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A case of surgical emphysema which occurred during a routine restorative dental procedure is presented. The differential diagnosis and management of this condition is discussed. Judicious use of intra-oral dental instruments using compressed air is advised.
Geoff Dillow, author of Dental compressed air and vacuum systems--2003, a supplement to the NHS Estates publication Health technical memorandum No 2022: Medical gas pipeline systems, examines issues surrounding the use of scavenging systems for nitrous oxide during relative analgesia (RA) procedures in dentistry. Practical advice to help reduce unnecessary exposure of practice staff is offered.
1. Aseptic necrosis of bone is a serious chronic complication of deep-sea diving and compressed-air work. 2. The changes to the bone which occur in this condition take time to develop to the stage where they cause the radiographic signs of bone necrosis, and consequently there is a delay of some months between the causal incident and the first diagnosis by radiography. 3. As a possible method for the earlier detection of bone necrosis the 24 h urinary excretion of hydroxyproline was measured over a period before and after experimental production of bone necrosis in rabbits by the intra-arterial injection of glass microspheres. 4. Total hydroxyproline excretion rose significantly within a few days of the injection in those rabbits in which there was later shown to be historical evidence of bone necrosis. This rise occurred long before there was any radiographic changes. 5. It is suggested that measurements of urinary hydroxyproline might be used to give an early indication of bone necrosis in man.
BACKGROUND: Pulmonary hypertension (PH) causes mortality in some congenital and acquired heart and lung diseases. However, inhalation of NO gas requires complicated and expensive instruments and elaborate preparations to avoid toxic gas administration. We tested the effectiveness and safety of inhaled nebulized nitroglycerin (Neb-NTG) in dogs with experimental PH. METHODS: Experimental PH was induced by continuous infusion of a thromboxane analog (U46619). The U46619 infusion rate was adjusted to maintain a systolic pulmonary artery pressure (PAP) at 40 mmHg in 10 anesthetized and mechanically ventilated dogs. Then, 20 micrograms/kg of NTG liquid nebulized by compressed air was inhaled. RESULTS: After infusion of U46619, the systolic, diastolic and mean PAP increased by 119%, 228% and 169%, respectively, and the systolic, diastolic and mean systemic arterial pressures (SAP) increased by 19%, 29% and 23%, respectively. The systolic pulmonary to systemic pressure ratio (Pp/Ps) and mean Pp/Ps increased by 83% and 113%, respectively, and the pulmonary vascular resistance (PVR), systemic vascular resistance (SVR) and pulmonary to systemic resistance ratio (Rp/Rs) increased by 341%, 100% and 145%, respectively. After inhalation of Neb-NTG in dogs with experimental PH, systolic, diastolic and mean PAP and PVR decreased by 25 +/- 4, 26 +/- 11, 25 +/- 9 and 31 +/- 21%, respectively. There were no significant changes in systolic, diastolic and mean SAP, SVR, cardiac output and plasma methemoglobin concentrations. The systolic and mean Pp/Ps decreased by 18 +/- 7 and 20 +/- 7%, respectively. The Rp/Rs decreased by 25 +/- 13%. CONCLUSIONS: The results of this study demonstrate that Neb-NTG is an effective and selective pulmonary vasodilator and may offer a new therapeutic option for PH.
