Canadian policy changes for alcohol-based hand rubs during the COVID-19 pandemic and unintended risks.

The COVID-19 pandemic led to major changes in public policies to address supply chain disruption and escalated the price of consumer disinfectant products. To address market demands on alcohol-based hand rubs and disinfectants, Health Canada implemented major changes to the regulations regarding composition, handling, transportation, and packaging to insure product availability. Furthermore, accelerated licensing of ingredients and packaging did not meet standard medical quality guidelines yet were authorized for manufacturing and packaging of alcohol-based hand rubs and disinfectants. The accountability associated with these policy changes were reactive, including industry self-reporting, consumer reporting, and Health Canada advisories and recalls that were responsive to products after they were available in the market. Nonetheless, Canadian public health policy increased hand sanitizers availability. However, some of the interim policies have raised major public health concerns associated with ethanol quality, packaging, and labeling, and enforcement of regulations. In this paper, we review the changes in the Canadian regulations amid the current pandemic and we evaluate the unintended health risks that might arise from these changes.

Toxicology of alcohol-based hand rubs formulated with technical-grade ethanol.

Alcohol-based hand rubs (ABHRs) formulated with technical-grade ethanol were temporarily permitted in Canada and the U.S beginning April 2020 to meet the current demand due to COVID-19. ABHRs formulated with technical-grade ethanol are low risk for general use. In this review, we discuss the toxicity of common contaminants found in technical-grade ethanol, as well as contaminants that may have been introduced into the products during formulation and packaging of ABHRs. Although primary route of exposure is via dermal absorption and inhalation, there have been reported elevated concerns regarding to ingestion of ABHRs. Overall, the highest risks were associated with methanol (for its toxicity), ethyl acetate (skin defattening), and acetaldehyde (carcinogenic and teratogenic). For these reasons Health Canada and the United States Food and Drug Administration have issued recalls on products containing some of these contaminants. More vigilant policing by regulatory agencies and general product users are required to ensure compliance, safety, and efficacy of these new products, as demand continue to rise during this unprecedented pandemic.

The "Dirty Liver" as a Coincidental Finding on Sonography: Sonographic Criteria for Biliary Microhamartomas of the Liver.

OBJECTIVES: Biliary microhamartomas of the liver are known as symptomless, benign, microscopic biliary duct deformations. The consistently improving quality of ultrasound technology has made it possible to visualize them, which has led to difficulty in distinguishing them from neoplastic liver alterations. The purpose of this study was to evaluate the appearance of biliary microhamartomas and their behavior on contrast-enhanced sonography. METHODS: We defined typical sonographic findings in biliary microhamartomas of the liver (1 main criterion and 3 secondary criteria). Nineteen patients were identified as have typical characteristics images of biliary microhamartomas as coincidental findings on liver sonography. All patients were included in a clinical follow-up program without histologic confirmation after they underwent risk assessment. Follow-up examinations were performed with B-mode sonographic examinations at 6, 12, and 18 months. In addition, in 15 patients, contrast-enhanced sonographic examinations of the liver were performed. RESULTS: None of the patients had a change in the number or size of the identifiable typical liver lesions (main criterion) after a mean follow-up period ± SD of 14.4 ± 6.5 months. There were also no alterations among the aforementioned secondary criteria in any of the participants. On contrast-enhanced sonography, the lesions of all patients showed a consistent pattern, with early arterial enrichment and persistent homogeneous contrast in the late portal venous phase. CONCLUSIONS: The sonographic appearance of biliary microhamartomas is characteristic and typical enough that histologic confirmation is not always necessary. Follow-up examinations to monitor any developments are usually adequate.

Comparison Between Various Color Spectra and Conventional Grayscale Imaging for Detection of Parenchymal Liver Lesions With B-Mode Sonography.

OBJECTIVES: The electronic colorization of grayscale B-mode sonograms using various color schemes aims to enhance the adaptability and practicability of B-mode sonography in daylight conditions. The purpose of this study was to determine the diagnostic effectiveness and importance of colorized B-mode sonography. METHODS: Fifty-three video sequences of sonographic examinations of the liver were digitized and subsequently colorized in 2 different color combinations (yellow-brown and blue-white). The set of 53 images consisted of 33 with isoechoic masses, 8 with obvious lesions of the liver (hypoechoic or hyperechoic), and 12 with inconspicuous reference images of the liver. The video sequences were combined in a random order and edited into half-hour video clips. RESULTS: Isoechoic liver lesions were successfully detected in 58% of the yellow-brown video sequences and in 57% of the grayscale video sequences (P = .74, not significant). Fifty percent of the isoechoic liver lesions were successfully detected in the blue-white video sequences, as opposed to a 55% detection rate in the corresponding grayscale video sequences (P= .11, not significant). In 2 subgroups, significantly more liver lesions were detected with grayscale sonography compared to blue-white sonography. CONCLUSIONS: Yellow-brown-colorized B-mode sonography appears to be similarly effective for detection of isoechoic parenchymal liver lesions as traditional grayscale sonography. Blue-white colorization in B-mode sonography is probably not as effective as grayscale sonography, although a statistically significant disadvantage was shown only in the subgroup of hyperechoic liver lesions.

