A survey of the management of transient loss of consciousness in the emergency department.

UNLABELLED: Transient loss of consciousness (TLoC) is a common presentation to the emergency department (ED). We sought to evaluate current practice in the management of patients with TLoC presenting to a large, city centre ED, against national standards. METHODS: The ED admissions database was searched to identify all patients attending with TLoC during October 2012. The clinical record of the attendance was reviewed to determine if the initial assessment met national standards. RESULTS: Ninety-one patients had a primary presentation with TLoC, representing 0.95% of ED attendances. Documentation of before/during/after the clinical event and clinical examination were done well. Notable aspects done less well included lying and standing blood pressure and recording of driving status. No patient was discharged from the ED with a copy of their 12-lead electrocardiogram (ECG). Sixty-five patients (71%) were discharged from the ED, with follow-up arranged for 11 (16%). Additional follow-up would have been appropriate in a further 15 cases (28%). CONCLUSION: Several aspects of the initial assessment of TLoC were done well. Areas for improvement include driving status documentation and advice, recording of postural blood pressures and ECG provision on discharge.

Drug and disease model resources: a consortium to create standards and tools to enhance model-based drug development.

Model-based drug development (MBDD) is accepted as a vital approach in understanding patients' drug-related benefit and risk by integrating quantitative information integration from diverse sources collected throughout drug development.(1) This perspective introduces the activities of the Drug and Disease Model Resources (DDMoRe) consortium, founded in 2011 through the Innovative Medicines Initiative Joint Undertaking (IMI-JU)(2) as a European public-private partnership to address a lack of common tools, languages, and standards for modeling and simulation (M&S) to improve model-based knowledge integration.CPT: Pharmacometrics & Systems Pharmacology (2013) 2, e34; doi:10.1038/psp.2013.10; advance online publication 20 March 2013.

In the Pursuit of Effective Affective Computing: The Relationship Between Features and Registration.

For facial expression recognition systems to be applicable in the real world, they need to be able to detect and track a previously unseen person's face and its facial movements accurately in realistic environments. A highly plausible solution involves performing a "dense" form of alignment, where 60-70 fiducial facial points are tracked with high accuracy. The problem is that, in practice, this type of dense alignment had so far been impossible to achieve in a generic sense, mainly due to poor reliability and robustness. Instead, many expression detection methods have opted for a "coarse" form of face alignment, followed by an application of a biologically inspired appearance descriptor such as the histogram of oriented gradients or Gabor magnitudes. Encouragingly, recent advances to a number of dense alignment algorithms have demonstrated both high reliability and accuracy for unseen subjects [e.g., constrained local models (CLMs)]. This begs the question: Aside from countering against illumination variation, what do these appearance descriptors do that standard pixel representations do not? In this paper, we show that, when close to perfect alignment is obtained, there is no real benefit in employing these different appearance-based representations (under consistent illumination conditions). In fact, when misalignment does occur, we show that these appearance descriptors do work well by encoding robustness to alignment error. For this work, we compared two popular methods for dense alignment-subject-dependent active appearance models versus subject-independent CLMs-on the task of action-unit detection. These comparisons were conducted through a battery of experiments across various publicly available data sets (i.e., CK+, Pain, M3, and GEMEP-FERA). We also report our performance in the recent 2011 Facial Expression Recognition and Analysis Challenge for the subject-independent task.

Effects of emissions from different type of residential heating upon cyclic guanosine monophosphate (cGMP) in blood platelets of residents.

We hypothesized that different types of residential heating would be associated with different levels of indoor carbon monoxide (CO) and further that this might result in a differential in the concentration of cyclic 3':5' guanosine monophosphate (cGMP) in blood platelets in exposed residents. Individuals, who were recruited from homes using different fuel for heating, donated a venous blood sample in the winter and in the summer. In the winter the median blood platelet cGMP value for the group using liquid propane gas (LPG) was 65% higher than for the group using piped natural gas for heating (p <0.001). Also in the group using LPG, the median concentration of cGMP in the winter was 39% higher than the summer median (p < 0.003). The mean indoor concentrations of CO were measured over a period of 1 week during the winter and were <1 ppm. We conclude that observed differences were associated with emissions from different types of heating but that CO exposure alone is too low to explain these.

