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A 20 year old female, 14 days post partum, presented to the Emergency Department in severe respiratory distress. Imaging of her chest revealed a left tension hydropneumothorax with significant mediastinal displacement. A chest drain was inserted and over 4L of cloudy-brown malodourous fluid was drained. Gardnerella Vaginalis was isolated on culture of the fluid. The pyohydropneumothorax and associated sepsis, was refractory to management with a chest drain and antimicrobial therapy. She required a video-assisted thoracoscopic surgery and decortication of her unexpanded lung. She ultimately made a full recovery. Gardnerella vaginalis is considered a dysbiosis of the genitourinary tract, rather than an overtly virulent pathogen. Although extremely rare, there are occasional reports of Gardnerella vaginalis causing infection, even at sites distant from the genitourinary tract. To our knowledge, this is the first documented case of Gardnerella vaginalis causing respiratory sepsis and a pyohydropneumothorax in a healthy, immunocompetent female during the post-partum period. Although it is a unique case, nevertheless, it highlights the need for physicians to be congnisant of G. vaginalis as a potential pathogen when treating post-partum sepsis and indeed, even as a potential pathogen when treating pulmonary infections in obstetric patients. This will lend to prompt initiation of appropriate antimicrobial treatment. Keywords: Pneumothorax, Post-partum, Sepsis, Gardnerella vaginalis

Common equipment in the dental operatory generate cumulative noise at sufficient decibel levels that can damage hearing. Although noise exposure in the dental office is typically intermittent, dentists and other dental care providers have been shown to be at risk of hearing loss. This article provides dentist-generated insight to use when incorporating hearing protection devices during dental practice. Four hearing protection devices (HPDs) were provided to 15 dentists in randomized sequence for evaluation. Perceptions were gathered via questionnaires and analyzed to determine mean ratings and product preferences. Battery requirements of electronic HPDs were also examined. Qualitative assessments of the HPDs evaluated are presented, including dentist preferences and recommendations. There were statistically significant differences ( P ≤ 0.0031) among the HPDs in terms of ease of insertion, aesthetics, ability to hear while using a handpiece, and the openness of the ear. Battery life was not found to differ between the 2 electronic HPDs evaluated. Dentists most highly valued ease of hearing, ability to communicate, and comfort while wearing HPDs. The DI-15 High-Fidelity Electronic Earplugs HPD was ranked the highest, followed by Music PRO Electronic Earplugs. Battery longevity for these electronic HPDs was similar under all tested conditions studied. Knowledge Transfer Statement: Dentists should understand the potential ramifications of hearing loss and be aware that there are commercially available hearing protection products that preserve the ability to communicate with patients and coworkers.

peer-reviewed Background Academic detailing is a form of continuing medical education in which a trained health professional such as a physician or pharmacist visits prescribers in their practice to provide evidence-based information. While academic detailing has been adopted in other countries, this strategy is not routinely used in Ireland. Objective The aim of this study was to assess the feasibility and acceptability to General Practitioners (GPs) of a pharmacist-led academic detailing intervention in Ireland. Setting General Practice in County Cork, Ireland. Method A mixed methods feasibility study comprising a pharmacist-led academic detailing intervention on urinary incontinence in older people, quantitative data from patient medical records, and qualitative data from focus groups with GPs. The medical records for all patients aged ≥ 65 years who were attending a participating GP with a diagnosis of urinary incontinence were analysed using a before-after approach. The measures of prescribing assessed before and after the intervention were: LUTS-FORTA criteria, Drug Burden Index, and the Anticholinergic Cognitive Burden scale. Focus groups were carried out with GPs who participated in the academic detailing intervention. Main outcome measure The quantitative prescribing patterns of the GPs and their qualitative responses from the focus groups. Results Twenty-three GPs participated in the academic detailing intervention from a selection of different types of general practice. The medical records of 154 patients were analysed. There was minimal or no change in any of the prescribing measures used. Fourteen GPs attended focus groups. GPs considered the topic of urinary incontinence as relevant to general practice. Participants appreciated the succinct nature of the information in the educational materials but expressed a preference for a more easily retrievable format, such as an online version rather than paper-based. Conclusion This study demonstrated that a pharmacist-led academic detailing intervention was acceptable to GPs in Ireland. Further research is needed in a larger population evaluating the impact and cost effectiveness of academic detailing to optimise patient care. peer-reviewed

This chapter provides a historical and contemporary overview of the coordinating and representational capacities, and consequent policy influence of the Canadian Federation of Agriculture (CFA) and the National Farmers' Union (NFU). It examines logic of membership and logic of influence factors. Canada's system of multi-level governance importantly shapes the organizational logic and cohesion of agricultural producers, and by extension, the influence of national farm interest groups. The CFA and the NFU have taken distinct substantive approaches to these issues and the threat posed to farmers' centrality in agri-food policy making by the controversy has aroused. The position of the CFA and that of the Government of Canada have been closely aligned on biotechnology policy. Both endorse the licensing of genetic modification (GM) foods and crops solely on the basis of available scientific evidence demonstrating their health and environmental safety.

