text:
Medical Glove Powder Report
September 1997
Do current Center policies adequately address potential adverse health effects of medical glove powder?
The Food and Drug Administration (FDA), as well as other state and federal agencies, has received requests to ban the use of glove powder. It has been suggested that experimental and clinical studies demonstrate that glove powder on medical gloves can enhance foreign body reactions, increase infections and act as a carrier of natural latex allergens. The National Institute of Occupational Safety and Health (NIOSH) recently issued a safety alert recommending the use of powder-free, reduced protein content latex gloves to reduce exposure to natural latex proteins (allergens).
For the purposes of this document, total particulate matter [glove powder] includes dusting or donning powders, mold-release compounds, and manufacturing debris. Dry lubricants such as cornstarch, silicone etc., are used to make donning gloves easier and to prevent gloves from sticking together during the manufacturing process. Cornstarch, which meets the specification for absorbable dusting powder in the United States Pharmacopoeia (USP), is the most common lubricant for patient examination gloves. Only absorbable dusting powders that have an approved Premarket Approval Application (PMA) or New Drug Application (NDA) may be used for lubricating surgeons gloves. There are no comprehensive studies of the amount of absorbable dusting powder used on powdered gloves. It is estimated that amounts of total particulates may range from 120 to 400 mg for a medium size powdered glove. [Appendix A]
Glove powder is composed of particles, thus, issues related to biologic responses to foreign bodies apply to both natural rubber latex (NRL) and synthetic gloves. Industry conversion from talcum powder, a non-absorbable lubricant, to absorbable cornstarch has greatly reduced the formation of granulomas. Adhesions of peritoneal tissue after surgery are associated with foreign bodies and remain a concern. The issue of the level of micro-organisms (bioburden) on gloves has been raised under various circumstances. However, evidence that bioburden and powder are related do not exist at this time. [Appendix B]
Experimental and clinical data demonstrate that: natural latex proteins are allergenic, natural latex proteins bind to cornstarch, aerosolized powder on NRL gloves is allergenic and can cause respiratory allergic reactions. These published studies support the conclusion that airborne glove powder represents a threat to individuals allergic to natural rubber latex and may represent an important agent for sensitizing non-allergic individuals. There are also published data (although limited) and clinical experience that cornstarch powder on NRL gloves may also be a contributing factor in the development of irritation and Type IV allergy. [Appendix B]
There are alternatives to dusting powder for lubricating natural rubber latex surfaces. The most common method is chlorination. Chlorine reacts with the natural rubber latex surface to reduce the natural tackiness, eliminating the need for adding dusting powder. The extra washing performed during the chlorination process provides an added benefit by also greatly reducing the level of soluble natural latex proteins. However, chlorination affects some of the mechanical and physical properties. Gloves made from alternative materials, not containing natural allergens, are available, but none possess the unique mix of properties offered by natural rubber latex. [Appendix C]
Market availability must be factored into any policy decision regarding medical glove powder. The large majority of medical gloves used in the U.S. are imported. In 1996, 20.8 billion medical gloves were imported into the U.S.: 90% natural rubber latex and 10% nonlatex. Of the 90% that were natural rubber latex, 2025% were powder-free and chlorinated. Only a small number of manufacturers are using a process other than chlorination to produce powder-free gloves. A rapid increase in the demand for non-powdered gloves could result in products with poor barrier integrity and/or unacceptable shelf life entering the U.S. market. In addition to concerns about glove quality, most alternatives to glove powder currently would entail substantially increased costs to the U.S. health care system. [Appendix D]
(1) The major adverse impact of glove powder appears to be its contributing role in natural rubber latex allergies.
(2) Glove powder acts as an airborne carrier of natural latex proteins.
(3) Exposure to airborne natural rubber latex allergens can be most effectively reduced by considering both the level of natural latex proteins and the amount of glove powder on medical gloves.
Immediately banning the use of glove powder would cause a market shortage that could result in inferior products and increased costs. Doing nothing to address the problem of airborne allergens which are carried by glove powder, would appear to be an abrogation of FDA's responsibility to protect public health. It appears that neither extreme offers a viable option. The following options are offered for consideration:
Provide adequate information for the consumer to make an informed decision. Require that the amount of water-soluble natural latex proteins and the amount of particulate present on powdered gloves be stated on the product label. In addition, establish upper limits for the amount of water-soluble natural latex proteins and glove powder allowed.
