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PubMed1999

Identification of determinants of pesticide exposure among Kenyan agricultural workers using empirical modelling.

The influence of factors such as type of pesticides used, use of personal protective devices and hygienic behaviour on acetylcholinesterase inhibition and activity levels in red blood cells of agricultural workers was studied in four areas in Kenya. Empirical modelling techniques were used to identify and quantify factors affecting acetylcholinesterase inhibition and activity. Use of personal protective devices was almost non-existent in areas 3 and 4 where mainly subsistence farmers were studied. Differences in hygienic behaviour between areas were relative small. WHO Class I pesticides were mostly found in area 1 (mainly large farms growing flowers) which also had highest amounts of pesticide use and highest frequency of pesticide spraying. Despite widespread use of protective devices in this area significant inhibition occurred. It became unclear whether acetylcholinesterase inhibition occurred as a result of protective clothing soaked with pesticides, thereby increasing dermal exposure, or because of other (unmeasured) factors. Inhibition, however, could have been much worse without protective devices. In area 1, most workers wore boots, which were found to be protective only when combined with an overall; wearing boots alone led to increased inhibition. Access to a washing facility or bathing facility had a positive effect on acetylcholinesterase levels. However, washing of hands and bathing immediately after spraying seemed reactive behaviour rather than proactive behaviour. Spraying was found to lead to more profound acetylcholinesterase inhibition than mixing. Workers who sprayed WHO Class III pesticides had less acetylcholinesterase inhibition than workers spraying more toxic pesticides.

Acetylcholinesterase↗
PubMed2005

Acute thromboembolic events during carotid artery angioplasty and stenting: etiology and a technique of neurorescue.

PURPOSE: To review the protected carotid stenting experience at two major referral centers to evaluate the frequency of clinically significant intraprocedural thromboembolic events, use of neurorescue techniques, and ultimate clinical outcomes. METHODS: A retrospective review was conducted of 254 cases of protected transfemoral carotid stenting performed at the Washington University-Barnes Hospital and The Fleni Institute of Buenos Aires in a 6-year period. Medical records of patients with periprocedural thromboembolic events were reviewed to determine the type of complication, method of treatment, and outcome. RESULTS: Among the 254 cases in which a carotid protection device was used, 2 (0.79%) episodes of witnessed, symptomatic thromboembolism occurred. Both patients suffered thromboembolic occlusion of the M1 branch of the middle cerebral artery (MCA) immediately following crossing of the internal carotid lesion with the protection device. Neurological symptoms consisted of agitation, aphasia, and hemiplegia in both patients. After rapid stent deployment across the carotid lesion, the MCA was cannulated and the occlusion treated with balloon angioplasty. This was followed by selective intra-arterial delivery of urokinase and intravenous abciximab. These maneuvers resulted in excellent restoration of blood flow in the MCA and its branches. With the exception of minor word-finding difficulties in one, both patients demonstrated full neurological recovery within the perioperative period. CONCLUSIONS: In our experience, intraprocedural thromboembolic events occur despite the use of cerebral protection devices, but are rare. Notably these complications appeared to occur at the time of lesion crossing by distal cerebral protection devices. These thromboembolic events can be successfully treated if the complication is rapidly identified and the physician is adequately prepared and proficient in neurorescue techniques.

Abciximab↗
PubMed2004

Protected carotid-artery stenting versus endarterectomy in high-risk patients.

