A prospective cohort study exploring the impact of tonsillectomy on feeding difficulties in children

OBJECTIVES

Paediatric feeding difficulties are common, affecting up to 25% of otherwise healthy children, symptoms include food refusal, gagging, choking, and excessive mealtime duration. These symptoms are commonly described in pre-operative discussions about tonsillectomy. This prospective study explores the impact of tonsillectomy on paediatric feeding difficulties.

DESIGN

This prospective cohort study invited caregivers of children undergoing tonsillectomy to complete a PediEAT questionnaire about their children's feeding behaviours, pre and post-operatively. The study was completed in two phases with 9 questions administered in phase 1 and three additional questions added for phase 2. A free text comments box was also provided. Responses were graded from 0 to 5, where 0 is 'never a problem' and 5 is 'always a problem' with eating behaviours.

SETTING

The study was conducted at our institution, a tertiary paediatric ENT unit.

PARTICIPANTS

Children aged between 6 months - 7 years undergoing tonsillectomy for any indication were invited to participate.

MAIN OUTCOME MEASURES

Changes to the Pedi-EAT scores pre and post operatively were the main outcome measure.

RESULTS

102 participants were recruited between January 2020 and January 2022. The mean age of participants was 4.1 years, 87% had a concurrent adenoidectomy. The mean time to completion of post-operative questionnaire was 23 weeks after surgery. 9 of the 12 questions showed a statistically significant improvement in post-operative scores using a paired student t-test (p < 0.05). The most significant improvements related to 'gets tired from eating and is not able to finish' (1.49 pre-op, 0.91 post op, p < 0.01) and 'eats food that needs to be chewed' (1.4 pre-op, 0.72 post-op, p < 0.01). 13% of participants only underwent tonsillectomy and this group also showed a statistically significant improvement in fatigue during eating (p < 0.05).

CONCLUSION

Symptoms of fatigue during eating and avoidance of food requiring mastication are most likely to improve following tonsillectomy in children.

Trends in hip fracture care in the Republic of Ireland from 2013 to 2018: results from the Irish Hip Fracture Database

Hip fractures continue to be one of the most serious and costly injuries suffered by older people globally. This paper describes the development of a national hip fracture audit and summarises the first 6 years of data from the Republic of Ireland. This can help inform care, standards and outcomes of hip fracture patients.

INTRODUCTION

Ireland has one of the highest standardised rates of hip fracture in the world behind northern European countries. The Irish Hip Fracture Database (IHFD) was established in 2012 to drive clinical and organisational improvements in quality and effectiveness of hip fracture care. This paper describes the progression of the IHFD between 2013 and 2018 and identifies trends and areas for improvement.

METHODS

The IHFD is a clinically led, web-based audit, with data collected through the national Hospital Inpatient Enquiry (HIPE) electronic system, the principal source of information from publicly funded acute hospitals in Ireland. Eligible cases are aged ≥ 60 years with hip fracture as defined by IHFD or with other specified hip fracture excluding periprosthetic fractures. As of 2015, all 16 trauma-receiving hospitals within Ireland submitted data. Demographics and adherence to six national quality standards are described.

RESULTS

A total of 17,983 cases were included in the analysis. National coverage has increased from 63% in 2013 to 99% in 2018. Demographic characteristics are unchanged, but higher levels of comorbidity are seen. Internal fixation and hemiarthroplasty are the most common modes of surgical repair with two-thirds of cases receiving spinal rather than general anaesthesia. Increasingly patients are being assessed by a geriatrician (11% in 2013 to 69% in 2018) and receive a bone health assessment (65% in 2013 to 84% in 2018).

CONCLUSION

While some hip fracture standards have improved, further improvements are required to compare favourably internationally. Reduction of surgical delay and ensuring early mobilisation post-operatively are immediate priorities for the IHFD.

Does the shoe really fit? Characterising ill-fitting footwear among community-dwelling older adults attending geriatric services: an observational cross-sectional study

Background

Falls in older people are common and can result in loss of confidence, fear of falling, restriction in activity and loss of independence. Causes of falls are multi-factorial. There is a paucity of research assessing the footwear characteristics among older people who are at high risk of falls, internationally and in the Irish setting. The aim of this study was to examine the proportion of older adults attending a geriatric day hospital in Ireland who were wearing incorrectly sized shoes.

Methods

A consecutive sample of 111 older adults aged 60 years and over attending a geriatric day hospital in a large Irish teaching hospital was recruited. Demographic data including age, mobility, medications, co-habitation status, footwear worn at home and falls history were recorded. Shoe size and foot length were measured in millimetres using an internal shoe gauge and SATRA shoe size stick, respectively. Participants’ self-reported shoe size was recorded. Footwear was assessed using the Footwear Assessment Form (FAF). A Timed Up and Go (TUG) score was recorded. Functional independence was assessed using the Nottingham Extended Activities of Daily Living (NEADL) Scale. The primary outcome of interest in this study was selected as having footwear within the suggested range (10 to 15 mm) on at least one foot. Participants who met this definition were compared to those with ill-fitting footwear on both feet using Chi-square tests, T-tests or Mann–Whitney U tests.

Results

The mean difference between shoe length and foot length was 18.6 mm (SD: 9.6 mm). Overall, 72% of participants were wearing footwear that did not fit correctly on both feet, 90% had shoes with smooth, partly worn or fully worn sole treading and 67% reported wearing slippers at home. Participant age, TUG score and NEADL score were not associated with ill-fitting footwear.

