Action guidance for addressing pollution from inhalational anaesthetics.

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well-being of current and future generations. Inhalational anaesthetics are a significant contributor to healthcare-related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well-established knowledge about inhalational anaesthetic pollution into practical action. CODA is a medical education and health promotion charity that aims to deliver climate action-oriented recommendations, supported by useful resources and success stories. The CODA-hosted platform is designed to maximise engagement of the global healthcare community and draws upon diverse experiences to develop global solutions and accelerate action. The action guidance for addressing pollution from inhalational anaesthetics is the subject of this article. These are practical, evidence-based actions that can be undertaken to reduce the impact of pollution from inhalational anaesthetics, without compromising patient care and include: removal of desflurane from drug formularies; decommissioning central nitrous oxide piping; avoidance of nitrous oxide use; minimising fresh gas flows during anaesthesia; and prioritising total intravenous anaesthesia and regional anaesthesia when clinically safe to do so. Guidance on how to educate, implement, measure and review progress on these mitigation actions is provided, along with means to share successes and contribute to the essential, global transition towards environmentally sustainable anaesthesia.

Analysis of the acute postoperative pain experience following oral surgery: identification of 'unaffected', 'disabled' and 'depressed, anxious and disabled' patient clusters.

BACKGROUND: Pain is defined as both a sensory and an emotional experience. Acute postoperative tooth extraction pain is assessed and treated as a physiological (sensory) pain while chronic pain is a biopsychosocial problem. The purpose of this study was to assess whether psychological and social changes occur in the acute pain state. METHODS: A biopsychosocial pain questionnaire was completed by 438 subjects (165 males, 273 females) with acute postoperative pain at 24 hours following the surgical extraction of teeth and compared with 273 subjects (78 males, 195 females) with chronic orofacial pain. Statistical methods used a k-means cluster analysis. RESULTS: Three clusters were identified in the acute pain group: 'unaffected', 'disabled' and 'depressed, anxious and disabled'. Psychosocial effects showed 24.8 per cent feeling 'distress/suffering' and 15.1 per cent 'sad and depressed'. Females reported higher pain intensity and more distress, depression and inadequate medication for pain relief (p < 0.001). Distress and depression were associated with higher pain intensity. The developed questionnaire had tested reliability (test-retest r = 0.89) and estimated validity. CONCLUSION: Cluster analysis showed constituent groups with a range of psychosocial effects in acute postoperative dental extraction pain and is associated with an increase in pain intensity.

Waveguide surface plasmon resonance studies of surface reactions on gold electrodes.

We describe the fabrication and characterisation of gold-coated graded index channel waveguide sensors designed for simultaneous electrochemical and surface plasmon resonance studies. The active sensing electrode area is a thin gold film between 0.5 and 5 mm in length and 200 microm wide deposited on top of a 3 microm wide waveguide which forms one arm of a Y-junction while the other arm of the Y-junction serves as a reference. Using these devices we have measured simultaneously the changes in transmittance through the device whilst carrying out cyclic voltammetry in either sulfuric or perchloric acid solution or during the deposition of an UPD layer of copper at the gold surface. In all cases we obtain stable and reproducible results which demonstrate the very high sensitivity of the devices to sub-monolayer changes occurring at the gold electrode surface. The response of these integrated optoelectrochemical devices is discussed in terms of a numerical model for the propagation of light within the waveguide structure.

Phase I pilot trial of the bispecific antibody MDXH210 (anti-Fc gamma RI X anti-HER-2/neu) in patients whose prostate cancer overexpresses HER-2/neu.

