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.

Fit testing and comfort evaluation of prophylactic dressing use for healthcare workers under N95/P2 respirators in one health service district in Australia.

BACKGROUND: This study evaluated the use of prophylactic dressings (silicone foam, silicone tape, hydrocolloid) under N95/P2 respirators to determine which dressings fit successfully. AIM: The aim was to develop a health service protocol for one state in Australia. METHODS: Data were collected during August and September 2021 as part of the Respiratory Protection Programme on 600 health workers using three types of prophylactic dressings. Five different types of respirators were used. Participant healthcare workers rated comfort on a four-point Likert scale. RESULTS: Successful fit was achieved by 63.6% of the respirator-dressing combinations. The best-performing respirator-dressing combination was the Trident® respirator with dressing Mepilex® Lite silicone foam (90.2% pass rate). High pass rates were found in the Trident® respirator with Mepilex® Border Lite with SofSicure silicone tape (79.1%); the 3M™ 1860 respirator with Mepilex® Border Lite with SofSicure silicone tape (74%); and the BSN orange duckbill respirator with Mepilex® Lite silicone foam (69.8%). The poorest-performing combination was the BYD™ respirator with Mepilex® Border Lite with SofSicure silicone tape (25.9% pass rate). Uncorrected chi-squared tests for association revealed significant associations between dressing type and outcome (P=0.004) and respirator type and outcome (P<0.001). Most respondents (82%) found the dressing combination markedly comfortable. CONCLUSIONS: When using prophylactic dressings under N95/P2 respirators, it is necessary to perform a fit test. In this study Trident® respirators had the highest probability of successful fit, while BYD™ respirators had the lowest. Combining Trident® respirators with Mepilex® Lite dressing was optimal. Most participants reported greater comfort with the dressings under the respirators.

Birth outcomes in women with gestational diabetes managed by lifestyle modification alone: The PANDORA study.

AIMS: To assess outcomes of women in the Pregnancy and Neonatal Diabetes Outcomes in Remote Australia (PANDORA) cohort with gestational diabetes mellitus (GDM) managed by lifestyle modification compared with women without hyperglycaemia in pregnancy. METHODS: Indigenous (n = 97) and Europid (n = 113) women managed by lifestyle modification were compared to women without hyperglycaemia (n = 235). Multivariate linear and logistic regressions assessed whether GDM-lifestyle women had poorer outcomes compared to women without hyperglycaemia. RESULTS: Women with GDM-lifestyle had higher body mass index and lower gestational weight gain than women without hyperglycaemia. On univariate analysis, gestational age at delivery was lower and induction rates were higher in women with GDM-lifestyle than without hyperglycaemia. On multivariable regression, GDM-lifestyle was associated with lower gestational age at delivery (by 0.73 weeks), lower birthweight z-score (by 0.26, p = 0.007), lower likelihood of large for gestational age (LGA) [OR (95% CI): 0.55 (0.28, 1.02), p = 0.059], and greater likelihood of labour induction [2.34 (1.49, 3.66), p < 0.001] than women without hyperglycaemia. CONCLUSION: Women with GDM managed by lifestyle modification had higher induction rates and their offspring had lower birthweight z-scores, with a trend to lower LGA than those without hyperglycaemia in pregnancy. Further studies are indicated to explore reasons for higher induction rates.

Trends in Indigenous and non-Indigenous caesarean section births in the Northern Territory of Australia, 1986-2012: a total population-based study.