Conclusions

Wearing incorrectly fitting shoes and shoes with unsafe features was common among older adults attending geriatric day services in this study. A large number of participants reported wearing slippers at home.

Photo-degradation of 2,4-dinitroanisole (DNAN): An emerging munitions compound

The US military is developing insensitive munitions (IM) that are less sensitive to shock and high temperatures to minimize unintentional detonations. DNAN (2,4-dinitroanisole) is one of the main ingredients of these IM formulations. During live-fire training, chunks of IM formulations are scattered by partial detonations and, once on the soil, they weather and dissolve. DNAN changes color when exposed to sunlight suggesting that it photodegrades into other compounds. We investigated the photo-degradation of DNAN both as a pure solid and as part of solid IM formulations, IMX101, IMX104 and PAX21. The concentrations of degradation products found were small, <1%, relative to DNAN concentrations. We saw transient peaks in the chromatograms indicating intermediate, unstable products but we consistently found methoxy nitrophenols and methoxy nitroanilines. We also found one unknown in most of the samples and other unknowns less frequently.

Outdoor dissolution of detonation residues of three insensitive munitions (IM) formulations

We seek to understand the environmental fate of three new insensitive munitions, explosive formulations developed to reduce the incidence of unintended detonations. To this end, we measured the size distribution of residues from low order detonations of IMX 101, IMX 104, and PAX 21-filled munitions and are studying how these three formulations weather and dissolve outdoors. The largest pieces collected from the detonations were centimeter-sized and we studied 12 of these in the outdoors test. We found that the particles break easily and that the dissolution of 2,4-dinitroanisole (DNAN) is quasi-linear as a function of water volume. DNAN is the matrix and the least soluble major constituent of the three formulations. We used DNAN's linear dissolution rate to estimate the life span of the pieces. Particles ranging in mass from 0.3 to 3.5 g will completely dissolve in 3-21 years given 100 cm y(-1) precipitation rates.

Explosive particle soil surface dispersion model for detonated military munitions

The accumulation of high explosive mass residue from the detonation of military munitions on training ranges is of environmental concern because of its potential to contaminate the soil, surface water, and groundwater. The US Department of Defense wants to quantify, understand, and remediate high explosive mass residue loadings that might be observed on active firing ranges. Previously, efforts using various sampling methods and techniques have resulted in limited success, due in part to the complicated dispersion pattern of the explosive particle residues upon detonation. In our efforts to simulate particle dispersal for high- and low-order explosions on hypothetical firing ranges, we use experimental particle data from detonations of munitions from a 155-mm howitzer, which are common military munitions. The mass loadings resulting from these simulations provide a previously unattained level of detail to quantify the explosive residue source-term for use in soil and water transport models. In addition, the resulting particle placements can be used to test, validate, and optimize particle sampling methods and statistical models as applied to firing ranges. Although the presented results are for a hypothetical 155-mm howitzer firing range, the method can be used for other munition types once the explosive particle characteristics are known.

Perchlorate contamination from the detonation of insensitive high-explosive rounds

The insensitive high-explosive PAX-21 was the first of its kind fielded in an artillery munition by the United States military. This formulation contains three main components: RDX, dinitroanisole, and ammonium perchlorate (AP). In March 2012, detonation tests were conducted on PAX-21 60mm mortar rounds to determine the energetic residues resulting from high-order and blow-in-place (BIP) detonations. Post-detonation residues were sampled and analyzed for the three main PAX-21 components. Concentrations of RDX and dinitroanisole in the samples were quite low, less than 0.1% of the munitions' original organic explosive filler mass, indicating high order or near high order detonations. However, disproportionately high concentrations of AP occurred in all residues. The residues averaged 15% of the original AP following high-order detonations and 38% of the original AP mass following the BIP operations. There was no correlation between AP residues and the RDX and dinitroanisole. Perchlorate readily leached from the detonation residues, with over 99% contained in the aqueous portion of the samples. Use of these rounds will result in billions of liters of water contaminated above drinking water perchlorate limits. As a result of this research, PAX-21 mortar rounds are currently restricted from use on US training ranges.

Insights into the dissolution and the three-dimensional structure of insensitive munitions formulations

Two compounds, 2,4-dinitroanisole (DNAN) and 3-nitro-1,2,4-triazol-5-one (NTO) are the main ingredients in a suite of explosive formulations that are being, or soon will be, fielded at military training ranges. We aim to understand the dissolution characteristics of DNAN and NTO and three insensitive muntions (IM) formulations that contain them. This information is needed to accurately predict the environmental fate of IM constituents, some of which may be toxic to people and the environment. We used Raman spectroscopy to identify the different constituents in the IM formulations and micro computed tomography to image their three-dimensional structure. These are the first three-dimensional images of detonated explosive particles. For multi-component explosives the solubility of the individual constituents and the fraction of each constituent wetted by water controls the dissolution. We found that the order of magnitude differences in solubility amongst the constituents of these IM formulations quickly produced hole-riddled particles when these were exposed to water. Micro-computed tomography showed that particles resulting from field detonations were fractured, producing conduits by which water could access the interior of the particle. We think that micro-computed tomography can also be used to determine the initial composition of IM particles and to track how their compositions change as the particles dissolve. This information is critical to quantifying dissolution and developing physically based dissolution models.

