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Background: Orthopaedic surgery regularly employs opioids for postoperative pain management. Multimodal pain protocols have been shown to reduce opioid prescriptions in orthopaedic surgery., Purpose: To analyze the impact of a division-level multimodal pain protocol for orthopaedic sports medicine surgery on opioid prescription reduction and pain level postoperatively., Study Design: Cohort study; Level of evidence, 3., Methods: All orthopaedic sports medicine procedures at a military treatment facility were categorized into 1 of 3 pain tiers. A pain protocol emphasizing multimodal pain control was implemented for each tier. A retrospective cohort study compared pre- and postprotocol pain groups for each respective tier (n = 40 in each) for visual analog scale (VAS) for pain scores 2 weeks postoperatively, postoperative opioid prescription, and time to discontinuation of postoperative opioids., Results: The mean number of opioid pills prescribed for all tiers decreased by 43.6% (preprotocol 35.7 ± 3.1; postprotocol 20.1 ± 1.5; P < .0001) after pain protocol implementation. Of the total opioids prescribed in the postprotocol cohort, a mean of 64.1% were consumed. There was no significant difference in overall visual analog scale for pain scores at 2 weeks postoperatively (preprotocol 2.72 ± 0.41; postprotocol 2.99 ± 0.43; P = .40). At 2 weeks postoperatively, only 1 patient continued opioids in the postprotocol group compared with 20 patients with continued opioid use in the preprotocol group ( P < .001)., Conclusion: A division-level multimodal pain protocol applied to orthopaedic sports medicine procedures led to decreased opioid prescription postoperatively with no significant difference in 2-week postoperative pain scores compared with more opioid reliant and variable protocols in a cohort of military service members. Despite the reduced prescription, patients consumed a mean of 64.1% of pills, indicating continued overprescription., Competing Interests: One or more of the authors has declared the following potential conflict of interest or source of funding: E.M.B. has received education payments from ImpactOrtho and SportsTek Medical. J.R.B. has received education payments from ImpactOrtho. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2024.)

N-nitrosodimethylamine (NDMA) is a carcinogenic disinfection byproduct that forms during chloramine disinfection of municipal wastewater effluents which are increasingly used to augment drinking water supplies due to growing water scarcity. Knowledge of wastewater NDMA precursors is limited and the known pool of NDMA precursors has not closed the mass balance between precursor loading, precursor NDMA yield, and formed NDMA. Benzalkonium chlorides (BACs) are the most prevalent quaternary ammonium surfactants and have antimicrobial properties. The extensive utilization of BACs in household, commercial and industrial products has resulted in their detection in wastewater at elevated concentrations. We report the formation of a potent NDMA precursor, benzyldimethylamine (BDMA) from the biodegradation of BACs during activated sludge treatment. BDMA formation and NDMA formation potential (FP) were functions of BAC and mixed liquor suspended solids concentration at circumneutral pH, and the microbial community source. Sustained exposure to microorganisms reduced NDMA FP through successive dealkylation of BDMA to less potent precursors. BAC alkyl chain length (C 8 - C 16 ) had little impact on NDMA FP and BDMA formation because chain cleavage occurred at the C-N bond. Wastewater effluents collected from three facilities contained BDMA from 15 to 106 ng/L, accounting for an estimated 4 to 38 % of the NDMA precursor pool., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: We aimed to assess echinococcosis serology performance for diagnosing cystic echinococcosis (CE) in children living in CE-endemic vs. non-endemic populations, and in different clinical settings., Methods: A retrospective cohort study, assessing children with ELISA test for echinococcosis, 2005-2021. Sensitivity, specificity, positive and negative predictive values (PPV and NPV) were calculated comparing CE-endemic vs. non-endemic populations, cases with/without eosinophilia, and cases with/without CE-suggestive imaging findings. Additionally, we examined the association between serology titers/levels (values) and clinical characteristics., Results: Of 273 cases, 66 (24%) were confirmed as CE. Overall, 97% of CE were in Bedouin children, and the pre-test probability was 28% vs. 9% (p < 0.001) in CE-endemic vs. non-endemic population, respectively. Sensitivity was higher in hepatic than extra-hepatic CE (74% vs. 47%). Overall specificity was 86%. PPVs were higher in CE-endemic population compared to non-endemic (66% vs. 22%), while NPVs were higher in non-endemic population (100% vs. 87%). Eosinophilia was associated with lower specificity (73% vs. 94%) and PPV (47% vs. 78%). Typical imaging was associated with higher specificity (94% vs. 82%) and PPV (91% vs. 11%), while NPVs were lower in typical imaging cases (77% vs. 98%). Higher titer levels (above median) were associated with typical imaging (76% vs. 49%), higher PPV (79% vs. 43%), albendazole treatment (100% vs. 56%), surgery (60% vs. 19%), and new imaging finding (75% vs. 0%)., Conclusions: Echinococcosis serology performance was impacted by disease endemicity, and by various clinical characteristics. These findings may assist physicians in the interpretation of echinococcosis serology results., (© 2023. The Author(s) under exclusive licence to Witold Stefański Institute of Parasitology, Polish Academy of Sciences.)