BACKGROUND: Carotid endarterectomy is more effective than medical management in the prevention of stroke in patients with severe symptomatic or asymptomatic atherosclerotic carotid-artery stenosis. Stenting with the use of an emboli-protection device is a less invasive revascularization strategy than endarterectomy in carotid-artery disease. METHODS: We conducted a randomized trial comparing carotid-artery stenting with the use of an emboli-protection device to endarterectomy in 334 patients with coexisting conditions that potentially increased the risk posed by endarterectomy and who had either a symptomatic carotid-artery stenosis of at least 50 percent of the luminal diameter or an asymptomatic stenosis of at least 80 percent. The primary end point of the study was the cumulative incidence of a major cardiovascular event at 1 year--a composite of death, stroke, or myocardial infarction within 30 days after the intervention or death or ipsilateral stroke between 31 days and 1 year. The study was designed to test the hypothesis that the less invasive strategy, stenting, was not inferior to endarterectomy. RESULTS: The primary end point occurred in 20 patients randomly assigned to undergo carotid-artery stenting with an emboli-protection device (cumulative incidence, 12.2 percent) and in 32 patients randomly assigned to undergo endarterectomy (cumulative incidence, 20.1 percent; absolute difference, -7.9 percentage points; 95 percent confidence interval, -16.4 to 0.7 percentage points; P=0.004 for noninferiority, and P=0.053 for superiority). At one year, carotid revascularization was repeated in fewer patients who had received stents than in those who had undergone endarterectomy (cumulative incidence, 0.6 percent vs. 4.3 percent; P=0.04). CONCLUSIONS: Among patients with severe carotid-artery stenosis and coexisting conditions, carotid stenting with the use of an emboli-protection device is not inferior to carotid endarterectomy.

Adult↗
PubMed2005

Silent cerebral ischemia detected with diffusion-weighted imaging in patients treated with protected and unprotected carotid artery stenting.

BACKGROUND AND PURPOSE: Percutaneous transluminal angioplasty with stent (CAS) is an alternative method to endarterectomy in the revascularization of carotid artery stenosis. Protected CAS is currently used to prevent distal embolization. Diffusion-weighted MRI (DWI) is the most sensitive tool to evaluate silent cerebral ischemia. The purpose of this research was to assess the incidence of cerebral embolic lesions during CAS and to evaluate whether cerebral protection devices can reduce the number of silent cerebral ischemia with respect to unprotected CAS. METHODS: Fifty-two patients with high-grade internal stenosis underwent CAS; 30 patients (group a) were treated with a cerebral protection device, and 22 (group b) were treated without it. All of the patients were evaluated preoperatively and postoperatively with fluid-attenuated inversion recovery and DWI sequences to depict the number of new embolic silent cerebral lesions. RESULTS: Embolic silent cerebral lesions occurred in 30% of CAS. Cerebral protection devices reduce the number of new lesions significantly reducing the consistent lesions ipsilateral to the treated vessel. Inconsistent lesions do not differ in both groups of patients. Clinical, radiological, and procedural variables do not correlate with the appearance of new cerebral lesions. CONCLUSIONS: Embolic cerebral lesions detected with DWI are more frequent with unprotected CAS, although they are present also with the use of cerebral protection devices. Probably a part of silent cerebral lesions arise from the procedural maneuver in the aortic arch.

Aged↗
PubMed2006

Platelet glycoprotein IIb/IIIa receptor inhibition as adjunctive treatment during saphenous vein graft stenting: differential effects after randomization to occlusion or filter-based embolic protection.

AIMS: Although embolic protection devices reduce complications during saphenous vein graft (SVG) stenting, adverse events still occur in approximately 10% of patients. IIb/IIIa antagonists have not been proven effective during SVG intervention. We hypothesized that adjunctive use of these agents might enhance the efficacy of embolic protection devices. METHODS AND RESULTS: In the prospective, multicentre FilterWire EX Randomized Evaluation trial, 651 patients undergoing SVG stenting were randomized to either filter-based FilterWire EX or balloon occlusion/aspiration GuardWire embolic protection devices. IIb/IIIa inhibitor use was at the discretion of the investigator, with randomization stratified by intended use. Patients pre-selected for IIb/IIIa inhibitor use (n = 345) had higher baseline risk, with increased 30-day major adverse cardiac events (MACE, 13.0 vs. 8.0%, P = 0.03). GuardWire assigned patients treated with IIb/IIIa inhibitors had higher 30-day MACE compared with those not treated with IIb/IIIa inhibitors (16.0 vs. 6.3%, P = 0.007). In contrast, MACE in high-risk FilterWire patients treated with IIb/IIIa inhibitors were similar to their lower risk, untreated counterparts (9.9 vs. 9.5%, P = 0.89). Multivariable analysis detected a borderline significant (P = 0.056) interaction for lower MACE between FilterWire and IIb/IIIa inhibitor use. Adjustment by the propensity to use IIb/IIIa inhibitors resulted in a significant (P = 0.023) interaction for lower MACE rates. IIb/IIIa inhibition in conjunction with FilterWire was associated with less abrupt closure, no reflow, or distal embolization. CONCLUSION: IIb/IIIa antagonists may improve procedural outcome during SVG stenting in high risk patients, utilizing filter-based embolic protection devices.

