The influence of candidates' physical attributes on patient ratings in simulated assessments of clinical practice.

BACKGROUND: We have previously shown that clinical examiners' scoring is not negatively impacted when a candidate has a tattoo, unnatural hair colour, or a regional accent. We investigated whether these physical attributes in exam candidates impact patient scoring. METHODS: Simulated/real patients were randomly assigned to watch five videos of simulated candidate performances of a cranial nerve examination: clear fail, borderline, good, 'clear pass' without an attribute, and 'clear pass' with one of the attributes (tattoo, purple hair, accent). Participants scored domains of communication and professionalism. We compared scores for the clear pass candidates with and without attributes. RESULTS: One hundred and eighty three patients participated. The total scores for the candidates with tattoos and purple hair were higher than the candidate with no physical attribute (p < 0.001). For the candidate with a Liverpool English accent no difference was identified (p = 0.120). CONCLUSIONS: The presence of certain physical attributes (tattoos or purple hair) was associated with higher scores given by patients to candidates in a simulated physical examination station.

Microwave- and heat-based decontamination of N95 filtering facepiece respirators: a systematic review.

BACKGROUND: In pandemics such as COVID-19, shortages of personal protective equipment are common. One solution may be to decontaminate equipment such as facemasks for reuse. AIM: To collect and synthesize existing information on decontamination of N95 filtering facepiece respirators (FFRs) using microwave and heat-based treatments, with special attention to impacts on mask function (aerosol penetration, airflow resistance), fit, and physical traits. METHODS: A systematic review (PROSPERO CRD42020177036) of literature available from Medline, Embase, Global Health, and other sources was conducted. Records were screened independently by two reviewers, and data was extracted from studies that reported on effects of microwave- or heat-based decontamination on N95 FFR performance, fit, physical traits, and/or reductions in microbial load. FINDINGS: Thirteen studies were included that used dry/moist microwave irradiation, heat, or autoclaving. All treatment types reduced pathogen load by a log10 reduction factor of at least three when applied for sufficient duration (>30 s microwave, >60 min dry heat), with most studies assessing viral pathogens. Mask function (aerosol penetration <5% and airflow resistance <25 mmH2O) was preserved after all treatments except autoclaving. Fit was maintained for most N95 models, though all treatment types caused observable physical damage to at least one model. CONCLUSIONS: Microwave irradiation and heat may be safe and effective viral decontamination options for N95 FFR reuse during critical shortages. The evidence does not support autoclaving or high-heat (>90°C) approaches. Physical degradation may be an issue for certain mask models, and more real-world evidence on fit is needed.

Decontaminating N95 and SN95 masks with ultraviolet germicidal irradiation does not impair mask efficacy and safety.

Inadequate supply of filtering facepiece respirators (FFRs) for healthcare workers during a pandemic such as the novel coronavirus outbreak (SARS-CoV-2) is a serious public health issue. The aim of this study was to synthesize existing data on the effectiveness of ultraviolet germicidal irradiation (UVGI) for N95 FFR decontamination. A systematic review (PROSPERO CRD42020176156) was conducted on UVGI in N95 FFRs using Embase, Medline, Global Health, Google Scholar, WHO feed, and MedRxiv. Two reviewers independently determined eligibility and extracted predefined variables. Original research reporting on function, decontamination, or mask fit following UVGI were included. Thirteen studies were identified, comprising 54 UVGI intervention arms and 58 N95 models. FFRs consistently maintained certification standards following UVGI. Aerosol penetration averaged 1.19% (0.70-2.48%) and 1.14% (0.57-2.63%) for control and UVGI arms, respectively. Airflow resistance for the control arms averaged 9.79 mm H2O (7.97-11.70 mm H2O) vs 9.85 mm H2O (8.33-11.44 mm H2O) for UVGI arms. UVGI protocols employing a cumulative dose >20,000 J/m2 resulted in a 2-log reduction in viral load. A >3-log reduction was observed in seven UVGI arms using >40,000 J/m2. Impact of UVGI on fit was evaluated in two studies (16,200; 32,400 J/m2) and no evidence of compromise was found. Our findings suggest that further work in this area (or translation to a clinical setting) should use a cumulative UV-C dose of 40,000 J/m2 or greater, and confirm appropriate mask fit following decontamination.