OBJECTIVE: To examine trends in caesarean section deliveries and factors associated with these trends for Indigenous and non-Indigenous mothers. DESIGN: Total population-based study. SETTING: Northern Territory of Australia, 1986-2012. POPULATION: Pregnancies among Northern Territory residents, limited to singleton live births with cephalic presentations delivered at 37-42 weeks' gestation (n = 78 561). METHODS: Descriptive analyses of demographic and obstetric risk factors. Poisson regression with robust variance to estimate the likelihood of caesarean delivery with and without labour compared with vaginal delivery, over time and between Indigenous and non-Indigenous mothers, adjusting for risk factors. MAIN OUTCOME MEASURES: Trends in caesarean sections and risk of caesarean delivery compared with vaginal delivery. RESULTS: The total rate of caesarean deliveries in the Northern Territory increased between 1986 and 2012. From the year 2000, the rise was driven by increases in caesareans with labour among nulliparous mothers and no labour caesareans among multiparous mothers. Increases in demographic and obstetric risk factors explained the rise in caesareans with labour among nulliparous Indigenous mothers, whereas other unmeasured variables contributed to the rise among non-Indigenous mothers. Increases in previous caesarean delivery contributed to the rise in all caesareans among multiparous mothers. Following adjustment, the risk of Indigenous nulliparous mothers having a caesarean with labour was 47% greater than for non-Indigenous nulliparous mothers [adjusted risk ratio 1.47 (95% CI 1.34-1.60)]. CONCLUSIONS: Increases in demographic and obstetric risk factors partially explained the increase in caesarean rates in the Northern Territory and the contribution of these factors differed between Indigenous and non-Indigenous mothers. TWEETABLE ABSTRACT: Caesarean section rates increased between 1986 and 2012 in the Northern Territory of Australia.

Consensus guidelines for implementation of quality processes to prevent invasive fungal disease and enhanced surveillance measures during hospital building works, 2014.

Healthcare-associated fungal outbreaks impose a substantial economic burden on the health system and typically result in high patient morbidity and mortality, particularly in the immunocompromised host. As the population at risk of invasive fungal infection continues to grow due to the increased burden of cancer and related factors, the need for hospitals to employ preventative measures has become increasingly important. These guidelines outline the standard quality processes hospitals need to accommodate into everyday practice and at times of healthcare-associated outbreak, including the role of antifungal stewardship programmes and best practice environmental sampling. Specific recommendations are also provided to help guide the planning and implementation of quality processes and enhanced surveillance before, during and after high-risk activities, such as hospital building works. Areas in which information is still lacking and further research is required are also highlighted.

Are newly qualified doctors prepared to provide supportive and end-of-life care? A survey of Foundation Year 1 doctors and consultants.

OBJECTIVE: To establish whether Foundation Year 1 (FY1) doctors in Edinburgh are sufficiently prepared to deliver generalist palliative care, with a view to informing developments in undergraduate and postgraduate medical education. METHODS: Questionnaires were sent to FY1 doctors and to supervising consultants. Semi-structured interviews were conducted with five FY1 doctors. RESULTS: A total of 60 FY1 doctors and 31 consultants replied. The majority of FY1 doctors did not feel well-prepared to deliver basic palliative care, especially when managing distress and social issues. Consultants agreed that FY1 doctors were underprepared. Junior doctors reported high levels of distress themselves, with few seeking support from senior colleagues. Both sets of respondents made suggestions for curricular improvements. CONCLUSIONS: Newly qualified doctors were not adequately prepared to deliver generalist palliative care and lacked first-hand experience of end-of-life issues. Current reviews of palliative care education should address the learning and supportive needs of our most junior doctors more effectively.

Emergence and control of an outbreak of infections due to Panton-Valentine leukocidin positive, ST22 methicillin-resistant Staphylococcus aureus in a neonatal intensive care unit.