Aged↗
PubMed2006

[Percutaneous carotid artery stenting in high-risk patients].

UNLABELLED: Recent studies have shown that percutaneous carotid artery angioplasty and stenting can be safely performed in patients with carotid artery stenosis, especially those considered to be at high-risk for surgery. AIM: We evaluated the safety and feasibility of carotid artery angioplasty and stenting, with and without distal protection devices in patients at high-risk for surgical endarterectomy. METHODS: A total of 169 consecutive patients underwent 185 procedures and 189 stents were deployed successfully in 195 lesions. The majority of patients (51%) had restenosis after a prior carotid endarterectomy, 40% were considered to be ineligible for carotid endarterectomy by both the vascular surgeons and the interventional cardiologist and 7% were considered ineligible for surgery due to hostile neck anatomy. RESULTS: Distal embolic protection devices were used in 52% of all cases. Procedural success was achieved in 181 of 185 procedures (98%). The overall rate of in-hospital major adverse cerebrovascular events (death, major stroke, and myocardial infarction) was 2.4%. In-hospital event rates in patients with prior carotid endarterectomy were comparable to patients with de novo lesions with 3.3% vs. 1.1% death/ stroke at 30 days, and 3.3% and 3.3% stroke/death rates at 30 days, respectively. When distal protection devices were used death/stroke rates were 0% as compared to 4.7% when distal protection was not used (p = NS). However, minor embolic phenomena were observed in both primary and secondary lesions independent of the use of distal protection. CONCLUSIONS: These results support the use of carotid artery angioplasty and stenting in high-risk patients with significant primary or secondary carotid artery stenosis. In both types of lesions, acceptable results justify its use as a valid revascularization method. While clinical embolic events occur in a minority of patients in both lesion types, they are not entirely prevented by distal protection devices.

Aged↗
PubMed2003

Dental and oral trauma and mouthguard use during sport activities in Israel.

The purpose of the present study was to evaluate the occurrence of oral and dental injuries in young Israeli population engaged in diverse sport activities. The participants' awareness of the use of protective devices, such as mouthguards, during sport activities was also evaluated. A population of 943 young adults, 95% males and 5% females (ages 18-19), was surveyed. A questionnaire was distributed relating to the type of sport activity practised, past oral and dental injuries over their lifetime, specifying the time and type of sports in which the injury occurred and the use and awareness of the protective devices. Of the total population examined, 850 (90%) were active in at least one type of sport, either as professionals or as amateurs. The analysis included the population that regularly participated in at least one sporting activity. The most commonly practised sports were soccer (54% of all active participants) and basketball (50%). The total number of dental and oral injuries experienced during all sport activities was 229, affecting 27% of the participants of whom 73 (9%) suffered dental injuries. Most dental injuries occurred during the basketball and soccer training sessions and matches reaching 42 and 41% of the total number of injuries, respectively, and affected 7.2 and 6.6% of the basketball and soccer players. Traumatic dental injuries in other sports occurred in less than 7% of the participants in these activities. Only 27% of the participants were aware of the protective devices, such as a mouthguards, and only 3% actually used these devices. These results point to the high risk of potential dental and oral injury during sport activities, the little knowledge about the benefits of using mouthguards and their limited utilization. The importance of public health education to increase the awareness of protective measures and devices and their actual use in Israel is the main focus. It should be a combined duty of dentists and sports physicians and of the coaches to encourage the use of protective devices during training and games.

Adolescent↗
PubMedDate not supplied

Effective prevention of massive periprocedural embolism during renal artery stenting.

