Transdermal Delivery of Niacin Through Polysaccharide Films Ameliorates Cutaneous Flushing in Experimental Wistar Rats

BACKGROUND

Niacin, an established therapeutic for dyslipidemia, is hindered by its propensity to induce significant cutaneous flushing when administered orally in its unmodified state, thereby constraining its clinical utility.

OBJECTIVE

This study aimed to fabricate, characterize, and assess the in-vitro and in-vivo effectiveness of niacin-loaded polymeric films (NLPFs) comprised of carboxymethyl tamarind seed polysaccharide. The primary objective was to mitigate the flushing-related side effects associated with oral niacin administration.

METHODS

NLPFs were synthesized using the solvent casting method and subsequently subjected to characterization, including assessments of tensile strength, moisture uptake, thickness, and folding endurance. Surface characteristics were analyzed using a surface profiler and scanning electron microscopy (SEM). Potential interactions between niacin and the polysaccharide core were investigated through X-ray diffraction experiments (XRD) and Fourier transform infrared spectroscopy (FTIR). The viscoelastic properties of the films were explored using a Rheometer. In-vitro assessments included drug release studies, swelling behavior assays, and antioxidant assays. In-vivo efficacy was evaluated through skin permeation assays, skin irritation assays, and histopathological analyses.

RESULTS

NLPFs exhibited a smooth texture with favorable tensile strength and moisture absorption capabilities. Niacin demonstrated interaction with the polysaccharide core, rendering the films amorphous. The films displayed slow and sustained drug release, exceptional antioxidant properties, optimal swelling behavior, and viscoelastic characteristics. Furthermore, the films exhibited biocompatibility and non-toxicity towards skin cells.

CONCLUSION

NLPFs emerged as promising carrier systems for the therapeutic transdermal delivery of niacin, effectively mitigating its flushing-associated adverse effects.

Quantitative Microbial Risk Assessment Framework Incorporating Water Ages with Legionella pneumophila Growth Rates

Water age in drinking water systems is often used as a proxy for water quality but is rarely used as a direct input in assessing microbial risk. This study directly linked water ages in a premise plumbing system to concentrations of Legionella pneumophila via a growth model. In turn, the L. pneumophila concentrations were used for a quantitative microbial risk assessment to calculate the associated probabilities of infection (Pinf) and clinically severe illness (Pcsi) due to showering. Risk reductions achieved by purging devices, which reduce water age, were also quantified. The median annual Pinf exceeded the commonly used 1 in 10,000 (10-4) risk benchmark in all scenarios, but the median annual Pcsi was always 1-3 orders of magnitude below 10-4. The median annual Pcsi was lower in homes with two occupants (4.7 × 10-7) than with one occupant (7.5 × 10-7) due to more frequent use of water fixtures, which reduced water ages. The median annual Pcsi for homes with one occupant was reduced by 39-43% with scheduled purging 1-2 times per day. Smart purging devices, which purge only after a certain period of nonuse, maintained these lower annual Pcsi values while reducing additional water consumption by 45-62%.

Rumen-protected l-carnitine supplementation during mating period altered metabolic status and reproductive performance of ewes

Current study hypothesized that dietary l-carnitine (LC) inclusion during the mating period ameliorates both metabolic status and reproductive performance of ewes. Seventy Baluchi ewes (52 ± 4.2 kg of bodyweight and 18 ± 6 months old of age) were enrolled in this study. Animals were randomly allocated into two dietary treatments, control (only basal diet) or basal diet plus supplementation with a rumen-protected LC (Carneon 20 Rumin-pro; 20% LC; Kaesler Nutrition GmbH) at the rate of 10 g/head/day from 21 days before until 35 days after introducing rams to the ewes (MP). Feed intake was monitored by subtracting the ort from feed offered. Blood sample collection was conducted on Days -10, +10 and +20 relative to MP. Pregnancy was confirmed on Day 30 post-MP. Feed intake of the ewes in the LC group was higher than the control (p < 0.05). LC supplementation increased the cholesterol concentration in the ewes (p < 0.05). Blood urea concentration of animals in the LC group was significantly lower than the control (p < 0.05). The mRNA expression of toll-like receptor 4 was evidently lower in animals supplemented with LC than the control (p < 0.05). Both lambing and fecundity rates in the LC group tended to be higher compared with the control. LC supplementation showed potential to alter certain metabolites in the ewes. A tendency for higher lambing rate may partly be driven by dams efficient energy partitioning to support foetal growth and maintaining pregnancy.

Erythromelalgia. Part II: Differential diagnoses and management

The management of erythromelalgia is challenging and requires multidisciplinary effort. Patient education is crucial as unsafe self-administered cooling techniques can lead to significant morbidity, including acral necrosis, infection, and amputation. The goal of management is pain control, reduction of flare frequency, and prevention of complications. This text is focused on the management of erythromelalgia and several other incompletely understood and under-recognized neurovascular disorders such as red scrotum syndrome, red ear syndrome, facial flushing, and complex regional pain syndrome.

Topical 10% Tranexamic Acid with and without Microneedling in the Treatment of Erythematotelangiectatic Rosacea: A Split-face Comparative Study

Objective

Erythematotelangiectatic rosacea (ETR) is recognized by flushing, persistent centrofacial erythema, and telangiectasia. Many lines of topical treatments have been used for ETR with variable outcomes. We aimed to evaluate the efficacy of 10% topical tranexamic acid (TXA) with and without microneedling in treating ETR.

Methods

All patients received treatment on both sides of the face, the right side was treated with microneedling combined with 10% topical TXA, and the left side was treated with 10% topical TXA only. All patients received three sessions at two weeks intervals. The final evaluation was done three months after the last treatment session.

Results

The study included 45 females. Their age ranged between 20 and 48 years. The duration of the disease ranged from two months to five years. Both sides of the face showed improvement after treatment. There was a clinically and dermoscopic significant improvement in the side treated with microneedling + TXA compared to the side of the face treated with TXA alone.

Limitations

The small sample size and the lack of long-term follow-up.

Conclusion

This study showed that TXA is an effective and safe treatment modality for ETR. Microneedling can enhance the delivery of TXA and lead to better outcomes regarding erythema and telangiectasia.

Late Prevalence of Typical and Atypical Symptoms of Frey's Syndrome after Parotidectomy for Benign Tumor

BACKGROUND

The treatment of choice for tumors located in the parotid gland is surgery. Nevertheless, postoperative complications are not infrequent. Regardless of the type of surgical procedure, the most common complication is Frey's syndrome (FS). Traditionally, FS includes unilateral gustatory sweating and flushing of the facial skin lining the parotid compartment. Recent research describes atypical discomfort associated with FS. The aim of this study was to assess the late prevalence and severity of both usual and atypical symptoms after parotidectomy for benign tumors.

METHODS

We conducted a cross-sectional study involving 86 subjects who underwent superficial parotidectomy at least one year before the study. The questionnaire included the sweating-flushing-itch-paresthesia-pain (SFIPP) Frey scale supplemented by specific questions about symptoms.

RESULTS

Sixty-seven out of eighty-six (77.9%) cases reported almost one symptom. The most frequent symptom was itch (36/67-53.7%), followed by pain (35/67-52.2%), while 28/67 (41.8%) subjects complained of atypical symptoms without flushing or sweating. A desire to treat the discomfort was reported by 50/67 (74.6%) subjects.

