Validation of the Kinetik Blood Pressure Monitor-Series 1 for use in adults at home and in clinical settings, according to the 2002 European Society of Hypertension International Protocol on the validation of blood pressure devices.

The aim of this study was to assess the blood pressure (BP) measurement accuracy of the Kinetik Blood Pressure Monitor-Series 1 (BPM-1) for use in home or clinical settings according to the 2002 European Society of Hypertension International Protocol (ESH-IP). Forty-two participants were recruited to fulfil the required number of systolic and diastolic BP measurements according to the ESH-IP. Nine sequential same-arm BP readings were measured and analysed for each participant using the test device and observer mercury standard readings according to the 2002 ESH-IP. Forty one participants were used to obtain 33 sets of systolic and diastolic BP readings and were included in the analysis. Mean difference between the device measurements and the observer (mercury standard) measurements was 1.1 ± 7.2/1.1 ± 6.8 mmHg (mean ± standard deviation; systolic/diastolic). The number of systolic BP differences between the test and observer measurements that fell within 5, 10 and 15 mmHg was 65, 86 and 92. For diastolic readings, the number of test-observer measurement differences within 5, 10 and 15 mmHg was 77, 91 and 94. The number of participants with at least two out of three differences within 5 mmHg was 28 for systolic and 40 for diastolic BP readings. Three participants had no differences between the test and observer measurements within 5 mmHg in both the systolic and diastolic measurement categories. The Kinetik BPM-1 device fulfilled the requirements of the ESH-IP validation procedure and can be recommended for clinical use and self-measurement within the home.

Response to infection control challenges in the deployed setting: Operations Iraqi and Enduring Freedom.

BACKGROUND: Infections caused by multidrug-resistant organisms (MDROs), including Acinetobacter, have complicated the care of military personnel injured in Operations Iraqi and Enduring Freedom. Cumulative data suggest that nosocomial transmission of MDROs in deployed medical treatment facilities (MTFs) has contributed to these infections. A 2008 review of deployed MTFs identified multiple factors impeding the performance of infection prevention and control (IC) practices. In response, efforts to emphasize IC basics, improve expertise, and better track MDRO colonization were pursued. METHODS: Efforts to increase awareness and enhance IC in deployed MTFs were focused on educating leaders and deploying personnel, producing deployed IC resources, and standardizing level IV and V admission screening for MDRO colonization. A repeat mission in 2009 reviewed interval progress. RESULTS: Increased awareness and the need for emphasis on basic IC practice, including hand hygiene, use of transmission-based (isolation) precautions, and cohorting of patients, were imparted to leaders and deploying personnel through briefings, presentations, and an All Army Activities message. Enhancement of IC expertise was implemented through increased standardization of IC practice, establishment of a predeployment IC short course, an IC teleconsultation service, and dedicated Internet resources. Standardization of admission colonization screening of personnel evacuated from the combat theater was established to better define and respond to the MDRO problem. A repeat review of the deployed MTFs found overall improvement in IC practice, including clear command emphasis in the Iraqi theater of operations. CONCLUSIONS: Maintaining a strong IC effort in the deployed setting, even in a stabilized operational environment, is difficult. Use of innovative strategies to enhance expertise and practice were implemented to reduce MDRO infections.

Cytotoxic and tubulin-interactive hemiasterlins from Auletta sp. and Siphonochalina spp. sponges.

Chemical and biological investigations of extracts from the sponge genus Auletta and two collections of Siphonochalina sp. have shown these organisms to be producers of the potent hemiasterlin class of antitumor agents. In addition to the previously known hemiasterlin (1) and hemiasterlin A (2), a new analogue, hemiasterlin C (3), was isolated and identified. The structures of 1 and 2 were assigned based on comparison to literature values, and 3 was identified on the basis of 1H NMR, 13C NMR, COSY, HSQC, and HMBC experiments. The cytotoxic and antitubulin activities of 1-3 were evaluated. In a comparative assay for inhibition of tubulin polymerization, the hemiasterlins were more potent than dolastatin 15 and equipotent with cryptophycin 1, but were somewhat less potent than dolastatin 10.

