scholarly journals Microdebrider is less aerosol-generating than CO2 laser and cold instruments in microlaryngoscopy

2021 ◽  
Author(s):  
Enni Sanmark ◽  
Lotta-Maria A. H. Oksanen ◽  
Noora Rantanen ◽  
Mari Lahelma ◽  
Veli-Jukka Anttila ◽  
...  
Keyword(s):  
High Risk ◽  
Surgical Procedures ◽  
Particle Concentration ◽  
Aerosol Particles ◽  
Aerosol Generation ◽  
Laryngeal Surgery ◽  
Step Down ◽  
Particle Sizer ◽  
Measured Particle ◽  
Cold Dissection

Abstract Objective COVID-19 spreads through aerosols produced in coughing, talking, exhalation, and also in some surgical procedures. Use of CO2 laser in laryngeal surgery has been observed to generate aerosols, however, other techniques, such cold dissection and microdebrider, have not been sufficiently investigated. We aimed to assess whether aerosol generation occurs during laryngeal operations and the effect of different instruments on aerosol production. Methods We measured particle concentration generated during surgeries with an Optical Particle Sizer. Cough data collected from volunteers and aerosol concentration of an empty operating room served as references. Aerosol concentrations when using different techniques and equipment were compared with references as well as with each other. Results Thirteen laryngological surgeries were evaluated. The highest total aerosol concentrations were observed when using CO2 laser and these were significantly higher than the concentrations when using microdebrider or cold dissection (p < 0.0001, p < 0.0001) or in the background or during coughing (p < 0.0001, p < 0.0001). In contrast, neither microdebrider nor cold dissection produced significant concentrations of aerosol compared with coughing (p = 0.146, p = 0.753). In comparing all three techniques, microdebrider produced the least aerosol particles. Conclusions Microdebrider and cold dissection can be regarded as aerosol-generating relative to background reference concentrations, but they should not be considered as high-risk aerosol-generating procedures, as the concentrations are low and do not exceed those of coughing. A step-down algorithm from CO2 laser to cold instruments and microdebrider is recommended to lower the risk of airborne infections among medical staff.

scholarly journals AEROSOL GENERATION DURING COUGHING - QUANTITATIVE DEFINITION FOR AEROSOL GENERATING PROCEDURES: OBSERVATIONAL STUDY

2021 ◽  
Author(s):  
Enni Sanmark ◽  
Lotta-Maria Oksanen ◽  
Noora Rantanen ◽  
Mari Lahelma ◽  
Veli-Jukka Anttila ◽  
...  
Keyword(s):  
High Risk ◽  
Operating Room ◽  
Aerosol Particles ◽  
Aerosol Concentration ◽  
Medical Procedures ◽  
Aerosol Generation ◽  
Limit Value ◽  
Aerosol Exposure ◽  
Particle Sizer ◽  
Quantitative Definition

ABSTRACT Aim: The purpose of the study was to determine aerosol exposure generated by coughing in operation room environments to create a quantitative limit value for high risk aerosol generating medical procedures. Background: Coughing is known to produce a significant amount of aerosols and is thus commonly used as a best reference for high-risk aerosol-generation. Accordingly, procedures during which aerosol generation exceeds the amount of aerosol generated in instances of coughing are seen as high risk aerosol generating procedures. However, no reliable quantitative values are available for high risk aerosol-generation. Methods: Coughing was measured from 37 healthy volunteers in the operating room environment. Aerosol particles generated during coughing within the size range of 0.3 - 10 microm were measured with Optical Particle Sizer from 40cm, 70cm, and 100cm distances. The distances reflected potential exposure distances where personnel are during surgeries. Results: A total of 306 coughs were measured. Average aerosol concentration during coughing was 1.580 +/- 13.774 particles/cm3 (range 0.000 - 195.528). Discussion: The aerosol concentration measured in this study can be used as a limit for high-risk aerosol generation in the operating room environment when assessing the aerosol generating procedures and the risk of operating room staff s exposure for aerosol particles. AUTHOR APPROVAL:All authors have approved the manuscript and have made significant contributions.

scholarly journals A global view on atmospheric concentrations of sub-3 nm particles measured with the Particle Size Magnifier

2016 ◽  
Author(s):  
Jenni Kontkanen ◽  
Katrianne Lehtipalo ◽  
Lauri Ahonen ◽  
Juha Kangasluoma ◽  
Hanna Manninen ◽  
...  
Keyword(s):  
Particle Size ◽  
Boreal Forest ◽  
Particle Concentration ◽  
Aerosol Particles ◽  
Subsequent Growth ◽  
Neutral Particles ◽  
Global View ◽  
Atmospheric Concentrations ◽  
Different Sources ◽  
Measured Particle