CONCLUSIONS

Late postparotidectomy local discomfort is not infrequent and includes both usual and "unusual" symptoms almost equally. Our results suggest the importance of informing patients about the occurrence of the syndrome and the available treatment options during pre- and postoperative counseling.

Observation of the clinical features of dupilumab-associated facial erythema

Introduction

Dupilumab is the first biologic agent used to clinically treat moderate and severe atopic dermatitis (AD) and is currently the only biologic agent used for this condition. Many studies have reported that moderate-to-severe AD was significantly improved after dupilumab injection, although head/neck dermatitis occurred with itching, flushing, and scaling. Moreover, because all the symptoms occur after dupilumab treatment, they are called "dupilumab facial redness (DFR)".

Aim

To retrospectively analyse the clinical characteristics and treatment of facial erythema in patients with atopic dermatitis treated with dupilumab.

Material and methods

The clinical data of patients with moderate-to-severe atopic dermatitis treated with dupilumab (600 mg for the first time, 300 mg every 2 weeks thereafter) in the department of dermatology from July 2020 to May 2022 were obtained. We described their characteristics and analysed their symptomatic treatment measures and efficacy.

Results

Twenty-one patients with DFR were included. Most clinical manifestations were erythema and pruritus, which differed from the symptoms of typical moderate-to-severe AD. After treatment, drug withdrawal, and dressing change, the symptoms of 17 patients were effectively controlled or completely improved, while these of 4 did not improve.

Conclusions

Although the mechanism of DFR is still unclear, symptomatic treatment is partially effective, and medication discontinuation and switching to Janus kinase inhibitors are acceptable for some patients.

The Efficacy and Safety of Botulinum Toxin A for the Treatment of Rosacea: A Systematic Review

The off-label use of botulinum toxin type-A (BoNT-A) in treating rosacea seems encouraging, but the evidence is still lacking regarding its efficacy and safety. This study was conducted to summarize the evidence regarding the efficacy and safety of BoNT-A in the treatment of rosacea patients. A comprehensive literature search was conducted in several databases, and 17 studies were included. Before-after and split-face comparisons showed that BoNT-A significantly alleviated the symptoms of facial erythema and flushing and improved the patient's quality of life/satisfaction. However, the symptoms recurred three to six months post-injection, requiring repeated treatments in some patients. The pooled rates of post-injection localized erythema, ecchymosis, and facial muscle affection represented 24.6%, 5.1%, and 4.3%, respectively. BoNT-A seems to be effective in alleviating the symptoms of rosacea with a low rate of adverse events. However, the recurrence of the symptoms a few months after the injection requires repeated sessions, which may raise cost-effectiveness issues. Large-scale clinical trials are required to confirm the effectiveness and define the optimal dosing regimen and the rate of recurrence. Future studies should allow for an adequate follow-up after the treatment, with repeated measurements of the outcomes.

A new 532 nm, variable-pulse-structure, dual-wavelength, KTP laser incorporating cryogen spray cooling, effectively treats rosacea

BACKGROUND

A new dual-wavelength, high-energy, solid-state laser incorporating both 532 and 1064 nm wavelengths was developed with cryogen spray cooling and the unique ability to deliver three types of pulse structures including single pulses of a specific pulse-duration or pulses composed of a train of subpulses in the millisecond or microsecond domain with an intervening delay over the selected pulse-duration. We investigate the efficacy of this laser using all three pulse structures and the 532 nm wavelength for treating rosacea.

METHODS

Twenty-one subjects were enrolled in this IRB-approved study. A total of up to three treatments were administered at monthly intervals. Each treatment consisted of a first pass tracing linear vessels with a 40 ms pulse-duration immediately followed by a second pass using a 5 ms pulse, using all three available pulse structures. Assessment of cross-polarized digital images by blinded physician observers compared baseline and 3-month follow-up images.

RESULTS

Blinded observers correctly identified the posttreatment images 89% of the time, in 17 of 19 subjects completing the study, with an average overall improvement rating of 39% after only three treatments. Side effects were limited to short-term erythema and edema.

CONCLUSION

This study demonstrates that this new, variable-pulse-structure, dual wavelength, solid state, KTP laser with dynamic cooling is a safe and effective for treating rosacea.

Effect of Nutritional Flushing Using Long-Term Energy and Protein Supplementation on Growth Performance and Reproductive Parameters of Doyogena Ewes in Ethiopia

The objective of the study was to establish the effect of appropriate supplementation days (days -21 to +7) using four isonitrogenous (14.7% CP) diets balanced to provide low (Lo-ME) or high (Hi-ME) metabolizable energy on the body condition score (BCS), body weight (BW) change, and reproductive performances of sheep. Thirty-five Doyogena ewes (27.71 ± 2.87 kg, 2-5 years of age, BCS of 2.0-2.5) grazing on natural pasture were randomly assigned to supplementary treatments consisting of combinations of enset leaf (EL) and commercial concentrate (CC): T0 (control), T1 (250 g EL + 500 g CC: Lo-ME), T2 (400 g EL + 500 g CC; Hi-ME), T3 (500 g EL + 400 g CC; Hi-ME), and T4 (500 g EL + 250 g CC; Lo-ME). The estrous cycle was synchronized with one intramuscular injection, 5 mg PGF2α, prior to artificial insemination. The dry matter (DM) from the pasture provided 1.10-1.46 kg/day, which corresponds to the DM requirements of the ewes until late gestation. However, the pasture provided a protein content of 9.52%, which was insufficient for breeding, mid-gestation, and gestation, requiring minimums of 16.1%, 13.1%, and 14.8%, respectively. The pasture could only provide enough energy for breeding ewes with a BW of up to 30 kg. The energy provided by pasture was insufficient for ewes weighing > 30 kg at mid-gestation and gestation, providing 6.9-9.2 MJ/day, below the requirement of 11.92-16.32 MJ/day required for mid-gestation and gestation. The energy was not sufficient for large ewes weighing > 40 kg. Supplementary diets T1-T4 provided DM in the range of 1.7-2.29 kg/day. This was sufficient for AI, mid-gestation, and gestation phases. Dietary supplements increased (p < 0.01) BW during breeding and mid-gestation. During lambing, T2 and T3 increased BW (p < 0.05) compared to T4 and T1. T4 had a similar effect (p > 0.05) on BW during lambing. T1, T2, and T3 significantly increased BCS (p < 0.05). T2 and T3 increased (p < 0.05) BCS at mid-gestation, but only T2 significantly increased BCD (p < 0.05) during lambing. All dietary supplements resulted in a shorter (p < 0.05) time to the resumption of estrous and the length of estrous (p < 0.05). T1, T2, and T3 resulted in a stronger estrous response (p < 0.05). Dietary supplements enhanced (p < 0.05) the conception rate and fecundity rate. The conception rate was highest in T2 and T3 at 85.7% and 83.3%, respectively. T2 had the highest fecundity rate at 151.7% (p < 0.05). Dietary supplementation increased the rate of lambing (LR), litter size (LS), and weight of lambs at birth (LBW). The LR for treatments T2, T3, and T4 was 100% versus 66.7% in the control. T1 and T2 significantly increased (p < 0.05) LS, but T4 had a similar LS to the control. Dietary supplements T1, T3, and T4 tended to increase (p < 0.05) LBW, but T2 increased LBW significantly (p < 0.05). Supplementation (T2, T3) with 400 g enset + 500 g CC and 500 g enset + 400 g CC are promising feed supplements to increase the reproductive capacities of Doyogena ewes in Ethiopia. Energy is as important to ewe flushing as protein.