Research on per- and polyfluoroalkyl substances (PFAS) frequently incorporates organofluorine measurements, particularly because they could support a class-based approach to regulation. However, standardized methods for organofluorine analysis in a broad suite of matrices are currently unavailable, including a method for extractable organofluorine (EOF) measured using combustion ion chromatography (CIC). Here, we report the results of an international interlaboratory comparison. Seven laboratories representing academia, government, and the private sector measured paired EOF and PFAS concentrations in groundwater and eel ( Anguilla rostrata ) from a site contaminated by aqueous film-forming foam. Among all laboratories, targeted PFAS could not explain all EOF in groundwater but accounted for most EOF in eel. EOF results from all laboratories for at least one replicate extract fell within one standard deviation of the interlaboratory mean for groundwater and five out of seven laboratories for eel. PFAS spike mixture recoveries for EOF measurements in groundwater and eel were close to the criterion (±30%) for standardized targeted PFAS methods. Instrumental operation of the CIC such as replicate sample injections was a major source of measurement uncertainty. Blank contamination and incomplete inorganic fluorine removal may introduce additional uncertainties. To elucidate the presence of unknown organofluorine using paired EOF and PFAS measurements, we recommend that analysts carefully consider confounding methodological uncertainties such as differences in precision between measurements, data processing steps such as blank subtraction and replicate analyses, and the relative recoveries of PFAS and other fluorine compounds.

Background: Cystic echinococcosis (CE) treatment is complicated, relying on cysts characteristics, host factors and possible treatment adverse events. We assessed childhood CE treatment characteristics., Methods: A retrospective cohort study, 2005-2021, which presents our experience with treating children with CE. We compared therapeutic interventions use in association with the location, size and number of cysts. Additionally, we assessed complications rate following those interventions., Results: Sixty six children had CE; 97% were Bedouins. Overall, 183 cysts were identified in 74 organs: liver (n = 47, 64%), lungs (n = 23, 31%), brain, para-ovarian, kidney and peritoneum (other-grouped, n = 4, 5%). Mean ± Standard deviation largest cyst size (per patient) was 6.6 ± 3.2 cm. Treatment with albendazole was administered to 94% of CE, while albendazole monotherapy was used in 27% (n = 18, including 4 cases with extra-hepatic cysts). Surgical interventions included drainage/puncture, aspiration, injection and reaspiration (PAIR; n = 20), mainly performed in hepatic-CE (40% vs. 4% in pulmonary-CE, and 0% in other-CE), excision and drainage (n = 34) and complete excision (n = 10), mainly done in other-CE (50% vs. 26% and 4% in pulmonary-CE and hepatic-CE, respectively). Larger cyst size was associated with complete excision compared with albendazole monotherapy. The number of cysts was not associated with the chosen intervention. Fever was recorded following 39% of surgical interventions. Local surgical complications were relatively rare., Conclusions: Cysts location and size affected treatment choice among CE patients. Procedures with drainage had relatively higher rate of complications, including recurrence. Albendazole monotherapy may be a viable therapeutic option in selected CE cases., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Oxidation of organic contaminants by sulfate radical (SO 4 •- ) is becoming more popular for the treatment of hazardous waste sites by in situ chemical oxidation (ISCO) and industrial wastewater by advanced oxidation processes (AOPs). It is well documented that SO 4 •- can produce similar oxygen-containing transformation products as hydroxyl radical-based treatment processes, but SO 4 •- also has the potential to produce organosulfates by radical addition. Experiments conducted with a suite of 23 aromatic and 5 aliphatic compounds, including several contaminants typically detected at hazardous waste sites, demonstrated the formation of at least one stable sulfate-containing product for 25 of the compounds. These compounds likely exhibit higher mobility in the subsurface due to a lower affinity for surfaces (e.g., aquifer solids, activated carbon) than most other transformation products. Although the health risks associated with organosulfates are still uncertain, some aromatic organosulfates produced in this study (i.e. phenyl sulfate and p-cresyl sulfate) are known to be harmful uremic toxins. Further study of organosulfate formation, fate, and toxicity is needed before SO 4 •- -based treatment processes are more widely employed.

Chemical disinfectants employed in water and wastewater treatment can produce a variety of transformation products, including carbonyl compounds (e.g., saturated and unsaturated aldehydes and ketones). Experiments conducted under conditions relevant to chlorination at drinking water treatment plants and residual chlorine application in distribution systems indicate that α,β-unsaturated carbonyl compounds readily react with free chlorine and free bromine over a wide pH range but react slowly with combined chlorine (i.e., NH 2 Cl). For nearly all of the 11 α,β-unsaturated carbonyl compounds studied, the apparent second-order rate constants for the reaction with free chlorine increased in a linear manner with hypochlorite (OCl - ) concentrations, yielding species-specific second-order rate constants for the reaction with OCl - ranging from 0.21 to 12 M -1 s -1 . Predictions based on the second-order rate constants indicate that a substantial fraction (i.e., >60%) of several of the more prominent α,β-unsaturated carbonyls (e.g., acrolein, crotonaldehyde) will be transformed to an appreciable extent in distribution systems by free chlorine. Products from the reaction of chlorine with acrolein, crotonaldehyde, and methyl vinyl ketone were tentatively identified using nuclear magnetic resonance (NMR) and gas chromatography coupled to high-resolution time-of-flight mass spectrometry (GC-HRT-MS). These products lacked unsaturated carbons and, in some cases, contained multiple halogens.