- Should not precipitate market shortage.
- Labeling requirement is achievable using current ASTM standard protocols.
- Market forces may lower both water-soluble protein and particulate levels.
- Con:
- Upper limits for water-soluble protein and particulates have to be established based on state-of-technology considerations.
- Labeling requirement would not be effective without education effort by industry and/or the FDA.
- Would require a new regulation.
Ban powdered medical gloves at some predetermined time in the future. Require manufacturers to convert to powder-free production or provide safety data, including foreign body and airborne allergen concerns, by a certain date.
- Should not precipitate market shortage.
- Requires no education effort.
- Offers a greater degree of protection from airborne natural latex allergens than Option 1.
- Con:
- Conversion date would have to be negotiated with industry to avoid market shortage.
- The effect of powder-free gloves on user preferences and needs for qualities such as tactile sensation, etc. are largely unknown.
- Would most likely result in increased costs to the U.S. health care system.
- It is not clear that the amount of particulates need to be reduced to the "powder-free" level in order to offer an acceptable level of protection from adverse health effects. Does not address natural latex protein level.
- Would require a new regulation.
Author: Mel Stratmeyer
These recommendations represent activities either currently ongoing or which could be initiated. Detailed action plans required to accomplish these recommendations are not addressed in this document, but will need to be developed.
Glove Powder
- Establish a maximum allowable powder level to reduce the amount of powder on powdered medical gloves by working with ASTM. *
- Standardize the maximum allowable amount of powder on powder-free medical gloves by working with ASTM. *
- Adopt the use of an accepted gravimetric method (such as ASTM D 6124-97) to measure total powder to demonstrate powder-free content claims.
- Ban medical gloves that contain talc and/or lycopodium.
- Reduce the level of water-soluble protein on finished medical gloves by working with ASTM to establish a maximum allowable glove protein level. *
Barrier Properties
- Define effects of processing, handling, and environment on the long-term barrier characteristics of all medical gloves (natural rubber latex and alternative materials). Establish shelf-life requirements.
- Promote the use of Process Controls, as described in the Quality System Regulation, for controlling manufacturing processes, such as chlorination, to minimize adverse effects on glove properties.
- Require manufacturers to label all medical gloves with the following additional information:
- the total quantity of glove powder content, unless the manufacturer has demonstrated by means of an accepted gravimetric method that the total powder is 2 mg or less;
- the total quantity of remaining water-soluble protein; and
- an expiration date as determined by shelf-life requirements.
- Explore the possible need to include glove powder content labeling on all product labels.
* In addition to ASTM, work with other voluntary standards organizations when appropriate.
Appendix A
Glove Powder Background
Since the introduction of surgical gloves to the operating theater in 1889, various types of lubricating materials have been used to aid in glove donning. These range from various wetting techniques to the use of dusting powders such as a mixtures of Lycopodium spores and talc, talcum powder alone, calcium carbonate, and different types of starch products. The first lubricant used was a powder made of Lycopodium spores (ground pines or club moss). This lubricant was quickly accepted and was used worldwide until the 1930's, when surgeons realized that it caused granuloma and adhesion formation. Lycopodium was toxic and became unacceptable for use as a glove lubricant. As a result, talcum powder (hydrous magnesium silicate), a non-absorbable lubricant, was introduced as a replacement for Lycopodium spores. In the 1940's talcum powder was also identified as a cause of post-operative complications such as granuloma and adhesion formation. In 1947 a modified cornstarch glove powder was introduced to the medical community as an absorbable and non-irritating powder. By the early 70's, many surgical glove manufacturers replaced talc with the modified cornstarch.
Cornstarch, which is absorbable through biological degradation, that meets the specification for absorbable dusting or dusting powder in the United States Pharmacopoeia (USP) is the most common lubricant for patient examination gloves. The absorbable dusting powder used on medical gloves is a chemically cross-linked cornstarch to which no more than 2% of magnesium oxide is mixed to prevent caking or turning to paste. Talc, cotton flock, and other non-absorbable materials are not acceptable as a lubricating, dusting or donning powder. ASTM* D 3578-95 (Standard Specification for Rubber Examination Gloves), D 5250-92 (Standard Specification for Polyvinyl Chloride Gloves for Medical Application) and ASTM
D 3577-91 (Standard Specification for Rubber Surgical Gloves) require the inside and outside surfaces of medical gloves to be free of talc.
