A staff questionnaire study of MRSA infection on ENT and general surgical wards.

Methicillin-resistant Staphyloccocus aureus (MRSA) infection has received much attention in both the medical and non-medical press. However, it is not widely encountered on ENT wards, given the profile of short-stay, relatively well patients, although its impact seems to be increasing. We wished to explore the knowledge and attitudes towards MRSA on general surgical and ENT wards, and see if there were any significant differences between specialties, or between doctors and nurses. A 13-item questionnaire with a Likert scale response with six knowledge questions and seven attitude questions was prepared. It was completed anonymously by all nursing and medical staffs on the ENT and general surgical wards of a large District General Hospital. ENT doctors displayed the lowest knowledge and attitude scores; however, this only attained significance in terms of the knowledge of the difference between infection and colonization. Overall, nurses displayed significantly more positive attitudes towards MRSA patients than doctors, but knowledge scores were not significantly different between professions. The study suggests a lack of knowledge about and preponderance of negative attitudes towards MRSA amongst ENT doctors. The difference between colonization and infection is not well understood. Reasons for this may include the relative rarity of MRSA cases on ENT wards.

Lorenz Curve and Gini coefficient: novel tools for analysing seasonal variation of environmental radon gas.

Using a methodology derived from Economics, the Lorenz Curve and Gini Coefficient are introduced as tools for investigating and quantifying seasonal variability in environmental radon gas concentration. While the Lorenz Curve presents a graphical view of the cumulative exposure during the course of the time-frame of interest, typically one year, the Gini Coefficient distils this data still further, to provide a single-parameter measure of temporal clustering. Using the assumption that domestic indoor radon concentrations show annual cyclic behaviour, generally higher in the winter months than in summer, published data on seasonal variability of domestic radon concentration levels, in various areas of the UK, Europe, Asia and North America, are analysed. The results demonstrate significantly different annual variation profiles between domestic radon concentrations in different countries and between regions within a country, highlighting the need for caution in ascribing seasonal correction factors to extended geographical areas. The underlying geography, geology and meteorology of a region have defining influences on the seasonal variability of domestic radon concentration, and some examples of potential associations between the Gini Coefficient and regional geological and geographical characteristics are proposed. Similar differences in annual variation profiles are found for soil-gas radon measured as a function of depth at a common site, and among the activity levels of certain radon progeny species, specifically (214)Bi deposited preferentially in human body-fat by decay of inhaled radon gas. Conclusions on the association between these observed measures of variation and potential underlying defining parameters are presented.

Radon remediation of a two-storey UK dwelling by active sub-slab depressurisation: effects and health implications of radon concentration distributions.

Radon concentration levels in a two-storey detached single-family dwelling in Northamptonshire, UK, were monitored continuously throughout a 5-week period during which active sub-slab depressurisation remediation measures were installed. Remediation of the property was accomplished successfully, with both the mean radon levels and the diurnal variability greatly reduced both upstairs and downstairs. Following remediation, upstairs and downstairs radon concentrations were 33% and 18% of their pre-remediation values respectively: the mean downstairs radon concentration was lower than that upstairs, with pre- and post-remediation values of the upstairs/downstairs concentration ratio, R(U/D), of 0.81 and 1.51 respectively. Cross-correlation between upstairs and downstairs radon concentration time-series indicates a time-lag of the order of 1 h or less, suggesting that diffusion of soil-derived radon from downstairs to upstairs either occurs within that time frame or forms a relatively insignificant contribution to the upstairs radon level. Cross-correlation between radon concentration time-series and the corresponding time-series for local atmospheric parameters demonstrated correlation between radon concentrations and internal/external pressure difference prior to remediation; this correlation disappears following remediation. Overall, these observations provide further evidence that radon concentration levels within a dwelling are not necessarily wholly determined by the effects of soil-gas advection, and further support the suggestion that, depending on the precise content of the building materials, upstairs radon levels, in particular, may be dominated by radon exhalation from the walls of the dwelling, especially in areas of low soil-gas radon.