Flecainide excretion in human breast milk.

Healthy human volunteers who intended not to breast feed were placed on a regimen of 100 mg oral flecainide every 12 hours for 5 1/2 days beginning 1 day after parturition. Milk and blood samples were collected during the dosing period and for 2 days after the last dose. Concentrations of flecainide in milk and plasma were assayed by HPLC. Apparent steady-state levels of flecainide in both milk and plasma were achieved in most cases by day 4 of the study. Highest daily average concentration of flecainide in milk ranged from 270 to 1529 ng/ml for the 11 subjects. Mean +/- SD milk to plasma flecainide ratios were 3.7 +/- 3.5, 3.2 +/- 2.3, 3.5 +/- 2.1, and 2.6 +/- 0.7 on study days 2, 3, 4, and 5, respectively. After the last dose of flecainide, peak milk levels of the drug occurred at 3 to 6 hours and then declined monoexponentially. The half-life for elimination of flecainide from milk was 14.7 +/- 3.5 hours and is very similar to the plasma elimination half-life of flecainide in healthy human subjects. The mean milk to plasma ratios for flecainide after the last dose were 2.3 +/- 1.0 and 2.9 +/- 1.1 at 24 and 48 hours after the dose, respectively. Based on the pharmacokinetics of flecainide in infants, the expected average steady-state plasma concentration of flecainide in a newborn infant consuming all of the milk production of its mother (approximately 700 ml/day) would not be expected to exceed about 62 ng/ml.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of pregnancies following the use of oral contraceptives.

The use of oral contraception by women doctors on the Medical Register for England and Wales in 1975 was studied and related to the outcome of their pregnancies. Nearly two thirds had used oral contraception at some time, but less than one third of their pregnancies had followed its use. Users tended to be younger at the time of the survey and to smoke in pregnancy more often. After allowing for these associations a poor outcome was just slightly more common in pregnancies occurring after OC use, particularly in conceptions occurring within a month or after a year of cessation. In contrast conceptions occurring in the 2nd or 3rd month after cessation had an unusually favourable outcome. It therefore seems likely that at least some of this weak association between oral contraception and poor outcome may be explained by factors that determine the length of time it takes to conceive. Overall it seems that any real risk to pregnancies conceived after cessation of oral contraception must be very small and outweighed by the undoubted advantages of its use.

PIP: The results of a survey of the outcome of pregnancies of women doctors, a proportion of whom had conceived after using oral contraception, are presented. Data on oral contraceptive use were gleaned from the Medical Register for England and Wales in 1975. Of the women doctors registered at this time, nearly two-thirds had used oral contraception at some time, but fewer than one-third of their pregnancies had followed oral contraceptive use. The survey yielded the following characteristics about women doctors who chose oral contraception: 1) they were younger at the time of the survey and 2) they tended to smoke in pregnancy more often. Allowing for these 2 associations, it was calculated that a poor outcome of pregnancy was just slightly more common in pregnancies occurring after oral contraceptive use, particularly in conceptions occurring within a month or after a year of cessation of oral contraception. In comparison, those conceptions which occurred in Month 2 or 3 after cessation of medication showed unusually favorable outcomes, leading to the conclusion that at least some of this weak association between oral contraception and poor outcome may be explained by factors that determine the length of time it takes to conceive. In general, however, the risk-benefit ratio for oral contraception seems weighted toward benefit.

Effect of work during pregnancy.

Obstetricians pay much attention to the diet and environment of the pregnant woman in prenatal care, but perhaps the woman's work also may affect pregnancy outcome. All women work in the home in addition to any work performed outside the home. The former component needs careful assessment; to get from home to work may be itself a stressful experience. In the workplace, women may encounter specific hazards of radiation or chemicals. More widespread are the problems of fatigue and boredom, which need careful assessment in relation to the outcome of pregnancy. These factors should be measured more precisely, thus allowing the physician to advise pregnant women better about the safe duration of work. Currently, advice tends to be overly cautious, as physicians are uncertain of the data on which such standards are based.

Self-checking the intrauterine device.