Controlling Legionella pneumophila in Showerheads: Combination of Remedial Intervention and Preventative Flushing

Shock chlorination and remedial flushing are suggested to address Legionella pneumophila (Lp) contamination in buildings or during their (re)commissioning. However, data on general microbial measurements (adenosine tri-phosphate [ATP], total cell counts [TCC]), and the abundance of Lp are lacking to support their temporary implementation with variable water demands. In this study, the weekly short-term (3-week) impact of shock chlorination (20-25 mg/L free chlorine, 16 h) or remedial flushing (5-min flush) combined with distinct flushing regimes (daily, weekly, stagnant) was investigated in duplicates of showerheads in two shower systems. Results showed that the combination of stagnation and shock chlorination prompted biomass regrowth, with ATP and TCC in the first draws reaching large regrowth factors of 4.31-7.07-fold and 3.51-5.68-fold, respectively, from baseline values. Contrastingly, remedial flushing followed by stagnation generally resulted in complete or larger regrowth in Lp culturability and gene copies (gc). Irrespective of the intervention, daily flushed showerheads resulted in significantly (p < 0.05) lower ATP and TCC, as well as lower Lp concentrations than weekly flushes, in general. Nonetheless, Lp persisted at concentrations ranging from 11 to 223 as the most probable number per liter (MPN/L) and in the same order of magnitude (10³-10⁴ gc/L) than baseline values after remedial flushing, despite daily/weekly flushing, unlike shock chlorination which suppressed Lp culturability (down 3-log) for two weeks and gene copies by 1-log. This study provides insights on the most optimal short-term combination of remedial and preventative strategies that can be considered pending the implementation of suitable engineering controls or building-wide treatment.

Health-Related Habits and Health Promotion Behaviors in People With Alcohol Flushing

There is limited investigation on health-related behaviors by alcohol flushing. A nationwide cross-sectional study was conducted using data from the Korea Community Health Survey. The final analysis included 130 192 adults with available information on alcohol flushing assessed by a self-reported questionnaire. About a quarter of participants were classified into alcohol flushers. After considering demographics, comorbidities, mental health, and perceived health status, multivariable logistic regression analysis revealed that flushers smoked or drank less and received vaccination or screening more than nonflushers. In conclusion, flushers have healthier behaviors than nonflushers.

Safety of Extending Implanted Vascular Access Device Maintenance Flush Frequency

BACKGROUND

Standards of care and guidelines acknowledge insufficient evidence that defines frequency of flushing for implanted vascular access devices (IVADs). Manufacturers recommend 4 weeks, but guidelines suggest that extending to 12 weeks is safe based on functionality.

OBJECTIVES

The study reviewed current standards of care for IVAD flush maintenance frequency, examined the characteristics of blood from IVADs by aspirating and observing contents prior to flushing when maintenance care is delayed beyond four weeks, and identified whether more research is required to determine optimal IVAD maintenance flush frequency.

METHODS

An outpatient oncology clinic gathered data related to IVAD flush frequency during the COVID-19 pandemic. The concern was potentially harmful substances being flushed into the patient. A new method was developed to allow for observation of physiologic characteristics within the IVAD. Abnormal-appearing substances aspirated from the devices were discarded prior to use.

FINDINGS

Visible clots and alterations in color and appearance were observed in 25% of the 59 patients observed between 8 and 17+ weeks when the IVAD reservoir was aspirated prior to flushing.

The Performance of Ultrafiltration Process to Further Refine Lactic Acid from the Pre-Microfiltered Broth of Kitchen Waste Fermentation

Lactic acid (LA) is an important chemical material facing rapid demand in recent years. The oriented fermentation of kitchen waste is a promising route for economic LA production. However, the refinement of LA from fermentation broth is a spiny issue. In this study, the performance of ultrafiltration (UF) process for the refinement of LA from the pre-microfiltered broth of kitchen waste fermentation was first investigated. The results showed that with 50 KDa polyethersulfone membrane, under the optimum pressure of 120 KPa, the pH of 6.0, and the backflushing mode with the deionized water for 3 min, the best performance was achieved with the chroma removal efficiency, turbidity removal efficiency, protein removal efficiency and total sugar removal efficiency of 54.3%, 89.8%, 71.7% and 58.5%, respectively, and LA recovery efficiency was 93.6%. The results indicated that the UF process could further effectively refine the pre-microfiltered broth of kitchen waste fermentation, and the combination of microfiltration and UF process is ideal for achieving desirable LA refinement performance. This study verified the feasibility of UF process in LA refinement from pre-microfiltered broth of kitchen waste fermentation, and based on the results, the further exploration of proper post-process to treat UF filtrate for obtaining LA product with higher quality should be explored in the future.

The Performance of Microfiltration Process for Purifying Lactic Acid in the Fermented Broth of Kitchen Waste

Fermentation broth is plentiful with lactic acid, an important chemical applied in many fields, such as food processing, the chemical industry, and cosmetics. However, the purification of the lactic acid from the broth is still troublesome, when considering the economy. This study first investigated the purification performance of microfiltration (MF) membrane technology for a fermentation broth from kitchen waste. The effect of operation pressure, broth pH, and membrane flushing mode on the membrane filtration performance were investigated. In addition, the change in filtration performance over the increase in cycle time was also investigated. The results showed that under the optimum pressure of 100 KPa, pH of 6.0, and a backflushing mode with deionized water for 3 min, the best performance was achieved, with chroma removal, turbidity removal, protein removal and total sugar removal efficiencies of 60, 92.8, 57.64 and 32.93%, respectively. The results indicated that the MF process could be a desirable broth purification process to some extent, and it is promising in actual application. The MF process combined with other post-purification processes will form the ideal process system, which should be explored in future research.

Gut Microbiota Changes during Dimethyl Fumarate Treatment in Patients with Multiple Sclerosis

The gut microbiota is involved in the development of the immune system and can modulate the risk for immune-mediated disorders such as multiple sclerosis (MS). Dysbiosis has been demonstrated in MS patients and its restoration by disease-modifying treatments (DMTs) is hypothesized. We aimed to study the changes in gut microbiota composition during the first 6 months of treatment with dimethyl fumarate (DMF), an oral DMT, and to identify the microorganisms associated with DMF side effects. We collected and analyzed the gut microbiota of 19 MS patients at baseline and after 1, 3, and 6 months of DMF treatment. We then cross-sectionally compared gut microbiota composition according to the presence of gastrointestinal (GI) symptoms and flushing. Overall, the gut microbiota biodiversity showed no changes over the 6-month follow-up. At the genus level, DMF was associated with decreased Clostridium abundance after 6 months. In subjects reporting side effects, a higher abundance of Streptococcus, Haemophilus, Clostridium, Lachnospira, Blautia, Subdoligranulum, and Tenericutes and lower of Bacteroidetes, Barnesiella, Odoribacter, Akkermansia, and some Proteobacteria families were detected. Our results suggest that gut microbiota may be involved in therapeutic action and side effects of DMF, representing a potential target for improving disease course and DMT tolerability.

