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Nonfatal occupational fall injuries in the West Virginia construction industry.

Descriptive analyses were conducted using the West Virginia workers' compensation and supplemental injury records to assess nonfatal occupational falls from elevated work surfaces in the construction industry. These analyses are based on the 182 fall injuries reported to the State workers' compensation during fiscal year 1991 for which there were complete supplemental injury data. County-specific injury rates were calculated for counties with six or more fall injuries. Most of these incidents occurred among young white males who were employed as either craftsmen and kindred workers (48%) or laborers (33%) on non-union jobs in the general construction category (SIC-15). The counties with the highest injury rates that exceed the State rate of 5.9 per 1000 construction workers were located around or near the major industrial areas of Kanawha and Monongalia counties. Of the 182 claimants in the study population, one-third had been employed in their occupation for 2 years or less. For 60% of the claimants, the length of employment with the company for which they were employed at the time of the fall injury was two years or less; 26% had been employed for six months or less. Approximately, 63% of the 182 claimants had received some type of fall protection training. Ladders and scaffolds were involved in 50% of all falls. Fall protection devices were not commonly used by the 182 construction workers who worked from elevated surfaces. Fifty percent of the claimants were using tools or handling materials when the fall occurred. Fifty-nine percent of the falls occurred from elevated work surfaces which were relatively low heights (< or = 10 feet) where few safety regulations apply even though the potential for a serious injury still exists.

Accidental Falls↗

Resistance of Ehrlich tumor cells to apoptosis can be due to accumulation of heat shock proteins.

Previously we have found that stationary Ehrlich ascites carcinoma (EAC) cells in vivo accumulated heat shock proteins (HSPs) and became resistant to necrotic death induced by prolonged energy deprivation of hyperthermia. Here we report that apoptotic death induced by nutrient starvation, transient ATP depletion, heat shock and a microtubule-disrupting drug, vinblastine, was also suppressed in stationary EAC cells comparing with exponential cells. When exponential (sensitive) cells were subjected to short-term heating with recovery to accumulate inducible form of HSP70, they also became resistant to all of the employed apoptosis-inducing exposures, and an inhibitor of cytosolic protein synthesis, cycloheximide, prevented acquisition of the resistance. It is suggested that in vivo accumulation of HSPs in stationary tumor cells can be endogenous protective device against apoptotic death induced by starvation or some anticancer treatments.

Adenosine Triphosphate↗

The nature of oxidants and antioxidant systems in the inhibition of mutation and cancer.

We briefly review current concepts with regard to the nature of oxygen-derived oxidants in biological systems. Of these substances, hydroxyl radicals derived from hydrogen peroxide seem most likely to be involved in the various stages of carcinogenesis. Hydrogen peroxide detoxification, primarily through glutathione activity, is essential in preventing hydroxyl-radical formation. Transition metals such as iron play a central role in this latter process. Alterations in cellular macromolecules are most likely to take place if hydroxyl-radical formation is directed toward specific intramolecular sites by appropriately sequestered metals. For this reason, repair and turnover events are apt to be more important protective devices than are the actions of molecules which scavenge hydroxyl radicals. Although many cellular constituents are potential targets in free-radical and oxidant attacks leading to carcinogenesis, nucleic acids have been most extensively studied in this connection. On the basis of these investigations, it is a facile conclusion that oxidants might be involved in the early events of carcinogenesis as well as in transformation or promotion. The literature on antioxidants in chemoprevention in animals is supportive of such a role. However, other biochemical effects of antioxidants should raise a note of caution in the interpretation of animal experiments.

Animals↗

Balloon valvoplasty of mitral bioprosthesis.

We describe a case of percutaneous balloon valvoplasty of a stenotic Ionescu-Shiley mitral bioprosthesis with the help of an original emboli-protecting device. The procedure reduced diastolic gradient from 29 to 9 mmHg. The calculated area of the orifice increased from 0.7 to 1.7 cm2. At 10 months follow-up examination there was no change of hemodynamic parameters.

Adult↗

Ethics in cardiopulmonary resuscitation.