Chemical oxidation with hydroxyl radical (HO • ) and sulfate radical (SO 4 •- ) is often used to treat water contaminated with aromatic compounds. Although oxidation of aromatics by these radicals has been studied for decades, the commonly accepted transformation pathway-sequential hydroxylation of the ring followed by ring cleavage and mineralization of the resulting products-does not account for the loss of the parent compound observed during the initial phase of the process. To assess the importance of pathways for aromatic compound oxidation that do not result in ring hydroxylation, we identified products formed after the initial reaction between HO • or SO 4 •- and benzene, toluene, ethylbenzene, and (BTEX) xylene isomers. We quantified products of ring hydroxylation and oxidation of alkyl substituents as well as a suite of ring-cleavage products, including acetaldehyde, formic acid, 6-, 7-, or 8-carbon oxoenals and oxodials. Other ring-cleavage products, which were most likely aldehydes and organic acids, were observed but not quantified. When SO 4 •- was used as the oxidant, aromatic organosulfates also were formed. Our results indicated that the initial phase of the oxidation process involves radical addition, hydrogen abstraction, or one-electron transfer to the ring followed by reaction with O 2 . The hydroxycyclohexadienylperoxy radical produced in this reaction can eliminate hydroperoxyl radical (HO 2 • ) to produce a phenolic compound or it can rearrange to form a bicyclic peroxy intermediate that subsequently undergoes ring cleavage. Hydroxylation of the ring and oxidation of the alkyl substituent accounted for approximately 15-40% of the reacted mass of the parent compound. Ring-cleavage products for which quantification was possible accounted for approximately 2 to 10% of the reacted mass. Our results raise concerns about the formation of toxic ring-cleavage products during the initial stage of oxidation whenever HO • or SO 4 •- is used for the treatment of water containing benzene or alkylbenzenes.

Introduction: The purpose of this study was to identify the location of the peroneal tendons in relationship to the fibular groove in an asymptomatic population of elite U.S. Military Service members., Materials and Methods: The peroneal tendons of 41 active duty U.S. Army Rangers were examined. Subjects were placed in a lateral recumbent position with the ankle in a resting neutral position to visualize the tendon in a retromalleolar short-axis view. Maximum active ankle eversion followed by gravity inversion was facilitated while the ultrasound probe was maintained in its original position. Distance from the fibrous lateral ridge of the retromalleolar groove to the anterior aspect of the peroneal brevis was measured in the short axis in neutral, eversion, and inversion., Results: The mean sagittal distance and standard deviation was 0.48 ± 0.9 mm. No subjects demonstrated greater than 1 mm difference between positions, and no dislocations were identified. Side-to-side difference and dominant vs nondominant differences were not statistically significant., Conclusion: The study demonstrates that the distance between the peroneal brevis and the lateral fibular ridge is consistent throughout extremes of motion. These results further the understanding of peroneal tendon function under dynamic examination. Our findings also establish side-to-side consistency prompting a bilateral examination to help identify abnormal pathology., (© The Author 2020. Published by Oxford University Press Association of Military Surgeons of the United States. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The prevalence of Achilles tendon (AT) pathology is common and can result in disability. Understanding normal AT properties can improve our ability to prevent AT injuries. We examined the cross-sectional area of the AT at multiple levels in an asymptomatic population of Army Rangers., Methods: This is a prospective cohort study composed of 41 voluntarily recruited United States Army Rangers deployed in a combat theater. All subjects were members of the Ranger Regiment participating in more than 20 h of intense bipedal non-sport weekly training with no history of AT pathology. While standing, each subject had bilateral AT calcaneal tuberosity insertions (0 cm) marked, along with skin markings made at 2 cm, 4 cm, and 6 cm superior to the AT insertion. AT diameter was measured at each level in the coronal and sagittal planes using ultrasound., Results: Mean sagittal diameter of the AT was 4.4 mm, 4.3 mm, 4.2 mm, and 3.9 mm at 0 cm, 2 cm, 4 cm, and 6 cm, respectively. Mean coronal diameter of the AT was 19.3 mm, 14.7 mm, 13.8 mm, and 14.5 mm at 0 cm, 2 cm, 4 cm, and 6 cm, respectively. The cross-sectional area was calculated as 0.66 cm2, 0.5 cm2, 0.46 cm2, and 0.44 cm2 at 0 cm, 2 cm, 4 cm, and 6 cm, respectively., Conclusion: Our data suggest that increased non-sport activity may not increase the cross-sectional area of the AT. Identifying the normal diameter at multiple levels throughout the most commonly injured area may improve the provider's ability to identify early disease processes and apply targeted interventions to help slow or prevent progression and possible rupture., Level of Evidence: Level III-V.

Background: The visual analog scale (VAS) is considered a reliable and validated measure of patient-reported acute pain. Patient-reported outcome measures are becoming the standard of care throughout the orthopedic community, but interpretation and clinical applications are still under investigation. The aim of the current study was to compare preoperative patient-reported VAS scores reported at the same visit to nursing staff and the treating surgeon. Our hypothesis was that there would be no difference in the scores reported., Methods: This study is a retrospective cohort of 201 consecutive foot and ankle patients treated by a single surgeon. The patients were asked to rate their pain intensity by the nursing staff and then by the surgeon using a standard horizontal VAS 0 to 10, from "no pain" to the "worst pain." Differences in reported pain values were analyzed., Results: The results demonstrate that patients reported higher pain scores to the surgeon in 81% of the encounters, nursing staff 8%, and equal 11%. On average, the VAS score reported to the surgeon was significantly ( P < .05) higher than that reported to the nursing staff., Conclusion: The current study found a statistically significant higher patient-reported pain score to the treating surgeon compared to the nursing staff. While the exact cause is unclear, the discrepant pain scores call into question the validity of the VAS, considered a fifth vital sign and standard outcome measure in an outpatient clinic setting., Level of Evidence: Level III, comparative study.