The goal of this study was to evaluate, in patients with prostate cancer, the toxicity profile and biologic activity of the bispecific antibody MDXH210, which has specificity for the non-ligand-binding site of the high-affinity immunoglobulin G receptor (Fc gamma RI) and the extracellular domain of the HER-2/neu proto-oncogene product. Patients with prostate cancer that expressed HER-2/neu were entered into a phase I dose-escalation trial of MDXH210. Patients received an intravenous infusion MDXH210 during a period of 2 h three times per week for 2 weeks and were monitored for toxicity. Pharmacokinetic and pharmacodynamic parameters were measured and included the biologic end points of monocyte-bound MDXH210, cytokine production, and clinical response. Seven patients were treated with MDXH210 doses ranging from 1 to 8 mg/m2. In general, MDXH210 was well tolerated, with only mild infusion-related malaise, fever, chills, and myalgias. No dose-limiting toxic effects were observed. Biologic effects included induction of low plasma concentrations of tumor necrosis factor-alpha and interleukin-6 observed immediately after MDXH210 infusion and 70% saturation of circulating monocyte-associated Fc gamma RI with MDXH210 at a dose level of 4 to 8 mg/m2. Five of six patients had stable prostate-specific antigen levels during the course of 40 days or more. Circulating plasma HER-2/neu levels decreased by 80% at days 12 and 29 (p = 0.03 and 0.06, respectively, by the Wilcoxon signed rank test). MDXH210 can be given safely to patients with HER-2/neu-positive prostate cancer in doses of at least 8 mg/m2. At the doses studied, biologic activity was demonstrated and characterized by binding of MDXH210 to circulating monocytes, release of monocyte-derived cytokines, a decrease in circulating HER-2/neu, and short-term stabilization of prostate-specific antigen levels.

Waveguide surface plasmon resonance sensor for electrochemically controlled surface reactions.

Electrochemical oxidation of the surface of a thin gold film overlaid on an optical waveguide and placed in a cell containing sulfuric acid is monitored by integrated optical surface plasmon resonance (IOSPR) combined with cyclic voltammetry. Waveguide transmittance correlates well with the charge transferred to and from the electrode to oxidize and reduce the surface, with a 60% reduction in transmittance being observed for complete formation of the surface oxide. IOSPR sensors combined with electrochemical measurement and control show potential for sensitive and robust integrated multisensors for electroactive species.

What I need to know about anthrax today.

The US Department of Defense has been concerned about the use of anthrax as a biological weapon by an enemy on US troops for a number of years. This is the reason why the military has embarked on a vaccination program for its forces deployed to regions of the world, which are considered high-risk areas. These areas have been in the Southwest Asia-Persian Gulf region as well as the Korean Peninsula. Many intelligence personnel have also been concerned about the possibility of biological agents being used by terrorists in the Continental United States. The recent anthrax incidents in Florida and elsewhere in the United States have significantly heightened concerns along these lines, especially following the terrorist attacks on the World Trade Center and the Pentagon on September 11th. The death of a Florida businessman, identification of infection in one of his co-workers, evidence of exposure and in some instances, cutaneous infection in some others, as well as evidence of contamination in their buildings, raised further concerns of the possibility of terrorist activity using biological warfare in this country. It is somewhat ironic that a disease that you probably haven't heard about since medical school has become the focus of national attention. Our goal in this communication is to refresh your understanding of what anthrax is and what you need to know about it today since anthrax is counted among the weapons of mass destruction. As a member of the medical profession, you will need to know what to look for in patients and how to treat them if they are contaminated with this biological agent. You will also have to serve as the "front line" of the public health system and alert the police and public health agencies.

Clinical outcome in female patients with pelvic pain and normal pelvic US findings.

PURPOSE: To understand the clinical outcome in patients with pelvic pain and negative pelvic ultrasonographic (US) findings. MATERIALS AND METHODS: Data from 86 female patients with pelvic pain and normal pelvic US findings seen in a US section over a 15-month period were evaluated 6-21 months after US. Medical chart review follow-up was available in 86 patients, and telephone interview follow-up was conducted in 85 patients. We collected data on the outcome of pain; subsequent imaging, treatment, and surgery; and the duration of pain before US. RESULTS: Pelvic pain improved or resolved in 66 (77%) of the 86 patients. In the group with acute or subacute pain (duration 6 months), seven (50%) of the 14 patients had improved symptoms. Further imaging (13 studies) was performed in nine patients: Twelve studies were normal, and one computed tomographic scan (1 month after the first US examination) showed diverticulitis. Eleven patients underwent 19 surgical procedures (endometrial sampling, hysteroscopy, laparoscopy, or hysterectomy). Four demonstrated clinically important disease (endometriosis and pelvic varices, endometriosis, adenomyosis, or pelvic adhesions). CONCLUSION: The majority of patients with pelvic pain and normal pelvic US findings had improvement or resolution of their symptoms, and those with acute or subacute pain were more likely to report improvement or resolution of pain than those with chronic pain. The yield of further imaging studies was low, and disease was identified in a minority of patients.