The primary objective of this study was to determine the influence of stretch-induced cell injury on the metabolism of cellular phosphatidylcholine (PC). Neonatal rat astrocytes were grown to confluency in Silastic-bottomed tissue culture wells in medium that was usually supplemented with 10 microM unlabeled arachidonate. Cell injury was produced by stretching (5-10 mm) the Silastic membrane with a 50-ms pulse of compressed air. Stretch-induced cell injury increased the incorporation of [3H]choline into PC in an incubation time- and stretch magnitude-dependent manner. PC biosynthesis was increased three- to fourfold between 1.5 and 4.5 h after injury and returned to control levels by 24 h postinjury. Stretch-induced cell injury also increased the activity of several enzymes involved in the hydrolysis [phospholipase A2 (EC 3.1.1.4) and C (PLC; EC 3.1.4.3)] and biosynthesis [phosphocholine cytidylyltransferase (PCT; EC 2.7.7.15)] of PC. Stretch-induced increases in PC biosynthesis and PCT activity correlated well (r = 0.983) and were significantly reduced by pretreating (1 h) the cells with an iron chelator (deferoxamine) or scavengers of reactive oxygen species such as superoxide dismutase and catalase. The stretch-dependent increase in PC biosynthesis was also reduced by antioxidants (vitamin E, vitamin E succinate, vitamin E phosphate, melatonin, and n-acetylcysteine). Arachidonate-enriched cells were more susceptible to stretch-induced injury because lactate dehydrogenase release and PC biosynthesis were significantly less in non-arachidonate-enriched cells. In summary, the data suggest that stretch-induced cell injury is (a) a result of an increase in the cellular level of hydroxyl radicals produced by an iron-catalyzed Haber-Weiss reaction, (b) due in part to the interaction of oxyradicals with the polyunsaturated fatty acids of cellular phospholipids such as PC, and (c) reversible as long as the cell's membrane repair functions (PC hydrolysis and biosynthesis) are sufficient to repair injured membranes. These results suggest that stretch-induced cell injury in vitro may mimic in part experimental traumatic brain injury in vivo because alterations in cellular PC biosynthesis and PLC activity are similar in both models. Therefore, this in vitro model of stretch-induced injury may supplement or be a reasonable alternative to some in vivo models of brain injury for determining the mechanisms by which traumatic cell injury results in cell dysfunction.
Abstract The effect of hyperbaric oxygen treatment (HBO) on sensory axon regeneration was examined in the rat. The sciatic nerve was crushed in both legs. In addition, the distal stump of the sural nerve on one side was made acellular and its blood perfusion was compromised by freezing and thawing. Two experimental groups received hyperbaric exposures (2.5 ATA) to either compressed air (pO2 = 0.5 ATA) or 100% oxygen (pO2 = 2.5 ATA) 90 minutes per day for 6 days. Sensory axon regeneration in the sural nerve was thereafter assessed by the nerve pinch test and immunohistochemical reaction to neurofilament. HBO treatment increased the distances reached by the fastest regenerating sensory axons by about 15% in the distal nerve segments with preserved and with compromised blood perfusion. There was no significant difference between the rats treated with different oxygen tensions. The total number of regenerated axons in the distal sural nerve segments after a simple crush injury was not affected, whereas in the nerve segments with compromised blood perfusion treated by the higher pO2, the axon number was about 30% lower than that in the control group. It is concluded that the beneficial effect of HBO on sensory axon regeneration is not dose-dependent between 0.5 and 2.5 ATA pO2. Although the exposure to 2.5 ATA of pO2 moderately enhanced early regeneration of the fastest sensory axons, it decreased the number of regenerating axons in the injured nerves with compromised blood perfusion of the distal nerve stump.
A case of injection of compressed air into a digit is reported. The air was injected at 50 PSI through a trivial puncture wound sustained some hours previously. The case had a benign course, in comparison to high pressure injection injuries with foreign material.