Domestic radon remediation of UK dwellings by Sub-Slab Depressurisation: evidence for a baseline contribution from constructional materials.

To quantify the effectiveness of Sub-Slab Depressurisation, widely used in the United Kingdom (U.K.) to mitigate indoor radon gas levels in residential properties, a study was made of radon concentration data collected from a set of 170 homes situated in Radon Affected Areas in Northamptonshire and neighbouring counties, remediated using conventional sump/pump technology. A high incidence of satisfactory remediation outcomes was achieved, with 100% of the houses remediated demonstrating post-remediation radon concentrations below the U.K. domestic Action Level of 200 Bq m(-3), while more than 75% of the sample exhibited radon mitigation factors (defined as the ratio of radon concentrations following and prior to remediation) <0.2. Two systematic trends are identified. Firstly, absolute radon concentration reduction following remediation is directly proportional to initial radon concentration, with a mean reduction factor of 0.96 and a residual component of around 75 Bq m(-3). Secondly, houses with lower initial radon concentrations demonstrate poorer (higher) mitigation factors. These observations support a model in which the total indoor radon concentration within a dwelling can be represented by two principal components, one susceptible to mitigation by sub-slab depressurisation, the other remaining essentially unaffected. The first component can be identified with radon emanating from the subsoil and bedrock geologies, percolating through the foundations of the dwelling as a component of the soil-gas, and potentially capable of being attenuated by sub-slab depressurisation or radon-barrier remediation technologies. The second contribution can be identified with radon emanating from materials used in the construction of the dwelling with a further contribution from the natural background level, and is essentially unaffected by ground-level remediation strategies. Modelling of a multi-component radon dependency using ground-radon attenuation factors derived from the experimental data, in conjunction with typical background and structural-radon levels, yields behaviour in good agreement with the observed dependence of mitigation factor on initial radon concentration.

A detailed evaluation of the individual health benefits arising in a domestic property following radon remediation--a case-study in Northamptonshire, U.K.

Radon gas occurs naturally in the environment with variable distribution, concentrating sufficiently in the built environment in some areas to pose a public health risk. Radon levels can be successfully reduced in affected buildings, and large-scale remediation programmes have been justified in terms of accrued costs and benefits. We present results from a house where radon levels in the main living-room and master bedroom were monitored on an hourly basis over extended periods before and after radon remediation by sub-slab depressurisation. These results were combined with results from a recent occupancy survey to estimate the health impact on occupants spending varying times in the home. Prior to remediation, mean hourly radon exposure is moderately linearly correlated (R(2)=0.66-0.78) with time spent in the house. Following remediation, correlation is significantly enhanced (R(2)=0.91-0.95), but the exposure reduction of an occupant following remediation is less than that predicted using the NRPB protocol.

The value of Seasonal Correction Factors in assessing the health risk from domestic radon: a case study in Northamptonshire, UK.

Following an intensive survey of domestic radon levels in the United Kingdom (UK), the former National Radiological Protection Board (NRPB), now the Radiation Protection Division of the Health Protection Agency (HPA-RPD), established a measurement protocol and promulgated Seasonal Correction Factors applicable to the country as a whole. Radon levels in the domestic built environment are assumed to vary systematically and repeatably during the year, being generally higher in winter. The Seasonal Correction Factors therefore comprise a series of numerical multipliers, which convert a 1-month or 3-month radon concentration measurement, commencing in any month of the year, to an effective annual mean radon concentration. In a recent project undertaken to assess the utility of short-term exposures in quantifying domestic radon levels, a comparative assessment of a number of integrating detector types was undertaken, with radon levels in 34 houses on common geology monitored over a 12-month period using dose-integrating track-etch detectors exposed in pairs (one upstairs, one downstairs) at 1-month and 3-month resolution. Seasonal variability of radon concentrations departed significantly from that expected on the basis of the HPA-RPD Seasonal Correction Factor set, with year-end discontinuities at both 1-month and 3-month measurement resolutions. Following this study, monitoring with electrets was continued in four properties, with weekly radon concentration data now available for a total duration in excess of three and a half years. Analysis of this data has permitted the derivation of reliable local Seasonal Correction Factors. Overall, these are significantly lower than those recommended by HPA-RPD, but are comparable with other results from the UK and from abroad, particularly those that recognise geological diversity and are consequently prepared on a regional rather than a national basis. This finding calls into question the validity of using nationally aggregated Seasonal Correction Factors, especially for shorter exposures, and the universal applicability of these corrections is discussed in detail.