Tidal Flushing Rather Than Non-Point Source Nitrogen Pollution Drives Nutrient Dynamics in A Putatively Eutrophic Estuary

The effects of nonpoint source nutrients on estuaries can be difficult to pinpoint, with researchers often using indicator species, monitoring, and models to detect influence and change. Here, we made stable isotope measurements of nitrogen and carbon in sediment, water column particulates, primary producers, and consumers at 35 stations in the reportedly eutrophic Barnegat Bay (New Jersey) to assess N sources and processing pathways. Combined with water quality and hydrological data, our C and N isoscapes revealed four distinct geographic zones with diverging isotopic baselines, indicating variable nutrient sources and processing pathways. Overall, the carbon stable isotopes δ13C) reflected the terrestrial-marine gradient with the most depleted values in the urban and poorly flushed north of the estuary to the most enriched values in the salt marsh-dominated south. In contrast, the nitrogen stable isotope values δ15N) were most enriched near the oceanic inlets and were consistent with offshore δ15N values in particulate organic matter. Several biogeochemical processes likely alter δ15N, but the relatively lower δ15N values associated with the most urbanized area indicate that anthropogenic runoff is not a dominant N source to this area. Our findings stand in contrast to previous studies of similar estuaries, as δ15N signatures of biota in this system are inversely correlated to population density and nutrient concentrations. Further, our analyses of archival plant (Spartina sp., Phragmites australis) and shell (Geukensia demissa, Ilyanassa obsoleta) samples collected between 1880 and 2020 indicated that δ15N values have decreased over time, particularly in the consumers. Overall, we find that water quality issues appear to be most acute in the poorly flushed parts of Barnegat Bay and emphasize the important role that oceanic exchange plays in water quality and associated estuarine food webs in the lagoon.

Retrospective Study from a Single Center on the Efficacy of Pulsed Lavage Following Excision of Burns ≥30% of the Total Body Surface Area in 63 Patients

BACKGROUND Ensuring the take rate of skin grafting and reducing the mortality of patients with severe burns have remained big challenges worldwide. This retrospective study from a single center aimed to evaluate the efficacy of pulsed lavage following excision of burns ≥30% of the total body surface area (TBSA) in 63 patients. MATERIAL AND METHODS Among 63 patients, the types of burns sustained were severe burns and extremely severe burns (≥30% TBSA). The degrees of the burns were second degree and third degree, and the causes were thermal, chemical, and electric. Patients with early aggressive excision were divided into a pulsed lavage group and control group. The constituent of the lavage fluid was 0.9% physiological saline. The evaluation of wound healing and complications was based on the wound healing rate and time, clinical symptoms, and examination. We determined the take rate of skin grafting, positive rate of postoperative bacterial cultures, changes in perioperative serum C-reactive protein (CRP) and procalcitonin (PCT) levels, and incidence of secondary grafting. RESULTS The take rate of skin grafting and the decreased rates of perioperative serum CRP and PCT levels were significantly higher in the pulsed lavage group than in the control group (P<0.05). Moreover, the positive rate of wound postoperative bacterial cultures and mortality in the pulsed lavage group showed remarkably lower levels (P<0.05). CONCLUSIONS Pulsed lavage following excision of burns ≥30% TBSA increased the take rate of skin grafting, alleviated the positive rate of postoperative bacterial cultures, decreased serum CRP and PCT levels, and reduced mortality.

Heparin versus normal saline locking for prevention of occlusion, catheter-related infections and thrombosis in central venous catheter in adults: Overview of systematic reviews

Venous access devices are used in health care. To prevent occlusions the evidence confirmed the need for routine catheter flushing before and after infusion as well as at the end of use. To date, the efficacy of heparin has not been demonstrated. The aim of this study was to evaluate the effectiveness of the locking of central venous catheters with heparin versus normal saline in adults to prevent occlusion, catheter-related infections and thrombosis in adults. A literature search using Medline, Embase, Cochrane Library and Cinahl was performed to identify all meta-analyses addressing the effectiveness of heparin versus normal saline in locking central venous catheters in adults. Four reviewers independently selected publications assessed quality and extracted data. Parameter estimates regarding occlusion, catheter- related infections and thrombosis were pooled using an umbrella review. We identified 6356 references. Seven systematic reviews were included in the study. Most of the studies included in the systematic reviews were conducted in oncohaematology departments, intensive care and cardiac surgery units among patients with multiple diseases and chronicity. Most studies report a heparin concentration of 10 to 5000 IU/ml versus normal saline and other solutions. There was no evidence that heparin was more effective than normal saline in reducing complications such as occlusion, catheter-related infections and thrombosis. No statistically significant difference was found between heparin and normal saline in reducing catheter occlusion. Heparin is not superior compared to normal saline.

Hydroxocobalamin: An Effective Treatment for Flushing and Persistent Erythema in Rosacea

BACKGROUND

Expression of inducible nitric oxide synthase (NOS) is higher in rosacea skin samples than in normal skin controls. Hydroxocobalamin is a potent inhibitor of all isoforms of NOS, capable of reducing the vasodilatations induced by nitric oxide.

OBJECTIVE

We aimed to evaluate the role of hydroxocobalamin in treating facial flushing and persistent erythema of rosacea.

METHODS

Thirteen patients with rosacea who displayed facial flushing and persistent erythema received 1 to 4 weekly intramuscular injections of hydroxocobalamin 1 to 2 mg. The outcomes were measured using the Clinician's Erythema Assessment (CEA) by photography and an infrared thermometer to evaluate the difference in skin surface temperature (SST) of the cheeks before and after treatment.

RESULTS

Thirty minutes after the first dose of intramuscular injection of hydroxocobalamin, the mean CEA significantly reduced from 2.2± 0.6 to 1.2±0.4 (p<0.001), and average SST also significantly reduced from 36.7±0.70°C to 36.2±0.61°C (p<0.001) on the cheeks.

CONCLUSION

In our patient sample, intramuscular administration of hydroxocobalamin was effective for immediate reduction of facial erythema associated with rosacea.