Effects on patients with asthma of eradicating visible indoor mould: a randomised controlled trial.

BACKGROUND: It is not clear whether associations between respiratory symptoms and indoor mould are causal. A randomised controlled trial was conducted to see whether asthma improves when indoor mould is removed. METHODS: Houses of patients with asthma were randomly allocated into two groups. In one group, indoor mould was removed, fungicide was applied and a fan was installed in the loft. In the control group, intervention was delayed for 12 months. Questionnaires were administered and peak expiratory flow rate was measured at baseline, 6 months and 12 months. RESULTS: Eighty-one houses were allocated to the intervention group and 83 to the control group; 95 participants in 68 intervention houses and 87 in 63 control houses supplied follow-up information. Peak expiratory flow rate variability declined in both groups, with no significant differences between them. At 6 months, significantly more of the intervention group showed a net improvement in wheeze affecting activities (difference between groups 25%, 95% CI 3% to 47%; p = 0.028), perceived improvement of breathing (52%, 95% CI 30% to 74%; p<0.0001) and perceived reduction in medication (59%, 95% CI 35% to 81%; p<0.0001). By 12 months the intervention group showed significantly greater reductions than the controls in preventer and reliever use, and more improvement in rhinitis (24%, 95% CI 9% to 39%; p = 0.001) and rhinoconjunctivitis (20%, 95% CI 5% to 36%; p = 0.009). CONCLUSIONS: Although there was no objective evidence of benefit, symptoms of asthma and rhinitis improved and medication use declined following removal of indoor mould. It is unlikely that this was entirely a placebo effect.

Restoration of cardiopulmonary function with 21% versus 100% oxygen after hypoxaemia in newborn pigs.

OBJECTIVE: To assess the consequences of hypoxaemia and resuscitation with room air versus 100% O(2) on cardiac troponin I (cTnI), cardiac output (CO), and pulmonary artery pressure (PAP) in newborn pigs. DESIGN: Twenty anaesthetised pigs (12-36 hours; 1.7-2.7 kg) were subjected to hypoxaemia by ventilation with 8% O(2). When mean arterial blood pressure fell to 15 mm Hg, or arterial base excess was < or = -20 mmol/l, resuscitation was performed with 21% (n = 10) or 100% (n = 10) O(2) for 30 minutes, then ventilation with 21% O(2) for 120 minutes. Blood was analysed for cTnI. Ultrasound examinations of CO and PAP (estimated from tricuspid regurgitation velocity (TR-Vmax)) were performed at baseline, during hypoxia, and at the start of and during reoxygenation. RESULTS: cTnI increased from baseline to the end point (p<0.001), confirming a serious myocardial injury, with no differences between the 21% and 100% O(2) group (p = 0.12). TR-Vmax increased during the insult and returned towards baseline values during reoxygenation, with no differences between the groups (p = 0.11) or between cTnI concentrations (p = 0.31). An inverse relation was found between increasing age and TR-Vmax during hypoxaemia (p = 0.034). CO per kg body weight increased during the early phase of hypoxaemia (p<0.001), then decreased. Changes in CO per kg were mainly due to changes in heart rate, with no differences between the groups during reoxygenation (p = 0.298). CONCLUSION: Hypoxaemia affects the myocardium and PAP. During this limited period of observation, reoxygenation with 100% O(2) showed no benefits compared with 21% O(2) in normalising myocardial function and PAP. The important issue may be resuscitation and reoxygenation without hyperoxygenation.

Occupational exposure of midwives to nitrous oxide on delivery suites.