The self-examination habits of 155 women wearing an intrauterine device have been analyzed. One-third were persistently unable to find the tail. There was a loose relationship between the type of device, the length of the tail, and failure to detect. The more parous and those of higher social class were more adept at detection, as were those who examined themselves each month.

Use of electromyographic and skin-conductance biofeedback relaxation training of facilitate childbirth in primiparae.

Matched groups of primigravid women received one of three antenatal training programmes: normal antenatal classes, normal classes plus electromyography biofeedback relaxation training, or normal classes plus skin-conductance biofeedback relaxation training. Myographic training was found to be effective within conventional antenatal constraints, whereas skin-conductance training was not. The women reported use of biofeedback training and related skills to be of some benefit during early labour. However, no difference between effectively trained electromyographic, ineffectively trained skin-conductance and control groups was found on labour and delivery performance measures.

Factors associated with delayed onset of regular respiration.

In a population of 16333 singleton births born in one week of April, 1970, 4.4% failed to establish regular respiration within 3 min of birth. A follow-up at 5 years of age collected medical, educational and sociological information on 79.6% of the survivors of the cohort identified by the birth survey. Data have been analysed to investigate the relationships between the delay in the onset of regular respiration and possible risk factors identifiable prior to or at the time of birth. Complex statistical analysis employing linear modelling techniques showed that the delay in the onset of respiration was primarily related to: null and high parity; antepartum haemorrhage (especially placenta praevia); pre-eclampsia; breech delivery; Caesarian section and low birthweight. There was no association with maternal smoking during pregnancy or with social class. These conclusions are reasonably consistent with those drawn from other studies using alternative measures of asphyxia.

Delayed onset of regular respiration and subsequent development.

A comprehensive survey carried out at birth, data on mortality and a 5 year follow-up covering medical, educational and sociological aspects of child development were available for singleton births born in one week of April 1970. The survey at 5 years of age included 12363 children, 79.6% of the surviving cohort. An assessment has been made of the extent to which delay in the onset of regular respiration at birth is associated with the subsequent development of the child. Using the results of our previous investigations, the relationships between this delay and other factors known at the time of birth have been taken into account. The distributions of a large number of development variables were not significantly different for groups of children determined by respiratory delay at birth, but there was an association with mortality and cerebral palsy. In addition, there was an unexpected relationship between delayed onset of respiration and subsequent bronchitis. This association remained significant after controlling for possible confounding effects using linear modelling techniques.

Doppler ultrasound of the uteroplacental circulation as a screening test for severe pre-eclampsia with intra-uterine growth retardation.

Two hundred primiparae underwent continuous-wave Doppler investigation of the uteroplacental circulation at 18-20 weeks gestation as a possible screening test for hypertension in pregnancy. Seventy-five women with abnormal waveforms suggestive of high uteroplacental resistance were tested again at 24 weeks when 21 demonstrated a persistent abnormality. Only nine (43%) of these went on to have an uncomplicated pregnancy, as compared with 150 (84%) of the remainder. Seventeen (8.5%) of the women in the study developed a hypertensive disorder of pregnancy, five of whom had abnormal waveforms at 18-20 weeks and at 24 weeks. These five women had a more severe degree of hypertension with proteinuria or intra-uterine growth retardation, and two required clinical intervention before term. The remaining 12 women were delivered at term of average, or heavier than average babies. Doppler investigation of the uteroplacental circulation at 24 weeks may prove to be a sensitive screening test for later severe pre-eclampsia with intra-uterine growth retardation.

The relationship of increased amniotic fluid volume to perinatal outcome.