There is a minority of patients in whom resuscitation is inappropriate. It is important to identify such patients beforehand and communicate the decision not to attempt resuscitation to the would-be first responders. In the absence of the patient's expressed wishes, any decision not to attempt resuscitation must be made by the senior doctor in charge. This doctor will take into account a number of factors and, when appropriate, consult with medical and nursing colleagues relatives, etc. before making such a decision. There are many factors influencing the decision to terminate resuscitation once it has been started. These are listed and discussed. Legal aspects are addressed and indications are made of the expected performance of lay and professional rescuers working under a variety of circumstances. The various definitions of death are described in the light of modern medical practice and the possibility of organ transplantation. There is an increasing fear of infection hazards to the rescuer during mouth to mouth ventilation. The risks are discussed and the use of protective devices is encouraged if they are immediately available. Finally, guidelines for hospital ethical CPR policy are outlined in the hope that they will be considered for adoption on a national and international scale.

Brain Death↗

Reactive oxygen species and iron--a dangerous partnership in inflammation.

Cells of nearly all forms of life require well-defined amounts of iron for survival, replication and expression of differentiated processes. It has a central role in erythropoiesis but is also involved in many other intracellular processes in the tissues of the body. It is the fourth most abundant element in the Earth's crust and the most abundant transition metal in living organisms for which its characteristic chemistry endows it with a series of properties enabling it to fulfil certain biological reactions especially those involving redox mechanisms. It is involved in the transport of oxygen, in electron transfer, in the synthesis of DNA, in oxidations by oxygen (O2) and hydrogen peroxide (H2O2) and in many other processes maintaining normal structure and function of virtually all mammalian cells. Because an iron atom can exist in two valency states, ferrous and ferric, iron became the primordial partner of oxygen in evolution. However, as de Sousa et al. (1989) state, such long standing partnerships have to use protective devices to ensure that the toxicity of neither partner is expressed in the presence of the other. Here, we discuss this dangerous partnership and its relevance to inflammation. The main themes of this review are the known roles of iron in the generation of reactive oxygen intermediates and new developments, including iron and transcription and the reaction of iron with nitric oxide. We also consider the widening recognition of the importance of oxygen metabolites in hypoxia-reperfusion injury and disease of the skin and joint.

Animals↗

Distal embolization during primary angioplasty: histopathologic features and predictability.

BACKGROUND: Distal embolization during primary percutaneous coronary interventions (PCIs) may affect myocardial reperfusion. We evaluated the prevalence and features of embolization during primary PCI and its relationship with clinical and angiographic variables. METHODS: Forty-six consecutive patients with acute myocardial infarction underwent primary PCI with a filter-based distal protection device. Histopathologic analysis was performed on retrieved embolic fragments, assessing the presence and relative amount of fibrin, necrosis, lipid droplets, collagen, mucopolysaccharides, and leukocytes, as well as the total debris volume. Such variables were related to baseline clinical and angiographic variables. RESULTS: Embolic material was recovered in 41 (89%) of 46 cases, with a mean total debris volume of 1.2 +/- 2.2 mm3. Prevalent histopathologic patterns were organized thrombus (47%), fresh thrombus (29%), and plaque fragments (24%). At multivariate analysis, none of the baseline clinical variables considered significantly predicted the total debris volume. Among angiographic variables, angiographic signs of high thrombus burden (cut-off coronary occlusion pattern or large intracoronary minus image) independently predicted the total debris volume at multivariate analysis (odds ratio 15.8, P < .005). Compared with its nonuse, abciximab did not affect the total number and the mean total volume of embolized material (15 +/- 16 vs 10 +/- 8 fragments, 1.5 +/- 2.5 vs 1.0 +/- 1.9 mm3, respectively, for both P > .20), or its qualitative composition. CONCLUSIONS: Distal embolization occurs in most patients during primary PCI and mainly consists of plaque fragments and partially organized thrombi, which are likely to be scarcely responsive to antiplatelet drugs. Baseline angiographic signs of a high thrombus burden are the only significant predictors of the extent of distal embolization.

Angioplasty↗

Assessment of preventive measures for accidental blood exposure in operating theaters: a survey of 20 hospitals in Northern France.