Dysbaric osteonecrosis is associated with exposure to large ambient pressure changes, and comprises necrotic lesions in the fatty marrow-containing shafts of the long bones, and the ball and socket joints (hips and shoulders). The fundamental causes are still in question and the illness remains a significant health hazard. Radiological and pathological features of both dysbaric and non-dysbaric osteonecrosis are indistinguishable and both are characterized by intramedullary venous stasis, ischemia and necrosis of bone. It has been generally accepted that gas bubbles (probably by initiating intramedullary venous stasis) are the prime cause of dysbaric osteonecrosis, as well as being responsible for Type 1 Decompression Sickness or 'the bends'. Importantly, however, not all series have found a correlation between dysbaric osteonecrosis and 'the bends'. Thus even though it is likely that gas bubbles remain the prime cause of dysbaric osteonecrosis, workers have proposed that in some cases there is another etiological factor which may exaggerate the pathologic effects of gas bubbles, making the bone more susceptible to necrosis. It is proposed that rapid compression by impeding venous drainage from bone initiates intramedullary venous stasis. In the presence of intramedullary gas bubbles, this may progress to thrombosis, ischemia and bone necrosis. The review offers an explanation for total sparing of the knee joint in dysbaric osteonecrosis, and sole involvement of the hip and shoulder (in terms of sub-articular lesions and subsequent joint collapse). In addition to continued observance of proper decompression procedures, a slower rate of compression may further reduce the incidence of dysbaric osteonecrosis. Bone death or osteonecrosis is a concept which Hippocrates put forward in antiquity (1), but it was not until 1794 that James Russell of Edinburgh wrote the first modern-day descriptions. In these cases infection was the predominant etiology (1,2). In 1888 Konig described necrosis of the adult femoral head without infection (3) (aseptic necrosis of bone) and in the same year Twynam reported a case of osteonecrosis in a caisson worker (4) in which there was still a significant infective component. In 1911 Bornstein and Plate, followed later and independently by Bassoe in 1913, presented radiological confirmation of aseptic necrosis of bone in compressed air workers (5). The first report of aseptic necrosis in an underwater diver subsequently appeared in 1936 (6). The condition of aseptic necrosis of bone in association with exposure to raised ambient pressure (previously referred to as caisson disease, pressure-induced osteoarthropathy (7), 'bone rot' (8) and other synonyms (6)) is now generally known as dysbaric osteonecrosis (6). Despite detailed examination of this problem by many authorities, dysbaric osteonecrosis still remains a significant occupational hazard with serious medico-legal consequences (5-13). This suggests that preventative measures are being based upon an incomplete understanding of the pathophysiology of the disease, and that other etiological factors are perhaps being overlooked.
Amongst 300 examinations of the shoulder in miners working with compressed air, degenerative changes were found in 44. Particularly striking was the frequency of acromioclavicular arthrosis and of paraglenoid hyperostosis. Five patients with paraglenoid hyperstosis were re-examined several years later. The authors regard these changes as a sign of shoulder arthrosis, analgous with hyperostosis of the head of the radius or of a rib and with labrum ossification of the hip joint.
Scuba diving with compressed air has become a recreational sport that can be performed at all stages of adulthood. The human body including all gas-filled cavities are exposed to an increased ambient pressure during a dive. In the present review article, specific aspects of diving related disorders are that are of importance in the otolaryngology field are presented and discussed: the multitude of causes for divers' vertigo and the so called divers ear. Furthermore, useful recommendations in the assessment of physical fitness for diving are presented. This review will provide a background and foundation for both, an adequate treatment of these diseases and a critical and responsible health education of the diver.
The quality of reprocessing gastroscopes, colonoscopes and duodenoscopes in daily routine of 25 endoscopy departments in hospitals and 30 doctors with their own practices was evaluated by microbiological testing in the HYGEA interventional study. In 2 test periods, endoscopes ready for use in patients were found contaminated at high rates (period 1: 49 % of 152 endoscopes; period 2: 39 % of 154 endoscopes). Culture of bacterial fecal flora (E. coli, coliform enterobacteriaceae, enterococci) was interpreted indicating failure of cleaning procedure and disinfection of endoscopes. Detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods - indicating microbially insufficient final rinsing and incomplete drying of the endoscope or a contaminated flushing equipment for the air/water-channel - pointed out endoscope recontamination during reprocessing or afterwards. Cause for complaint was found in more than 50 % of endoscopy facilities tested (period 2: 5 in hospitals, 25 practices). Reprocessing endoscopes in fully automatic chemo-thermally decontaminating washer-disinfectors with disinfection of final rinsing water led to much better results than manual or semi-automatic procedures (failure rate of endoscopy facilities in period 2 : 3 of 28 with fully automatic, 8 of 12 with manual, 9 of 15 with semi-automatic reprocessing). The study results give evidence for the following recommendations: 1. Manual brushing of all accessible endoscope channels has to be performed even before further automatic reprocessing; 2. For final endoscope rinsing, water or aqua dest. should only be used disinfected or sterile-filtered; 3. Endoscopes have to be dried thoroughly using compressed air prior to storage; 4. Bottle and tube for air/water-channel flushing have to be reprocessed daily by disinfection or sterilization, and in use, the bottle have to be filled exclusively with sterile water. The HYGEA study shows that microbiological testing of endoscopes is useful for detection of insufficient reprocessing and should be performed for quality assurance in doctors' practices, too. The study put recommendations for reprocessing procedures in more concrete terms.