Abstract. The measurement of sub-3 nm aerosol particles is technically challenging. Therefore, there is a lack of knowledge about the concentrations of atmospheric sub-3 nm particles and their variation in different environments. In this study, the concentrations of ~ 1–3 nm particles measured with a Particle Size Magnifier (PSM) were investigated at nine sites around the world. Sub-3 nm particle concentrations were highest at the sites with strong anthropogenic influence. In boreal forest measured particle concentrations were clearly higher in summer than in winter, suggesting the importance of biogenic precursor vapors in this environment. At all sites sub-3 nm particle concentration had daytime maxima, which are likely linked to the photochemical production of precursor vapors and the emissions of precursor vapors or particles from different sources. When comparing ion concentrations to the total sub-3 nm particle concentrations, electrically neutral particles were observed to dominate in polluted environments and in boreal forest during spring and summer. Generally, the concentrations of sub-3 nm particles seem to be determined by the availability of precursor vapors rather than the level of the sink caused by pre-existing aerosol particles. The results also indicate that the formation of the smallest particles and their subsequent growth to larger sizes are two separate processes, and therefore studying the concentration of sub-3 nm particles separately in different size ranges is essential.

scholarly journals Identification of the source events for aerosol generation during oesophago-gastro-duodenoscopy

Gut ◽  
2021 ◽  
pp. gutjnl-2021-324588
Author(s):  
Florence K A Gregson ◽  
Andrew J Shrimpton ◽  
Fergus Hamilton ◽  
Tim M Cook ◽  
Jonathan P Reid ◽  
...  
Keyword(s):  
Particle Concentration ◽  
Particle Number ◽  
Protective Equipment ◽  
Average Particle ◽  
Respiratory Pathogens ◽  
Tidal Breathing ◽  
Aerosol Generation ◽  
Wide Range ◽  
Monitoring Study ◽  
Particle Sizer

ObjectiveTo determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events.DesignA prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient’s mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject.ResultsPatients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L−1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L−1). Aerosol recording during OGD showed an average particle number concentration of 595 L−1 with a wide range (3–4320 L−1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient’s reference voluntary coughs (11 710 vs 2320 L−1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered.ConclusionCoughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.

scholarly journals Quantification of Aerosol Particle Concentrations During Endoscopic Sinonasal Surgery in the Operating Room

2020 ◽  
pp. 194589242096233
Author(s):  
Alex Murr ◽  
Nicholas R. Lenze ◽  
William Colby Brown ◽  
Mark W. Gelpi ◽  
Charles S. Ebert ◽  
...  
Keyword(s):  
Operating Room ◽  
Particle Concentration ◽  
Surgical Techniques ◽  
Indirect Evidence ◽  
Airborne Particle ◽  
Endoscopic Endonasal ◽  
Aerosol Generation ◽  
Particle Sizer ◽  
Endoscopic Sinonasal Surgery ◽  
Live Patient

Background Recent indirect evidence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmission during endoscopic endonasal procedures has highlighted the dearth of knowledge surrounding aerosol generation with these procedures. As we adapt to function in the era of Coronavirus Disease 2019 (COVID-19) a better understanding of how surgical techniques generate potentially infectious aerosolized particles will enhance the safety of operating room (OR) staff and learners. Objective To provide greater understanding of possible SARS-CoV-2 exposure risk during endonasal surgeries by quantifying increases in airborne particle concentrations during endoscopic sinonasal surgery. Methods Aerosol concentrations were measured during live-patient endoscopic endonasal surgeries in ORs with an optical particle sizer. Measurements were taken throughout the procedure at six time points: 1) before patient entered the OR, 2) before pre-incision timeout during OR setup, 3) during cold instrumentation with suction, 4) during microdebrider use, 5) during drill use and, 6) at the end of the case prior to extubation. Measurements were taken at three different OR position: surgeon, circulating nurse, and anesthesia provider. Results Significant increases in airborne particle concentration were measured at the surgeon position with both the microdebrider (p = 0.001) and drill (p = 0.001), but not for cold instrumentation with suction (p = 0.340). Particle concentration did not significantly increase at the anesthesia position or the circulator position with any form of instrumentation. Overall, the surgeon position had a mean increase in particle concentration of 2445 particles/ft3 (95% CI 881 to 3955; p = 0.001) during drill use and 1825 particles/ft3 (95% CI 641 to 3009; p = 0.001) during microdebrider use. Conclusion Drilling and microdebrider use during endonasal surgery in a standard operating room is associated with a significant increase in airborne particle concentrations. Fortunately, this increase in aerosol concentration is localized to the area of the operating surgeon, with no detectable increase in aerosol particles at other OR positions.