In addition to dusting powder, other lubricants may also be used in the manufacturing process. Latex and some polymers are tacky and gloves made of these materials stick to the mold or former. A mold-release lubricant such as calcium carbonate or a mixture of calcium carbonate and cornstarch is used to enable the removal of gloves from molds. The other side of the glove may be coated with a donning lubricant, such as cornstarch or silicone, to make donning gloves easier and to prevent gloves from sticking during the manufacturing process.
Over the past three years, FDA has received requests to ban the use of all glove powders. These requests have been based on repeated clinical and experimental studies reporting that cornstarch on surgical gloves can damage tissue's resistance to infection, enhance the development of infection, serve as a potential source of occupational asthma, and provide a source of natural latex protein exposure to natural latex allergic individuals. The issues regarding the use of glove powder, except for the transport of natural latex protein allergens, apply to the use of glove powder on both natural rubber latex and synthetic gloves.
As a result of continuing concern over adverse reactions to cornstarch, in 1971 FDA required manufacturers to place a warning label on the glove packages. The warning label stated, "CAUTION: After donning, remove powder by wiping gloves thoroughly with a sterile wet sponge, sterile wet towel, or other effective method." Studies have shown that efforts to remove the cornstarch from the surgical gloves using washbasins and wet cloths are unsuccessful. It has been reported that such efforts have led to added clumping, creating even less absorbable aggregates.
Because of multiple concerns about the adverse health effects of all particulate matter from the surface of medical gloves (Appendix B), there is a recognized need for "low powder" and "powder-free" glove products. Particulates found on the gloves can include dusting powder, mold- or former-release compounds, lint, dust, colloidal solids, cotton, cellulose, wood fibers, metal, paper particles from packaging, and manufacturing debris. The most common particulates on gloves are dusting powder and former-release compounds added by manufacturers. Gloves with sufficiently low amounts of residual particulates are referred to as "powder-free", or "powderless." Several brands of powder-free examination and surgical gloves have been developed, some using powder-free manufacturing processes. Gloves labeled as "powder-free" may be coated with a polymer or added powder may have been removed through washing and chlorination. Although gloves are labeled as "powder-free", they contain various amounts of powder or particulates matter. FDA has adopted 2 milligrams particulate weight (based on the ASTM test standard D 6124-97) per glove powder or less as a basis for approving powder-free gloves. Alternatively, the Office of Device Evaluation (ODE) has accepted a negative iodine test to support "powder-free" claims. However, virtually all glove manufacturers provide particulate weight. For comparison purposes, a medium size powdered glove, depending on the processing, contains about 120-400 milligrams of residual debris, former-release and dusting powder.
Problems associated with the use of powder-free examination and surgical gloves include concerns about the particulate levels remaining on the gloves, use of chlorination, and the treatment with other chemical agents that may have a deleterious effect on the physical properties and/or performance of the gloves.
Surgeon's Gloves
Surgeon's gloves, defined as "a device made of natural or synthetic rubber intended to be worn by operating room personnel to protect a surgical wound from contamination …" are classified as Class I medical devices under 21 CFR 878.4460.
Absorbable dusting powder for lubricating a surgeon's glove is classified by the FDA General and Plastic Surgery panel under 21 CFR Part 878.4480 as a class III device which requires an approved PMA. Only absorbable dusting powders from manufacturers that have an approved PMA or NDA (before it was regulated as a device) may be used on surgeon's gloves. Powder used for lubricating examination gloves has not yet fallen under the same regulatory guidelines as those for surgical gloves.
Patient Examination Gloves
Patient examination gloves were classified as Class I medical devices in the October 21, 1980 Federal Register under 21 CDR 880.6250 and amended in the January 13, 1989 Federal Register. The amendment revoked the Premarket Notification 510(k) and Good manufacturing Practices (GMP) exemptions previously designated for examination gloves.
The description for patient examination gloves made of natural rubber, vinyl, or other materials given in regulation 880.6250 define the patient examination glove as "… a disposable device intended for medical purposes that is worn on the examiner's hand or finger to prevent contamination between patient and examiner."