Objectives: Reports of the test accuracy of the urinalysis for diagnosing urinary tract infections (UTIs) in young febrile infants have been variable. We evaluated the test characteristics of the urinalysis for diagnosing UTIs, with and without associated bacteremia, in young febrile infants., Methods: We performed a planned secondary analysis of data from a prospective study of febrile infants ≤60 days old at 26 emergency departments in the Pediatric Emergency Care Applied Research Network. We evaluated the test characteristics of the urinalysis for diagnosing UTIs, with and without associated bacteremia, by using 2 definitions of UTI: growth of ≥50 000 or ≥10 000 colony-forming units (CFUs) per mL of a uropathogen. We defined a positive urinalysis by the presence of any leukocyte esterase, nitrite, or pyuria (>5 white blood cells per high-power field)., Results: Of 4147 infants analyzed, 289 (7.0%) had UTIs with colony counts ≥50 000 CFUs/mL, including 27 (9.3%) with bacteremia. For these UTIs, a positive urinalysis exhibited sensitivities of 0.94 (95% confidence interval [CI]: 0.91-0.97), regardless of bacteremia; 1.00 (95% CI: 0.87-1.00) with bacteremia; and 0.94 (95% CI: 0.90-0.96) without bacteremia. Specificity was 0.91 (95% CI: 0.90-0.91) in all groups. For UTIs with colony counts ≥10 000 CFUs/mL, the sensitivity of the urinalysis was 0.87 (95% CI: 0.83-0.90), and specificity was 0.91 (95% CI: 0.90-0.92)., Conclusions: The urinalysis is highly sensitive and specific for diagnosing UTIs, especially with ≥50 000 CFUs/mL, in febrile infants ≤60 days old, and particularly for UTIs with associated bacteremia., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Ramilo has received research grants from Janssen. Dr Ramilo has received fees for participation in advisory boards from Abbvie, Janssen, and Regeneron and for lectures from Abbvie, Pfizer, and Johnson & Johnson, all of which are unrelated to the current study; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Our objectives were to determine the effect of post rigor calcium chloride injection or freezing on 1) sarcoplasmic calcium concentration and calpain-2 activity of beef longissimus lumborum (LL) and semimembranosus (SM) steaks aged 1, 4, and 14days post-treatment and on 2) Warner-Bratzler shear force, water holding capacity, and consumer acceptability of LL and SM steaks aged 4 and 14days post-treatment. Free calcium levels in the calcium, frozen, and control steaks averaged 1256, 127, and 121μM for the LL and 1520, 120, and 111μM for the SM, respectively. Measurable LL native calpain-2 activity was lower in calcium and frozen steaks than control steaks (P<0.01), while SM native calpain-2 activity was lowest in calcium steaks and intermediate in frozen steaks (P<0.01). LL calcium steaks were more tender (P=0.04) than control steaks. In conclusion, calcium chloride injection and freezing activate calpain-2 earlier postmortem in both muscles and calcium injection improves LL tenderness., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: Amplification is a core component of early intervention for children who are hard of hearing, but hearing aids (HAs) have unique effects that may be independent from other components of the early intervention process, such as caregiver training or speech and language intervention. The specific effects of amplification are rarely described in studies of developmental outcomes. The primary purpose of this article is to quantify aided speech audibility during the early childhood years and examine the factors that influence audibility with amplification for children in the Outcomes of Children with Hearing Loss study., Design: Participants were 288 children with permanent hearing loss who were followed as part of the Outcomes of Children with Hearing Loss study. All of the children in this analysis had bilateral hearing loss and wore air-conduction behind-the-ear HAs. At every study visit, hearing thresholds were measured using developmentally appropriate behavioral methods. Data were obtained for a total of 1043 audiometric evaluations across all subjects for the first four study visits. In addition, the aided audibility of speech through the HA was assessed using probe microphone measures. Hearing thresholds and aided audibility were analyzed. Repeated-measures analyses of variance were conducted to determine whether patterns of thresholds and aided audibility were significantly different between ears (left versus right) or across the first four study visits. Furthermore, a cluster analysis was performed based on the aided audibility at entry into the study, aided audibility at the child's final visit, and change in aided audibility between these two intervals to determine whether there were different patterns of longitudinal aided audibility within the sample., Results: Eighty-four percent of children in the study had stable audiometric thresholds during the study, defined as threshold changes <10 dB for any single study visit. There were no significant differences in hearing thresholds, aided audibility, or deviation of the HA fitting from prescriptive targets between ears or across test intervals for the first four visits. Approximately 35% of the children in the study had aided audibility that was below the average for the normative range for the Speech Intelligibility Index based on degree of hearing loss. The cluster analysis of longitudinal aided audibility revealed three distinct groups of children: a group with consistently high aided audibility throughout the study, a group with decreasing audibility during the study, and a group with consistently low aided audibility., Conclusions: The current results indicated that approximately 65% of children in the study had adequate aided audibility of speech and stable hearing during the study period. Limited audibility was associated with greater degrees of hearing loss and larger deviations from prescriptive targets. Studies of developmental outcomes will help to determine how aided audibility is necessary to affect developmental outcomes in children who are hard of hearing.