We studied a group of 135 patients with polyhydramnios diagnosed on the basis of ultrasonic findings (greatest vertical diameter of the liquor column greater than or equal to 8.0 cm) between 32 and 36 weeks gestation (study group). We compared the obstetric characteristics and perinatal outcome of the study group with a similar number who constituted our control group. The incidence of women aged 20 years or less was higher in the study group (8.9%) compared with 4.5% in the control group. Of the 135 patients who were diagnosed to have polyhydramnios ultrasonically, the clinical diagnoses prior to referral for ultrasonic scanning, were, suspected large for date fetuses in 34 patients (25.2%), clinically suspected polyhydramnios in 28 (20.7%), gestational diabetes in 21 (15.6%) and insulin dependent diabetes in 6 (4.4%) compared with 13.3%, 5.2%, 3.0% and 0.7%, respectively in the control group (P less than 0.05). Preterm delivery occurred in 11.1% in the study group compared with the incidence of 6.7% in the control group. The incidence of fetal distress, low Apgar Score, macrosomic infants, major fetal anomalies, gross and corrected perinatal mortality rate and admission to special/intensive care nursery was significantly higher in the study group compared with that of the control (P less than 0.01). We found ultrasonic examination is a reliable technique to assess the amount of amniotic fluid volume and it alerts the clinician to possible future problems in pregnancy, labor and neonatal period.

Ultrasound evaluation of amniotic fluid: outcome of pregnancies with severe oligohydramnios.

We studied a group of 247 patients out of 7725 patients who had an ultrasonic examination between 32 and 36 weeks gestation and were found to have oligohydramnios (amniotic fluid volume (AFV) less than or equal to 2.0 cm). We compared the features of labor and mode of delivery and perinatal outcome in this group with that of a normal control group of 247 patients who also had an ultrasonic examination between 32 and 36 weeks gestation and were found to have normal AFV (greater than 2.0 to less than 8.0 cm). The incidence of induction of labor, of elective cesarean section, of preterm delivery (less than 37 weeks' gestation) was significantly higher in the oligohydramnios group (study group) as compared with the incidence in the control group (P less than 0.05). The incidence of fetal distress in antenatal and intrapartum period, pH (less than or equal to 7.2), of low Apgar score (0-5), of intrauterine growth retardation (IUGR) (less than tenth centile) infants, of major fetal anomaly and perinatal mortality rate (PNMR) are significantly higher in the oligohydramnios group as compared with the incidence and PNMR in the normal control group (P less than 0.05). The ultrasonic finding of oligohydramnios should alert the clinician regarding the possibility of problems in labor and perinatal period.

Cyriax's Friction Massage: A Review.

This article reviews the existing literature on connective tissue in an attempt to provide additional substantiation for the use of Dr. James Cyriax's friction massage. J Orthop Sports Phys Ther 1982;4(1):16-22.

Trial of the use of masks in the gynaecological operating theatre.

A randomly controlled trial was performed on 41 women having gynaecological surgery in which the team of surgeons and nurses wore or did not wear masks. After major abdominal surgery, 3 of 5 patients in the unmasked group developed wound infections whereas no infection was observed in the 4 patients of the masked group. A greater number of Streptococci were also found by settle-plates on the operating table in the unmasked group. No infection was recorded after minor or vaginal surgery.

The risks of obstetrics and gynaecology in practice.

In the United Kingdom, claims relating to obstetrics and gynaecology account for a quarter of all medico-legal costs. Obstetric claims are relatively few, but damages awarded are high, partly because of the nature of the injuries suffered, such as brain damage to the infant. Claims often arise very late, and it is therefore advisable to keep obstetric records for long periods. In gynaecology by contrast, claims are more numerous but damages and legal costs are lower. The solutions to these problems must lie in well-conducted practice, sufficient involvement of senior specialists (with proper supervision of more junior staff) and the keeping of good records. More basically one will have to strive for a society in which these issues are dealt with in a less adversarial manner.

Birth at home.

Recently the National Birthday Trust performed a confidential survey of home births in the United Kingdom. A good response rate was obtained from midwives, who recruited two groups of women prospectively; those planned and accepted as suitable for a home delivery at 37 weeks and a matched group of similar women who were booked for hospital by 37 weeks. Some 16% of such women were transferred to hospital in late pregnancy (4%) or in labour (12%). This figure rose to 40% among the primiparous women in the survey. The survey report presents an analysis of 4,500 home births and 3,300 hospital controls. Outcomes could therefore be presented by the woman's intent or by what actually happened. In essence it seems that a woman who is appropriately selected and screened for a home birth is putting herself and her baby at no greater risk than a mother of a similar low-risk profile who is hospital booked and delivered. Home births will probably increase to 4-5% of all maternities in UK during the next decade and this needs preparatory planning.