BACKGROUND: Accidental exposures to blood of body fluids (ABE) expose health care workers (HCW) to the risk of occupational infection. OBJECTIVES: Our aim was to assess the prevention equipment available in the operating theater (OT) with reference to guidelines or recommendations and its use by the staff in that OT on that day and past history of ABE. METHODS: Correspondents of the Centre de Coordination de la Lutte contre les Infections Nosocomiales (CCLIN) Paris-Nord ABE Surveillance Taskforce carried out an observational multicenter survey in 20 volunteer French hospitals. RESULTS: In total, 260 operating staff (including 151 surgeons) were investigated. Forty-nine of the 260 (18.8%) staff said they double-gloved for all patients and procedures, changing gloves hourly. Blunt-tipped suture needles were available in 49.1% of OT; 42 of 76 (55.3%) of the surgeons in these OT said they never used them. Overall, 60% and 64% of surgeons had never self-tested for HIV and hepatitis C virus (HCV), respectively. Fifty-five surgeons said they had sustained a total of 96 needlestick injuries during the month preceding the survey. Ten of these surgeons had notified of 1 needlestick injury each to the occupational health department of their hospital (notification rate, 10.4%). CONCLUSION: The occurrence of needlestick injury remained high in operating personnel in France in 2000. Although hospitals may improve access to protective devices, operating staff mindful of safety in the OT should increase their use of available devices, their knowledge of their own serostatus, and their ABE notification rate to guide well-targeted prevention efforts.

France↗

A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis.

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.

Humans↗

Symptomatic patients have similar outcomes compared with asymptomatic patients after carotid artery stenting with emboli protection.

In a single-center cohort of 174 consecutive patients, we sought to evaluate whether the use of emboli protection devices (EPDs) results in equivalent rates of adverse events in symptomatic and asymptomatic patients after carotid artery stenting (CAS) with EPDs. Death or stroke occurred in 3.3% in the symptomatic group and in 3.5% of the asymptomatic group at 30 days (p = NS). At 6 months, there was also no significant difference in the rate of stroke or death between the groups. Unlike surgical revascularization, symptomatic patients did not have a greater risk for stroke and death compared with asymptomatic patients after CAS with EPDs.

Aged↗

The evidence for cerebral protection: an analysis and summary of the literature.

It has been considered likely that the majority of cerebral ischaemic episodes following carotid artery stenting are due to cerebral embolisation. It is intuitive therefore, to attempt to prevent these presumptive emboli, whether they are comprised of air or formed elements, from reaching the brain. Various pharmacological and mechanical solutions are being used. The available literature is hampered by comparisons against historical controls of unprotected CAS with many confounding variables that may influence outcome. There is no clinical Level-I evidence to support the use of protection devices but Level-III and Level-IV evidence suggest benefit.

Blood Vessel Prosthesis↗

The relationship between plasma MMP-1, -7, -8 and -13 levels and embolic potential during carotid endoluminal intervention.

BACKGROUND: Patients undergoing carotid endoluminal intervention are at risk of embolic stroke even with the use of distal protection devices. Matrix metalloproteinases (MMPs) have been implicated as a causal factor in plaque instability leading to spontaneous embolisation. We investigated whether plasma MMP levels correlated with the embolisation during carotid endoluminal intervention. METHODS: Thirty circumferentially intact carotid endarterectomy specimens were subjected to a standardised angioplasty procedure in a pulsatile ex vivo model. Emboli collected in a series of distal filters were counted and sized. Plasma samples were collected pre-operatively and analysed for MMP-7 and MMP-8 levels using Western immunoblotting. MMP-1 and MMP-13 levels were determined using ELISA. Emboli number and maximum size were correlated with plasma levels of the MMPs using Spearmans rank. RESULTS: Total MMP-8 levels were related to maximum embolus size (r=0.442, p=0.005) but not emboli number (r=0.342, p=0.052). MMP-1, -7 and -13 were not correlated with either emboli number or with maximum embolus size. CONCLUSION: Pre-operative plasma MMP-8 levels are related to the size of emboli from plaques during carotid endovascular intervention. Further in vivo studies need to be performed to assess the importance of this finding. There is potential for development of plasma markers to identify those patients at greater risk of embolic stroke during carotid endoluminal intervention.

Aged↗

In-stent restenosis after carotid angioplasty and stenting: a challenge for the vascular surgeon.