Controlled expedient disposal of excess gun propellant

The expedient field disposal of excess gun propellants on the ground is an integral part of live-fire training in many countries. However, burning excess propellant in the field will leave significant quantities of energetic residues and heavy metals in the environment. Compounds such as dinitrotoluene and nitroglycerin and metals such as lead will leach into the soil column, eventually migrating to groundwater. Contamination of the environment will lead to high remediation costs and the possible loss of the training facility. After investigating the contamination at several propellant disposal sites, a portable propellant burn pan was developed and tested. The pan was transported to training sites where excess propellant was loaded and burned in a controlled manner. Up to 120 kg of excess single-base propellant charges have been burned during two series of tests at a consumption rate of greater than 99.9%. Less than 0.03% of the energetic material was recovered outside the burn pan. Recovered lead is largely contained within the pan. The turnover rate for burns is 15 min. The residues can be collected following cool-down for proper disposal.

Dissolution and sorption of hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) and 2,4,6-trinitrotoluene (TNT) residues from detonated mineral surfaces

Composition B (Comp B) is a commonly used military formulation composed of the toxic explosive compounds 2,4,6-trinitrotoluene (TNT), and hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX). Numerous studies of the temporal fate of explosive compounds in soils, surface water and laboratory batch reactors have been conducted. However, most of these investigations relied on the application of explosive compounds to the media via aqueous addition and thus these studies do not provide information on the real world loading of explosive residues during detonation events. To address this we investigated the dissolution and sorption of TNT and RDX from Comp B residues loaded to pure mineral phases through controlled detonation. Mineral phases included nontronite, vermiculite, biotite and Ottawa sand (quartz with minor calcite). High Performance Liquid Chromatography and Attenuated Total Reflectance Fourier Transform Infrared spectroscopy were used to investigate the dissolution and sorption of TNT and RDX residues loaded onto the mineral surfaces. Detonation resulted in heterogeneous loading of TNT and RDX onto the mineral surfaces. Explosive compound residues dissolved rapidly (within 9 h) in all samples but maximum concentrations for TNT and RDX were not consistent over time due to precipitation from solution, sorption onto mineral surfaces, and/or chemical reactions between explosive compounds and mineral surfaces. We provide a conceptual model of the physical and chemical processes governing the fate of explosive compound residues in soil minerals controlled by sorption-desorption processes.

Desorption of nitramine and nitroaromatic explosive residues from soils detonated under controlled conditions

Potentially toxic nitroaromatic and nitramine compounds are introduced onto soils during detonation of explosives. The present study was conducted to investigate the desorption and transformation of explosive compounds loaded onto three soils through controlled detonation. The soils were proximally detonated with Composition B, a commonly used military explosive containing 2,4,6-trinitrotoluene (TNT), hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX), and octahydro 1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX). Gas-exchangeable surface areas were measured from pristine and detonated soils. Aqueous batches of detonated soils were prepared by mixing each soil with ultrapure water. Samples were collected for 141 d and concentrations of Composition B compounds and TNT transformation products 2-amino-4,6-dinitrotoluene (2ADNT), 4-amino-2,6-dinitrotoluene (4ADNT), and 1,3,5-trinitrobenzene (1,3,5-TNB) were measured. The RDX, HMX, and TNT concentrations in detonated soil batches exhibited first-order physical desorption for the first, roughly, 10 d and then reached steady state apparent equilibrium within 40 d. An aqueous batch containing powdered Composition B in water was sampled over time to quantify TNT, RDX, and HMX dissolution from undetonated Composition B particles. The TNT, RDX, and HMX concentrations in aqueous batches of pure Composition B reached equilibrium within 6, 11, and 20 d, respectively. Detonated soils exhibited lower gas-exchangeable surface areas than their pristine counterparts. This is likely due to an explosive residue coating on detonated soil surfaces, shock-induced compaction, sintering, and/or partial fusion of soil particles under the intense heat associated with detonation. Our results suggest that explosive compounds loaded to soils through detonation take longer to reach equilibrium concentrations in aqueous batches than soils loaded with explosive residues through aqueous addition. This is likely due to the heterogeneous interactions between explosive residues and soil particle surfaces.

Disinfection by-products in filter backwash water: implications to water quality in recycle designs

The overall purpose of this research was to investigate disinfection by-product (DBP) concentrations and formation potential in filter backwash water (FBWW) and evaluate at bench-scale the potential impact of untreated FBWW recycle on water quality in conventional drinking water treatment. Two chlorinated organic compound groups of DBPs currently regulated in North America were evaluated, specifically trihalomethanes (THMs) and haloacetic acids (HAAs). FBWW samples were collected from four conventional filtration water treatment plants (WTP) in Nova Scotia, Canada, in three separate sampling and plant audit campaigns. THM and HAA formation potential tests demonstrated that the particulate organic material contained within FBWW is available for reaction with chlorine to form DBPs. The results of the study found higher concentrations of TTHMs and HAA9s in FBWW samples from two of the plants that target a higher free chlorine residual in the wash water used to clean the filters (e.g., clearwell) compared to the other two plants that target a lower clear well free chlorine residual concentration. Bench-scale experiments showed that FBWW storage time and conditions can impact TTHM concentrations in these waste streams, suggesting that optimization opportunities exist to reduce TTHM concentrations in FBWW recycle streams prior to blending with raw water. However, mass balance calculations demonstrated that FBWW recycle practice by blending 10% untreated FBWW with raw water prior to coagulation did not impact DBP concentrations introduced to the rapid mix stage of a plant's treatment train.

