Experimental measurement of breath exit velocity and expirated bloodstain patterns produced under different exhalation mechanisms

In an attempt to obtain a deeper understanding of the factors which determine the characteristics of expirated bloodstain patterns, the mechanism of formation of airborne droplets was studied. Hot wire anemometry measured air velocity, 25 mm from the lips, for 31 individuals spitting, coughing and blowing. Expirated stains were produced by the same mechanisms performed by one individual with different volumes of a synthetic blood substitute in their mouth. The atomization of the liquid at the lips was captured with high-speed video, and the resulting stain patterns were captured on paper targets. Peak air velocities varied for blowing (6 to 64 m/s), spitting (1 to 64 m/s) and coughing (1 to 47 m/s), with mean values of 12 m/s (blowing), 7 m/s (spitting) and 4 m/s (coughing). There was a large (55–65%) variation between individuals in air velocity produced, as well as variation between trials for a single individual (25–35%). Spitting and blowing involved similar lip shapes. Blowing had a longer duration of airflow, though it is not the duration but the peak velocity at the beginning of the air motion which appears to control the atomization of blood in the mouth and thus stain formation. Spitting could project quantities of drops at least 1600 mm. Coughing had a shorter range of near 500 mm, with a few droplets travelling further. All mechanisms could spread drops over an angle >45°. Spitting was the most effective for projecting drops of blood from the mouth, due to its combination of chest motion and mouth shape producing strong air velocities. No unique method was found of inferring the physical action (spitting, coughing or blowing) from characteristics of the pattern, except possibly distance travelled. Diameter range in expirated bloodstains varied from very small (<1 mm) in a dense formation to several millimetres. No unique method was found of discriminating expirated patterns from gunshot or impact patterns on stain shape alone. Only 20% of the expirated patterns produced in this study contained identifiable bubble rings or beaded stains

Update richtlijn psoriasis 2017

The update of the NVDV guideline psoriasis 2017 is summarized. In the update the chapters methotrexate, fumaric acid esters, biologics, children, serum concentrations and antibody formation and quality of life are renewed. In addition chapters on secukinumab, apremilast, choice of treatment, combination treatment, psoriatic arthritis and pregnancy and breastfeeding during biologic treatment have been added. The update is based on the NVDV guideline psoriasis 20111, European Dermatology Forum (EDF) guideline Psoriasis 20152 and new search and analyses by the workgroup. The most important differences in the update 2017 compared to the NVDV guideline psoriasis 2011 are discussed