PURPOSE: This study aims to review the incidence of in-stent restenosis (ISR), the factors which determine restenosis, and to evaluate the use of various endovascular techniques for the management of ISR following carotid artery stenting (CAS). METHODS: Four hundred and seven patients (334 men, mean age 63 years, range 46-86, median 65 years) were treated with CAS between December 2000 and March 2004. Three hundred and seventy-two (89%) patients had at least one ultrasound evaluation performed 6 months after procedure (range 6-40). Recurrent stenosis >80% detected with duplex ultrasound scans were further evaluated by angiography and treated with repeat endovascular procedure. RESULTS: CAS was performed successfully in all cases with a Carotid WallStent (Boston Scientific) using a cerebral protection device (filter). Perioperative complications included four (0.9%) minor and two (0.4%) major strokes these latter two patients died at 5 and 12 days after the operation. No other deaths occurred. A total of 15 carotid arteries (3.6%) in 14 patients had ISR. All ISR were treated with a repeat endovascular procedure: three balloon angioplasty alone, eight angioplasty and secondary stenting, four angioplasty with cutting balloon. Postsurgical restenosis was confirmed to be the only predictive factor for the development of in-stent restenosis (OR 14.5, 95% CI 2.3-113.4, p=0.005). Endovascular treatment of ISR achieved technical success without periprocedurale complications and the absence of significant restenosis over a median follow up time of 12.4 months (range 3.5-30.7). CONCLUSION: Our experience with a large cohort of CAS showed an encouragingly low incidence of ISR (3.6%) and successful treatment by repeat endovascular intervention. We recommend attempting all endovascular possibilities before performing stent removal.

Aged↗

Value of diffusion-weighted MRI during carotid angioplasty and stenting.

INTRODUCTION: The incidence of neurological injury following carotid angioplasty and stenting is of great interest to those advocating it as an alternative to endarterectomy in the management of critical carotid stenosis. A significant inter-observer variation exists in determining the presence or absence of a neurological deficit following the procedure objective imaging would be advantageous. In this study, we sought to assess diffusion weighted MRI as a diagnostic tool in evaluating the incidence of neurological injury following carotid angioplasty and stenting (CAS). PATIENTS AND METHODS: The first 110 cases of CAS in our unit were included in this series. The procedure was abandoned in three patients. Patients underwent intracranial and extracranial MR angiography, together with diffusion-weighted MRI (DWI) prior to and following CAS and had a formal neurological assessment in the intensive care unit after the procedure. RESULTS: One hundred and ten Procedures were attempted in 98 patients. Twenty-eight percent were asymptomatic. Following CAS, 7.2% of patients had a positive neurological exam (two major strokes with one fatality) and 21% had positive DWI scans, equating to a sensitivity of 86% and a specificity of 85% for DWI in detecting cerebral infarction following CAS. The positive predictive value of the test was 0.3 and negative predictive value 0.99. The major stroke and death rate was 1.8%. While the use of a cerebral protection device appeared to significantly reduce the incidence of cerebral infarction (5% vs. 25%, p = 0.031) this may be a reflection of the learning curve encountered during the study. CONCLUSION: The incidence of subclinical DWI detected neurological injury was significantly higher than clinical neurological deficit following CAS. Conventional methods of neurological assessment of patients undergoing CAS may be too crude to detect subtle changes and more sensitive tests of cerebral function are required to establish whether these subclinical lesions are relevant.

Aged↗

Initial study on the effects of Prestige oil on human health.

The big oil tanker Prestige wrecked at 130 miles from the coast of Galicia, on the Northwest of Spain, in November 19, 2002. During the accident over 40,000 tons of oil were spilled, and along the next weeks 22,000 more reached the shore in the way of three black tides. A great number of people participated in the cleaning tasks. The objective of this study was to initially evaluate the damage caused by Prestige oil in exposed individuals both from the cytogenetic and the endocrine points of view. Exposure level was determined by analysing volatile organic compounds in the environment and heavy metals in blood. Cytogenetic damage was determined by sister chromatid exchanges (SCE), and plasmatic prolactin and cortisol levels were used as biomarkers of endocrine toxicity. Finally we have determined the possible influence of GST genetic polymorphisms (GSTM1 and GSTT1 deletion polymorphisms, GSTP1 Ala105Val) on the evaluated effects. The exposed population was classified according to the performed cleaning tasks in three groups: volunteers that collaborated for 1 week (N=25), hired manual workers (N=20) and hired high-pressure cleaner workers (N=23). The control population consisted of 42 individuals. Exposure to Prestige oil caused cytogenetic damage in exposed individuals, being its effect influenced by age, sex, tobacco consumption and GSTM1 polymorphism. With regard to endocrine toxicity, our results showed that xenobiotics present in Prestige oil induced alterations in hormonal status, and thus it may be considered as an endocrine disruptor. Therefore, the selected parameters have shown to be good indicators of toxicity related to exposure to Prestige oil. In addition, data obtained point to the importance of using protective devices in preventing the effects related to the exposure.