scholarly journals Methotrexate in combination with other DMARDs is not superior to methotrexate alone for remission induction with moderate-to-high-dose glucocorticoid bridging in early rheumatoid arthritis after 16 weeks of treatment: the CareRA trial

2014 ◽  
Vol 74 (1) ◽  
pp. 27-34 ◽  
Author(s):  
P Verschueren ◽  
D De Cock ◽  
L Corluy ◽  
R Joos ◽  
C Langenaken ◽  
...  
Keyword(s):  
Rheumatoid Arthritis ◽  
High Risk ◽  
Disease Activity ◽  
Early Rheumatoid Arthritis ◽  
Remission Induction ◽  
Avant Garde ◽  
High Risk Patients ◽  
Risk Patients ◽  
Secondary Endpoints ◽  
Step Down

ObjectivesTo compare the efficacy and safety of intensive combination strategies with glucocorticoids (GCs) in the first 16 weeks (W) of early rheumatoid arthritis (eRA) treatment, focusing on high-risk patients, in the Care in early RA trial.Methods400 disease-modifying antirheumatic drugs (DMARD)-naive patients with eRA were recruited and stratified into high risk or low risk according to classical prognostic markers. High-risk patients (n=290) were randomised to 1/3 treatment strategies: combination therapy for early rheumatoid arthritis (COBRA) Classic (methotrexate (MTX)+ sulfasalazine+60 mg prednisone tapered to 7.5 mg daily from W7), COBRA Slim (MTX+30 mg prednisone tapered to 5 mg from W6) and COBRA Avant-Garde (MTX+leflunomide+30 mg prednisone tapered to 5 mg from W6). Treatment modifications to target low-disease activity were mandatory from W8, if desirable and feasible according to the rheumatologist. The primary outcome was remission (28 joint disease activity score calculated with C-reactive protein <2.6) at W16 (intention-to-treat analysis). Secondary endpoints were good European League Against Rheumatism response, clinically meaningful health assessment questionnaire (HAQ) response and HAQ equal to zero. Adverse events (AEs) were registered.ResultsData from 98 Classic, 98 Slim and 94 Avant-Garde patients were analysed. At W16, remission was reached in 70.4% Classic, 73.6% Slim and 68.1% Avant-Garde patients (p=0.713). Likewise, no significant differences were shown in other secondary endpoints. However, therapy-related AEs were reported in 61.2% of Classic, in 46.9% of Slim and in 69.1% of Avant-Garde patients (p=0.006).ConclusionsFor high-risk eRA, MTX associated with a moderate step-down dose of GCs was as effective in inducing remission at W16 as DMARD combination therapies with moderate or high step-down GC doses and it showed a more favourable short-term safety profile.EudraCT number:2008-007225-39.

scholarly journals Size-resolved particle number emissions in Beijing determined from measured particle size distributions

2020 ◽  
Vol 20 (19) ◽  
pp. 11329-11348 ◽  
Author(s):  
Jenni Kontkanen ◽  
Chenjuan Deng ◽  
Yueyun Fu ◽  
Lubna Dada ◽  
Ying Zhou ◽  
...  
Keyword(s):  
Particle Size ◽  
Air Quality ◽  
Particle Number ◽  
Aerosol Particles ◽  
Urban Environments ◽  
Integrated Assessment Model ◽  
Assessment Model ◽  
Size Distributions ◽  
Particle Size Distributions ◽  
Measured Particle

Abstract. The climate and air quality effects of aerosol particles depend on the number and size of the particles. In urban environments, a large fraction of aerosol particles originates from anthropogenic emissions. To evaluate the effects of different pollution sources on air quality, knowledge of size distributions of particle number emissions is needed. Here we introduce a novel method for determining size-resolved particle number emissions, based on measured particle size distributions. We apply our method to data measured in Beijing, China, to determine the number size distribution of emitted particles in a diameter range from 2 to 1000 nm. The observed particle number emissions are dominated by emissions of particles smaller than 30 nm. Our results suggest that traffic is the major source of particle number emissions with the highest emissions observed for particles around 10 nm during rush hours. At sizes below 6 nm, clustering of atmospheric vapors contributes to calculated emissions. The comparison between our calculated emissions and those estimated with an integrated assessment model GAINS (Greenhouse Gas and Air Pollution Interactions and Synergies) shows that our method yields clearly higher particle emissions at sizes below 60 nm, but at sizes above that the two methods agree well. Overall, our method is proven to be a useful tool for gaining new knowledge of the size distributions of particle number emissions in urban environments and for validating emission inventories and models. In the future, the method will be developed by modeling the transport of particles from different sources to obtain more accurate estimates of particle number emissions.