AIMS: To compare environmental and biological monitoring of midwives for nitrous oxide in a delivery suite environment. METHODS: Environmental samples were taken over a period of four hours using passive diffusion tubes. Urine measurements were taken at the start of the shift and after four hours. RESULTS: Environmental levels exceeded the legal occupational exposure standards for nitrous oxide (100 ppm over an 8 hour time weighted average) in 35 of 46 midwife shifts monitored. There was a high correlation between personal environmental concentrations and biological uptake of nitrous oxide for those midwives with no body burden of nitrous oxide at the start of a shift, but not for others. CONCLUSIONS: Greater engineering control measures are needed to reduce daily exposure to midwives to below the occupational exposure standard. Further investigation of the toxicokinetics of nitrous oxide is needed.

Scenarios for autoimmunization of T and B cells in myasthenia gravis.

We have studied responses in thymoma patients to interferon-alpha and to the acetylcholine receptor (AChR) in early-onset myasthenia gravis (EOMG), seeking clues to autoimmunizing mechanisms. Our new evidence implicates a two-step process: (step 1) professional antigen-presenting cells and thymic epithelial cells prime AChR-specific T cells; then (step 2) thymic myoid cells subsequently provoke germinal center formation in EOMG. Our unifying hypothesis proposes that AChR epitopes expressed by neoplastic or hyperplastic thymic epithelial cells aberrantly prime helper T cells, whether generated locally or infiltrating from the circulation. These helper T cells then induce antibody responses against linear epitopes that cross-react with whole AChR and attack myoid cells in the EOMG thymus. The resulting antigen-antibody complexes and the recruitment of professional antigen-presenting cells increase the exposure of thymic cells to the infiltrates and provoke local germinal center formation and determinant spreading. Both these and the consequently enhanced heterogeneity and pathogenicity of the autoantibodies should be minimized by early thymectomy.

Biological monitoring of midwives' exposure to N(2)O using the Bio-VOC breath sampler.

The use of exhaled breath as a biological monitoring tool is still not widely used. Although there are now commercially available kits, there are limited data on biological guidance values for all but a few substances for breath monitoring. The study investigated the possibility of using an indirect breath sampler to measure the levels of nitrous oxide in the exhaled breath of midwives at a midpoint during their shift. Levels of nitrous oxide in the exhaled breath were measured at (0-727 ppm) with a mean level of 64 ppm. The correlation between the established personal environmental monitoring and exhaled breath monitoring was generally poor as was the correlation between duration of nitrous oxide exposure and levels in the exhaled breath. Clearly the use of exhaled breath as a tool for biological monitoring is more appropriate than other invasive procedures. The breath sampler used has been a readily acceptable tool for occupational hygiene monitoring in a busy hospital ward.

Processing of cardiac valve allografts: 2. Effects of antimicrobial treatment on sterility, structure and mechanical properties.

This is the second in a series of papers that report experiments to investigate the properties required for effective tissue valve implants. This paper is concerned with investigations into alternative antimicrobial treatments and the effect these treatments produce on the structural and biomechanical properties of ovine aortic valves. Six treatments were studied: heat, peracetic acid (at two concentrations), chlorine dioxide, a surfactant cleaning agent and a solvent/detergent treatment. Samples of myocardial tissue were exposed to a mixed bacterial culture or one of three virus cultures and then decontaminated. Two of the six treatments (0.35% peracetic acid and heat) were effective in removing both bacterial and viral contamination, reducing levels of contamination by 2.5 to 3 logs, whilst a third (chlorine dioxide) was effective against viruses ( approximately 3 log reduction). Valves subjected to these treatments were examined by microscopy and measurements of mechanical properties were made. All three treatments seriously damaged endothelial cells and leaflet fibroblasts. Heat treatment also damaged connective tissue components (collagen and elastin) but these changes were not seen after chemical treatment. Mechanical testing confirmed severe damage following heat treatment but chemical treatment showed only minor effects on the elasticity of the leaflets and none on extensibility. These minor effects could be mitigated by exposure to a lower dose of peracetic acid and this treatment could be safely combined with cryopreservation or storage in 85% glycerol. Peracetic acid was the preferred disinfection method for use in the subsequent in vivo studies in sheep.

Environmental monitoring of nitrous oxide during dental anaesthesia.