In situ cooling with ice water for the easier removal of self-expanding nitinol stents.

BACKGROUND: It is yet to be determined what effects temperature has on the properties of nitinol in order to simplify the process of removing nitinol self-expanding metal stents (SEMS). MATERIALS AND METHODS: We describe the procedure for removal of SEMS in a total of 11 cases with 9 patients. A study involving cooling of nitinol stents in situ with ice water just before their removal was attempted. RESULTS: All stents were removed successfully. In partially covered and in fully covered stents, the stent rigidity was noticeably reduced following cooling. Stent removal was performed by inversion, which was achieved by pulling on the stent from its distal end. No adverse events were observed during this trial. CONCLUSION: The higher pliability of the stents after ice-water cooling facilitates stent removal. With this method, a mobilization of all stents by the invagination technique was achieved. The separation of the uncoated stent ends from the intestinal wall by the invagination technique, as well as the mucosal vasoconstriction resulting from the cooling, lead to an easier SEMS removal and may serve to prevent severe bleeding of the mucosal wall during this process.

Maxillary sinus-floor elevation with nanoporous biphasic bone graft material for early implant placement.

BACKGROUND: Insufficient bone height in the posterior maxilla is caused by bone atrophy after tooth extraction and continued pneumatization of the maxillary sinus. To allow for implant placement in this area, external sinus-floor elevations are performed. For this indication, the application of various bone graft materials can be a reliable alternative to autologous bone. PURPOSE: The aim of this study was to analyze a nanoporous bone graft material under the condition of early implant treatment in sinus floor elevations. MATERIALS AND METHODS: Sixty-six patients received 94 individual external sinus-floor elevations as a precondition for implant surgery. As grafting material, a synthetic, nanoporous bone graft material consisting of a mixture of nano-hydroxyapatite and nano-ß-tricalciumphosphate crystals, combined with blood from the defect side, was used. Depending on the remaining vertical bone height, implant placement was performed either simultaneously with bone augmentation or consecutively in a delayed approach. After a 4-month healing period, the patients received 218 implants and were followed up clinically, radiographically, and histologically. To quantify the bone situation at implant placement, immunohistochemical analysis using tenascin-C was performed. RESULTS: We achieved an average vertical bone increase of 8.28 mm (SD, 2.59) for the one-stage approach and 10.99 mm (SD, 1.73) for the two-stage approach after sinus-floor elevation. The augmented areas showed mean resorption rates of 10.32% (one stage) and 10.82% (two stages) of vertical graft during the observation period. Immunohistochemical analysis after 4 months of healing showed high tenascin activity, indicating bone growth. Good primary stability was achieved during implant placement. Mean peri-implant marginal bone loss was 0.45 mm (SD, 0.31). CONCLUSION: After a mean observation time of 21.45 months, the biomaterial showed good osseointegration and bone stability radiographically. Adding to this the positive histological and immunohistochemical findings, we conclude that, after a relatively short 4-month healing period, the biomaterial showed predictable results.

Injection anthrax--a new outbreak in heroin users.

BACKGROUND: Injection anthrax is a rare disease that affects heroin users and is caused by Bacillus anthracis. In 2012, there were four cases in Germany, one of which was fatal, as well as a small number of cases in other European countries, including Denmark, France, and the United Kingdom. Three cases among drug users occurred in Germany in 2009/2010, in the setting of a larger outbreak centered on Scotland, where there were 119 cases. CASE PRESENTATION AND CLINICAL COURSE: We present three cases of injection anthrax, two of which were treated in Regensburg and one in Berlin. One patient died of multi-organ-system failure on the day of admission to the hospital. The others were treated with antibiotics, one of them also with surgical wound debridement. The laboratory diagnosis of injection anthrax is based on the demonstration of the pathogen, generally by culture and/or by polymerase chain reaction, in material removed directly from the patient's wound. The diagnosis is additionally supported by the detection of specific antibodies. CONCLUSION: Injection anthrax may be viewed either as an independent disease entity or as a special type of cutaneous anthrax with massive edema, necrotizing fasciitis in many cases, and about 30% mortality. It has appeared in recent years among heroin users in various European countries. In patients with suggestive clinical presentation and a history of heroin use, anthrax infection must be suspected early, so that the appropriate diagnostic tests can be performed without delay. Timely treatment can be life-saving. It is therefore important that physicians--and the individuals at risk--should be well-informed about this disease.