Risk of Ischemic Stroke in High Risk Atrial Fibrillation Patients during Periods of Warfarin Discontinuation for Surgical Procedures

2016 ◽  
Vol 42 (5-6) ◽  
pp. 346-351 ◽  
Author(s):  
Adnan I. Qureshi ◽  
Nauman Jahangir ◽  
Ahmed A. Malik ◽  
Mohammad Rauf Afzal ◽  
Fayyaz Orfi ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
High Risk ◽  
Surgical Procedures ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Systemic Hypertension ◽  
Ventricular Ejection Fraction

Importance: The risk of ischemic stroke during periods of warfarin discontinuation for surgical procedures is recognized but not well characterized. Objective: The study aimed to quantitate the risk of ischemic stroke associated with high risk atrial fibrillation during periods of warfarin discontinuation. Design, Setting and Participants: A cohort of 4,060 patients (mean follow-up period of 3.5 ± 1.3 years) were randomized into the Atrial Fibrillation Follow-Up Investigation of Rhythm Management study. Patients enrolled in the study had atrial fibrillation plus at least one other risk factor for stroke or death: age ≥65 years', systemic hypertension, diabetes mellitus, congestive heart failure, transient ischemic attack, prior stroke, left atrium >50 mm, left ventricular fractional shortening <25% or left ventricular ejection fraction <40%. Exposure: Warfarin discontinuation for procedure. Main Outcome and Measures: The association of warfarin discontinuation with the incidence of ischemic stroke using pooled repeated measures and Cox proportional hazards analyses during follow-up after adjusting for age, gender, obesity, diabetes mellitus, hypercholesterolemia, cigarette smoking and study period. Results: Warfarin discontinuation for procedure occurred in 265 (0.4%) of the 71,355 person observations. Compared with those without warfarin discontinuation, the rate of ischemic stroke was higher among participants with surgery-related warfarin discontinuation (1.1% of 265 person observations vs. 0.2% of 71,090 person observations, p = 0.001). Warfarin discontinuation was associated with an increased risk for ischemic stroke (relative risk 5.8; 95% CI 1.8-18.4) after adjusting for potential confounders. The population-attributable risk associated with surgery-related warfarin discontinuation was estimated to be 23.1% (95% CI 15.2-30.9%) for ischemic stroke. Conclusions and Relevance: The 6-fold higher risk of ischemic stroke associated with discontinuation of warfarin for surgical procedures must be recognized in high risk atrial fibrillation patients and considered in the risk-benefit analysis of any procedure.

Decision analysis of prophylactic mastectomy and oophorectomy in BRCA1-positive or BRCA2-positive patients.

1998 ◽  
Vol 16 (3) ◽  
pp. 979-985 ◽  
Author(s):  
V R Grann ◽  
K S Panageas ◽  
W Whang ◽  
K H Antman ◽  
A I Neugut
Keyword(s):  
Quality Of Life ◽  
Ovarian Cancer ◽  
High Risk ◽  
Surgical Procedures ◽  
Brca2 Gene ◽  
Cost Effective ◽  
Prophylactic Surgery ◽  
Breast And Ovarian Cancer ◽  
Prophylactic Surgical Procedures

PURPOSE Young Ashkenazi Jewish women or those from high-risk families who test positive for BRCA1 or BRCA2 mutant genes have a significant risk of developing breast or ovarian cancer by the age of 70 years. Many question whether they should have prophylactic surgical procedures, ie, bilateral mastectomy and/or oophorectomy. METHODS A Markov model was developed to determine the survival, quality of life, and cost-effectiveness of prophylactic surgical procedures. The probabilities of developing breast and ovarian cancer were based on literature review among women with the BRCA1 or BRCA2 gene and mortality rates were determined from Surveillance, Epidemiology, and End Results (SEER) data for 1973 to 1992. The costs for hospital and ambulatory care were estimated from Health Care Financing Administration (HCFA) payments in 1995, supplemented by managed care and fee-for-service data. Utility measures for quality-adjusted life-years (QALYs) were explicitly determined using the time-trade off method. Estimated risks for breast and ovarian cancer after prophylactic surgeries were obtained from the literature. RESULTS For a 30-year-old woman, according to her cancer risks, prophylactic oophorectomy improved survival by 0.4 to 2.6 years; mastectomy, by 2.8 to 3.4 years; and mastectomy and oophorectomy, by 3.3 to 6.0 years over surveillance. The QALYs saved were 0.5 for oophorectomy and 1.9 for the combined procedures in the high-risk model. Prophylactic surgeries were cost-effective compared with surveillance for years of life saved, but not for QALYs. CONCLUSION Among women who test positive for a BRCA1 or BRCA2 gene mutation, prophylactic surgery at a young age substantially improves survival, but unless genetic risk of cancer is high, provides no benefit for quality of life. Prophylactic surgery is cost-effective for years of life saved compared with other medical interventions that are deemed cost-effective.

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