The purpose of this work is to establish an analytical model and standard way to predict the performance characteristics of a four-point contact, or gothic arch type, rolling element ball bearing. Classical rolling element bearing theory, as developed by Jones, has been extended to include the complex kinematics of the four-point contact bearing; thereby providing complete elementwise attitude and internal load distribution of the bearing under operating conditions. Standard performance parameters, such as element contact stresses, contact angles, inner ring deflections, nonlinear stiffness's, torque, and L10 life, are solved explicitly via standard Newton–Raphson techniques. Race control theory is replaced with a minimum energy state theory to allow both spin and slip to occur at the ball-to-raceway contact. The developed four-point model was programed within the orbis software program. Various test cases are analyzed and key analytical results are compared with the Jones four-point contact ball bearing analysis program, the Wind Turbine Design Guideline, DG03, and traditional two-point (angular contact) analysis codes. Model results for the internal distribution of ball loads and contact angles match the Jones program extremely well for all cases considered. Some differences are found with the DG03 analysis methods, and it is found that modeling a four-point contact bearing by overlaying two opposed angular contact bearings can result in gross errors.

The neurohypophysial hormone vasopressin contributes to control of urine output and, while urine flow shows a clear daily rhythm, there has been debate as to whether this is true of neurohypophysial hormones. A study was performed on fifteen adult males, with a mean age of 25 years, over a 24 h period, nine blood samples being taken at regular intervals for the determination of neurohypophysial hormones and indices of fluid balance. Samples were taken via an indwelling cannula so that sleep was undisturbed. A daily variation in the plasma concentrations of oxytocin and vasopressin was demonstrated with concentrations reaching a nadir in the late afternoon. Concentrations of both hormones peaked at 02.00 h. Vasopressin concentrations were inversely correlated with packed cell volume, indicating that the altered hormone release was affecting fluid retention. Consistent with this was the observation that the relationship of plasma osmolality to vasopressin depended on the time of day. To determine the effect of ageing, a similar study was performed on nine healthy elderly subjects with a mean age of 70 years. The nocturnal peak of vasopressin was markedly attenuated, while oxytocin release was similar to that in the younger group. These observations confirm the existence of a daily rhythm in the plasma concentrations of neurohypophysial hormones and indicate that the amplitude of the vasopressin change decreases with age.

Better understanding of the long-term delivery of parenteral nutrition (PN) in neonates and children has increased the survival for patients who have neonatal short bowel syndrome. Most infants with short bowel syndrome experience progressive enteral adaptation and are weaned from PN. This report describes the authors' clinical experience with nine infants and children who had refractory short bowel syndrome; single or sequential procedures were performed to lengthen the small bowel. Gut lengthening procedures used included a small bowel nipple valve constructed distally, to provide temporary partial obstruction and thereby induce dilatation and lengthening of the proximal small intestine (six patients). Bianchi's technique was used in three patients primarily and in six others after the bowel had been dilated and lengthened by the nipple valve. Kimura's gut lengthening technique was used in one patient after the small bowel had spontaneously become dilated subsequent to a Bianchi procedure. In all, 16 lengthening procedures were performed on the nine patients. Preoperatively, the nine patients tolerated less than 10% of their caloric intake enterally, with no evidence of improvement for a minimum of 6 months. Small bowel segments ranged from 6 to 92 cm originally and were increased an average of 2 1/2 times the original length. Two patients have been totally weaned from PN. For the patients whose lengthening procedure was performed more than 1 year ago, the percentage of enteral caloric intake averages 50%. One of the patients was profoundly impaired neurologically and was not resuscitated from an apneic episode. Another patient died in his sleep of unknown causes 1 year after intestinal lengthening.(ABSTRACT TRUNCATED AT 250 WORDS)

This chapter examines (i) the organic marketplace in terms of the changing dynamics of supply and demand; (ii) the attributes of those who consume organic foods; (iii) the strategies that have been set in place to recruit more people as organic food consumers; and (iv) the constraints and opportunities for further expansion of the market for organic foods. In doing so, the chapter addresses, at least in part, once of the principal concerns that has arisen within the organic sector as a consequence of its growth, i.e. the concern that expansion has come at the cost of the core values and practices on which organic agriculture was founded.