Prevalence and significance of heterogeneous testes revealed on sonography: ex vivo sonographic-pathologic correlation.

OBJECTIVE: Heterogeneous or mottled testes in middle-aged or elderly men are often encountered on sonography. To determine the prevalence, cause, and significance of this finding, we examined 50 testes (25 pairs) from autopsy specimens with sonography and gross and microscopic pathology. SUBJECTS AND METHODS: Testicles were obtained at autopsy from a series of 25 male cadavers (age range, 16-80 years; mean, 62 years). Eight subjects had a history of cancer. Ex vivo sonography was performed and two board-certified radiologists graded the testis by consensus as normal, heterogeneous, or "other abnormality" (cyst, dilated rete, echogenic focus, or halo). Microscopic pathology was obtained in all abnormal (sonographic or gross pathologic) testes. The severity of tubular sclerosis (atrophy) was graded on a scale of 0-3+ by a uropathologist. RESULTS; No testicular tumors were detected. Sonography revealed normal testes in 33 specimens, heterogeneous in seven specimens, and other in 10 specimens (one cyst, two dilated rete, three halos, and seven echogenic foci). Histology revealed that all seven cases of mottled or heterogeneous testis corresponded to extensive (grades 2 and 3) regions of tubular sclerosis (atrophy). A new sonographic finding of the "halo" was attributable to a thickened, adherent tunica albuginea. CONCLUSION: The prevalence of heterogeneous testes in this elderly population was 14% and represented seminiferous tubule atrophy and sclerosis. The prevalence of clinically occult testicular cancer or metastases in this autopsy subject group was nil. Older patients with a mottled or heterogeneous testis, normal color Doppler flow, and no palpable abnormality probably do not need sonographic follow-up.

A randomized phase II trial comparing two different sequence combinations of autologous vaccine and human recombinant interferon gamma and human recombinant interferon alpha2B therapy in patients with metastatic renal cell carcinoma: clinical outcome and analysis of immunological parameters.

PURPOSE: The clinical observation of spontaneous regression in patients with renal cell carcinoma (RCC) and the response to various immunotherapeutic therapies strongly suggest a role for the host immune system in this disease. Prior studies showed that sequential administration of interferon (IFN) gamma and IFN alpha to RCC patients was safe. Clinical responses as well as immune changes in the peripheral blood mononuclear cell compartment were observed. Autologous tumor cell vaccines (AV) have also demonstrated activity in renal cell carcinoma. We hypothesize that the addition of AV to sequential IFN gamma and a therapy might improve the tumor-specific immune response by providing an appropriate source of antigen in the appropriate cytokine environment. To our knowledge, this is the first trial using AV combined with IFN alpha and IFN gamma. The purpose of this study was to evaluate the feasibility of manufacturing and administering (AV) from resected tumor samples, and administration of AV with combination IFN gamma and IFN alpha therapy. Finally, the impact on immunological parameters of these treatment options was assessed. MATERIALS AND METHODS: Patients with metastatic RCC were randomly assigned to receive AV plus bCG along with a sequential administration of IFN gamma and a either together or after initiation of vaccine. Toxicity and clinical responses were evaluated. Modulations of the immune system were investigated by analyzing phenotype, cytokine mRNA expression, T cell proliferation and cytotoxicity in the peripheral blood mononuclear cell compartment. RESULTS: Fourteen patients with metastatic renal cell carcinoma were enrolled in this study; 9 were available for response evaluation. In a 70 day period, 3 (33%) showed mixed responses, 5 (56%) stable disease and 1 (11%) progression of disease. Toxicities were consistent with previous clinical reports. In the flow-cytometry phenotype analysis, stimulation of distinct subsets of circulating T-lymphocytes and a decrease of CD8+ T cell subsets was demonstrated. T-cell proliferation to allogeneic tumor cell stimulation improved following treatment. IL-4 and IL-5 mRNA levels were reduced in all patients after treatment. Patients who responded to treatment did not produce any IL-4 mRNA at all, before or after treatment. CONCLUSIONS: AV with IFNgamma and IFNalpha therapy might induce a MHC class-mediated cytotoxic T lymphocyte (CTL) response. We suggest that adequate therapy might direct T cell response toward a Th1 type response. We hypothesize a state of improved immune readiness in patients who might eventually respond to immunotherapy.