The foramen ovale which is the fetal connection between the right and left atrium persists in about 30 % of the adult population. In the presence of a persistent foramen ovale (PFO) shunting of blood may occur from the right to the left atrium, and bubbles can reach the systemic circulation during or after the decompression phase of a dive with compressed air. Therefore, divers with PFO may have an increased risk to develop ischemic cerebral lesions and neurologic decompression sickness (DCS). Significant right-to-left shunting may be diagnosed using transcranial doppler ultrasound of the medial cerebral artery and echocardiography with echo contrast media and Valsalva provocation. However, there are no official guidelines concerning PFO screening in medical fitness exams for professional or recreational divers in Germany. Therefore, it remains in the diver's choice to be screened for PFO. Divers with a history of DCS should be monitored for PFO, especially when diving strictly adhered to decompression tables. Divers with PFO who refuse to stop diving after DCS should be advised to adhere to very save dive profiles.
PURPOSE: To describe the development and clinical evaluation of a new, hand-powered or alternatively motor-driven, MRI and CT compatible percutaneous bone biopsy system. MATERIALS AND METHODS: A new coaxial drill system (Cook Europe A/S) was designed for percutaneous, MR-guided bone biopsies and powered either by hand or an optional motor (10-250 rotations/minute using 6 bar [88.2 PSI] compressed air). The system has been used in 23 patients. Fourteen procedures were performed in a 1.5 T MR scanner (Philips-Gyroscan ACS-NT) which has an attached C-arm (Philips-BV 212-Angio) in case fluoroscopy is required, and 9 procedures in a CT scanner (Siemens-Somatom Plus). RESULTS: Driven by hand or by the pneumatic motor unit, the system achieved safe and accurate MR-guided access to all of the lesions and was even able to penetrate osteosclerotic lesions. MR- or CT-guided percutaneous biopsy yielded a correct diagnosis in all but 5 cases. No procedural complications occurred. CONCLUSION: MR-guided percutaneous bone biopsy performed with the new coaxial drill system was found to be safe and reliable, and suitable for obtaining histological specimens from skeletal lesions even when covered with thick cortical or sclerotic bone.
Venturi-principle atomizers, which rely on compressed air to aerosolize medications, are commonly used in clinical practice to apply topical anesthetics and vasoconstrictors to the mucous membranes of the nose and throat. Unfortunately, the mechanism by which these devices operate leads to aspiration of external contaminants back into the device at the end of the spray cycle. This "flaw" in design may make Venturi-principle atomizers unsafe for clinical practice because of the risk of patient cross-infection. This article reviews the mechanism of action of Venturi-principle atomizers, presents the scientific literature regarding their potential for cross-infection of patients, and discusses alternative device options.
OBJECTIVE: Our purpose was to study the effects of prolonged mild hypoxemia on type I nitric oxide synthase (NOS) messenger RNA, protein, and enzymatic activity in the fetal sheep brain. STUDY DESIGN: Pregnant sheep were randomly allocated to receive maternal nitrogen (n = 8) or compressed air (controls, n = 5) to reduce fetal brachial artery PO(2) by 25% for 5 days. Type I NOS mRNA (determined by ribonuclease protection assay) protein (determined by Western blot) and enzymatic activity (determined by citrulline assay) were measured in the hippocampus, striatum, cerebellum, and frontal cortex. Data are presented as mean +/- SEM and were compared by means of one-way analysis of variance or two-sample t test. RESULTS: The reduction in maternal inspired oxygen concentration decreased fetal PO(2) by 26% and oxygen content by 25% without an associated change in PCO(2) or pH. Fetal hypoxemia increased type I NOS mRNA by threefold in the striatum and by 2-fold in the frontal cortex and cerebellum, but it did not change mRNA expression in the hippocampus (P <.05). Type I NOS protein and catalytic activity increased only in the striatum (P <.05). CONCLUSION: Prolonged mild hypoxemia has a differential effect on type I NOS mRNA in fetal sheep brain areas. Type I NOS protein and catalytic activity significantly increased only in the striatum. Our data suggest that fetal type I NOS gene expression is regulated at transcriptional, post-transcriptional, and translational levels.