Endocrine Glands↗

NAC for noise: from the bench top to the clinic.

Noise-induced hearing loss (NIHL) is an important etiology of deafness worldwide. Hearing conservation programs are in place and have reduced the prevalence of NIHL, but this disorder is still far too common. Occupational and recreational pursuits expose people to loud noise and ten million persons in the US have some degree of noise-induced hearing impairment. It is estimated that 50 million in the US and 600 million people worldwide are exposed to noise hazards occupationally. Noise deafness is still an important and frequent cause of battlefield injury in the US military. A mainstay of hearing conservation programs is personal mechanical hearing protection devices which are helpful but have inherent limitations. Research has shown that oxidative stress plays an important role in noise-induced cochlear injury resulting in the discovery that a number of antioxidant and cell death inhibiting compounds can ameliorate deafness associated with acoustic trauma. This article reviews one such compound, N-acetylcysteine (NAC), in terms of its efficacy in reducing hearing loss in a variety of animal models of acute acoustic trauma and hypothesizes what its therapeutic mechanisms of action might be based on the known actions of NAC. Early clinical trials with NAC are mentioned.

Acetylcysteine↗

Pseudo-no-reflow phenomenon in ostial saphenous vein graft intervention using FilterWire EX protection.

Distal protection using FilterWire EX has been shown to be effective in reducing the incidence of debris embolization and no-reflow phenomenon in saphenous vein graft (SVG) intervention. We present a case of mechanical obstruction of antegrade flow by atherothrombotic debris collected in the FilterWire EX after stent implantation of the ostial SVG lesion, masqueraded as no-reflow phenomenon. The condition was promptly reverted by thrombosuction using an Export Aspiration Catheter. A heavy debris burden was recovered by the thrombosuction and there was no evidence of myonecrosis after the procedure. We emphasize that different distal protection device can complement each other in special situations. A brief overview of the various approaches in preventing distal embolization in SVG intervention was also given.

Angioplasty, Balloon, Coronary↗

Late outcomes after intervention of vein grafts in diabetics with abciximab use.

OBJECTIVES: We sought to evaluate late clinical outcomes following elective percutaneous coronary interventions for saphenous vein graft with planned abciximab use in diabetics. BACKGROUND: Diabetes adversely affects long-term outcomes after percutaneous coronary intervention including percutaneous coronary intervention of saphenous vein grafts. Glycoprotein IIb/IIIa inhibitors reduce adverse outcomes of native vessel percutaneous coronary intervention in diabetics; however, their effects in diabetic patients undergoing percutaneous coronary interventions of saphenous vein grafts is not known. METHODS: We evaluated 509 elective percutaneous coronary interventions of saphenous vein grafts. Glycoprotein IIb/IIIa inhibitors were used in 99% of the percutaneous coronary interventions. Distal protection devices were not used. Clinical follow-up (mean 30+/-20 months) was available in 369/397 (93%). RESULTS: Overall, procedural success rate was 97% and was similar for diabetics and non-diabetics. Procedural major adverse cardiac events occurred in 4.8% diabetics, and 4.1% non-diabetics (p = NS). Late outcomes were similar for diabetics and non-diabetics with major adverse cardiac event rates of 57.6%, and 54.9%, respectively, p=NS. Multivariate logistic regression identified graft age and the presence of thrombus as predictors of increased late major adverse cardiac events. CONCLUSIONS: Following routine use of abciximab, late outcomes after percutaneous coronary interventions of saphenous vein grafts were similar for diabetics and non-diabetics suggesting that the historically observed adverse effect of diabetes on late outcomes after percutaneous coronary interventions of saphenous vein grafts may be attenuated by glycoprotein IIb/IIIa use. Selective use of glycoprotein IIb/IIIa inhibitor should be considered for diabetics undergoing percutaneous coronary interventions of saphenous vein grafts.

Abciximab↗