Insulin activates the insulin receptor to downregulate the PTEN tumour suppressor.

Insulin and insulin-like growth factor-1 signaling have fundamental roles in energy metabolism, growth and development. Recent research suggests hyperactive insulin receptor (IR) and hyperinsulinemia are cancer risk factors. However, the mechanisms that account for the link between the hyperactive insulin signaling and cancer risk are not well understood. Here we show that an insulin-like signaling inhibits the DAF-18/(phosphatase and tensin homolog) PTEN tumour suppressor in Caenorhabditis elegans and that this regulation is conserved in human breast cancer cells. We show that inhibiting the IR increases PTEN protein levels, while increasing insulin signaling decreases PTEN protein levels. Our results show that the kinase region of IRß subunit physically binds to PTEN and phosphorylates on Y27 and Y174. Our genetic results also show that DAF-2/IR negatively regulates DAF-18/PTEN during C. elegans axon guidance. As PTEN is an important tumour suppressor, our results therefore suggest a possible mechanism for increased cancer risk observed in hyperinsulinemia and hyperactive IR individuals.

Large vapour cloud explosions, with particular reference to that at Buncefield.

This paper first briefly surveys the energy releases in some major accidents. It then examines the analyses of the explosion at the Buncefield fuel storage site in the UK, one of the most intense accidental explosions in recent times. This followed the release of approximately 300 tonnes of winter-grade gasoline, when a 15 m high storage tank was overfilled for about 40 min before ignition of the resulting flammable mixture. The ensuing explosion was of a severity that had not been identified previously in a major hazard assessment of this type of facility. It was therefore imperative to investigate the event thoroughly and develop an understanding of the underlying mechanisms to inform future prevention, mitigation and land-use planning issues. The investigation of the incident was overseen by the Buncefield Major Incident Investigation Board. A separate Explosion Mechanism Advisory Group examined the evidence and reported on the severity of the explosion. It concluded that additional work was necessary and recommended that a two-stage project be initiated, phase 1 of which has been completed. The analyses of the damage and the derivation of explosion over-pressures are described. Possible explosion mechanisms and the evidence for them at Buncefield are discussed, in the light of other major incidents. Mechanisms that are reviewed include high-speed turbulent combustion, quasi-detonations, fully developed detonations, the generation of fireballs, flame instabilites, radiative heat transfer and aspects of two-phase burning. Of particular importance is the acceleration of turbulent flames along the line of trees and hedgerows. A number of conclusions are drawn and suggestions made for further research.

A longitudinal study into the new and long-term use of self-monitoring blood glucose strips in the UK.

AIMS: To determine the impact of self-monitoring blood glucose (SMBG) strip use in patients with type 2 diabetes in the UK. METHODS: The study period was April 1, 2004 to July 31, 2005. Data from primary care was extracted from The Health Improvement Network database. Patients identified with diabetes and matching the inclusion criteria were defined as new users of SMBG, prevalent users, or non-users. Patients were also defined as treated with insulin, with oral agents (OA), or not pharmacologically treated. Change in glycosylated hemoglobin (HbA(1c)) at baseline and after 12 months was compared. RESULTS: 2559 patients met the inclusion criteria. For new users, HbA(1c) fell by 0.59% (P=0.399) for those treated with insulin, 1.52% (P<0.001) for those treated with OA, and 0.51% (P<0.001) for no treatment. In prevalent users, changes were 0.31% (P<0.001), 0.34% (P<0.001), and 0.09% (P=0.456), respectively. In non-users, changes were 0.28% (P=0.618), 0.42% (P<0.001), and an increase of 0.05% (P=0.043), respectively. A significant decrease in mean HbA(1c) was associated with increasing strip use in OA patients newly initiated on strips. CONCLUSION: This observational study showed a significant decrease in HbA(1c) for new users of SMBG treated either non-pharmacologically or with OA, and for prevalent users treated with insulin or OA. Reduced HbA(1c) with increasing strip use was observed but was only significant for OA-treated new users. This suggests that SMBG use has a role in the treatment of non-insulin treated patients with type 2 diabetes.