We report the case of a massive embolism of atheromatous material during stenting of a tight renal artery stenosis, which was prevented by using a distal embolic protection device and aggressive aspiration of the blood through a guiding catheter. A 72-year-old man who was referred to our institution for coronary artery disease treated with coronary angioplasty underwent renal angiography which revealed a tight stenosis (99%) located at the ostium of the right renal artery extending for 15 mm into the main tract. The diameter of the artery was estimated to be 5.5 cm in the main tract, and the plaque had a soft appearance complicated by the presence of a thrombus (persistence of contrast agent in the plaque on selective renal angiography). Renal artery Doppler ultrasound and renal scintigraphy confirmed the need for renal revascularization. An embolus protection device (FilterWire EZ, Boston Scientific, Natick, MA, USA) was successfully opened distally to the stenosis after gentle predilation. After stent deployment (Genesis 5.5x18 mm, Cordis, J&J Medical, Miami Lakes, FL, USA), aggressive aspiration of the blood through the guiding catheter was performed. A large amount of embolic material with macroscopic particles was retrieved into the basket of the embolic protection device and in the blood aspirated with the guiding catheter. Good functional results were obtained on Doppler analysis of intrarenal blood flow, with a resistive index of 70. Despite the fact that the extensive use of embolic protection devices in renal artery stenting is still under discussion, this technique may be advisable in selected cases with favorable anatomy and high embolic risk, especially in patients with complex and hazy lesions.

Aged↗
PubMed2005

Atheroemboli during renal artery angioplasty: an ex vivo study.

OBJECTIVE: We hypothesized that atheroemboli released during renal angioplasty could be responsible for the modest functional result of renal angioplasty even after anatomic reduction of renal artery stenosis. To test this hypothesis, we enumerated and sized fragments released during ex vivo angioplasty and stenting of human renal artery atherosclerotic specimens removed during aortorenal endarterectomy. METHODS: Thirty-three intact aortorenal atheroma specimens (16 pairs with adjacent aortic atheroma and one specimen with a single renal artery orifice) were removed from 17 patients with renal artery occlusive disease who underwent renal artery endarterectomy. specimens. Endarterectomy specimens were removed with a ring of aortic plaque and "fitted" with a polytetrafluoroethylene "adventitia". Ex vivo angioplasty was technically successful in 31 of the 33 specimens and was performed by using a 0.018-inch guidewire and 3.0-mm and 5.0-mm angioplasty balloons inflated for 30 seconds at 15 atmospheres pressure. Stenting was performed with either a 5-mm or 6-mm self-expanding Wallstent. Each artery was flushed with 20 mL of saline after guidewire placement, each angioplasty, and stent placement. The effluent was collected for analysis for counting with either a microscope (size >100 microm) or a Coulter counter (size <100 microm). The number and size of embolic fragments in the effluent collected after each manipulation was recorded. RESULTS: Each manipulation of the specimens, including simply advancing the guidewire through the atherosclerotic lesion, released thousands of fragments. The numbers of fragments in each size category increased with decreasing particle size. Positioning and deploying the Wallstent released an additional bolus of fragments similar to that released after balloon angioplasty. CONCLUSIONS: Ex vivo renal angioplasty releases thousands of atherosclerotic fragments of sufficient size to create vascular occlusions and initiate significant renal parenchymal damage. The results of renal angioplasty procedures could be improved by placing distal protection devices to prevent atheroembolization. CLINICAL RELEVANCE: Athero-emboli produce a local arteritis in the kidney and could cause substantial damage to the renal parenchyma. This report explores the quantity of athero-emboli released during ex vivo angioplasty and stenting of renal atheroma specimens. The number of emboli found in this ex vivo study suggest that the use of protection devices may be advisable to protect the end organ, as done with angioplasty of the carotid artery. Of necessity, this was an ex vivo study and direct application to the clinical setting will need further study. Fortunately, multi-center trials examining the value of protection devices are currently in progress.

Aged↗
PubMed2004

An in vitro analysis of a carotid artery stent with a protective porous membrane.