The need to manage the key symptoms of chronic obstructive pulmonary disease (COPD) (breathlessness, cough and sputum) is an important treatment objective. Viozan (sibenadet HCl, AR-C68397AA) is a novel dual D2 dopamine receptor, beta2-adrenoceptor agonist, which combines conventional bronchodilatory activity with the sensory nerve modulation afforded by dopamine agonism. The efficacy of this agent in relieving patient symptoms has been determined in a series of large-scale clinical studies; the results of a 3-month, placebo-controlled multi-centre study are reported. Effect on patient symptoms was determined using a novel patient-reported assessment instrument, the Breathlessness, Cough and Sputum Scale (BCSS). Patients with smoking-related COPD were required to complete a 2-week baseline period before being randomized to one of three treatment groups; sibenadet (500 microg three times daily) plus placebo (twice daily); salmeterol (50 microg twice daily) plus placebo (three times daily); placebo (twice daily) plus a second placebo (three times daily). All treatments were delivered via pressurized metered dose inhaler (pMDI) for 12 weeks. From enrolment, patients were required to complete daily diary cards to record symptoms of breathlessness, cough and sputum, medication use and adverse events. The primary outcome measure was the difference between the mean BCSS total score measured over the baseline period and the mean BCSS total score in the final 4 weeks of the treatment period. Secondary measures included assessment of lung function, rescue medication use, exacerbations, health-related quality of life, opinion of efficacy and safety. Although an initial reduction in BCSS total score (indicating symptom improvement) was seen with sibenadet therapy, this effect was not maintained for the study duration. Salmeterol therapy, however, resulted in a sustained reduction in BCSS total score. No notable benefit over placebo was seen in lung function, exacerbations or health-related quality of life with either active treatment. While the results of this study failed to demonstrate sustained efficacy with sibenadet therapy, they do indicate the value of symptom assessment in the clinical evaluation of new drugs for the treatment of COPD.

We believe that this is the first report of a gasless endoscopic in situ bypass technique. We have pursued this minimally invasive procedure with the hope that wound complications and operative time might be improved without compromising graft patency. Having demonstrated the feasibility of minimally invasive lower-extremity bypass we would urge further study to assess the safety and efficacy of this promising approach.

Air leak is a major contributor to increased length of stay and postoperative morbidity following pulmonary surgery. The effectiveness of a new photopolymerized synthetic hydrogel (FocalSeal, Focal, Inc., Lexington, MA) as a sealant for pulmonary air leaks was determined in 10 mongrel dogs (20-35 kg). The animals were anesthetized and underwent left-sided anterolateral thoracotomy with amputation of a 2 x 3-cm segment of the lung apex. Hemostasis was achieved and terminal bronchial openings of 1.5 to 3 mm with vigorous air leaks were identified. After successful injury, the dogs were randomly assigned to sealant (n = 5) or control (n = 5) groups. In treated animals, the sealant was applied by brushing the solution to the cut parenchymal surface and solidified while briefly interrupting ventilation (40-60 seconds) using visible illumination (450-550 nm) from a xenon light source. Controls received no sealant. A single chest tube was maintained at the injury site with a continuous negative pressure of 20 cm of water. All dogs were extubated and allowed to breathe spontaneously under sedation for 24 hours. Chest radiographs were taken postsurgery and presacrifice. All control animals (n = 5) showed persistent vigorous air leak for the duration of the 24-hour observation period. All treated air leaks resolved immediately, and four of five remained sealed throughout the observation period. One leak reappeared after 17 hours due to inadequate sealant thickness over a 3-mm terminal bronchus. Gross evaluation of the treatment group at the end of 24 hours demonstrated intact sealant well adherent to the parenchyma. No evidence of atelectasis or excessive edema was seen, and no sealant-related complications or toxic effects were noted. Radiologically, lungs were fully inflated. Histologic evaluation at 24 hours revealed no evidence of a strong cellular response to the synthetic sealant, and no fibrosis or adhesions were seen, the onset of the healing process was favorable, indicating good biocompatability. In conclusion, this material was found to be an effective means for sealing bronchial and parenchymal air leaks in this model and warrants clinical evaluation.

A further step in the process of developing better service and standards of care for patients with COPD The full version of the new NICE guidelines on the management of chronic obstructive pulmonary disease (COPD) is published as a supplement to this issue of Thorax .1 These guidelines have been developed for the National Institute for Clinical Excellence (NICE) by the National Collaborating Centre for Chronic Conditions (NCC-CC) based at the Royal College of Physicians, London with the involvement of many members of the British Thoracic Society (BTS). The Guideline Development Group and Consensus Reference Group involved in the production of the guidelines included members with diverse professional backgrounds and, crucially, also included patient representatives. The scope of the guidelines is wide. They address the diagnosis and assessment of people with COPD as well as the pharmacological and non-pharmacological management of stable disease and exacerbations. With the recent update to the GOLD guidelines2 and the forthcoming publication of joint guidelines by the American Thoracic Society (ATS) and the European Respiratory Society (ERS), the need for new British guidelines could be questioned. I have no doubt that there is a role for these guidelines as they address issues such as pulmonary rehabilitation from a British perspective and, most importantly, are truly evidence-based. Moreover, in the absence of a National Service Framework for respiratory medicine, and the reality that such a framework is unlikely to be introduced in the near future, these NICE guidelines offer the best hope of raising the standards of care of this common disabling chronic disease. The key issues for practising clinicians are: Significant changes in practice have evolved since the BTS guidelines on the management of COPD were published in 1997, …

The combination of peripheral vascular disease, neuropathy and increased susceptibility to infection are responsible for diabetic foot problems. In patients with evidence of diabetic foot disease, it is important to take measures to keep good care of the hands, which can also be compromised. The hand is a common site for acupuncture. This case report demonstrates serious limb threatening complications following acupuncture treatment for pain from rheumatoid arthritis and sensory neuropathy. Copyright © 2002 John Wiley & Sons, Ltd.

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