Variable Legionella Response to Building Occupancy Patterns and Precautionary Flushing

When stay-at-home orders were issued to slow the spread of COVID-19, building occupancy (and water demand) was drastically decreased in many buildings. There was concern that widespread low water demand may cause unprecedented Legionella occurrence and Legionnaires’ disease incidence. In lieu of evidenced-based guidance, many people flushed their water systems as a preventative measure, using highly variable practices. Here, we present field-scale research from a building before, during, and after periods of low occupancy, and controlled stagnation experiments. We document no change, a > 4-log increase, and a > 1.5-log decrease of L. pneumophila during 3- to 7-week periods of low water demand. L. pneumophila increased by > 1-log after precautionary flushing prior to reoccupancy, which was repeated in controlled boiler flushing experiments. These results demonstrate that the impact of low water demand (colloquially called stagnation) is not as straight forward as is generally assumed, and that some flushing practices have potential unintended consequences. In particular, stagnation must be considered in context with other Legionella growth factors like temperature and flow profiles. Boiler flushing practices that dramatically increase the flow rate and rapidly deplete boiler temperature may mobilize Legionella present in biofilms and sediment.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Reproductive Performance of Ewes, Fed Flushing Diet at Different Management Feeding Program

&lt;b&gt;Background and Objective:&lt;/b&gt; There is very rare information regarding data of reproduction performance of small ruminant with different management flushing program in Asian countries. The aim of this study was to evaluate the implementation of flushing diet program containing lemuru fish oil with time management difference, by evaluating the reproductive performance of local Garut ewes. &lt;b&gt;Materials and Methods:&lt;/b&gt; Twenty of garut ewes (average body weight 30.06±6.20 kg) were used in this experiment using Completely Randomized Block Design (CRBD), in four treatments with five animals of each treatment. The treatments were without flushing (F0 as control), flushing at the beginning of mating (F1 = 2 weeks pre-mating until 2 weeks just after-mating), two times flushing (F2 = F1 plus 4 weeks flushing during mid gestation) and three times flushing (F3 = F2 plus 2 weeks flushing at the end of gestation and 2 weeks after parturition). The ratio of flushing or basal concentrate to forage was 70:30. Basal concentrate was given during untreated. Nutrients consumption, body condition score (BCS), average daily gain (ADG), feed efficiency ratio (FER) and reproduction parameters were evaluated. The data of sex ratio and birth type were expressed descriptively. &lt;b&gt;Results:&lt;/b&gt; The results showed that the treatment had significant effect (p<0.05) on crude fat consumption, total digestible nutrients (TDN) and changes of BCS values, but had no effect on other nutrients consumptions. All treatments did not affect to total birth weight, the number of embryo, litter size, gestation period and sex ratio. The percentage of ewes pregnancy with the flushing treatment was 25% higher than the control. The flushing treatments were significantly effect on partus weight of ewes (p<0.05). &lt;b&gt;Conclusion:&lt;/b&gt; It was concluded that three times flushing program at early, middle and late of gestation could improve the nutritional status and reproductive performance of ewes, such as fat intake, partus weight, improved percentage of pregnancy and type of birth, but did not affect to total birth weight, litter size, pregnant period and sex ratio.

Pseudoxanthomatous Mastocytosis in a 2-Month Female Infant

Mastocytosis is a rare disease characterized by infiltration of mast cells in various tissues like skin, bone marrow, liver, spleen, and gastrointestinal tract. Here, we present a case report of diffuse cutaneous mastocytosis (pseudoxanthomatous type) in a neonate which is a rare presentation.

Rosacea and Diet: What is New in 2021?

OBJECTIVE

Rosacea is a common inflammatory cutaneous condition with a complex yet unknown etiopathogenesis. Diet and certain food items are known to trigger or worsen rosacea symptoms, but conflicting and often inconsistent advice is given to patients regarding this link. We provide an up-to-date literature review on the relationship between rosacea and diet.

METHODS

Using the keywords "alcohol," "diet," "flushing," "food," "inflammation," "rosacea," "skin-gut axis" and "spice" we systemically searched the databases PubMed, MEDLINE and EMBASE for English-language articles in July 2020.

RESULTS

The most frequently reported triggers implicated in rosacea include alcohol, spicy food, cinnamaldehyde-containing foods (e.g., tomatoes, citrus fruits, chocolate), hot drinks, and histamine-rich foods (e.g., aged cheese, wine, processed meats). Some food items appear to play a protective role, such as omega-3, which appears to protect against ocular rosacea. The relationship between certain food items and the subtype of rosacea is varied, with inconsistent results shown in the few studies that examined this. As an example, alcohol worsens flushing and fatty food triggers both erythematotelangiectatatic and phymatous rosacea in susceptible individuals.

CONCLUSION

While several food types appear to be associated with exacerbation of rosacea, there are no recommendations that can be applied to all patients. Further studies are needed to examine the exact link between diet and rosacea subtypes.

Pre- and post-flushing of three schools in Arizona due to COVID-19 shutdown

A one-day water sampling and flushing study was conducted for three schools in Maricopa County that experienced prolonged building inactivity due to the COVID-19 pandemic: an elementary school, middle school, and high school. Grab samples were taken at hand washing sinks, water fountains, and hose bibbs before and after flushing. Samples were analyzed for free chlorine, UVA254, copper, lead, total trihalomethanes, pH, conductivity, temperature, and Legionella species. All three schools experienced an increase in free chlorine post-flush. Copper concentrations were higher for first draw samples than post-flush samples for all schools. Conductivity, temperature, and pH did not see a major change after flushing. UVA254 values decreased after flushing. Bromoform species saw a 20% increase after flushing at the elementary school. Legionella spp. did not decrease post-flush at the elementary school. Overall, flushing changed the water quality at the schools. However, equipment flushing may be necessary to fully remediate Legionella spp.

ARTICLE IMPACT STATEMENT

Prolonged closure of buildings causes water quality issues such as lack of disinfectant and Legionella. Flushing can restore water quality.

Biophotonic Therapy with Fluorescent Light Energy Decreases Facial Erythema, Improves Signs and Symptoms of Rosacea, and Increases Patient Satisfaction: A Postmarket Study

BACKGROUND

Rosacea is a difficult-to-manage chronic inflammatory skin condition reported to have a negative psychosocial impact on patients. Novel approaches are sought to target the many signs and symptoms of the condition while also improving the quality of life of patients.

OBJECTIVE

We assessed the efficacy of the Kleresca^® biophotonic platform (KLOX Technologies Inc., Laval, Canada), which creates fluorescent light energy (FLE), to induce a novel form of photobiomodulation for treating rosacea. We also assessed patient satisfaction with their facial appearance and concerns about perceptions of others before and after treatment.

METHODS

Nine patients were treated once a week for four weeks with FLE. Patients and the treating clinician completed questionnaires throughout and after the treatment to grade the rosacea signs and symptoms and capture patients' perceptions of the treatment and their condition.

RESULTS

FLE significantly reduced the inflammatory erythematous reaction of the face, improved flushing and erythema associated with rosacea, and had a positive impact on patients' self-perception and emotional wellbeing.

CONCLUSION

Our results support FLE as an effective, noninvasive treatment modality for rosacea.

Misleading clinical presentation of carcinoid syndrome

Rare cases of carcinoid syndromes can develop from either gastrointestinal neuroendocrine tumors (NETs) without liver metastasis or large retroperitoneal involvement. We report a case of a patient with isolated flushing highly suggestive of carcinoid syndrome caused by an ileal NET with adjacent lymph node metastases but with no liver metastases. The final diagnose was delayed for this patient due to a combination of misleading clinical presentation and negative usual screening tests (urinary 5-HIAA and serum chromogranine A). Given its high sensitivity and specificity, ⁶⁸Ga-DOTATATE PET/CT confirmed the diagnosis of neuroendocrine tumor. Therefore, this case reminds clinicians that carcinoid syndrome may manifest as flushing only and highlights that imaging is a major aspect of the evaluation and diagnosis of patients with suspected gastrointestinal NETs.

Updates and Best Practices in the Management of Facial Erythema

Facial erythema is a common dermatologic complaint. There are many medical and procedure-based treatments to help reduce the appearance of unwanted facial redness. The authors review a variety of treatment options and techniques to reduce facial erythema and prominent facial veins including topical medical therapies, a variety of lasers, light- and energy-based devices as well as the use of neuromodulators and sclerotherapy. The benefits and potential pitfalls of each procedure modality are also highlighted.