Physicochemical characterization of cement kiln dust for potential reuse in acidic wastewater treatment

Cement kiln dust (CKD) is a fine-grained material produced during the manufacture of cement. Current reuse options are limited and the bulk of CKD not reused in the cement manufacturing process is sent to landfills or stored on-site. Due to the calcium oxide (CaO) content of CKD, it has the potential to be used as a replacement for lime in treating acidic wastewaters such as acid rock drainage (ARD). This paper outlines the results of an examination of the physical and chemical properties of CKD samples collected from six cement plants. The CKD samples were analyzed for major oxides using X-ray diffraction (XRD), available lime, specific surface area, particle size, and morphology using scanning electron microscope (SEM) and compared with a commercial quicklime product. Conductivity, pH, and calcium concentrations of slaked CKD and quicklime solutions were used as indicators of reactivity of the CKD. Slaking of two of the CKD samples with the highest free lime contents (e.g., 34 and 37% free CaO) gave elevated pH values statistically comparable to those of the commercial quicklime sample that was characterized as having 87% available CaO. Acid neutralization trials indicate that even CKD samples with low free lime contents could be effective at neutralizing acidic wastewaters.

Energetic residues from field disposal of gun propellants

Military training with howitzers and mortars produces excess propellant that is burned on the training range and can result in point sources containing high concentrations of unreacted propellant constituents. Propellants contain energetic compounds such as nitroglycerin (NG) and 2,4-dinitrotoluene (2,4-DNT), both of which are found at firing positions and propellant disposal areas. To quantify the mass of residue remaining from the field-expedient disposal of propellants, two mortar propellants and one howitzer propellant were burned under different field conditions. These conditions included burning on a snow pack, at the bottom of a snow pit, and in a pan surrounded by snow for the mortar propellants and on dry and wet sand for the howitzer propellant. For the mortar propellant, the energetics (NG) remaining after burning in the bowl, on frozen ground, and on snow were 0.21%, 5.2% and 18%, respectively. For the howitzer propellant, the difference in energetics (2,4-DNT) remaining after disposal on wet and dry sand was <0.1%, with the overall residue rate of around 1%, similar to that for the mortar propellant burned in an open container. These tests demonstrate that environmental factors, especially in winter, can play a significant role in the effectiveness of field-expedient disposal of propellants.

Field observations of the persistence of Comp B explosives residues in a salt marsh impact area

Field observations of weathering Comp B (RDX/TNT 60/40) residue were made on a live-fire training range over four years. The Comp B residue was formed by low-order detonations of 120-mm mortar projectiles. Physical changes were the disaggregation of initially solid chunks into masses of smaller diameter pieces and formation of red phototransformation products that washed off with rain or tidal flooding. Disaggregation increased the surface area of the residue, thereby increasing the potential for dissolution. The bulk of the mass of Comp B was in the craters, but solid chunks were scattered asymmetrically up to 30m away.

Investigating the fate of nitroaromatic (TNT) and nitramine (RDX and HMX) explosives in fractured and pristine soils

Explosives compounds, known toxins, are loaded to soils on military training ranges predominantly during explosives detonation events that likely fracture soil particles. This study was conducted to investigate the fate of explosives compounds in aqueous slurries containing fractured and pristine soil particles. Three soils were crushed with a piston to emulate detonation-induced fracturing. X-ray diffraction, energy-dispersive X-ray spectrometry, gas adsorption surface area measurements, and scanning electron microscopy were used to quantify and image pristine and fractured soil particles. Aqueous batches were prepared by spiking soils with solutions containing 2,4,6-trinitrotoluene (TNT), hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX), octahydro 1,3,5,7-tetranitro-1,3,5,7-tetrazocine (HMX), and 2,4-dinitrotoluene (2,4-DNT). Samples were collected over 92 d and the concentrations of the spiked explosives compounds and TNT transformation products 2-amino-4,6-dinitrotoluene (2ADNT) and 4-amino-2,6-dinitrotoluene (4ADNT) were measured. Our results suggest soil mineralogical and geochemical compositions were not changed during piston-induced fracturing but morphological differences were evident with fractured soils exhibiting more angular surfaces, more fine grained particles, and some microfracturing that is not visible in the pristine samples. TNT, 2,4-DNT, RDX, and HMX exhibited greater analyte loss over time in batch solutions containing fractured soil particles compared to their pristine counterparts. 2ADNT and 4ADNT exhibited greater concentrations in slurries containing pristine soils than in slurries containing fractured soils. Explosives compound transformation is greater in the presence of fractured soil particles than in the presence of pristine soil particles. Our results imply fractured soil particles promote explosive compound transformation and/or explosives compounds have a greater affinity for adsorption to fractured soil particle surfaces.

Effect of coagulation and flocculation conditions on water quality in an immersed ultrafiltration process

The removal of natural organic matter under variable coagulation and flocculation pretreatment conditions was evaluated for three surface waters in an immersed ultrafiltration (UF) process. Coagulation with alum, flocculation and UF treatment were conducted in a bench-scale test apparatus designed to simulate pilot- and full-scale water treatment systems. Variable coagulation and flocculation operating conditions were investigated, including coagulant dose, hydraulic retention time (HRT) and mixing intensity (e.g. velocity gradient). Treatment performance was evaluated by measuring specific water quality parameters in the permeate stream, including dissolved organic carbon (DOC), UV254 and true colour. Coagulant dose was found to be the most important variable for treatment performance with regard to permeate water quality, with significantly lower alum dosages required to achieve enhanced coagulation water quality targets than conventional filtration systems. Experiments conducted to evaluate variable flocculation stage HRT and applied velocity gradient demonstrated that traditional set points for these operating variables, applied in conventional filtration systems, may not be required in UF systems. In particular, optimized UF permeate water quality was found with reduced flocculation retention times (e.g. <10 minutes) and mixing intensities (e.g. < 100 s(-1)). The impact of intermittent air scour, or air sparging, operations in the UF process tank during operation was also evaluated. The use of air scour, tested as an intermittent operation at an applied velocity gradient of 50 s(-1) was found to significantly reduce DOC concentrations and UV254 measurements in the UF permeate stream when compared with UF operations without air scour.