Powder used for lubricating examination gloves should meet the USP monograph for absorbable dusting powder or be shown to be equivalent in terms of safety and effectiveness. The 510 (k) must state the type, specifications and source of powder or other dusting lubricant used on the gloves. ASTM is currently developing the Standard Test Method for Residual Powder on Medical Gloves (D 6124-97). The standard does not include a weight limit for the total powders on powder-free medical gloves.
Quality System Regulation
FDA published, in the Federal Register (FR) on October 7, 1996, a revised GMP or Quality Systems (QS) regulation which contains requirements on the control of naturally occurring material on medical devices such as adverse protein on gloves.
The new QS regulation has several revised definitions, such as the definition for manufacturing materials in §820.3(p) which is:
"Manufacturing material means any material or substance used in or used to facilitate the manufacturing process, a concomitant constituent, or a byproduct constituent produced during the manufacturing process, which is present in or on the finished device as a residue or impurity not by design or intent of the manufacturer."
A concomitant constituent is an ingredient that naturally exists in a component of a medical device or that exists in a manufacturing material used in, or used to facilitate, the manufacturing process. The allergenic or adverse proteins that naturally occur in the natural rubber latex component of medical devices are concomitant constituents.
Specific requirements for the use and removal of manufacturing materials are in §820.70 Process Controls where §820.70(h) states:
"Manufacturing material. Where a manufacturing material could reasonably be expected to have an adverse effect on product quality, the manufacturer shall establish and maintain procedures for the use and removal of such manufacturing material to ensure that it is removed or limited to an amount that does not adversely affect the device's quality. The removal or reduction of such manufacturing material shall be documented."
Thus, to meet direct health care concerns and to meet GMP requirements, water-soluble proteins on medical devices have to be limited by manufacturers when such proteins can be expected to have an adverse effect on patients and users.
Authors: Terrell Cunningham, Andrew Lowery
Appendix B
Adverse Health Effects
I. Biological Reactions
Glove dusting powder is composed of particles and there are predictable biological reactions to particles. The bulk of the glove powder is cornstarch, which is a resorbable particle and reactions are expected to be minimal and of short duration. This section reviews the nature of the biological reactions and the available information on these reactions to glove powder.
General Reports
A review article appearing in the peer reviewed literature in 1990, provides background information and an excellent summary of the problems associated with the use of glove powder (1). Powders have been demonstrated to cause inflammation and granulomas but a much higher dose of cornstarch is needed compared to talc. This study also cites a number of other substances such as suture material, gauze fluff, and cellulose that may cause these biological reactions more frequently than does cornstarch which is the major particulate component of glove powder. Studies on changes in starch processing were also examined and autoclaved starch is rapidly resorbed (48 hrs. in rat peritoneum) and irradiated starch was still present at 70 days. Studies on washing the powder off were also reported and washing with saline clumps the powder rather than removing it.
There are additional general reports which do not contribute much to the discussion and do not provide recent references (2, 3). Zaza et al (4) report a good study on natural latex sensitivity with some reference to glove powder. There was no difference in sensitivity incidences when the different kinds of gloves were compared. However, nurses with cosmetic sensitivity had higher incidence. The availability and widespread use of cosmetic powders with talc and with cornstarch is cited and is an important issue in evaluating the risks associated with glove powder.
Contamination of Surgical Wounds and Peritoneal Adhesions
Contamination of surgical wounds and peritoneal adhesions are the biological reactions most frequently cited in the literature. There were pleas for powder-free gloves (5, 6) and indications that glove powder does contaminate the wounds since washing of gloves is ineffective (6).
The issue of peritoneal adhesions from the use of powdered surgical gloves is the major issue in the literature and most of these studies are from Europe (11-12). The studies are well documented, and the assumption is that the glove powder is cornstarch and not talc. But this is not really proven in all cases. Peritoneal adhesions following surgery are a major complication with estimates that 6080% of intestinal obstructions are due to adhesions. The presence of foreign bodies is a major cause of these adhesions and the reactions are likely to be to sutures. However, the overall recommendation is to keep foreign bodies out of the operative area and this includes glove powder. Powder-free gloves are recommended and some available gloves or methodologies for preparing gloves are provided.