Flushing: A Diagnostic Dilemma

Carcinoid tumors are uncommon tumors that are often diagnosed in later stages of the disease due to their indolent nature, vague clinical presentation and overlap of symptoms with other conditions. We report a case of rectosigmoid carcinoid tumor which was found incidentally on screening colonoscopy in an elderly woman that went undiagnosed for several years due to confounding effects of symptoms of post-hysterectomy menopause with that of carcinoid syndrome. Persistent episodic flushing with or without diarrhea not resolved with standard treatment should lead to suspicion of neuroendocrine tumors (NETs). This case report emphasizes the need to broaden our perspective of menopausal symptoms and pay attention to the characteristic clinical symptoms of NETs.

Heparin versus 0.9% saline solution to maintain patency of totally implanted venous access ports in cancer patients: A systematic review and meta-analysis

AIM

The use of heparin and 0.9% saline solution is always controversial for central venous catheters. However, there is no systematic review or guideline about whether saline solution can replace heparin solution in adult cancer patients with totally implantable venous access ports (TIVAPs). The purpose of this review is to evaluate whether saline solution can replace heparin saline to lock TIVAPs.

METHODS

The following databases were searched: PubMed, the Cochrane Library, Web of Science, Embase, CINAHL and Ovid (January 1, 1982, and February 21, 2020). All statistical analyses of the meta-analysis were completed using the Review Manager 5.3.

RESULTS

A total of 201 studies were identified from these databases after initial review, and four studies met inclusion criteria, including 2652 cases. There was little heterogeneity among the included studies (I² < 30%), and all analyses were conducted by the fixed-effects model. The total complications, catheter occlusions, catheter-related bloodstream infections and other complication rates in the heparin solution group were higher than in the saline solution group. In the subgroup analysis of heparin concentration, total complication rates in the saline solution group were higher than with 50 U of heparin and lower than with 100 U of heparin. However, the differences in these complications were small, and no significant difference was observed (all P > 0.05).

CONCLUSIONS

Based on existing clinical studies, we recommend that saline solution can replace 50 or 100 U/ml of heparin as a safe and effective flush solution for TIVAPs.

Botulinum Toxin: An Effective Treatment for Flushing and Persistent Erythema in Rosacea

Botulinum toxin has been used to treat persistent erythema and flushing in rosacea for several years. Here, we describe two women and one man, each with rosacea with flushing and permanent erythema refractory to conventional treatment, who achieved satisfactory and lasting results following intradermal application of botulinum toxin. Two different botulinum toxin types were used. Toxin concentrations of 3.75U per 0.1 mL (abobotulinum) and 1.25U per 0.1 mL (incobotulinum) were used for each patient were used for each patient. The outcomes were measured using polarized photography to evaluate the decrease in vascular involvement. In the three cases presented here, botulinum toxin was effective for controlling erythema and flushing associated with rosacea; we also observed a prolonged duration of these improvements without the rebound effect of topical therapies.

Systemic mastocytosis with flushing and hypotension: A case report and literature review

Systemic mastocytosis (SM) is a heterogeneous disease of the bone marrow, which is characterized by the abnormal proliferation and infiltration of mast cells in one or more organs, such as the skin, bone marrow, digestive tract, liver and spleen. Urticaria pigmentosa is a typical but infrequent manifestation of SM. Other clinical presentations are non-specific, varying from pruritus and hypotension to multiple organ dysfunction, which may be lethal when hemodynamic changes occur, such as the sharp decline in blood pressure observed in the present case. In patients who lack skin lesions, the diagnosis of SM is frequently challenging. The present study reported on a 58-year-old male who presented with episodic flushing and syncope. The patient demonstrated marked neutrophilia and reduced blood potassium concentrations soon after the onset of each episode, which was able to last several hours, ranging from once to four times a year. SM without skin lesions was suspected and confirmed after multifocal bone marrow aspiration, which revealed dense infiltrates of mast cells (≥15 mast cells), with positive toluidine blue and CD117 staining. The present case illustrates the significance of taking SM or mast cell activation syndrome into consideration when unexplained recurrent hypotension or even syncope are observed, care should be taken to exclude differential diagnoses, as some of them may have much poorer prognoses and require alternative treatments.

Case Report: Mastocytosis: The Long Road to Diagnosis

Mastocytosis is a heterogeneous group of disorders characterized by expansion and accumulation of clonal mast cells. Patients mainly present with either cutaneous lesions, anaphylaxis, or both. Its low prevalence and unusual features often hinder its diagnosis for several years. We report the case of an 18-year-old male who was referred to our department with a long-standing history of atypical skin lesions, allergic rhinitis, exercise-induced bronchoconstriction and what was believed to be food-related flushing and anaphylaxis, that was later diagnosed with mastocytosis. This case illustrates the need to consider investigating for mastocytosis when recurrent anaphylaxis is present, especially in the presence of atypical skin lesions, even if normal serum basal tryptase levels and allergic sensitization are present.

The effects of long- or short-term increased feed allowance prior to first service on litter size in gilts

Replacing stock is costly in any pig production. In addition, it takes time for young animals to reach the same level of productivity as more mature animals. Therefore, the aim of this study was to investigate the effects of long- or short-term increased feed allowance (covering the luteal and follicular phases) prior to service in the second estrus on first parity performance. In order to achieve this, altrenogest was used to synchronize the gilts cycle to allow a precise feeding strategy, and only gilts inseminated 0-10 d after altrenogest withdrawal were included in the study. Altrenogest was given at days 0-18 to control the luteal phase and, therefore, treatments covered different feeding strategies in either or both the luteal phase (days 0-18) and follicular phase (days 18-25). High feed allowance (H) was induced using 0.97 kg more feed per day compared to the low feed allowance (L) given 2.33 kg/d. Four feeding strategies, low-low (LL), high-high (HH), high-low (HL), and low-high (LH), were included. Once gilts had been inseminated, feed allowance was reduced to 2.23 kg/d to prevent the loss of embryos in early gestation. A tendency was observed between feeding strategy and backfat thickness before altrenogest treatment, showing that total born piglets were positively correlated to backfat in the LL and LH (no increased feed allowance or short-term increased feed allowance), treatments (P = 0.076), compared to when gilts had longer periods with high feed allowance (HH and HL). High feed allowance in the follicular phase (LH) tended to increase the number of total born piglets compared to the other groups (P = 0.069) when applied in the follicular phase of the second standing estrus after the gilts were given altrenogest. This would be equivalent to the last 5-7 d of a 21-d cycle in gilts. The three other feeding strategies, comprising either the luteal and follicular phases (HH) or the luteal phase (HL) or none (LL), did not increase litter size. The weight of the gilt when entering the insemination section also had an effect on total born piglets (P < 0.001) with an increase in litter size with increased weight of the sow, but no differences between treatments. In conclusion, the weight of the gilt had an influence on the total litter size and gilts with low backfat tended to respond more positively to a longer period with high feed allowance than fatter gilts.