Ion-exchanged tapered-waveguide laser in neodymium-doped BK7 glass.

We report what is to our knowledge the first operation of a planar dielectric tapered-waveguide laser. The waveguide laser is fabricated by potassium-ion exchange in Nd(3+) -doped BK7 glass and consists of a single-mode channel waveguide of a few micrometers' width followed by a linear taper up to a broad region with a width of ~180microm . A slope efficiency of 42% is found both in the tapers and in standard channel waveguides fabricated upon the same substrate, indicating that the tapers and the channels have similar internal losses; hence the low-loss nature of the tapered beam expansion. The output from either end of the tapered structure is found to be nearly diffraction limited.

Consistency of retrospective triage decisions as a standardised instrument for audit.

OBJECTIVES: To determine the level of agreement between senior medical staff when asked to perform retrospective case note review of nursing triage decisions, both before and after development of a consensus approach. METHODS: Four medical reviewers independently allocated triage categories to 50 emergency department patients after review of their case notes. They were blind to the identity of the triage nurse and their triage categorisation. The process was repeated twice, firstly after agreement on a consensus approach and then using formal guidelines. RESULTS: Agreement between reviewers was initially fair to moderate (kappa = 0.27 to 0.53). This failed to improve after development of a consensus approach (kappa = 0.29 to 0.57). There was a trend towards better agreement when guidelines were used but agreement was still only moderate (kappa = 0.31 to 0.63). CONCLUSIONS: Audit of nurse triage categorisation by senior medical staff performing case note review has only fair to moderate consistency between reviewers. Use of this technique will result in frustration among those whose performance is being audited if they recognise inconsistency in the standard they are compared against.

Integrated optical surface plasmon resonance immunoprobe for simazine detection.

This paper presents the detailed design and characterisation of a regenerable integrated optical surface plasmon resonance immunoprobe as a detector for the triazine herbicide simazine. A sensor design theoretically optimised for use in the aqueous environment is presented and its fabrication described. Experimental results on the sensitivity to changes in bulk refractive index of the analyte and on non-specific binding of ovalbumin are presented. Binding inhibition immunoassays were conducted for simazine and the lower limit of detection determined to be 0.16 microgram/l using anti-simazine IgG antibodies and 0.11 microgram/l using anti-simazine Fab fragments. A sample test cycle of 20 min was established.

Focal aneurysmal dilatation of subchorionic vessels simulating chorioangioma.

Subchorionic vascular aneurysms of the placenta are rare lesions and may present confusion with chorioangioma or focal mesenchymal dysplasia on sonography. To our knowledge, the findings of placental aneurysms have not been reported in the ultrasound literature. We present a case with detailed sonographic evaluation, including spectral and color Doppler and pathological analysis, that was mistaken for chorioangioma prenatally. Knowledge of this benign entity may allow the sonologist to recommend conservative management in similar cases.

Prostate seed implant quality assessment using MR and CT image fusion.

PURPOSE: After a seed implant of the prostate, computerized tomography (CT) is ideal for determining seed distribution but soft tissue anatomy is frequently not well visualized. Magnetic resonance (MR) images soft tissue anatomy well but seed visualization is problematic. We describe a method of fusing CT and MR images to exploit the advantages of both of these modalities when assessing the quality of a prostate seed implant. METHODS AND MATERIALS: Eleven consecutive prostate seed implant patients were imaged with axial MR and CT scans. MR and CT images were fused in three dimensions using the Pinnacle 3.0 version of the ADAC treatment planning system. The urethra and bladder base were used to "line up" MR and CT image sets during image fusion. Alignment was accomplished using translation and rotation in the three ortho-normal planes. Accuracy of image fusion was evaluated by calculating the maximum deviation in millimeters between the center of the urethra on axial MR versus CT images. Implant quality was determined by comparing dosimetric results to previously set parameters. RESULTS: Image fusion was performed with a high degree of accuracy. When lining up the urethra and base of bladder, the maximum difference in axial position of the urethra between MR and CT averaged 2.5 mm (range 1.3-4.0 mm, SD 0.9 mm). By projecting CT-derived dose distributions over MR images of soft tissue structures, qualitative and quantitative evaluation of implant quality is straightforward. CONCLUSIONS: The image-fusion process we describe provides a sophisticated way of assessing the quality of a prostate seed implant. Commercial software makes the process time-efficient and available to any clinical practice with a high-quality treatment planning system. While we use MR to image soft tissue structures, the process could be used with any imaging modality that is able to visualize the prostatic urethra (e.g., ultrasound).