One European study had some interesting data and is the only study to have numbers that reflect incidence of reactions to glove powder (10). In 1991-1993, 448 patients were evaluated and peritoneal granulomas were found in 26% of the patients. There were suture granulomas in 25% of the patients and the surgeons of 309 patients used powdered gloves. Of these, 14 (5%) had documented starch granulomas. The overall conclusions were: the more operations on a patient; the more likely granulomas would appear. These are related to foreign bodies with sutures being the major cause. However, they do advocate avoiding depositing glove powder into the wound.
Experimental Studies
Some very interesting animal studies, mostly done in Europe, examined glove powder. The overall conclusions can be summarized that glove powder consists of particles and there is a biological response to those particles. The presence of a foreign body increases the risk of infection and cornstarch is a foreign body. However, of all the foreign bodies studied, cornstarch promotes the least
reaction (13-16).
Other Concerns with Glove Powder
There are miscellaneous reports of glove powder being left behind on devices or instruments (17, 18).
When this literature survey began, it was anticipated that pulmonary complications and associated granulomas would be the major issue. This does not appear in the literature and pulmonary complications in patients are not described.
Powder and cancer
Chronic inflammatory responses are of concern and there is some continuing thought, but no evidence, that a site of chronic inflammatory responses may be more prone to developing a cancer. In addition, there is always the concern of foreign body carcinomas (19) demonstrated in rodents. The biggest issue with granulomas from the chronic inflammatory response is that they mimic cancers and there may be a misdiagnosis. There is no evidence of genotoxicity, mutagenicity, or carcinogenicity with cornstarch. Granulomas may mimic carcinomas and biopsies may be necessary for decision making (7).
General Issues with Cornstarch
Cornstarch is a powder of particles and as such, the reactions are as those expected to particles. However, since cornstarch is a biodegradable particle, chronic responses are rare. Any modification of cornstarch that prolongs its degradation will increase the magnitude of the reactions. Any contamination with talc will greatly increase the biological reactions. Cornstarch is a common substance in every day life. Powders and cosmetic products with cornstarch are available over-the-counter (OTC) in all stores. In addition cornstarch is common in baking and cooking. There are numerous reports of reactions to powders in cosmetics and in the work place that are not associated with health care (20, 21).
Bioburden and Powder
The issue of the level of micro-organisms on non-sterile medical gloves has been raised under various circumstances. The only study available on bioburden is an ongoing FDA funded study. Progress reports indicate organisms of pathogenic potential were found on examination gloves in some instances. However, the issue of powder should be kept separate from the bioburden since there is no evidence that bioburden and powder are related.
Surgeons gloves are sterilized and thus, there is no remaining living bioburden on the finished product. Surgeons gloves, which are often highly powdered for ease in donning over wet hands, are routinely washed prior to use and the methods of washing and the effectiveness of the procedure are not well described and remain an area of concern for powder and bioburden from washing contamination.
Powder Free Gloves
Articles on the availability and suitability of powder-free gloves appeared with pleas to surgeons to use them (22, 23).
Review of Biological Reactions to Powdered Gloves
- The use of cornstarch rather than talc for powdering gloves greatly reduced the formation of granulomas in surgical patients. Experimental studies in animals (mice, rats, rabbits) clearly point out that talc is a potent stimulator of granulomas. Experimental studies in the same animal models showed cornstarch did not stimulate granulomas. However, if the cornstarch was not resorbed it could stimulate granulomas and some of this was associated with irradiation rather than autoclave sterilization of the cornstarch. It is also apparent that contamination of glove powder with nonresorbable particulates will cause increased formation of granulomas.
- Granulomas to particles from starch coated gloves were described early. There are few granulomas described in the current literature. However, adhesions of peritoneal tissue after surgery is associated with foreign bodies and remains a concern. Glove powder is implicated in these reactions. Proof is fairly substantial with some pathology sections which appear to be agglomerated cornstarch, however, sutures are a more common cause.
- The studies on peritoneal adhesions clearly recommend the use of powder-free gloves.
- The summary reviews on the hazards of powdered gloves, with the exception of adhesions, do not have recent (after mid 1980's) problems. They demonstrate the incidence of reactions to glove powder has diminished since elimination of talc and may still be declining.