The MCFONTZL classification system for soft-tissue injuries to the face.

A review of the literature and case records reflected a need for the development of a clinically applicable assessment scheme and classification system for soft-tissue laceration injuries to the face. Herein, a systematic approach for assessing facial lacerations is proposed based on location, depth of penetration, branching, directionality, size, presence of soft-tissue defect, and translation of such injuries into the current procedural terminology (CPT) code. Moreover, a new classification system for facial laceration injuries is presented that may serve as the basis for simplification of current billing codes. Prospective clinical application of this classification system may lead to standardization of facial injury assessment and improvement in the incomplete and inconsistent patient record. This system will establish a reliable database that may identify factors in soft-tissue injuries that contribute to poor aesthetic results or secondary functional deformities. These data will lead to the modification of established treatment plans.

Blindness after reduction of facial fractures.

Blindness in patients suffering maxillofacial trauma is usually caused by optic nerve or optic canal injuries. It is, however, an uncommon complication of facial trauma, with a reported incidence of only 2 to 5 percent. Blindness may also follow surgical repair of facial fractures. Many mechanisms, such as intraoperative direct nerve injury, retinal arteriolar occlusion associated with orbital edema, or delayed presentation of indirect optic nerve injury sustained at the time of the initial trauma, have been implicated in causing this blindness. In this article, four cases of visual loss after surgical repair of facial trauma are reported. In a review of the University of Maryland Shock Trauma experience with facial trauma over 11 years, we discovered that 2987 of the 29,474 admitted patients (10.1 percent) sustained facial fractures, and that 1338 of these fractures (44.8 percent) involved one or both of the orbits. One thousand two hundred forty of these patients underwent operative repair of their facial fractures. Three patients experienced postoperative complications that resulted in blindness, a total incidence of only 0.242 percent. Postoperative ophthalmic complications seem to be primarily mediated by indirect injury to the optic nerve and its surrounding structures. The most frequent cause of postoperative visual loss is an increase in intraorbital pressure in the optic canal. When our data were added to the summarized cases, blindness was attributable to intraorbital hemorrhage in 13 of 27 cases (48 percent). In addition, 5 cases in our review attribute the visual loss to unspecified mechanisms of increased intraorbital pressure, bringing the total cases of visual loss caused by intraorbital pressure or hemorrhage to 18 of 27 cases, or 67 percent. Within the restricted confines of the optic canal, even small changes in pressure potentially may cause ischemic optic nerve injury.

Antifungal metabolites (monorden, monocillin IV, and cerebrosides) from Humicola fuscoatra traaen NRRL 22980, a mycoparasite of Aspergillus flavus sclerotia.

The mycoparasite Humicola fuscoatra NRRL 22980 was isolated from a sclerotium of Aspergillus flavus that had been buried in a cornfield near Tifton, Ga. When grown on autoclaved rice, this fungus produced the antifungal metabolites monorden, monocillin IV, and a new monorden analog. Each metabolite produced a clear zone of inhibition surrounding paper assay disks on agar plates seeded with conidia of A. flavus. Monorden was twice as inhibitory to A. flavus mycelium extension (MIC > 28 microg/ml) as monocillin IV (MIC > 56 microg/ml). Cerebrosides C and D, metabolites known to potentiate the activity of cell wall-active antibiotics, were separated from the ethyl acetate extract but were not inhibitory to A. flavus when tested as pure compounds. This is the first report of natural products from H. fuscoatra.

Duration of complete atrioventricular block after congenital heart disease surgery.

Children with complete heart block following surgery for congenital heart diseases were prospectively followed to assess the timing for recovery of atrioventricular conduction, and to determine if there were clinical variables that reliably predict permanent heart block. Recovery of atrioventricular conduction occurred by postoperative day 9 in 97% of patients with transient heart block.

Long-term performance of bipolar epicardial atrial pacing using an active fixation bipolar endocardial lead.