Safety and feasibility of 3-month interval access and flushing for maintenance of totally implantable central venous port system in colorectal cancer patients after completion of curative intended treatments

Patients with colorectal cancer (CRC) treated with curative intent surgery undergo continuous fluorouracil (5-FU) infusion-based chemotherapy using totally implantable central venous port system (TICVPS) in cases with high risk of recurrence. Approximately 30% of patients relapse after therapy completion, especially within 2 years. Hence, many patients with high risk CRC keep the TICVPS for 6 to 24 months after treatment with regular intervals of TICVPS flushing. However, little is known about the proper interval duration of the port. The aim of this study is to investigate whether a 3 months extended interval is safe and if port maintenance is feasible.A retrospective cohort was compiled of patients with CRC who underwent curative intent surgery and perioperative chemotherapy using TICVPS between 2010 and 2017. The primary end point was TICVPS maintenance rate, including maintenance of TICVPS for at least 6 months, planned TICVPS removal after 6 months, and regaining the use of TICVPS at the time of recurrence.A total of 214 patients with CRC underwent curative intent treatments during the study period. Among them, 60 patients were excluded, including 6 patients for early recurrence within 3 months and 54 patients with violation of flushing interval. Finally, 154 patients were analyzed. Mean flushing interval was 98.4 days (95% confidence interval [CI], 96.2-100.6; range, 60-120). In December 2018, 35 patients kept the TICVPS, 92 patients had planned removal, 25 patients reused the TICVPS, and 2 patients had to unexpectedly remove the TICVPS due to site infection and pain. Thus, the functional TICVPS maintenance rate was 98.8% (152/154). Thirty-eight patients relapsed, and 30 patients were treated with intravenous chemotherapy. Among them, 25 patients (83.3%) reused the maintained TICVPS without a reinsertion procedures.Our study demonstrated that 3-month interval access and flushing is safe and feasible for maintaining TICVPS during surveillance of patients with CRC. An extended interval up to 3 months can be considered because it is compatible with CRC surveillance visit schedules.

Stimulation of follicle growth and development during estrus in Ettawa Grade does fed a flushing supplement of different polyunsaturated fatty acids

Background and Aim

Flushing with the manipulation of fatty acids, particularly polyunsaturated fatty acids, like linoleic and α-linolenic acids in the ration, is a strategy to raise the nutritional status of the female mammals to improve ovarian function and follicle development. This study was designed to investigate the effectiveness of flushing supplementation with different types of polyunsaturated and saturated fatty acids in stimulating follicle growth and development during estrus in Ettawa Grade does with a low initial body condition score (BCS ≤2).

Materials and Methods

Eighteen Ettawa Grade does in the second parity, with an average body weight of 32.11±2.19 kg, were divided into three groups according to the fatty acid supplemented to their ration: (i) About 2.8% lauric acid flushing (group); (ii) 2.8% linoleic acid flushing (LA group); and (iii) 2.8% α-linolenic acid flushing (ALA group). The ration was formulated to be isocaloric (total digestible nutrient = 77%) and isonitrogenous (crude protein = 15%). The experiment was conducted for 35 days; that is, 14 days for acclimatization and synchronization of the estrous cycle and 21 days for fatty acid flushing until the appearance of the next estrus. A completely randomized design was applied.

Results

According to the results, none of the different fatty acids in the ration affected the nutrient intakes, BCSs, average daily gains, and plasma glucose, cholesterol, and progesterone concentrations of the three groups of does. However, the BCSs (by 0.8-0.9) and the plasma cholesterol concentrations were higher after fatty acid flushing for 21 days than before the flushing period. The ALA group had the highest number of large-sized preovulatory follicles, whereas the LAURIC group had the highest plasma estradiol concentration during estrus. All three groups had similar plasma progesterone concentrations during estrus after fatty acid flushing.

Conclusion

Flushing supplementation with 2.8% ALA from flaxseed oil gave the best results in terms of stimulating the highest number of large-sized preovulatory follicles in Ettawa Grade does.

Microbial growth and importance of flushing inside closed-type infusion devices during administration of lipid emulsion in vitro setting

Background: We investigated the extent of growth of microorganisms with simultaneous administration of lipid emulsions with infusions for Total Parenteral Nutrition (TPN), assuming that the lipid emulsions contaminated with microorganisms are stagnant in a closed-type infusion device. We also investigated if bacterial growth can be prevented in the infusion device by flushing the inside of the infusion device with saline solution after the administration of lipid emulsion from the side tube in vitro setting. Methods: We made a preparation by adding Escherichia coli to the lipid emulsion and started the infusion simultaneously with the infusion solution for TPN and lipid emulsion with the piggyback method. Immediately after the completion of lipid emulsion infusion, we conducted flushing with saline solution. The volume of saline solution was none, 5, 10, or 20 mL at a flow rate of 1 mL/s. Infusion solution that was stagnant in the infusion device was collected immediately before completing the lipid emulsion infusion and 20 h after flushing, i.e., 24 h after starting the infusion for TPN, and the number of viable bacteria was determined. Results: The number of viable E. coli increased in the infusion device of all three species used in this experiment 24 h after starting the lipid emulsion infusion without flushing. We found that bacterial growth could be prevented through flushing with saline solution after the completion of lipid emulsion infusion and flushing out the stagnant infusion solution in the closed-type infusion device. Conclusions: We found that if E. coli was present in the closed-type infusion device, it would multiply. We also found that the number of viable bacteria varied according to the variety and internal structure of the closed-type infusion device as well as the liquid volume used for flushing, although flushing can prevent the growth of microorganisms. Proper management and manipulation of infusion is required to prevent infection.

Brief Report on Double-Chamber Syringes Patents and Implications for Infusion Therapy Safety and Efficiency

This review aimed to map the existing patents of double-chamber syringes that can be used for intravenous drug administration and catheter flush. A search was conducted in the Google patents database for records published prior to 28 October 2020, using several search terms related to double-chamber syringes (DCS). Study eligibility and data extraction were performed by two independent reviewers. Of the initial 26,110 patents found, 24 were included in this review. The 24 DCS that were found display two or more independent chambers that allow for the administration of multiple solutions. While some of the DCS have designated one of the chambers as the flushing chamber, most patents only allow for the sequential use of the flushing chamber after intravenous drug administration. Most DCS were developed for drug reconstitution, usually with a freeze-dried drug in one chamber. Some patents were designed for safety purposes, with a parallel post-injection safety sheath chamber for enclosing a sharpened needle tip. None of the DCS found allow for a pre- and post-intravenous drug administration flush. Given the current standards of care in infusion therapy, future devices must allow for the sequential use of the flushing chamber to promote a pre-administration patency assessment and a post-administration device flush.

Assessment of efficacy of postinfusion tubing flushing in reducing risk of cytotoxic contamination

PURPOSE

Infusion of cytotoxic drugs carries the risk of occupational exposure of healthcare workers. Since disconnecting an infusion line is a source of contamination, flushing of tubing after infusion of cytotoxic agents is recommended, but the optimal volume of rinsing solution is unknown. The objective of this study was to assess whether postinfusion line flushing completely eliminates cytotoxics.