Health implications of radon distribution in living rooms and bedrooms in U.K. dwellings--a case study in Northamptonshire.

Environmental radon exposure of residents of domestic premises in the United Kingdom (UK) and elsewhere in Europe is estimated on the basis of the measured radon concentrations in, and the relative occupancies of, the principal living room and bedroom. While studies on radon concentration variability in the individual units in apartment blocks in various countries have been described, little data has been reported on variability in two-storey single-family dwellings, and the majority of extant studies consolidate living room and bedroom data early in the analysis. To investigate this further, detailed analysis was made of radon concentration data from a set of thirty-four homes situated in areas of Northamptonshire known to exhibit high radon levels. All homes were of typical UK construction of brick/block/stone walls under a pitched tile/slate roof. Approximately 50% of the sample were detached houses, the remainder being semi-detached (duplex) or terraced (row-house). Around 25% of the sample possessed cellars, while 12% were single-storey dwellings (bungalows), reflecting the typical incidence of this type of dwelling in England. In the two-storey homes, all monitored bedrooms were on the upper floor. Distribution of the ratios of bedroom/living room radon concentrations (BR/LR ratio) in individual properties was left-skewed (mean 0.67, median 0.73, range 0.05-1.05) with a tail extending to just above 1.0. The mean is consistent with the outcome of earlier extensive studies in England, while the variability depends principally on the characteristics of the property, and not on seasonal factors. In a small set of homes, the BR/LR ratio was anomalously low, (mean 0.3). BR/LR ratios in single-storey homes clustered around a value of 1.0, indicating that house design, rather than lifestyle, is the dominant factor in determining bedroom radon concentrations. Homes with higher mean annual radon concentrations showed lower BR/LR ratios, supporting our proposal that, in some homes, radon emanation from building materials may comprise a significant component of the overall radon level.

Radon mitigation in domestic properties and its health implications--a comparison between during-construction and post-construction radon reduction.

Although United Kingdom (UK) Building Regulations applicable to houses constructed since 1992 in Radon Affected Areas address the health issues arising from the presence of radon in domestic properties and specify the installation of radon-mitigation measures during construction, no legislative requirement currently exists for monitoring the effectiveness of such remediation once construction is completed and the houses are occupied. To assess the relative effectiveness of During-Construction radon reduction and Post-Construction remediation, radon concentration data from houses constructed before and after 1992 in Northamptonshire, UK, a designated Radon Affected Area, was analysed. Post-Construction remediation of 73 pre-1992 houses using conventional fan-assisted sump technology proved to be extremely effective, with radon concentrations reduced to the Action Level, or below, in all cases. Of 64 houses constructed since 1992 in a well-defined geographical area, and known to have had radon-barrier membranes installed during construction, 11% exhibited radon concentrations in excess of the Action Level. This compares with the estimated average for all houses in the same area of 17%, suggesting that, in some 60% of the houses surveyed, installation of a membrane has not resulted in reduction of mean annual radon concentrations to below the Action Level. Detailed comparison of the two data sets reveals marked differences in the degree of mitigation achieved by remediation. There is therefore an ongoing need for research to resolve definitively the issue of radon mitigation and to define truly effective anti-radon measures, readily installed in domestic properties at the time of construction. It is therefore recommended that mandatory testing be introduced for all new houses in Radon Affected Areas.

Identification of tidal and climatic influences within domestic radon time-series from Northamptonshire, UK.