Bipolar epicardial leads are not yet widely available for atrial use. Since September 1986, we have used a bipolar active fixation endocardial lead (Cardiac Pacemakers model number's 4266, 4268, and 4269) as a bipolar epicardial atrial lead by attaching the corkscrew tip to the atrial surface and imbricating atrial tissue around the more proximal electrode. A total of 77 bipolar epicardial atrial leads have been implanted using this approach in 72 patients with congenital heart disease (ages 3 months to 38.7 years; mean 8.9 +/- 8.8 years). Indications for atrial pacing included AV block (n = 46), sinus node dysfunction (n = 17), and antitachycardial pacing (n = 9). Indications for epicardial pacing included the presence of an intracardiac right to left shunt (n = 33), concomitant cardiac surgery (n = 26), surgeon preference (n = 7), and lack of transvenous access to the atrial endocardium (n = 6). Follow-up (median 23 months; mean 28.0 +/- 23.1 months; range 1-78 months) data beyond 1 month postimplantation were available for 44 leads. Atrial sensing was > or = 2.0 mV for 26 leads (59%) with sensing possible at > or = 0.75 mV for 42 leads (95%). Threshold data were available at 5 V for 37 leads and at 2.5 V for 36 leads with mean pulse width thresholds measuring 0.21 +/- 0.33 ms and 0.34 +/- 0.34 ms, respectively. Two leads failed (high capture thresholds at 5 days [n = 1], lead fracture at 42 months [n = 1]; one of which was replaced. Four additional leads were replaced electively (marginal thresholds [n = 1], intermittent phrenic nerve stimulation [n = 1], damaged during subsequent surgery [n = 1], clinically irrelevant insulation break [n = 1]) concomitant with additional cardiac surgery. Until a commercially available lead is developed and released, improvisation with a bipolar active fixation endocardial lead as a bipolar epicardial atrial lead is a reasonable approach to providing bipolar atrial sensing and pacing in patients for whom endocardial pacing is contraindicated.

Patterns of facial laceration from blunt trauma.

The clinical characteristics of craniofacial injuries resulting from various modes of blunt trauma, including motor vehicle accidents, falls, and assault, have been described extensively in the literature. In this study, specifically targeted blunt trauma to selected areas of the face was used to recreate soft-tissue laceration injuries on 19 cadaver heads. The patterns of laceration produced were then examined by location, size, penetrated skin depth, and associated muscle and bony involvement. Results showed reproducible patterns of lacerations on the forehead, bilateral superior orbital rim, nose, perimaxillary region, and chin. Six of 19 cadaver faces were undermined prior to blunt trauma to determine the effects of subcutaneous attachments on laceration patterns. Results showed no consistent difference in laceration patterns between undermined skin and intact skin. Our findings suggest that in response to blunt trauma, the skin breaks along selected lines of least resistance that closely parallel cleavage lines of the face and that the patterns of laceration generated are associated with inherent structural and biomechanical properties of the skin, independent of subcutaneous attachments. Blunt trauma lacerations to the face therefore may occur in a consistent and reproducible manner and may be subject to classification.

Coffee, tea, or frostbite? A case report of inflight freezing hazard from dry ice.

Occupational and recreational cold exposure is fairly well described in the literature. This is a case report of a passenger on a commercial airline flight who suffered third degree frostbile due to the attempted therapeutic use of a cold pack. This cold pack was offered by the flight attendant and consisted of a section of dry ice used for cooling in the galley. The resulting injury consisted of a full thickness cold injury of the left lumbar amounting to approximately 1.5% TBSA (total body surface area). The occurrence of third degree frostbite due to a medicinally used ice pack such as this has not been noted in the past writings. The resulting injury, care and outcome of such an injury are described and discussed.

Long-term outcome in patients with pacemakers following the Fontan operation.

Patients with pacemakers after Fontan surgery compared favorably with nonpaced patients with respect to survival. In patients with atrioventricular block, dual chamber pacing was superior to VVI pacing.