Interactive 3-dimensional computerized tomography reconstruction in evaluation of the living renal donor.

PURPOSE: We evaluated the efficacy of helical computerized tomography and a software program capable of 3-dimensional (D) reconstruction in assessment of the living renal donor. MATERIALS AND METHODS: A total of 20 consecutive patients (40 renal units) were evaluated using computer software and anatomical findings were assessed. Patient time and charges were compared with renal angiography and excretory urography (IVP). RESULTS: A total of 25 anomalies were identified in 21 kidneys using 3-D imaging. Accessory arteries were seen in 13 kidneys. Abnormal venous anatomy was found in 7 kidneys, including circumaortic renal veins in 2, multiple veins in 4 and a renal vein that drained into the gonadal vein in 1. Collecting system anomalies included a bifid pelvis and a duplicate ureter in 1 case each. Benign cysts were noted in 3 kidneys. Three patients were excluded from study due to persistent hypertension, death of the recipient before transplantation and bilateral aberrant vasculature, respectively. Intraoperative findings of the 17 kidneys removed for transplantation correlated with those demonstrated on 3-D reconstruction. Total preoperative imaging charges were decreased 50% compared to renal angiography and IVP, and the procedure related discomfort and potential morbidity were reduced significantly. Procedure time was reduced from 7 hours to 30 minutes with no resultant mandatory time off work or periprocedure restrictions in patient diet and/or activity. CONCLUSIONS: The enhanced 3-D computerized tomography reformation and reconstruction process appears to be as accurate as renal angiography for arterial anatomy, and more sensitive than renal angiography and IVP in evaluating venous and parenchymal anatomy. This software program provides superior and interactive imaging at substantially lower cost with minimal patient time, discomfort and morbidity.

Sensitivity enhancement of integrated optical sensors by use of thin high-index films.

The proportion of power carried in the superstrate medium by the guided modes of integrated optical waveguides can be increased by the addition of a thin high-index film. Enhanced refractive-index sensing is demonstrated with channel waveguide Mach-Zehnder interferometers with Ta(2)O(5) overlays. Sensitivity increases by a factor greater than 50, and a detection limit better than 5 x 10(-7) is obtained. This approach is broadly applicable to sensing at waveguide surfaces where the strength of evanescent fields dictates performance.

Intervillous blood flow in patients with missed abortion.

AIM: Analysis of the color Doppler features of intervillous flow in cases of missed abortion, and their comparison with the findings in normal pregnancy. METHODS: Transvaginal color and pulsed Doppler was used in the analysis of 38 patients with missed abortion and 40 patients with normal pregnancy. The gestational age ranged from 6 to 11 weeks. Repeated analysis of variance was used to compare the groups. RESULTS: Two types of Doppler signals were detected in the intervillous space: pulsatile and continuous. Impedance in the intervillous space of both groups did not change significantly with the gestational age. For the group with missed abortion, the mean resistance index (RI) was 0.37 +/- 0.03 and pulsatility index (PI) 0.75 +/- 0.07. For the control group, the mean RI was 0.36 +/- 0.02 and PI 0. 72 +/- 0.04. The differences in RI and PI for all gestational age groups and between the two patient groups were not statistically significant. With advancing gestation, continuous, venous-like signal became stronger and randomly dispersed throughout the placenta. Peak flow velocity values obtained from both groups did not change significantly with gestational age, nor between the two groups. Conclusion. The new generation of sensitive Doppler units can detect the intervillous flow as a continuous progressive process at 6-11 weeks of gestation. The vascular resistance in the intervillous space does not change in cases of missed abortion.