Analysis of data from extended radon concentration time-series obtained from domestic and public-sector premises in the vicinity of Northampton, UK, and elsewhere, confirms that, in addition to the generally recognised climatic influences, 'Earth Tides' and 'Ocean Tidal Loading' drive periodic radon liberation via geophysically driven groundwater level variations. Regression and cross-correlation with environmental parameters showed some degree of association between radon concentration and mean temperature and rainfall. Fourier analysis of radon time-series identified periodicities of the order of 23.9 h (luni-solar diurnal, K(1)), 24.0 h (solar day, S(1)), 168 h (1 week) and 661.3 h (lunar month, M(m)), while cross-correlation with tidal strength demonstrated periodicity of the order of 14 days (lunar-solar fortnight, M(f)). These results suggest that astronomical influences, including tides, play a part in controlling radon release from the soil.

Radon anomalies preceding earthquakes which occurred in the UK, in summer and autumn 2002.

During the course of an investigation into domestic radon levels in Northamptonshire, two hourly sampling real-time radon detectors were operated simultaneously in separate locations 2.25 km apart in Northampton, in the English East Midlands, for a 25-week period. This period of operation encompassed the period in September 2002 during which the Dudley earthquake (magnitude - 5.0) and smaller aftershocks occurred in the English West Midlands, UK. We report herein our observations regarding the occurrence of simultaneous short-period radon anomalies and their timing in relation to the Dudley, and other, earthquakes which occurred during the monitoring period. Analysis of the radon time-series reveals a short period when the two time-series displayed simultaneous in-phase short-term (6-9 h) radon anomalies prior to the main Dudley earthquake. Subsequent investigation revealed that a similar period occurred prior to another smaller but recorded earthquake in the English Channel.

The use of the Montgomery T-tube in difficult paediatric airways.

OBJECTIVE: We report our experience of using Montgomery T-tubes in children. METHOD: A retrospective review of medical records was performed. Data collected included particular clinical circumstances, the details of usage of the tube, and the eventual outcome. RESULTS: Between January 1999 and October 2003, our unit performed 293 tracheostomies, 76 laryngotracheal reconstructions and 31 other major airway procedures in children. 10 children have had a Montgomery T-tube inserted. Nine were boys. In eight cases, the T-tube was used because of severe granulations and subsequent fibrotic narrowing in the subglottis after laryngotracheal reconstruction surgery. These children had undergone between one and four major procedures prior to T-tube placement. In the other two cases, the T-tube was used to stent severe glottic and supraglottic stenosis (due to previous laser surgery for papillomas in one case and congenital ectodermal dysplasia in the other). At the time of T-tube placement the children were aged 2-18 years (median 8 years). The tube was initially fitted so as to protrude above the glottis in all cases. In one case, the T-tube was removed on the first post-operative day. One tube was removed after a week due to severe crusting. One tube blocked after 2 weeks. One child had re-stenosis in the supraglottis necessitating the placement of a T-tube with a longer upper limb. Two children have subsequently died from non-airway causes. Two children still have their T-tube in situ, one of whom is due to have it removed in the next few weeks. Six have been successfully decannulated and are well. CONCLUSIONS: The Montgomery T-tube provides a useful adjunct to the management of a small number of children with the most difficult airway problems. Its use can be problematic, however, and requires awareness of its specific complications. We have confined usage to complex stenoses where a reconstruction would be inappropriate, or (in one instance) to stent an unsupported larynx after revision reconstruction (tracheal resection).

Time-integrating radon gas measurements in domestic premises: comparison of short-, medium- and long-term exposures.

To identify the most applicable technology for the short-term assessment of domestic radon levels, comparative assessments of a number of integrating detector types, including track-etch, electret and activated charcoal were undertaken. Thirty-four unremediated dwellings in a high-radon area were monitored using track-etch detectors exposed for one-month and three-month periods. In parallel, one-week measurements were made in the same homes at one-month intervals, using co-located track-etch, charcoal and electret detectors exposed simultaneously, while three of the homes were also monitored by continuous-sampling detectors at hourly intervals over extended periods. Calibration of dose-integrating devices against each other and against continuous-monitoring systems confirmed good responsivity and linearity. Although track-etch, charcoal and electret devices are suitable in principle for one-week measurements, zero-exposure offset and natural radon variability cause many one-week results to be equivocal, necessitating repetition of the measurement. One-week exposures can be reliable indicators in low-radon areas or for new properties, but in high-radon areas, the use of three-month exposures is indicated. This analysis also established confidence limits for short-term measurements.