Objectives: Children who are hard of hearing (CHH) have restricted access to acoustic and linguistic information. Increased audibility provided by hearing aids (HAs) influences language outcomes, but the advantages of appropriately fit HAs can only be realized if children wear their devices on a consistent basis. The purpose of this article was to characterize long-term HA use in CHH, based on parent-report measures, and identify factors that influence longitudinal trends in HA use., Design: Participants were parents of 290 children with mild to severe hearing loss. At every visit, parents estimated the average amount of time the child used HAs per day during the week and on the weekends. Parent reports of daily HA use were analyzed to determine if different patterns of HA use were observed longitudinally during the study. Independent predictor variables were then related to longitudinal trends in HA use within three age groups (infant, preschool, school age)., Results: On average across multiple visits, parents reported that their children wore their HAs for 10.63 hr per day (SD = 3.29). Data logging values were lower than parent-report measures (M = 8.44, SD = 4.06), suggesting that parents overestimated daily HA use. The majority of children in each age group wore HAs at least 8 hr per day from their first research testing interval to their last, based on parent-report measures. Maternal education level predicted longitudinal trends in HA use for infants and school-age CHH. Degree of hearing loss was related to trends in school-age children only., Conclusions: These results indicated that the majority of CHH increased HA use over time, but a sizable minority demonstrated a low level of use or decreased use in the time period studied. Maternal education level influenced longitudinal trends in daily HA use. Degree of hearing loss influenced trends in school-age children only. Audiologists and early intervention service providers might aid in improving HA use by providing regular hands-on training with the HAs and individualized problem-based strategies to address the challenges families experience with attaining a high level of use. Families may also benefit from practical demonstrations of the benefits of consistent HA use, such as hearing loss simulations, examples of listening in noise with and without HAs, or listening to malfunctioning HAs.

Historically, it was assumed that reactive, inorganic phosphorus present in pristine environments was solely in the form of orthophosphate. However, this assumption contradicts theories of biogenesis and the observed metabolic behavior of select microorganisms. This paper discusses the role of ion chromatography (IC) in elucidating the oxidation-reduction cycle of environmental phosphorus. These methods employ suppressed-IC, coupled with tandem conductivity and electrospray mass spectrometry detectors to identify and quantify phosphorus oxyanions in natural water, synthetic cosmochemical, and biological samples. These techniques have been used to detect phosphite and orthophosphate in geothermal hot springs. Hypophosphite, phosphite, and orthophosphate have been detected in synthetic schreibersite corrosion samples, and termite extract supernatant. Synthetic schreibersite corrosion samples were also analyzed for two poly-phosphorus compounds, hypophosphate and pyrophosphate, and results show these samples did not contain concentrations above the 1.3 and 2.0 μM respective 3σ limit of detection. These methods are readily adaptable to a variety of matrices, and contribute to the elucidation of the oxidation-reduction cycle of phosphorus oxyanions in the environment. In contrast to most studies, these techniques have been used to show that phosphorus actively participates in redox processes in both the biological and geological world.

Objectives: To identify healthcare worker (HCW) and work-site characteristics associated with HCWs' reported use of recommended respiratory-infection control practices in primary and emergency care settings., Design: A cross-sectional study using a self-administered questionnaire for HCWs during the summer and fall of 2005., Setting: Primary and emergency care clinics at 5 medical centers in King County, Seattle, Washington., Results: Nurse professionals who reported receiving training (odds ratio [OR], 2.5 [confidence interval {CI}, 1.1-5.9]; P=.029), instructional feedback from supervisors (OR, 3.0 [CI, 1.5-5.9]; P=.002), and management support for implementing safe work practices had a higher odds of also reporting adherence to recommended respiratory precautions, compared with nurses who did not. Training was the only important determinant for adherence to respiratory precaution measures among medical practitioners (OR, 5.5 [CI, 1.2-25.8]; P=.031). The reported rate of adherence to hand hygiene practices was higher among nurse professionals who were male (OR, 2.2 [CI, 1.0-4.9]; P=.045), had infants, small children, or older adults living at home (OR, 2.2 [CI, 1.2-3.9]; P=.007), reported cleanliness and orderliness of the establishment where they worked (OR, 2.0 [CI, 1.1-3.5]; P=.019), had received respiratory-infection control training (OR, 3.2 [CI, 1.8-6.0]; P<.001), and reported fears about catching a dangerous respiratory infection at work (OR, 2.3 [CI, 1.2-4.5]; P=.011)., Conclusion: A number of HCW and work-site characteristics associated with HCWs' use of recommended respiratory-infection control measures have been identified. These potentially influential characteristics should be considered as targets or guides for further investigation, which should include the evaluation of intervention strategies.

Background: The severe acute respiratory syndrome (SARS) epidemic and concern about pandemic influenza prompted the Centers for Disease Control and Prevention (CDC) to develop guidelines to prevent the transmission of all respiratory infections in health care settings during first contact with a potentially infected person. The extent to which health care workers and institutions use these CDC recommended practices is uncertain., Methods: The study examined health care worker adherence to CDC recommended respiratory infection control practices in primary care clinics and emergency departments of 5 medical centers in King County, Washington, using a self-administered questionnaire. All clinical, allied, and administrative health care workers in study settings were invited to participate: 653 (53%) responded, and 630 were included., Results: The survey revealed important shortcomings in overall personal and institutional use of CDC recommended practices, including deficiencies in posted alerts, patient masking and separation, hand hygiene, personal protective equipment, staff training, and written procedures. Use of recommended measures was generally higher among nursing staff than medical practitioners., Conclusion: This study found significant gaps in adherence to CDC recommendations for the control of respiratory infections in ambulatory care clinical settings. Practical strategies are needed to identify and reduce barriers to implementation of recommended practices for control of respiratory infections.