Plasma etching and ashing for demonstrating the three-dimensional ultrastructure of the internal organs of helminths is described. Adult worms of the cestode Caryophyllaeides fennica were dehydrated through an ethanol series, critical point dried (Polaron E3000) and sputter coated with 60% gold-palladium (Polaron E5100) and glued to a standard scanning electron microscope (SEM) stub positioned as required for ashing. After initial SEM viewing of worm surfaces for orientation, stubs were placed individually in the reactor chamber of a PT7150 plasma etching and ashing machine. Worms were exposed to a radio frequency (RF) potential in a low pressure (0.2 mbar) oxygen atmosphere at room temperature. The oxidation process was controlled by varying the times of exposure to the RF potential between 2 to 30 min, depending on the depth of surface tissue to be removed to expose target organs or tissues. After each exposure the oxidized layer was blown from the surface with compressed air, the specimen sputter-coated, and viewed by SEM. The procedure was repeated as necessary, to progressively expose successive layers. Fine details of organs, cells within, and cell contents were revealed. Ashing has the advantage of providing three dimensional images of the arrangement of organs that are impossible to visualize by any other procedure, for example facilitating testes counts in cestodes. Both freshly-fixed and long-term stored helminths can be ashed. Ashing times to obtain the desired results were determined by trial so that some duplicate material was needed.
Workers at four different woodworking processes--two logging sites, four sawmills, one major woodchipping operation, and five joineries situated in the state of New South Wales in Australia--were studied for personal inhalable dust exposures (N = 182). The geometric mean exposure at logging sites was 0.6 mg/m3 (N = 7), sawmills 1.6 mg/m3 (N = 93), woodchipping 1.9 mg/m3 (N = 9), and joineries 3.7 mg/m3 (N = 66). Overall, 62% of the exposures exceeded the current standards. Among joineries, 95% of the hardwood exposures and 35% of the softwood exposures were above the relevant standards. A majority of workers (approximately 90%) did not wear appropriate respirators approved for wood dust, while the ones who did wear them, used them on average less than 50% of the time. The significant determinants of personal wood dust exposures (n = 163) were found to be local exhaust ventilation, job title, use of handheld tools, cleaning method used, use of compressed air, and green or dry wood processed. Type of wood processed (softwood or hardwood) was not found to be statistically significant.
Divers breathing compressed air at depths beyond 30 m experience a type of behavioural impairment known as inert gas narcosis. This condition degrades performance on a wide range of tasks and has the potential to compromise safety. Symptoms associated with narcosis include slowed response time, amnesia, and euphoria. Studies have also found disturbances to mechanisms regulating ocular control in response to vestibular stimulation; however, these experiments have been limited to very low frequency head movement (0.2 Hz). Thus, to further examine the effects of narcosis on visual/vestibular mechanisms, the vestibular ocular reflex (VOR) was assessed across a range of higher frequencies more representative of natural head movement (2.0-4.7 Hz). Seven subjects were tested prior to, during and after exposure to narcosis which was induced using 30% nitrous oxide. Standard room air was breathed as a control. The results indicated that narcosis decreased the velocity of compensatory eye movements in response to head rotation (decrease in VOR-gain), with more pronounced decreases occurring at the higher frequencies. The lag between eye and head position (phase lag) was also decreased by nitrous oxide; an effect that was again more pronounced at higher frequencies. These results indicate that narcosis disrupts ocular regulatory mechanisms which help to stabilize images on the retina during head movement.