Impact of recycling filter backwash water on organic removal in coagulation-sedimentation processes

The overall purpose of this research was to examine the impacts of filter backwash water (FBWW) and membrane backwash water (MBWW) recycles on water quality in coagulation-sedimentation processes. Specifically, the impact of recycling 5 or 10% by volume of FBWW and MBWW with surface water on the removal of natural organic matter (NOM) was evaluated at bench-scale using a standard jar-test apparatus and measurement of specific water quality parameters including total organic carbon (TOC), dissolved organic carbon (DOC), UV254, turbidity, total aluminum and zeta potential. The results of jar test conducted on a source water with a specific UV absorbance (SUVA) value within the range of 2-4 mg/Lm showed a significantly higher removal of DOC from the raw water that was blended with 5 and 10% by volume of FBWW as compared to control trials where backwash water was not added. Increasing rates of MBWW that did not contain destabilized hydroxide precipitates did not significantly change DOC concentrations in the settled water samples as compared to the control trials. For source waters that are characterized as having low turbidity with medium SUVA values, these results could hold particular significance for plants that have reached treatment ceilings in terms of dissolved NOM removal using conventional coagulation designs.

Biostability and disinfectant by-product formation in drinking water blended with UF-treated filter backwash water

The overall objective of this study was to investigate the impact of blending membrane-treated water treatment plant (WTP) residuals with plant-filtered water on finished water quality in terms of biostability and disinfectant by-product (DBP) formation. Filter backwash water (FBWW) was treated with a pilot-scale ultrafiltration (UF) membrane to produce permeate that was blended with plant-finished water. The batch studies involved storing samples for a specified time with a disinfectant residual to simulate residence time in the distribution system. Both chlorinated and non-chlorinated FBWW streams were evaluated, and the experimental design incorporated free chlorine, monochloramine, and chlorine dioxide in parallel to a model system that did not receive a disinfectant dose. The results of the study found that blending 10% UF-treated FBWW with plant-filtered water did not have an impact on water biostability as monitored with heterotrophic plate counts (HPCs) or DBP concentrations as monitored by TTHM and HAA5 concentrations. However, the presence of preformed THM and HAA species found in chlorinated FBWW streams may result in higher levels of initial DBP concentrations in blended water matrices, and could have a significant impact on finished water quality in terms of meeting specific DBP guidelines or regulations.

Identity and distribution of residues of energetic compounds at army live-fire training ranges

Environmental investigations have been conducted at 23 military firing ranges in the United States and Canada. The specific training facilities most frequently evaluated were hand grenade, antitank rocket, and artillery ranges. Energetic compounds (explosives and propellants) were determined and linked to the type of munition used and the major mechanisms of deposition.

RDX and TNT residues from live-fire and blow-in-place detonations

Snow was used as a collection medium to examine 1,3,5-hexahydro-1,3,5-trinitrotriazine (RDX) and 2,4,6-trinitrotoluene (TNT) residues post-detonation of 60-, 81-, and 120-mm mortar rounds, 105- and 155-mm howitzer rounds, M67 hand grenades, 40-mm rifle grenades, and blocks of C4. Residue-covered snow samples were collected, processed, and analyzed for explosives without cross-contamination from previous detonations and other potential matrix interferences. Detonation trials were performed following standard military live-fire and blow-in-place techniques. When possible, replicate munitions were detonated under similar conditions to provide a more reliable estimation of the mass of unconsumed high explosive residues. Overall the amount of energetic residues deposited from live-fire detonations were considerably less than the energetic residues deposited by blow-in-place detonations.

Transjugular liver biopsy is a safe and effective intervention to guide management for patients with a congenital bleeding disorder infected with hepatitis C

The prevalence of hepatitis C virus (HCV) infection in adult patients with a congenital bleeding disorder (CBD) approaches 95% and is a major cause of morbidity and mortality. Histological examination of the liver remains the cornerstone of management decisions in patients without a CBD. The reluctance to perform liver biopsies in patients with a CBD has been a major limitation in the management of these patients. We are currently the only haemophilia centre in Australasia performing liver biopsies in patients with a CBD for the purpose of guiding prognostic and therapeutic decisions. We report here the results of our centre's experience with transjugular liver biopsy (TJLB) in patients with a CBD. An adequate specimen for histological assessment was attained from all of the patients. There were no major complications recorded. Patients were hospitalized for < or = 48 h for haemostasis prophylaxis. The diagnostic specimen obtained from patients was integral in guiding their future management. We suggest that with a coordinated multidisciplinary approach, TJLB can be performed in patients with a CBD.