Infections affecting the central nervous system caused by Blastomyces dermatitidis are rare but curable. We describe a case of a 24-year-old man who presented to the emergency department with progressive bilateral lower extremity weakness over 1 month. On the day of admission, he had minimal muscle strength and was hyperreflexic in the lower extremities. Sensation, however, was intact. Skin examination revealed annular, raised, crusted lesions on his face and legs. A magnetic resonance imaging (MRI) scan showed marrow replacement of the T7 and T8 vertebral bodies and an epidural mass with cord compression. A chest radiograph showed an infiltrate, and a subsequent needle biopsy revealed yeast resembling B. dermatitidis. A skin biopsy was then obtained, and the culture grew out B. dermatitidis. He received 4 weeks of amphotericin B lipid complex (total of 6 grams), followed by oral itraconazole. After 1 week on antifungals, he was able to walk with a walker and the skin lesions virtually resolved. At 5 months he was ambulatory and riding a bicycle daily. Blastomycosis should be included in the differential diagnosis of epidural masses.

The nature of ultrahigh-energy cosmic rays (UHECRs) at energies >10(20) eV remains a mystery. They are likely to be of extragalactic origin, but should be absorbed within approximately 50 Mpc through interactions with the cosmic microwave background. As there are no sufficiently powerful accelerators within this distance from the Galaxy, explanations for UHECRs range from unusual astrophysical sources to exotic string physics. Also unclear is whether UHECRs consist of protons, heavy nuclei, neutrinos or gamma-rays. To resolve these questions, larger detectors with higher duty cycles and which combine multiple detection techniques are needed. Radio emission from UHECRs, on the other hand, is unaffected by attenuation, has a high duty cycle, gives calorimetric measurements and provides high directional accuracy. Here we report the detection of radio flashes from cosmic-ray air showers using low-cost digital radio receivers. We show that the radiation can be understood in terms of the geosynchrotron effect. Our results show that it should be possible to determine the nature and composition of UHECRs with combined radio and particle detectors, and to detect the ultrahigh-energy neutrinos expected from flavour mixing.

This article is an exploration of the etiology of female subjectivity and its relationship to unconscious and conscious images of mother and mother's body. Within the analytic process in dream and phantasy internal aspects of daughter's subjective beliefs and feelings about her body, sexuality, pregnancy, maternal capacity, and mental strength emerge. An analysis of their transformations into language, conscious beliefs, and cultural biases are juxtaposed with the development of women's subjectivity. The concept of the "illness of the signifier" is shown to be the outcome of the painful difficulties of realizing the meaning of the maternal presence as they are constructed internally and culturally.

Vanilloid receptor 1 (TRPV1), a nonspecific cation channel expressed primarily in small sensory neurons, mediates inflammatory thermal pain sensation. The function and expression of TRPV1 are enhanced during inflammation and certain neuropathies, leading to sustained hyperalgesia. Activation of TRPV1 in the spinal cord and periphery promotes release of adenosine, which produces analgesia by activating A(1) and A(2A) adenosine receptor (AR) on central and peripheral neurons. This study provides evidence of a direct interaction of AR analogs with TRPV1. Adenosine analogs inhibit TRPV1-mediated Ca(2+) entry in human embryonic kidney (HEK293) cells stably expressing TRPV1 (HEK/TRPV1) and DRG neurons. This inhibition was independent of A(2A)AR activation. Specific binding of [(3)H]resiniferatoxin (RTX) in plasma membrane preparations was inhibited by CGS21680, an A(2A)AR agonist. Similar degrees of inhibition were observed with both agonists and antagonists of ARs. Adenosine analogs inhibited [(3)H]RTX binding to affinity-purified TRPV1, indicative of a direct interaction of these ligands with the receptor. Furthermore, specific capsaicin-sensitive binding of [(3)H]CGS21680 was observed in Xenopus oocyte membranes expressing TRPV1. Capsaicin-induced inward currents in DRG neurons were inhibited by adenosine and agonist and antagonist of A(2A)AR at nanomolar concentrations. Increasing the concentrations of capsaicin reversed the inhibitory response to capsaicin, suggesting a competitive inhibition at TRPV1. Finally, exposure of HEK/TRPV1 cells to capsaicin induced an approximately 2.4-fold increase in proapoptotic cells that was abolished by adenosine analogs. Together, these data suggest that adenosine could serve as an endogenous inhibitor of TRPV1 activity by directly interacting with the receptor protein.