METHODS

Infusions were simulated with 3 cytotoxics (gemcitabine, cytarabine, and paclitaxel) diluted in 5% dextrose injection or 0.9% sodium chloride injection in 250-mL infusion bags. Infusion lines were flushed using 5% dextrose injection or 0.9% sodium chloride solution at 2 different flow rates. The remaining concentration of cytotoxics in the infusion line was measured by a validated high-performance liquid chromatography (HPLC) method after passage of every 10 mL of flushing volume until a total of 100 mL had been flushed through.

RESULTS

All cytotoxics remained detectable even after line flushing with 80 mL of flushing solution (a volume 3-fold greater than the dead space volume within the infusion set). Gemcitabine and cytarabine were still quantifiable via HPLC even after flushing with 100 mL of solution. Efficacy of flushing was influenced by the lipophilicity of drugs but not by either the flushing solvent used or the flushing flow rate. After 2-fold dead space volume flushing, the estimated amount of drug remaining in the infusion set was within 0.19% to 0.56% of the prescribed dose for all 3 cytotoxics evaluated.

CONCLUSION

Complete elimination of cytotoxics from an infusion line is an unrealistic objective. Two-fold dead space volume flushing could be considered optimal in terms of administered dose but not from an environmental contamination point of view. Even when flushed, the infusion set should still be considered a source of cytotoxic contamination.

Congenital Mastocytosis: Case Report and Review of the Literature

Mastocytosis is a rare infiltrative disorder characterized by mast cell proliferation within the skin and various extra-cutaneous organ systems. We report the case of a full-term neonate admitted to the neonatal intensive care unit for evaluation of diffuse skin lesions on her face, trunk and extremities. Initially, the lesions appeared to be consistent with a blueberry muffin rash. However, over a period of days the lesions became vesicular and changed in shape and number. The neonate underwent evaluation for infective etiologies, skin biopsy of the lesions, and flow cytometry analysis of the peripheral blood. The surgical pathology examination of the skin biopsy demonstrated mast cells consistent with a diagnosis of cutaneous mastocytosis. A review of relevant literature is also provided.

The Efficacy, Safety, and Convenience of a New Device for Flushing Intravenous Catheters (Baro Flush™): A Prospective Study

Background and Objectives: An effective flushing technique is essential to reduce intravenous (IV)-related complications and improve patient care. New technology should contribute to such improvements, while reducing costs and increasing care efficiency. This study evaluated the efficacy, safety, and convenience of a new flushing technique using a Baro Flush™ controller. Materials and Methods: We evaluated the efficacy and safety of Baro Flush™ by measuring the infusion flushing volume and pressure in vitro. Afterwards, we prospectively enrolled 3000 patients with flushing and assigned 1500 patients with a new technique for flushing and 1500 with a conventional flushing method, which was performed by 48 registered nurses (RNs) at the Gil Medical Center in June 2018. The efficacy, safety, and convenience of the new flushing method were evaluated though a questionnaire survey. Results: The average flushing pressure was 12.5 ± 0.6 psi (86.18 ± 4.14 kPa) with 1.2 ± 0.2 mL per flush, as recommended by the Centers for Disease Control and Prevention based on 85 experiments. No IV-catheter-related complications were reported by the RNs during the study. More than 80% of the RNs reported that the new flushing method was easier to learn, improved care efficacy, and was more convenient than conventional flushing. Conclusions: The new flushing method using a Baro Flush™ controller showed improved efficacy, safety, and convenience compared with the conventional flushing method, and no IV-catheter-related complications occurred, including occlusion and inflammation. The new flushing method promises to reduce IV-catheter-related complications and shows improved efficacy, safety, and convenience.

Considerations for large building water quality after extended stagnation

The unprecedented number of building closures related to the coronavirus disease (COVID-19) pandemic is concerning because water stagnation will occur in many buildings that do not have water management plans in place. Stagnant water can have chemical and microbiological contaminants that pose potential health risks to occupants. Health officials, building owners, utilities, and other entities are rapidly developing guidance to address this issue, but the scope, applicability, and details included in the guidance vary widely. To provide a primer of large building water system preventative and remedial strategies, peer-reviewed, government, industry, and nonprofit literature relevant to water stagnation and decontamination practices for plumbing was synthesized. Preventative practices to help avoid the need for recommissioning (e.g., routine flushing) and specific actions, challenges, and limitations associated with recommissioning were identified and characterized. Considerations for worker and occupant safety were also indicated. The intended audience of this work includes organizations developing guidance.

Effects of flush feeding strategy before breeding on reproductive performance of modern replacement gilts: impacts on ovulation rate and litter traits

AbstractThe effects of two feed levels offered during two estrous cycles before insemination were evaluated on the reproductive performance of gilts. A total of 93 gilts (PIC Hendersonville, TN) were individually housed and manually fed twice a day with 2.1 or 3.6 kg/d of a corn and soybean meal-based diet (3.15 Mcal ME/kg and 0.64% standardized ileal digestible lysine), during two estrous cycles before breeding (cycle 1, between first and second estrus; cycle 2, between second and third estrus). Gilts were weighed at the beginning of the experiment, at second and third estrus, and at slaughter (30.2 ± 1.2 d of gestation). Follicles were counted at second estrus, and the embryo-placental units and the corpora lutea were individually counted, measured, and weighed at slaughter. Gilts fed 3.6 kg/d had greater BW gain during cycle 1 and cycle 2 (P < 0.001; + 9.8 kg and + 10.0 kg, respectively) becoming heavier at second and third estrus (P < 0.001). At second estrus, gilts fed 3.6 kg/d had 1.6 more medium-large follicles (P = 0.074) but no difference in follicle size (P = 0.530) was observed. Gilts fed 3.6 kg/d in cycle 1 or cycle 2 had a greater ovulation rate at third estrus (P < 0.016) than those receiving 2.1 kg/d. Also, 3.6 kg/d in cycle 2 increased early embryo mortality (P = 0.006; 2.3 vs. 1.1 dead embryos) and consequently reduced total embryo survival (P = 0.002; 84.6 vs. 90.1%). Gilts fed 3.6 kg/d during cycle 1 had two more total embryos (P < 0.001; 17.2 vs. 15.1) and two more vital embryos on day 30 (P < 0.001; 16.7 vs. 14.5) in comparison with gilts fed 2.1 kg/d. The coefficient of variation for placental length was greater for gilts fed 3.6 kg/d during cycle 1 (P = 0.003). No further significant effects of feeding levels were observed on embryo and placental traits (P ≥ 0.063). These results suggest that the feeding level during the first cycle after pubertal estrus is crucial to set ovulation rate and potential litter size for breeding at next estrus. However, flush feeding gilts before insemination can negatively impact litter size by reducing embryo survival when breeding at third estrus.

Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee

In 2017, a National Rosacea Society Expert Committee developed and published an updated classification of rosacea to reflect current insights into rosacea pathogenesis, pathophysiology, and management. These developments suggest that a multivariate disease process underlies the various clinical manifestations of the disorder. The new system is consequently based on phenotypes that link to this process, providing clear parameters for research and diagnosis as well as encouraging clinicians to assess and treat the disorder as it may occur in each individual. Meanwhile, a range of therapies has become available for rosacea, and their roles have been increasingly defined in clinical practice as the disorder has become more widely recognized. This update is intended to provide a comprehensive summary of management options, including expert evaluations, to serve as a guide for tailoring treatment and care on an individual basis to achieve optimal patient outcomes.