Interpreting short and medium exposure etched-track radon measurements to determine whether an action level could be exceeded.

Radon gas is naturally occurring, and can concentrate in the built environment. It is radioactive and high concentration levels within buildings, including homes, have been shown to increase the risk of lung cancer in the occupants. As a result, several methods have been developed to measure radon. The long-term average radon level determines the risk to occupants, but there is always pressure to complete measurements more quickly, particularly when buying and selling the home. For many years, the three-month exposure using etched-track detectors has been the de facto standard, but a decade ago, Phillips et al. (2003), in a DEFRA funded project, evaluated the use of 1-week and 1-month measurements. They found that the measurement methods were accurate, but the challenge lay in the wide variation in radon levels - with diurnal, seasonal, and other patterns due to climatic factors and room use. In the report on this work, and in subsequent papers, the group proposed methodologies for 1-week, 1-month and 3-month measurements and their interpretation. Other work, however, has suggested that 2-week exposures were preferable to 1-week ones. In practice, the radon remediation industry uses a range of exposure times, and further guidance is required to help interpret these results. This paper reviews the data from this study and a subsequent 4-year study of 4 houses, re-analysing the results and extending them to other exposures, particularly for 2-week and 2-month exposures, and provides comprehensive guidance for the use of etched-track detectors, the value and use of Seasonal Correction Factors (SCFs), the uncertainties in short and medium term exposures and the interpretation of results.

Analysis of the individual health benefits accruing from a domestic radon remediation programme.

Although radon can be present within buildings at sufficient levels to pose a health risk, levels can be reduced relatively easily. Recent studies on a group of radon-remediated homes, based on assessment of collective population-average risk coefficients, have estimated the benefits and cost effectiveness accruing from remediation and have confirmed that domestic remediation in UK radon Affected Areas would result in significantly reduced cancer risks to the population in those areas. Although the population-average approach used hitherto has applied occupancy and lung-cancer risk factors, these are potentially misleading in assessing discrete populations. The study reported here uses the recently developed European Community Radon Software (ECRS) to quantify individual risks in a sample of householders who remediated their homes following indications that radon levels exceeded the action level. The study proceeds from population-averaged to 'individual risk' evaluation, successfully comparing individual and collective risk assessments, and demonstrates that those who remediate are not representative of the general population. Health benefits accruing from remediation are three times lower than expected, largely because remediators are older, live in smaller households, and smoke less than the population average, leading to the conclusion that the current strategy employed in the UK is failing to target those most at risk.

The practical use of electrets in a public health radon remediation campaign.

As part of a long-term assessment of domestic radon in Northamptonshire, England, a batch of 50 commercially available electrets was deployed for nearly 1,000 exposures, individual exposure periods ranging from one to eight weeks. Responsivity was comparable with that of recently-calibrated Durridge RAD-7 continuously-monitoring equipment. Voltage history analysis indicated mean voltage decay during manufacturers' QA assessment of 0.059+/-0.026 Vday(-1), increasing to 0.114+/-0.073 Vday(-1) during storage to first use and to 0.204+/-0.49 Vday(-1) during inter-deployment storage. At a representative elevated radon concentration of 500 Bqm(-3), the resulting perturbation is 3% over a 7-day deployment; at the typical mean Northamptonshire level of 80 Bqm(-3) it approaches 22%. Each electret can be used for up to 25 measurements, which makes the technology attractive for organisational use. It is not suited for deployment by individual householders.

Does a specialist voice clinic change ENT clinic diagnosis?