The search for an endogenous ligand for the vanilloid receptor (VR or TRPV1) has led to the identification of N-arachidonyl dopamine (NADA). This study investigates the role of protein kinase C (PKC)-mediated phosphorylation on NADA-induced membrane currents in Xenopus oocytes heterologously expressing TRPV1 and in dorsal root ganglion (DRG) neurons. In basal state, current induced by 10 microM NADA is 5-10% of the current induced by 1 microM capsaicin or protons at pH 5. However, PKC activator, phorbol 12,13-dibutyrate (PDBu) strongly potentiated ( approximately 15-fold) the NADA-induced current. Repeated application of NADA at short intervals potentiated its own response approximately fivefold in a PKC-dependent manner. PKC inhibitor, bisindolylmaleimide (BIM, 500 nM), a mutant TRPV1 (S800A/S502A), and maximal activation of PKC abolished the potentiation induced by repeated application of NADA. As a further confirmation that NADA could stimulate PKC, pretreatment with NADA potentiated the response of protons at pH 5 (approximately 20 fold), which was dramatically reduced in the mutant TRPV1. In DRG neurons, capsaicin (100 nM) induced a approximately 15 mV depolarization and initiated a train of action potentials compared with 1 microM NADA that produced a approximately 5 mV response. Pretreatment with PDBu induced significantly larger depolarization and potentiated NADA-induced current. Furthermore, exposure of NADA to the intracellular surface of the membrane-induced larger currents suggesting inaccessibility to the intracellular binding site might contribute to its weaker action. These results indicate that NADA is a potent agonist of VR when the receptor is in the PKC-mediated phosphorylation state.

The primary site of lead storage is in bone but relatively little attention has focused on this physiological compartment. Recent advances in measurement technology now permit the direct in vivo quantitative measurement of lead in bone, and this measure has great use in clinical and epidemiologic studies. Lead in bone is not a physiological sink, but can be mobilized back into the circulation in response to normal or pathological changes in mineral metabolism. Bone lead may be a significant source of target organ exposure under certain conditions, such as pregnancy, kidney disease, and menopause. Finally, the accumulation of lead in bone cells may have toxic consequences for bone status, and some of the mechanisms by which lead could affect bone mineral metabolism may also play a role in other target organ effects of lead.

The semiotics of gender are investigated in this article for the purpose of exploring the way that deep unconscious motives in relationship to cultural biases give rise to gender concepts. Theories of semiotic processes, including Jacques Lacan's concept of the psychoanalytic signifier, are explained briefly and applied to the signs of gender. The article concludes that gender concepts develop out of biology, unconscious feelings, and social patterning, and are not given, natural, and irrevocable.

Intercellular contacts in the subfornical organ (SFO) of kittens 3, 16, and 29 days old were studied in thin sections and by the freeze-etch method. Gap junctions appeared between growing nerve processes and target cells. The junctions were interspersed between immature synapses lacking mitochondria as well as full pre- and postsynaptic membrane specializations. Gap junctions were seen on filopodia as well as on more mature processes. The morphology of these junctions was typical of those described earlier but they were of small size (0.2-0.3 micron). Gap junctions of peculiar form were also seen between ependymal elements in the SFO at 16 days. These were of large size (0.5-0.8 micron) and were often of segmented character. This segmentation consisted of bands 3-4 particles in width with a center-to-center spacing of 90 nm with particle free corridors between corresponding to the width of about two rows of particles. The margin of the group might be circumscribed by a row of particles. Although gap junctions of large size were seen between ependymal cells in thin section, features corresponding to the particle free corridors have not been observed to date.

Experience with the extended myocutaneous flap, including distal randomly vascularized tissue, is seldom reported. This report details the use of five extended flaps--sternocleidomastoid, posterior trapezius, total rectus abdominis, tensor fascia lata and inferior gluteal. An average delay of 2 weeks was used to ensure viability. These flaps facilitated the resection of otherwise inoperable craniofacial and pelvic tumours by providing a safe primary closure. Such flaps are unique in their size and their particular application.

During the course of 134 craniotomies under local anesthesia, 274 sensory responses to electrical stimulation were recorded as to cortical site, type of sensation, and the site and lateralization of peripheral referral. The region of cortex exposed was largely the sensorimotor region near the Sylvian fissure and the temporal lobe. Differences in the type of sensation were seen on either side of the central fissure. Sensation of movement and specific sensations were reported more commonly from stimulation in the precentral region and crude sensation from the postcentral area. "Pain" was reported only once and taste not at all despite the large somatic sensory representation of the tongue. About 30% of the responses were referred to the ipsilateral side or bilaterally, with a somewhat higher percentage in the pre- than in the postcentral region. In general, the expected somatotopic sequence was followed, with tongue and mouth having the largest representation. An unexpected number of referrals to the head/face were found in the suprasylvian region, and it was uncertain whether this was part of Somatosensory area II. Eleven cases with sensory referrals to trunk/limbs in the suprasylvian area were found predominantly in the precentral region. No somatotopic pattern could be seen in these or on review of Penfield's material. Possible anatomical pathways for transmission of these responses were reviewed and questions raised as to the mechanisms involved.

Potassium accumulation or impaired potassium clearance has been hypothesized to contribute to epileptogenesis in gliotic epileptogenic foci. To test this hypothesis, potassium clearance rates following direct cortical stimulation were measured in the cortex of monkeys rendered epileptic by the injection of alumina gel into the motor area. Reactive gliosis at the sites in which potassium clearance was measured was then quantitated histologically and compared with potassium clearance rates. Dense gliosis was associated with slowed potassium clearance, although the base-line potassium level appeared no different in actively epileptogenic areas or gliotic areas compared with normal areas. Possible mechanisms and significance of slowed potassium clearance in the alumina focus are discussed.