Treatment of drinking water residuals: comparing sedimentation and dissolved air flotation performance with optimal cation ratios

Spent filter backwash water (SFBW) and clarifier sludge generally comprise the majority of the waste residual volume generated and in relative terms, these can be collectively referred to as combined filter backwash water (CFBW). CFBW is essentially a low-solids wastewater with metal hydroxide flocs that are typically light and slow to settle. This study evaluates the impact of adding calcium and magnesium carbonates to CFBW in terms of assessing the impacts on the sedimentation and DAF separation processes. Representative CFBW samples were collected from two surface water treatment plants (WTP): Lake Major WTP (Dartmouth, Nova Scotia, Canada) and Victoria Park WTP (Truro, Nova Scotia, Canada). Bench-scale results indicated that improvements in the CFBW settled water quality could be achieved through the addition of the divalent cations, thereby adjusting the monovalent to divalent (M:D) ratios of the wastewater. In general, the DAF process required slightly higher M:D ratios than the sedimentation process. The optimum M:D ratios for DAF and sedimentation were determined to be 1:1 and 0.33:1, respectively. It was concluded that the optimisation of the cation balance between monovalent cations (e.g., Na(+), K(+)) and added divalent cations (i.e., Ca(2+), Mg(2+)) aided in the settling mechanism through charge neutralisation-precipitation. The increase in divalent cation concentrations within the waste residual stream promoted destabilisation of the negatively charged colour molecules within the CFBW, thereby causing the colloidal content to become more hydrophobic.

In situ reflection electron microscopy of Ge island nucleation on mesa structures

We have used in situ electron microscopy to observe the nucleation of Ge islands on lithographically patterned Si(001) mesas. Images were obtained at video rate during chemical vapor deposition of Ge, using a reflection electron microscopy geometry that allows nucleation to be observed over large areas. By comparing the kinetics of nucleation and coarsening on substrates modified by different annealing conditions, we find that the final island arrangement depends on the nature of the mesa sidewalls, and we suggest that this may be due to changes in diffusion of Ge across the nonplanar surface.

RDX loss in a surface soil under saturated and well drained conditions

On military training ranges, low-order, incomplete detonations deposit RDX (hexahydro-1,3,5-trinitro-1,3,5-triazine) into surface soils. In this study, we evaluated RDX biodegradation in surface soils obtained from a military training range in Alaska. Two factors were compared: (i) soil water potential during the incubations; and (ii) the use of acetonitrile (ACN) as an RDX carrier to spike samples. Organic solvents have been used in laboratory studies to dissolve slightly water-soluble contaminants before addition to soil. We added ACN to obtain final soil ACN concentrations of 0 mg kg(-1) (0%), 1000 mg kg(-1) (0.1%) and 10 000 mg kg(-1) (1%). We then compared RDX attenuation in the soil under saturated and unsaturated conditions. RDX fell below the limit of detection within 3 wk of study initiation under the saturated condition. A maximum degradation rate of 0.15 mg RDX L(-1) d(-1) was measured. Under the unsaturated condition, 42% of the original RDX was still present at study termination (5 wk). The addition of acetonitrile at 0.1 or 1.0% had no affect on RDX loss in the saturated soil. In the unsaturated soil, however, ACN at 1.0% inhibited RDX loss by as much as 25%. These findings indicate that soil water potential and carrier solvent concentrations can impact the rate and extent to which RDX is attenuated in a surface soil.

The effect of particle size reduction by grinding on subsampling variance for explosives residues in soil

Efforts to characterize the surface soil contamination on military training ranges have been compromised by the inability to obtain representative subsamples of soils submitted to analytical laboratories for determination of explosives residues. Two factors affecting subsampling error for explosives residues were examined using soils collected from hand grenade and anti-tank ranges. These factors were increased subsample size and particle size reduction prior to subsampling of soils. Increasing the subsample size from 2 to 50 g did not reduce the soil subsampling error because of the extreme heterogeneous distribution of the solid contaminants. Alternatively, particle size reduction by machine grinding on a ring mill reduced subsampling error to less than 10% relative standard deviation for replicate analyses using 10-g subsamples.

Minimizing venous thromboembolic complications in the orthopaedic patient

Venous thromboembolic events (VTE), which include deep venous thrombosis (DVT) and pulmonary embolus (PE), are the most common life-threatening complications associated with orthopaedic surgical procedures. DVT is particularly prevalent in patients undergoing total knee and hip arthroplasty, occurring at a rate of 50 to 60%. In addition, up to 2% of orthopaedic patients receiving pharmacologic prophylaxis still develop PE. Because the majority of candidates for these procedures are older adults with a multitude of comorbid conditions, standard prophylactic practices may not always result in optimal clinical outcomes. Thus, it is important for nurses to have a general understanding of appropriate thromboprophylaxis. This article will provide an overview of the current recommended guidelines and explore the risks and benefits of both pharmacologic agents and adjunctive treatment modalities.

Peripheral arterial disease detection, awareness, and treatment in primary care

CONTEXT

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis that is common and is associated with an increased risk of death and ischemic events, yet may be underdiagnosed in primary care practice.

OBJECTIVE

To assess the feasibility of detecting PAD in primary care clinics, patient and physician awareness of PAD, and intensity of risk factor treatment and use of antiplatelet therapies in primary care clinics.

DESIGN AND SETTING

The PAD Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) program, a multicenter, cross-sectional study conducted at 27 sites in 25 cities and 350 primary care practices throughout the United States in June-October 1999.

PATIENTS

A total of 6979 patients aged 70 years or older or aged 50 through 69 years with history of cigarette smoking or diabetes were evaluated by history and by measurement of the ankle-brachial index (ABI). PAD was considered present if the ABI was 0.90 or less, if it was documented in the medical record, or if there was a history of limb revascularization. Cardiovascular disease (CVD) was defined as a history of atherosclerotic coronary, cerebral, or abdominal aortic aneurysmal disease.