Polytolypin, a new antifungal triterpenoid from the coprophilous fungus Polytolypa hystricis.

Polytolypin [1], a new pentacyclic triterpenoid exhibiting antifungal and antibiotic activity, has been isolated from cultures of Polytolypa hystricis (JS189), a fungal colonist of porcupine dung. Two known compounds [2 and 3] were also isolated. Polytolypin was obtained by chromatographic fractionation of the EtOAc extract of P. hystricis liquid cultures, and the structure was assigned on the basis of 2D nmr and hrms data.

Comparison of skin-tissue tensions using the composite and the subcutaneous rhytidectomy techniques.

Controversy as to benefits, risks, and long-term durability of the subcutaneous rhytidectomy as compared with the composite and the subcutaneous musculoaponeurotic system (SMAS) rhytidectomy procedures has persisted over the last several years. Conventional surgical wisdom holds that deep-tissue support would provide both immediate and long-term benefits in rhytidectomy patients. Recent investigations have shown that deep-tissue support using the SMAS technique decreases epidermis closure tension. This effect has potential implications on vascularity, healing, scar formation, duration of results, and tension-related trophic changes. Twelve fresh frozen cadavers were dissected. At random, one side was treated with the composite technique as described by Hamra, whereas the other was treated with a standard subcutaneous rhytidectomy without SMAS intervention. Using this approach, variability between techniques could be more accurately compared. Dissection levels were made as identical as possible on both sides. Tensions were then measured from premarked, standard key points, evaluating (1) the amount of tension required to move the point 2 cm; (2) with a pull of 1.00 kg, the amount of skin that could then be excised; and (3) after securing the composite 2.0 cm reference points using deep-tissue support sutures, the amount of tension needed to advance the skin to closure. We found that the composite method has a higher resistance to stretch than the subcutaneous method, which translates into a lesser amount of skin excision possible at a given tension. The added resistance is most likely the result of the deep fibromuscular layer. Resistance could be overcome by placement of deep support sutures, and the effect of the fibromuscular layer (SMAS) is effectively neutralized through increased viscoelastic support. This effect potentially helps to protect the dermal plexuses from the effects of tension created using the composite technique. The tension necessary to advance the epidermis to closure therefore compares favorably to the subcutaneous rhytidectomy method.

A regional survey of opioid use by patients receiving specialist palliative care.

A study was conducted to determine the patterns of opioid use in patients under the care of specialist palliative care (SPC) teams in Trent Region, both in the community and in inpatient settings. The design was a survey of point prevalence by case note and drug chart review. The case notes and prescription records of 1007 patients were reviewed, and data collected on age, sex, diagnosis, date of referral, care settings, opioid form and dose on referral, and most recent opioid form and dose. Nine hundred and seventy patients had cancer; their ages ranged from 18 to 98 years (mean 66.5; median 69). Care was delivered by community specialist nurse for 39%, hospice daycare (DC) for 31%, hospice based homecare for 11%, hospice inpatient unit (IPU) for 15%, hospice outpatient (OP) for 5%, and other for 0.5%. There was no record of medication in 2% of the notes. No opioids had been prescribed for 43% of patients (range 24% IPU to 49% DC), 10% of patients were using weak opioids only (range 0.9% IPU to 16% OP), and 45% of patients were using strong opioids (range 39% DC to 75% IPU), the majority being on morphine (87% of total strong opioids). Daily oral morphine equivalence (OME) dosages ranged form 0.4 mg to 3600 mg (mean 166; median 60; mode 60). Dose changes under SPC ranged from -780 mg to +3900 mg OME, 42% patients having had no change in their dosage and 15% having reduced their opioid dose whilst under SPC. This survey challenges the popular impression that patients receiving SPC require large doses of morphine. The highest prevalence of potent opioid prescribing was in hospice IPUs, largely owing to the use of parenteral diamorphine. Conversely, IPUs had the lowest prevalence of weak opioids. Staff caring for patients with cancer must consider the need for downward as well as upward titration of opioid dosages.

