative myocardial infarction. Additionally, platelet counts after surgery were higher in the group of patients who received eptifibatide, perhaps indicative of a platelet-sparing effect during cardiopulmonary bypass.

Sternal instability after midline sternotomy.

The purpose of this paper is to discuss sternal instability a problem occasionally associated with midline sternotomy, including the etiology, predisposing conditions, diagnosis and management. Among the methods of repair, sternal weaving and pectoralis muscle advancement are thought to be especially effective.

Preconception counseling and women's compliance with folic acid supplementation.

QUESTION: I am counseling patients to take folic acid when they plan pregnancy and during early pregnancy. Is there any proof that counseling really causes women to comply? ANSWER: A recent Motherisk study showed that counseling women who were planning pregnancy about folic acid use is very effective: 71% of those counseled took folic acid, compared with only 17% of those who were not counseled.

Inhibitors of the platelet receptor glycoprotein IIb-IIIa and complications during percutaneous coronary revascularization. Management strategies for the cardiac surgeon.

Platelet-mediated thrombosis has a pivotal role in the pathophysiology of acute ischemic coronary syndromes (AICS) and the acute complications of percutaneous coronary interventions. Because cross-linking of the activated platelet receptor glycoprotein (GP) IIb-IIIa by plasma fibrinogen represents the final common pathway to coronary thrombus formation, several GP IIb-IIIa inhibitors have been developed as a potentially more effective antithrombotic therapy than agents currently used for this purpose, namely aspirin and heparin. However, use of GP IIb-IIIa inhibitors in patients with AICS and those scheduled for percutaneous coronary interventions may increase the risk of serious clinical and bleeding events among patients who require emergency or urgent bypass surgery. This review describes clinical experience with various GP IIb-IIIa inhibitors and suggests management strategies for patients undergoing emergency or urgent bypass surgery shortly after treatment with GP IIb-IIIa inhibitors.

Steroid-DNA conjugates: improved triplex formation with 5-amido-(7-deoxycholic acid)-dU incorporated oligonucleotides.

The synthesis of oligodeoxyribonucleotides incorporating 7-deoxycholic acid conjugated at C5 of dU is described. When used as third strand, these form oligonucleotide triplexes with higher stability compared to unmodified controls at physiological pH.

Exact solutions of some urn models of relaxation in glassy dynamics.

We consider two simple models, called "urn models," for a general N-ball, M-urn problem. These models find applications in the study of relaxation in glassy dynamics. We obtain exact analytical results in these two cases for the average relaxation time tau to reach the ground state. In model I we also obtain the functional dependence of tau for large N, and in model II we obtain an asymptotic (N-->infinity) dependence of tau as a function of the number of urns M.

Recurrent catamenial hemopneumothorax.

A case of recurrent hemorrhagic catamenial hemopneumothorax resulting from diffuse pleural endometriosis is presented. The pathogenesis of this rare entity is discussed, and the immediate and long-term surgical and medical options for therapy are reviewed.

The prevention of experimentally induced postoperative adhesions.

For many years, various substances have been used to prevent postoperative adhesions, with suboptimal effectiveness. Saline has been postulated to have a positive effect, but it is reabsorbed from the abdominal cavity within 24 hours. To determine whether a longer-lasting intraperitoneal solution would be effective in preventing postoperative adhesions, 36 rats were divided into three groups: in 15 rats, a 2.5 per cent hyperosmolar solution of peritoneal dialysis fluid was injected intraperitoneally immediately following exploratory laparotomy, which included traumatization of the intestinal serosa at two sites; in 12 rats, normal saline was injected by the same procedure; and in 9 rats, no fluid was injected after the same operation. After 3 weeks, the group receiving the hyperosmolar peritoneal dialysis solution achieved the best results in both sites, the group that received normal saline showed marginal improvement, and the control group fared the worst.

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation.

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.

Comparison of surgical bypass and percutaneous balloon dilatation with primary stent placement in the treatment of central venous obstruction in the dialysis patient: one-year follow-up.

Central venous stenosis and occlusion are complications that are being observed with increasing frequency as a result of the use of long-term central venous catheters. These complications are especially problematic in patients with end-stage renal disease and functioning ipsilateral arteriovenous (AV) grafts or fistulas (AV grafts). We have previously demonstrated that the 1-year patency rate for simple balloon angioplasty in these patients is less than 10%. To compare the results of surgical treatment vs. percutaneous dilatation with stent placement, we undertook this retrospective study. All patients underwent multiple central venous catheter placements and had functioning ipsilateral AV grafts. Twenty-six patients were divided into two groups. The surgical treatment group included 13 patients: 10 with subclavian vein thrombosis and three with innominate vein thrombosis. All patients in the surgical group had arm swelling and edema. Surgical bypass procedures were performed in these patients using either polytetrafluoroethylene or saphenous vein. The stent group also included 13 patients; all of them had a diagnosis of subclavian or innominate vein obstruction and were treated with percutaneous transluminal angioplasty and placement of either a self-expanding rigid stent (n = 6) or a balloon-expandable flexible stent (n = 7). Two patients required multiple stent placements. No significant complications occurred in either group. The 1-year mortality rate in both groups was 31%. The percentages of patients who were symptom free at 6 and 12 months were also similar in the two groups. We conclude that surgical bypass and percutaneous transluminal angioplasty with stent placement are both efficacious in the treatment of central venous obstruction.

Percutaneous bailout therapy of a perforated vein graft using a stent-autologous vein patch.

A 74-yr-old man with two prior coronary bypass surgeries experienced perforation of an occluded aortocoronary vein graft during a transluminal extraction catheter (TEC) procedure for unstable angina. The perforation was successfully closed using a Palmaz 154 stent covered with a short segment of autologous antecubital vein.

Imaging in phaeohyphomycosis of the brain: case report.

A case of multiple, conglomerated brain abscesses due to Xylohypha bantiana, with unique imaging features, is presented. This is the first culture-proven case of brain infection due to this fungus in the neuroimaging literature.

Laparoscopic cholecystectomy: the Dammam Central Hospital experience.

Over a one year period (June 1992-June 1993), 260 patients (208 females and 52 males) with mean age of 37 years (range 13-80), underwent laparoscopic cholecystectomy (LC) for symptomatic gallstones. Thirty patients were admitted as emergency (20 acute cholecystitis, 10 acute pancreatitis). The procedure was performed successfully in 232 cases (89%). In 28 patients (18 electives, 10 emergencies), the procedure was converted to open for a variety of reasons, difficult anatomy being the commonest. Our mean operative time was 99.9 minutes (range 30-290 minutes). There were 3 major complications (2 common bile duct injuries and one abdominal aortic injury) and 4 minor complications (2 wound infections, one prolonged ileus and one chest infection). There was one death due to sickle cell crisis on the fifth post-operative day. The mean hospital stay was 2.3 days and 6.5 days for LC and converted cases, respectively. Our results suggest that laparoscopic cholecystectomy can be offered and conducted safely and effectively in the great majority of patients presenting acutely or electively with cholelithiasis, and that the results we achieved during the first year of our experience with LC is comparable to those reported from Europe and North America.