PURPOSE: To prove the effectiveness of a new stent concept with integrated protection (MembraX [MX]) by comparing it with five cerebral protection devices designed for carotid angioplasty in an in vitro model. MATERIALS AND METHODS: Two simulation series of embolization from carotid angioplasty have been performed. In the first series, polyvinyl-alcohol particles (150-250 microm [small], 355-500 microm [medium], 710-1000 microm [large]; 5 mg each) were injected into a silicone flow model simulating the aortic arch with a carotid bifurcation. The particles were injected proximally to the partially deployed MX stent or one of the following protection devices: Angioguard (AG), FilterWire EX (EX), Trap, Neuroshield (NS), or GuardWire Plus (GW). Particles evading the protection device were caught in a filter at the end of the flow model and weighed. In the second series, human plaque material (8-12 particles; total weight 6.09 +/- 0.01 mg; 500-1500 microm) was injected into the model with the respective devices. MX was compared with the AG, EX, Trap, and NS devices. RESULTS: MX had the most effective overall filtration performance for polyvinyl alcohol particles in the effluent of the internal carotid artery (ICA; 0.43 mg, 2.9%), compared with NS (0.53 mg, 3.5%), GW (1.10 mg, 7.0%), EX and AG (1.18 and 1.21 mg, respectively; 7.8% and 8.0%), and Trap (1.24 mg, 8.2%). MX performed best for the small particles (2.0% passed particles into ICA; P < .05 compared with all). Human plaque material was retained best in the in vitro model by MX (0.0%), followed by NS (0.8%), EX (1.3%), Trap (2.6%), and AG (4.4%). CONCLUSIONS: In vitro, none of the tested devices had the ability to prevent embolization completely. Comparing current designs, the MX device captured the highest percentage of the three different particle groups. Tested with human plaque emboli, MX performed effectively in filtering the particles in the ICA.

Analysis of Variance↗
PubMed2001

Cerebral protection with filter devices during carotid artery stenting.

BACKGROUND: Distal embolization of debris during percutaneous carotid artery stenting may result in neurological deficit. Filter devices for cerebral protection potentially reduce the risk of embolization. METHODS AND RESULTS: Elective carotid stent implantation using 3 different types of distal filter protection devices was attempted in 88 consecutive lesions (84 patients) in the internal carotid artery that had >70% diameter stenosis (mean, 78.7+/-10.7%). Procedures were performed in 3 different centers. The mean age of the patients was 69+/-8 years, 75% were men, and 35.7% had neurological symptoms. In 86 lesions, a stent was successfully implanted (97.7%). In 83 of these 86 procedures (96.5%), it was possible to position a filter device. In 53% of filters, there was macroscopic evidence of debris. Collected material consisted of lipid-rich macrophages, fibrin material, and cholesterol clefts. Neurological complications during the procedure, in the hospital, and at 30 days of clinical follow-up occurred in only one patient (1.2%). This patient suffered a minor stroke that resolved within 1 week. Two major adverse cardiac events (2.3%) occurred during the 30 days of follow-up. CONCLUSIONS: Filter protection during carotid artery stenting seems feasible and safe. In the present series, the incidence of neurological complications was low.

Aged↗
PubMed2000

Medical evaluation for respirator use.

The purpose of a respirator is to prevent the inhalation of harmful airborne substances or to provide a source of respirable air when breathing in oxygen-deficient atmospheres. For a physician to recommend the use of respirator, general background information on respiratory-protective devices is required. The first part of this clinical practice review describes the general aspects of industrial hygiene, respirators and a respirator-certification program. The second part addresses matters related to medical certification for respirator use. Medical certification for respirators is an important part of the activities of the occupational physician. To determine whether a worker is able to tolerate the added strain of a respiratory protective device is a complex process in which factors such as fitness for work, health of the individual, characteristics of the work itself, and the properties, type, and requirements of the respiratory protective device, have to be considered. Medical certification is of utmost importance for respirator use, and it should be viewed as an element in a comprehensive respiratory protection program. A comprehensive program is the key element in affording the workers' effective respiratory protection once the initial steps of the hierarchy of methods of hazard control have proved insufficient or infeasible. As a result, the need for the industrial hygiene/safety officer, the worker, the employer and the medical professional to work as a team is much more than in any other field of occupational medicine--a necessary requirement for making the right decision.

Decision Making↗
PubMed2005

Knowledge, attitude and practices related to occupational health problems among salt workers working in the desert of Rajasthan, India.