Genetic stability of cold-adapted A/Leningrad/134/47/57 (H2N2) influenza virus: sequence analysis of live cold-adapted reassortant vaccine strains before and after replication in children.

We previously reported that the A/Leningrad/134/47/57 (H2N2) cold-adapted virus (A/Len/47) used in preparing reassortant live attenuated vaccines for children acquired 14 (11 coding) mutations in genes coding for proteins other than haemagglutinin and neuraminidase during cold-adaptation. Preservation of these mutations in genomes of viruses isolated from children on the second, fifth, or eighth day after vaccination was examined by sequence analysis. The sequence data demonstrated that all nine coding mutations selected for examination were conserved in the genomes of all 11 strains investigated, indicating that the mutations accompanying cold-adaptation and attenuation of the A/Len/47 master vaccine are highly stable.

Benefits and potential risks of atrial antitachycardia pacing after repair of congenital heart disease.

UNLABELLED: Atrial reentry tachycardia is common after surgical repair of congenital heart disease. The arrhythmia is often difficult to treat and is occasionally life-threatening. This study reports experience with atrial antitachycardia (AAIT mode) pacing for the management of atrial reentry tachycardia, with emphasis on the risks and benefits of automatic pacing therapy. Eighteen patients (2-32 years of age) with a variety of congenital heart lesions underwent atrial antitachycardia pacemaker placement for recurrent atrial tachycardia that was amenable to pace termination prior to the implantation procedure. An appropriate antitachycardia program was determined by repeated induction and termination of atrial tachycardia using the noninvasive programmed stimulation mode of the pacemaker. Over 4-30 months of follow-up, 6 patients had 189 episodes of tachycardia successfully converted with AAI-T pacing, 4 patients had 8 episodes of tachycardia detected but not successfully converted, and 8 patients had no episodes of tachycardia with antibradycardia pacing alone. The number of patients receiving pharmacological therapy other than digoxin or beta blockade fell from 12 to 6. Two subjects died suddenly, 1 while wearing a Holter monitor. In both, tachycardia was detected and pace cardioversion attempted. CONCLUSIONS: Atrial antitachycardia pacing is a useful tool in the management of patients with congenital heart disease and atrial arrhythmias; however, in selected cases, it may not prevent and may even exacerbate the lethal complications of the tachycardia. Antitachycardia function evaluation is recommended under varying levels of autonomic stress prior to institution of automatic therapy.

A comparison of flap vascular anatomy in three rhytidectomy techniques.

The purpose of this study was to examine differences in blood supply to facial flaps created by three rhyditectomy techniques. The techniques chosen for comparison included a two-layer technique, consisting of separate subcutaneous and extended submuscular aponeurotic system (SMAS) dissections, the Composite dissections as described by Hamra, and a subperiosteal dissection. Six cadavers were injected with lead oxide before dissection, and eight were injected after dissection. After allowing the lead oxide to set, the soft tissues were removed from the face. Vascular patterns of the face were interpreted from x-rays taken of the specimens. Results of the injections performed before dissection confirmed contributions of previously described arteries, including the transverse facial, facial, infra-orbital and terminal branches of the ophthalmic. In addition, there are numerous branches that connect these vessels to each other. The most consistent of these include the masseteric, jugal, submental, labial, angular and nasal arteries. The patterns of communications between these vessels allow for the visualization of three vertically oriented vascular zones, each connected to the next by choke zones where anastomoses occur. Dissections performed before injection reveal increased filling of the vessels through more of the flap on the Composite side when compared with the two-layered dissection, absence of vessels in the SMAS, and filling across all three zones on the subperiosteal side. We conclude that there are vascular regions in the face connected by anastomotic choke zones. Separate subcutaneous and sub-SMAS dissections interrupt the vascular connection between zones. Arterial continuity is better-maintained in the Composite lift and is literally undisturbed in the subperiosteal lift.(ABSTRACT TRUNCATED AT 250 WORDS)