MAIN OUTCOME MEASURES

Frequency of detection of PAD; physician and patient awareness of PAD diagnosis; treatment intensity in PAD patients compared with treatment of other forms of CVD and with patients without clinical evidence of atherosclerosis.

RESULTS

PAD was detected in 1865 patients (29%); 825 of these (44%) had PAD only, without evidence of CVD. Overall, 13% had PAD only, 16% had PAD and CVD, 24% had CVD only, and 47% had neither PAD nor CVD (the reference group). There were 457 patients (55%) with newly diagnosed PAD only and 366 (35%) with PAD and CVD who were newly diagnosed during the survey. Eighty-three percent of patients with prior PAD were aware of their diagnosis, but only 49% of physicians were aware of this diagnosis. Among patients with PAD, classic claudication was distinctly uncommon (11%). Patients with PAD had similar atherosclerosis risk factor profiles compared with those who had CVD. Smoking behavior was more frequently treated in patients with new (53%) and prior PAD (51%) only than in those with CVD only (35%; P <.001). Hypertension was treated less frequently in new (84%) and prior PAD (88%) only vs CVD only (95%; P <.001) and hyperlipidemia was treated less frequently in new (44%) and prior PAD (56%) only vs CVD only (73%, P<.001). Antiplatelet medications were prescribed less often in patients with new (33%) and prior PAD (54%) only vs CVD only (71%, P<.001). Treatment intensity for diabetes and use of hormone replacement therapy in women were similar across all groups.

CONCLUSIONS

Prevalence of PAD in primary care practices is high, yet physician awareness of the PAD diagnosis is relatively low. A simple ABI measurement identified a large number of patients with previously unrecognized PAD. Atherosclerosis risk factors were very prevalent in PAD patients, but these patients received less intensive treatment for lipid disorders and hypertension and were prescribed antiplatelet therapy less frequently than were patients with CVD. These results demonstrate that underdiagnosis of PAD in primary care practice may be a barrier to effective secondary prevention of the high ischemic cardiovascular risk associated with PAD.

Bend elasticity of mixtures of V-shaped molecules in ordinary nematogens

Freedericksz measurements were performed on mixtures of a nematic mesogen and a V-shaped molecule. The bend elastic constant was found to decrease significantly with increasing concentration of the V-shaped molecule. The results are discussed theoretically, taking into account the detailed structure of the molecules.

Catalytic reductive dehalogenation of hexachloroethane by molecular variants of cytochrome P450cam (CYP101)

CYP101 (cytochrome P450cam) catalyses the oxidation of camphor but has also been shown to catalyse the reductive dehalogenation of hexachloroethane and pentachloroethane. This reaction has potential applications in the biodegradation of these environmental contaminants. The hexachloroethane dehalogenation activity of CYP101 has been investigated by mutagenesis. The effects of active-site polarity and volume were probed by combinations of active-site mutations. Increasing the active-site hydrophobicity by the Y96A and Y96F mutations strengthened hexachloroethane binding but decreased the rate of reaction. Increasing the polarity with the F87Y mutation drastically weakened hexachloroethane binding but did not affect the rate of reaction. The Y96H mutation had little effect at pH 7.4, but weakened hexachloroethane binding while increasing the rate of dehalogenation by up to 40% at pH 6.5, suggesting that the imidazole side-chain was partially protonated at pH 6.5 but not at pH 7.4. Substitutions by bulkier side-chains at F87, T101 and V247 weakened hexachloroethane binding but increased the dehalogenation rate. The effect of the individual mutations was additive in multiple mutants, and the most active mutant for hexachloroethane reductive dehalogenation at pH 7.4 was F87W-V247L (80 min-1 or 2.5 x the activity of the wild-type). The results suggested that the CYP101 active site shows good match with hexachloroethane, the Y96 side-chain plays an important role in both hexachloroethane binding and dehalogenation, and hexachloroethane binding and dehalogenation places conflicting demands on active-site polarity and compromises were necessary to achieve reasonable values for both.

Solitary fibrous tumour of the forearm. A rare tumour in an atypical site

Solitary fibrous tumour (SFT) is a rare spindle cell neoplasm that usually arises from serosal surfaces. Although it is now increasingly recognized in extra-serosal locations, only two previous cases of SFT arising in an extremity have been reported. We describe another such case and review the literature regarding extra-serosal SFT.

Self-reported chemical sensitivity and wartime chemical exposures in Gulf War veterans with and without decreased global health ratings

This cross-sectional telephone survey study assessed prevalence rates of current chemical sensitivity, frequency of chemical odor intolerance, and self-reported Persian Gulf chemical exposures among 41 randomly sampled Department of Veterans Affairs outpatients who were Persian Gulf War (PGW) and PGW-era veterans. The participants were drawn from an initial random list of 100 veterans, of whom 28 PGW and 20 era veterans had correct telephone data on file. Of those contacted, 86% of PGW veterans (24/28) and 85% of era veterans (17/20) agreed to participate. Significantly more PGW veterans with poorer global health after military service reported considering themselves now "especially sensitive to certain chemicals" (86%, 12/14) than did the PGW veterans or era veterans in stable health (both comparison groups 30%, 3/10). Among PGW veterans, the subset with worse health associated with marked increases in chemical odor intolerance since their military service had a significantly higher odds ratio for exposure to multiple chemicals, notably wartime pesticides and insect repellent, than did comparison groups. The high rate of chemical sensitivity of PGW veterans with deteriorated health is almost three times that in PGW-era veterans and in elderly primary care outpatient veterans at the same Department of Veterans Affairs medical center and in community-based civilian samples (i.e., 30%). These preliminary findings suggest the need for further study of chemical sensitivity, including tests for acquired increases in neural sensitizability to multiple low-level chemicals, in ill PGW veterans.