Workers in the salt industry are exposed to direct sunlight, salt dust and contact with brine. To assess their awareness, attitude and practices related to occupational health problems, 205 salt workers were interviewed about health hazards and problems related to their working conditions, usage of protective measures and suggestions for their improvisation. The brine workers had a fair knowledge of their occupational health problems (98.7%), protective measures (100.0%) and their benefits (100.0%) as compared to non brine workers for whom these figures were 89.0%, 85.8% and 78.7% respectively. The brine workers (29.5%) and non brine workers (31.5%) used unconventional measures to prevent contact with salty water, salt dust, raw salt and glare. There was a huge gap between their knowledge and practice with protective devices, though they suggested improvements in protective devices to increase their acceptability.

Adult↗
PubMedDate not supplied

Attenuation characteristics of hearing aid earmolds.

The purpose of this study was to determine the attenuation characteristics of several hearing aid earmolds. Six earmolds and an E-A-R earplug modified to act as an earmold were evaluated according to the standard procedure. The six earmolds consisted of two types (shell and skeleton) having different materials (Lucite and vinylflex) and different styles (normal and tragus lock). The traditional earmolds provided approximately 17 dB less attenuation as compared with the E-A-R earmolds. The attenuation provided by the traditional earmolds was not influenced by the type, material, or style. The traditional earmolds had a noise reduction rating of less than 3.3 dB, whereas the noise reduction rating for the E-A-R earmolds was greater than 18.2 dB. Traditional earmolds should not be considered as a substitute for a hearing protection device. However, E-A-R earmolds could be used as a substitute for a hearing protection device provided the level of the noise minus the noise reduction rating would be acceptable.

Adult↗
PubMed2003

A review of sharps injuries and preventative strategies.

Exposure to bloodborne pathogens from sharps injuries continues to pose a significant risk to healthcare workers (HCW). The number of sharps injuries sustained by HCW is still unclear, primarily due to under-reporting. In this review a mean rate of 4.0% (range 1.0-6.2%) sharps injuries per 10000 HCW was calculated from eight studies involving more than 7000 HCW. Nurses and doctors were most at risk of sharps injuries, frequently from hollow-bore needles. Approaches to reduce this risk have included education and training on the safe handling and disposal of sharp devices, awareness campaigns and legislative action. More recently, preventative strategies have focused on needle protective devices, which may reduce the rate of sharps injuries. Introducing needle protective devices should be considered particularly in high-risk areas, after training, education, evaluation and cost-benefit analysis.

Blood-Borne Pathogens↗
PubMed2006

Incidence of new brain lesions after carotid stenting with and without cerebral protection.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) may be a useful tool to evaluate the efficacy of cerebral protection devices in preventing thromboembolic complications during carotid angioplasty and stenting (CAS). The goals of this study were (1) to compare the frequency, number, and size of new DWI lesions after unprotected and protected CAS; and (2) to determine the clinical significance of these lesions. METHODS: DWI was performed immediately before and within 48 hours after unprotected or protected CAS. Clinical outcome measures were stroke and death within 30 days. RESULTS: The proportion of patients with any new ipsilateral DWI lesion (49% versus 67%; P<0.05) as well as the number of new ipsilateral DWI lesions (median=0; interquartile range [IQR]=0 to 3 versus median=1; IQR=0 to 4; P<0.05) were significantly lower after protected (n=139) than unprotected (n=67) CAS. The great majority of these lesions were asymptomatic and less than 10 mm in diameter. Although there were no significant differences in clinical outcome between patients treated and not treated with protection devices (7.5% versus 4.3%, not significant), the number of new DWI lesions was significantly higher in patients who developed a stroke (median=7.5; IQR=1.5 to 17) than in patients who did not (median=0; IQR=1 to 3.25; P<0.01). CONCLUSIONS: The use of cerebral protection devices significantly reduces the incidence of new DWI lesions after CAS of which the majority are asymptomatic and less than 10 mm in diameter. The frequent occurrence of these lesions and their close correlation with the clinical outcome indicates that DWI could become a sensitive surrogate end point in future randomized trials of unprotected versus protected CAS.

Aged↗