Sensorimotor responses to stimulation of the medical frontal and cingulate area were studied in seven unrestrained, unsedated patients who suffered from intractable seizures. Complex postural synergies involving the trunk and proximal extremities appeared contralaterally or occasionally bilaterally. Contraversive turning of head and eyes was not observed. Sensory responses from the supplementary motor area were referred contralaterally and focally; those from the cingulate gyrus were widely referred. Speech impairment from stimulation of the supplementary motor area showed striking similarities with that obtained from stimulation in the frontostriatal region or lateral aspect of the frontal lobe. The observations support the hypothesis that interference with striatal function may be the basis of speech inhibition produced by stimulation of the frontal lobe.

The prevalence of Coxiella burnetti infection (Q fever) was determined among Nova Scotia (N.S.) and Prince Edward Island (P.E.I.) blood donors by using the complement fixation and microimmunofluorescence (IF) test. The complement fixation and IF antibody tests measured antibody prevalence for the phase II or phase I and II antigens, respectively. Complement-fixing antibodies to phase II antigen were detected in 4.1% of 997 N.S. and 5.0% of 219 P.E.I. blood donors. Anti-phase II antibodies were detected by microimmunofluorescence in 11.8 and 14.6% of the blood donors in the two provinces, respectively. Anti-phase I antibodies were detected among 2.8% of the N.S. blood donors and 6.3% of the P.E.I. blood donors. Comparison of rates of anti-phase II IF by counties in N.S. revealed that there was at least one county where infection by C. burnetti is hyperendemic. Rates of antibody prevalence were similar in all three areas of P.E.I. examined. We conclude that "Q fever" is endemic in N.S. and P.E.I. and that the microimmunofluorescence test is more suitable than the complement fixation test for seroepidemiologic studies.

A stereotaxic radiotherapy technique that permits accurate delivery of highly localized dose to a small intracranial target has been developed. The technique facilitates precise integration of the diagnostic and therapeutic procedures including target localization, treatment planning, simulation, repetitive patient irradiation, and daily treatment verification. A conventional linear accelerator and computed tomography scanner as well as special diagnostic and therapeutic guides are used. A suitable dosimetric distribution is achieved using arc therapy with small radiation fields and 10-MV x rays.

In man and chimpanzee, the large-celled region in the posteroinferior portion of the lateroventral thalamic mass, commonly called the nucleus ventralis posterior thalami, is separated cytoarchitecturally into two regions. The anterior portion is called the nucleus ventrointermedius (Vim) and the posterior part, the nucleus ventrocaudalis (Vc). In the chimpanzee it was found that most of the fibers from the superior cerebellar peduncle entered Vim on the way to distribution in the anterior half of the lateroventral thalamic mass. Fibers from the posterior spinal column (medial lemniscus) entered the Vc. No overlap was evident in the radiations from the two sources. An unusual human case is presented suporting the sensory function of Vc since a lesion in this nucleus resulted in persistent contralateral paresthesia. On the other side, a discrete lesion in Vim caused no sensory disturbance.

Pain following tooth extraction was assessed in 60 patients using the McGill Pain Questionnaire and the Anxiety Differential, along with other measures of patient expectations and behavior. The McGill Pain Questionnaire demonstrated efficacy in assessing postextraction pain with subscale measures relating to situational anxiety, recovery time and use of analgesics. Significant overlap among the subscales (7--58% common variance) was found suggesting further scale refinement is indicated. Pain descriptive words used and mean subscale scores were similar to those previously reported for toothache pain.

We used the indirect microimmunofluorescence test to determine the presence of antibodies in sheep, cattle, goat, cat, and dog sera to phase I and II Coxiella burnetii antigens in Nova Scotia. Only 6.7 per cent of the 329 sheep tested had antibodies to phase II antigen and none had antibodies to phase I. Of 29 goats tested, 7 per cent and 3.5 per cent had antibodies to phase II and phase I antigens, respectively. In contrast, 23.8 per cent of the 214 cattle tested had antibodies to phase II antigen, and 24.2 per cent had antibodies to phase I antigen; 24.1 per cent of 216 cats tested had antibodies to phase II antigen and 6 per cent had antibodies to phase I antigen. None of the 447 dogs tested had antibodies detected. We conclude that cattle and cats may be reservoirs for human Q fever in Nova Scotia.

Lumbar cerebrospinal fluid (CSF) norepinephrine (NE) concentrations were preoperatively determined in five patients using a radioenzymatic assay technique. Stereotaxic thalamotomy was performed using depth coagulating electrodes with stimulating points at 5.0-mm intervals along the shaft. No significant alterations in prestimulation lumbar CSF NE levels were noted 12 days after electrode installation. Stimulating points within the caudate nucleus were anatomically localized using ventricular landmarks and stimulation-induced neurophysiological responses were recorded. Twelve hours after intermittent electrical stimulation of the caudate nucleus, lumbar CSF NE concentrations were significantly decreased. Our data suggest the presence of noradrenergic pathways in man that are inhibited by caudate nucleus stimulation.

The instrument is based upon a radiolucent ring fixed to the skull by four pins. This locks into a frame for CT scanning from which the x, y and z stereotactic coordinates are derived. The head ring may be locked into a compatible support on the operating table for biopsy. A similar support and localization system is used for rotational radiotherapy. With the current 14 MeV apparatus, fields as small as 2 cm in diameter are available with 90% dosage fall-off in the surrounding 1-cm shell.