Preparing to perform an awake fiberoptic intubation

Fiberoptically guided tracheal intubation represents one of the most important advances in airway management to occur in the past thirty years. Perhaps its most important role is in management of the anticipated difficult airway. This is a situation in which the dangers of encountering the life-threatening "can't intubate, can't ventilate" situation can be avoided by placement of an endotracheal tube while the patient is awake. Although skill at the procedure of endoscopy is obviously necessary in this setting, these authors hold that success or failure of the technique frequently depends on the adequacy of preparation. These measures include 1) pre-operative assessment of the patient; 2) careful explanation of what lies in store; 3) "setting the stage"; 4) preparing the equipment to be used; and 5) preparing the patient (antisialogue, sedation, application of topical anesthesia to the upper airway). If these preparatory measures are carried out meticulously, the likelihood of performing a successful and comfortable awake fiberoptic tracheal intubation is greatly increased.

A Framework to Assess Regional Environmental Impacts of Dedicated Energy Crop Production

Numerous studies have evaluated air quality and greenhouse gas mitigation benefits of biomass energy systems, but the potential environmental impacts associated with large-scale changes in land-use patterns needed to produce energy crops have not been quantified. This paper presents a framework to assess the potential soil, water, and biodiversity impacts that may result from the large-scale production of dedicated energy crops. The framework incorporates producer economic decision models with environmental models to assess changes in land use patterns and to quantify the consequent environmental impacts. Economic and policy issues that will affect decisions to produce energy crops are discussed. The framework is used to evaluate erosion and chemical runoff in two Tennessee regions. The analysis shows that production of dedicated energy crops in place of conventional crops will significantly reduce erosion and chemical runoff.

Isolation and characterization of the human MRE11 homologue

Mutation of the Saccharomyces cerevisiae RAD52 epistasis group gene, MRE11, blocks meiotic recombination, confers profound sensitivity to double-strand break damage, and has a hyperrecombinational phenotype in mitotic cells. We isolated a highly conserved human MRE11 homologue using a two-hybrid screen for DNA ligase I-interacting proteins. Human MRE11 shares approximately 50% identity with its yeast counterpart over the N-terminal half of the protein. MRE11 is expressed at the highest levels in proliferating tissues, but is also observed in other tissues. The MRE11 locus maps to human chromosome 11q21 in a region frequently associated with cancer-related chromosomal abnormalities. A MRE11-related locus was found on chromosome 7q11.2-q11.3.

Exogenous GM1 ganglioside effects on conductive and sensorineural hearing losses

Both CBA/J mice with neonatal cochlea removals and CBA/J mice with neonatal atresias of the external auditory meatus have significantly smaller ventral cochlear nucleus is greater in the mice with cochlea removals, but the soma area reduction is greater in the mice with external auditory meatus atresias. GM1 gangliosides were subcutaneously injected daily into a group of CBA/J mice with conductive hearing loss caused by neonatal removals of their left external auditory meatus, and into a group of CBA/J mice unilaterally deafened by left cochlea removals. In the mice with conductive hearing loss, the ganglioside treatment significantly ameliorated the atrophy of spiral ganglion neurons, ventral cochlear nucleus neurons, and ventral cochlear nucleus volume. In unilaterally deafened mice, the ganglioside treatment had no measurable effect on the atrophy of ventral cochlear nucleus neurons or of ventral cochlear volume. It is suggested that GM1 ganglioside treatment potentiates growth factors which sustain spiral ganglion integrity and that this sustained activity of the spiral ganglion in turn maintains the integrity of the cochlear nuclei.

White phosphorus poisoning of waterfowl in an Alaskan salt marsh

The cause of the yearly death of an estimated 1,000 to 2,000 migrating dabbling ducks (Anas spp.) and 10 to 50 swans (Cygnus buccinator and C. columbianus) has remained a mystery for the last ten years in Eagle River Flats (ERF), a 1,000 ha estuarine salt marsh near Anchorage, Alaska, used for artillery training by the U.S. Army. We have gathered evidence that the cause of this mortality is the highly toxic, incendiary munition white phosphorus (P4). The symptoms of poisoning we observed in wild ducks included lethargy, repeated drinking, and head shaking and rolling. Death was preceded by convulsions. Farm-reared mallards dosed with white phosphorus showed nearly identical behavioral symptoms to those of wild ducks that became sick in ERF. White phosphorus does not occur in nature but was found in both the sediments where dabbling ducks and swans feed and in the gizzards of all carcasses collected in ERF. We hypothesize that feeding waterfowl are ingesting small particles of the highly toxic, incendiary munition P4 stored in the bottom anoxic sediments of shallow salt marsh ponds.

Adherence to exercise interventions in the treatment of hypercholesterolemia

The goals of this study were to determine the rate of adherence to exercise treatment of hypercholesterolemia and to identify personality and demographic factors associated with adherence. Of the 31 subjects entering the 26-week program, 12 attended 80% or more of the scheduled sessions. Adherence was positively associated with the perceived seriousness of hypercholesterolemia, the expectation of benefit from treatment, and depressed feelings of helplessness and hopelessness. Negative associations were identified between adherence and the perception of health status being under the control of chance or of powerful others. Older subjects were more likely to be adherers at 8 and 16 weeks but not at 26 weeks.