Methicillin resistant Staphylococcus aureus (MRSA) infection can cause significant morbidity and mortality in neonates. We investigated a nosocomial MRSA outbreak in a neonatal intensive care unit (NICU), using a novel typing method. Following two fatal cases, in May 2011, a prospective outbreak investigation was conducted, involving neonates, mothers and healthcare workers in a large tertiary NICU in Sydney. MRSA isolates were characterized by antimicrobial susceptibility testing, a multiplex PCR-based reverse line blot (mPCR/RLB) binary typing system and other molecular typing methods. Over 7 months, 14 neonates were colonized with MRSA and six infected: three with superficial lesions and three with life-threatening disease, including the two index cases, who died despite empirical treatment with vancomycin. Isolates from 15 neonates were indistinguishable by RLB typing and identified as a PVL-producing ST22 SCCmec IV MRSA strain, which was resistant to gentamicin and trimethoprim-sulphamethoxazole. The outbreak strain was also isolated from one healthcare worker, one environmental swab and one father, but the source remained obscure. During the same period several different non-multiresistant and multiresistant MRSA strains were isolated from five neonates, five mothers (including two whose infants were colonized with the outbreak strain), one father, three healthcare workers and two environmental swabs. Rapid turnaround time of typing results allowed us to recognize and define the outbreak and implement targeted infection control interventions. PVL-producing ST22 SCCmec IV MRSA appears to be a virulent and highly transmissible pathogen in the NICU, which was difficult to control.

Internationally distributed frozen oyster meat causing multiple outbreaks of norovirus infection in Australia.

BACKGROUND: Between November 2003 and January 2004, outbreaks of norovirus in 3 Australian jurisdictions involving 83 cases of illness were associated with imported oyster meat. METHODS: Cohort studies were conducted in 2 jurisdictions to identify relative risks of illness for the consumption of oysters. A case series was conducted in the third jurisdiction. RESULTS: The cohort studies conducted in the first 2 jurisdictions identified relative risks of illness of 17 (95% confidence interval, 5-51) and 35 (95% confidence interval, 5-243), respectively, for the consumption of oysters. Multiple strains of norovirus were detected in fecal specimens from 8 of 14 patients and in 1 of the 3 batches of implicated oyster meat using seminested reverse-transcriptase polymerase chain reaction methods. Traceback investigations revealed that all oyster meat was harvested from the same estuary system in Japan within the same month. CONCLUSIONS: These outbreaks demonstrate the potential of foodborne disease to spread internationally and the need for national and international collaboration to investigate such outbreaks. Foodborne illness related to norovirus is underestimated because of underreporting of human cases and challenges in laboratory detection of viruses in foods, both of which can delay public health action.

The role of surgery in children with neurofibromatosis.

BACKGROUND/PURPOSE: Neurofibromatosis frequently is complicated by the development of symptomatic lesions such as optic gliomas and plexiform neurofibromas that require operative resection. Although characteristically benign, these neoplasms have often devastating functional and cosmetic effects and must be monitored for malignant transformation. The purpose of this study is to identify and describe the surgical considerations in the care of children with neurofibromatosis. METHODS: The authors reviewed the charts of all children (<21) at our institution with neurofibromatosis who underwent an operative procedure from 1979 to 1999. Patient demographics, symptomatic lesions, malignant transformation, form of surgical intervention, type of anesthesia, and outcome were collected. RESULTS: A total of 249 patients with either neurofibromatosis 1 or 2 were identified. Of these, 50 (20%) underwent a total of 93 operations. The average age at operation was 9.4 years (1.2 to 21 years). There were 40 soft tissue procedures, 21 intracranial, and 32 miscellaneous. The soft tissue masses typically were treated with wide local excision, and in 8 of these procedures multiple resections were performed. Fourteen of the 50 patients had malignancies. Five of the tumors were soft tissue sarcomas, and 9 were intracranial malignancies. Three patients died, 2 from malignancy and 1 from acute, obstructive hydrocephalus after operation. There were 3 patients alive with malignancy and 8 others living with varying levels of disability. CONCLUSIONS: Neurofibromatosis in the pediatric patient frequently requires surgical intervention, often because of symptoms such as pain or cosmetic deformity, or for malignancy. Children should be watched carefully for signs of malignant transformation and undergo biopsy for neurofibromas that exhibit rapid growth. Management of sarcomas should be aggressive with consideration given to re-excision, placement of brachytherapy catheters, metastectomy, and limb salvage with adjuvant therapy when possible. Preoperatively, children should receive clinical and radiographic (computed tomography or magnetic resonance imaging) evaluation for hydrocephalus.

Evaluation of the cleaning and disinfection efficacy of the DEKO-190; award-based automated washer/disinfector.