AIM: The study was carried out to see if levels of nitrous oxide in dental theatres and community dental clinics were being controlled in accordance with the Control of Substances Hazardous to Health Regulations. SETTING: A multi-centre study looked at exposure levels in a dental teaching hospital and two community dental clinics in the South Wales area between 1997 and 1998. METHODS: A MIRAN infra-red spectrophotometer was used to measure static levels of nitrous oxide during general anaesthesia and conscious sedation. NIOSH method 6600 was used to collect personal samples of the individual administering the anaesthetic. RESULTS: The results showed compliance with the regulations when averaged out over an 8 hour time weighted average. However, over short periods of time peak concentrations of up to 1190 ppm were observed through static sampling, and up to 734 ppm through personal sampling. CONCLUSIONS: The results highlighted the need to provide adequate control measures such as anaesthetic gas scavenging, to reduce occupational exposure to dental staff in dental operating theatres and community dental clinics, therefore providing a safe working environment.

Staff exposure to anaesthetic gases in theatre and non theatre areas.

Environmental monitoring of anaesthetic gases was carried out in theatre areas in eight hospitals as well as in Delivery suites, radiology, radiotherapy and Dental suites. High staff exposures occurred in nontheatre areas although exposures in theatres were generally satisfactory. Environmental control measures are required where staff exposures exceed legal standards.

Antibodies for neoplastic disease : solid tumors.

The ease with which polyclonal, monoclonal, and engineered antibody fragments can be prepared allows access to a series of reagents with high selectivity and affinity. These reagents therefore have long held promise as a means of influencing the growth and spread of malignant disease. Over a number of decades therapeutic antibodies have been developed either as single entities or conjugated to a variety of potential disease-ameliorating agents.

An environmental survey of compliance with Occupational Exposure Standards (OES) for anaesthetic gases.

Environmental monitoring of nitrous oxide and volatile agents was carried out between August 1996 and October 1997 within operating theatre areas in eight hospitals within the Bro Taf Health Authority. Static monitoring and personal sampling were undertaken to assess compliance with the Occupational Exposure Standards introduced in January 1996 by the Health and Safety Executive for anaesthetic agents. The monitoring concentrated on nitrous oxide with the results showing that compliance was being achieved. Limited monitoring was carried out of the volatile agents, which again were well below the Occupational Exposure Limits. Monitoring was also carried out in nontheatre areas in which anaesthetic agents were used. The results show that many of these locations, such as delivery suites and radiology units, have inadequate ventilation and no anaesthetic gas scavenging, both of which combined to produce levels that exceeded the standards.

Should radiologists image and report sacroiliac joints in patients referred for examination of the lumbar spine?

It is routine to image the sacroiliac joints (SIJs) in patients referred for radiographic examination of the lumbar spine but there were only two consistent with ankylosing spondylitis in a review of 392 radiographic reports of lumbar spine examinations. A more sensible policy would be to only image and report on the SIJs if the clinical history were indicative of ankylosing spondylosis.

Parametric release for EtO sterilization.

The use of microwave spectroscopy as a process-control monitor to measure ethylene oxide (EtO) is an exciting breakthrough in EtO sterilization. Technologies employed until now have lacked the specificity or long-term stability to measure EtO, but microwave spectrometers now in EtO facilities have shown consistent and accurate results. This article explains the technology.

Microbiological monitoring of bone grafts: two years' experience at a tissue bank.

In the first two years of operation of a tissue bank, bone was processed on 63 occasions from 22 cadaveric donors and on 37 occasions from 185 living donors. A standardized protocol for microbiological sampling, culturing and interpretation of the results was developed. Semi-quantitative culture of washings of bone was performed on receipt by the tissue bank, and broth enrichment cultures of bone samples were performed at the end of processing, and again after irradiation. One bone donation was rejected because of heavy contamination with Klebsiella sp. on receipt, and contamination of six donations with Burkholderia cepacia was shown to have come from a water deionizer. Contamination of bone on receipt by the tissue bank decreased during the study period, probably related to increasing experience of staff harvesting bone. Microbiological surveillance of bone grafts protect recipients from infection, and is useful as a quality control of the process of bone banking.