General ENT clinics lack the high quality diagnostic equipment and multidisciplinary advice that is available in the voice clinic. We wished to find out if referral to a specialist voice clinic from general ENT consultant clinics resulted in a change in diagnosis. Lists of voice clinic attendees were reviewed between January 2003 and May 2004. Notes were obtained for 20 patients who attended voice clinic after referral from a general ENT clinic: 3 had no diagnosis on referral to voice clinic, a diagnosis was given after attendance; 8 had their referring diagnosis changed by attendance; and 9 had no change. The voice clinic adds diagnostic value to the service available in general ENT clinics.

Statin myotoxicity is associated with changes in the cardiopulmonary function.

The mechanism of the muscle toxicity associated with lipid-lowering therapy remains obscure. Pathological and biochemical findings in patients with statin myotoxicity suggest impaired fatty acid oxidation. Exhaled gas analysis can be used to assess substrate utilization including fatty acid oxidation. In order to determine if muscle toxicity due to lipid-lowering therapy might be related to abnormalities in lipid oxidation, exhaled gas analysis was performed in the fasted state on 11 patients subsequent to statin-associated myositis reactions. Results were compared to those of 16 normal controls who were measured both on and off statin therapy. Post-myositis patients showed a depressed anaerobic threshold (AT) (P=0.009) compared to controls while age-adjusted maximal oxygen consumption (VO2max) and ventilatory efficiency (VE/VCO2) were not significantly different. The fasting respiratory exchange ratio (RER) of post-myositis patients off statins was abnormally increased (P=0.00001) as was their S1-slope (P=0.023). Controls demonstrated a significant increase in their RER while taking statins consistent with decreased lipid oxidation (P <0.00001). These findings suggest that abnormal lipid oxidation in certain patients may predispose them to the myotoxicity caused by lipid-lowering therapies.

Differences in TIMI frame count following successful reperfusion with stenting or percutaneous transluminal coronary angioplasty for acute myocardial infarction.

The Thrombolysis In Myocardial Infarction (TIMI) flow grade achieved in the infarct-related artery (IRA) during reperfusion therapy for acute myocardial infarction (AMI) is directly related to myocardial salvage. Recently, several series have demonstrated the safety of stenting in AMI and documented a larger postprocedure luminal diameter than that found at angioplasty, although no study has compared the effect of PTCA and stenting in AMI on flow characteristics of the IRA. The residual stenosis and the number of frames required to opacify standardized angiographic landmarks normalized for vessel length (corrected TIMI frame count) or compared with flow in a corresponding normal coronary artery (TIMI frame count index) were determined for the IRA of 39 patients who underwent angioplasty or stenting for AMI. Baseline characteristics were similar for the 20 patients who underwent stenting and the 19 patients who underwent percutaneous transluminal coronary angioplasty. After intervention, the luminal diameter was greater (3.24 vs 2.09 mm, p <0.0001) and the residual stenosis was less (-9.4% vs. 26.7%, p <0.0001) after stenting than after percutaneous transluminal coronary angioplasty. These changes in vessel geometry were associated with a lower corrected TIMI frame count (16.1 vs 30.7, p <0.002) and a lower TIMI frame count index (0.68 vs 1.3, p <0.002). Thus, stenting in AMI is associated with a greater postprocedure luminal diameter and improvement in coronary blood flow as measured by the TIMI frame count method.

Effects of Palmaz-Schatz stents on angled coronary arteries.

This review of consecutive, single Palmaz-Schatz stent implantations reveals that coronary lesion angulation does not result in suboptimal results or increased restenosis after stenting. The implantation of a rigid stent at an arterial hinge point is associated with an increased restenosis rate.

Equations describing passive transport through vesicular membranes.

A theoretical description of the kinetics of the passive transport of both lipophobic and lipophilic nonelectrolytes, weak acids, and weak bases through membranes of large unilamellar vesicles is discussed. Equations are derived which may be used to obtain permeability coefficients and predict the extent of LUV entrapment of permeant molecules. Theoretical curves are generated to illustrate the difference between lipophobic and lipophilic permeation. By applying a diffusional approach rather than a simple first order kinetic approach to the problem of passive transport, some of the inconsistencies observed in other works are corrected.