The DEKO-190 Washer-Disinfector combines both automatic washing and thermal disinfection functions and is designed for the decontamination of ward utensils (such as bedpans and urine bottles) and instruments used in minor surgery prior to sterilization. We undertook a microbiological evaluation of the disinfection efficacy of the machine, using its short wash plus disinfection programme and sealed suspensions of test organisms placed at various points within the instrument. Suspensions of Enterococcus faecalis and Poliovirus were totally inactivated, the counts of aerobic organisms within a stool specimen being reduced by a factor of 10(4)whilst spores of Clostridium perfringens were unaffected. The cleaning efficacy of the DEKO-190 was also evaluated under clinical conditions by visual inspection and was found to be satisfactory. Ward-based combined washer-disinfection machines, such as the DEKO-190, have the potential to improve the efficacy of cleaning protocols within healthcare institutions.

Machado-Joseph disease in east Arnhem Land, Australia: chromosome 14q32.1 expanded repeat confirmed in four families.

Four kindreds of east Arnhem Land Australian aboriginal people from Groote Eylandt and adjacent communities display symptoms of a similar spinocerebellar degeneration (multiple-system degenerative disease). The familial pattern indicates an autosomal dominant inheritance, though with varying penetrance in different families. This condition is clinically and pathologically consistent with Machado-Joseph disease (MJD), and there is the possibility of Portuguese ancestry. These families exhibit anticipation, particularly in the case of paternal inheritance, with those with earlier age of onset presenting a clinical pattern consistent with MJD type I. There was no expansion of the CAG repeat region of the SCA1 gene in these families. The demonstration of expansion of the CAG repeat on chromosome 14q32.1 in all four families confirms the diagnosis of MJD.

Subcellular distribution and mobilization of MAC-1 (CD11b/CD18) in neonatal neutrophils.

The CD11b/CD18 (Mac-1) heterodimeric surface glycoprotein contributes to a broad range of adherence-dependent neutrophil inflammatory functions. Previous investigations have indicated that diminished expression or regulation of Mac-1 may underlie abnormalities of stimulated adhesion and chemotaxis of neonatal neutrophils in vitro and inflammatory deficits in human neonates. To define the pathogenic mechanisms contributing to these findings, we compared the distribution and translocation of Mac-1 in subcellular fractions of neonatal and adult neutrophils before and after chemotactic stimulation. The total cell content of Mac-1 and the proportions of Mac-1 in beta fractions (vitamin B12 binding protein-rich granules), pre-gamma fractions (gelatinase-rich granules), or gamma fractions (plasma membrane) of neonatal neutrophils were comparable with those of adult neutrophils. However, after stimulation with N-formyl-methionyl-leucyl-phenylalanine (FMLP; 10 nmol/L, 37 degrees C, 15 minutes), neonatal neutrophils demonstrated (1) diminished translocation of Mac-1 from pre-gamma fractions (P less than .05), and (2) diminished surface expression of Mac-1 (P less than .05), as compared with healthy adult neutrophils. As shown in enzymatic and immunochemical assays, neonatal cells contained significantly (P less than .01) diminished levels of neutrophil gelatinase. In response to FMLP (0.1 to 10 nmol/L, 37 degrees C, 15 minutes), neonatal suspensions also released significantly (P less than .001) less gelatinase, as compared with adult neutrophil suspensions. These observations demonstrate that diminished mobilization of Mac-1 from gelatinase-rich granular pools in neonatal neutrophils is associated with abnormal surface expression of this glycoprotein after chemotactic stimulation. This abnormality may contribute, in part, to abnormal migratory properties of neonatal neutrophils in response to inflammatory stimuli.

Hypersensitivity to Sta-Lok and Loctite anaerobic sealants.

Three cases of allergic contact hypersensitivity to Sta-Lok and Loctite anaerobic sealants are reported. These two anaerobic sealants constitute a +100 million annual market in industrial sealants used to join metal surfaces together. To the best of my knowledge, these are the first reported cases of allergic contact hypersensitivity to these agents.