- Most of the literature comes from Europe.
- Washing of gloves does not completely remove the powder and may cause clumping and delay resorption of the glove powder.
- All of these reports are based on surgical gloves since they are used on patients with whom follow-up is routine and problems would be noted.
- Cornstarch is the major component of glove powder and is a common powder used in a variety of occupations. (The bottles of talc and cornstarch that are OTC as baby powder have instructions "do not inhale." Pulmonary reactions to baby powder are documented. There are some peritoneal reactions to OTC powder used in the genital areas.)
Author: Katharine Merritt
II. Prevalence and health impact of Type I allergy to natural rubber latex (NRL)
Millions of health care workers, including groups such as physicians, nurses, respiratory technicians, and phlebotomists, use NRL gloves on a daily basis. The advent of universal precautions policies dramatically altered the usage of NRL gloves by the health care workers. Prior to universal precautions, gloves were only employed in instances when the patient was known to be infected with a given infectious agent, such as the hepatitis B virus. A multi-state study by Kaczmarek et al (24) found 100% compliance with universal precautions policies by the health care facilities in the study. Actual observed compliance by health care workers during routine procedures that could involve contact with patient body fluids was substantial, but not universal, ranging up to 92% during arterial blood gas procedures. Although many devices employed in the health care environment include natural latex, it is clear that NRL gloves are a crucial source of exposure to natural latex allergens for many health care workers.
Health care workers are recognized as comprising a high-risk group for natural latex allergy. Every study of health care workers has demonstrated an appreciable prevalence of natural latex sensitization as evidenced by natural latex-specific IgE antibodies and/or positive skin tests for natural latex allergy. For example, a study by Kibby and Akl (25) reported that 8.2% of hospital employees were skin test positive for natural latex reagent and 6.7% of them had class II or higher ELISAs for natural latexspecific IgE antibodies. A national, multi-center study by Kaczmarek et al (26) found that 5.5% of health care workers had natural latex-specific IgE antibodies. Nine point nine percent of the natural latex skin prick tests of 101 physicians were positive in a study by Arellano and colleagues. (27) Operating room nurses have also been studied. A study by Lagier et al (28) reported a prevalence of 10.7% natural latex skin prick test positivity among 197 operating room nurses. Finally, in a study that included dental personnel with hospital employees, Yassin et al (29) observed a prevalence of natural latex skin prick test positivity of 17%.
The general population is exposed to natural latex from a variety of sources, including consumer products such as natural latex balloons, as well as medical devices such as barrier contraceptives and the NRL gloves of health care providers, e.g., dental personnel. The prevalence of natural latex allergy among the general population has been estimated to range between 1% and 6%, lower than the corresponding range for health care workers. The upper end of the range is based on a study of blood donors in southeastern Michigan (30). This study has been questioned because blood donors may not be fully representative of the general population. There is a consensus that further study is warranted. The CDRH Epidemiology Team is currently conducting a seroprevalence study of natural latex-specific IgE antibodies among NHANES (National Health and Nutrition Examination Survey) III participants. This study, with an estimated sample size of several thousand individuals, will substantially increase the understanding of the epidemiology of natural latex allergy among the general population.
Author: Ron Kaczmarek
III. Role of glove powder in allergic reactions to natural rubber latex (NRL)
Clinical studies
A number of publications since the mid 1980's, reported respiratory problems and asthma like attacks in hospital employees and patients. The problem was ascribed to inhalation of airborne natural latex allergen in the areas of heavy use of powdered gloves (31-39). Affected individuals were frequent users of medical gloves, mainly nurses and physicians. The reactions to airborne natural latex allergens were also reported in other occupationally exposed individuals (38, 40) and/or environmentally exposed individuals (35). It is estimated that roughly 30% of natural latex sensitive individuals develop respiratory problems (31), and that aerosolized glove powder in areas of frequent glove use may affect direct users as well as those who do not use natural latex products, but are in the same areas (41). Furthermore, a recent study from Finland demonstrated a rather low prevalence of respiratory allergy reactions in one hospital, in which powder-free gloves were used for an extended period of time (42). The conclusions regarding the role of glove powder in the above clinical reports were based on medical histories of individuals presenting symptoms, on positive skin tests and, in some cases, on positive inhalation test.
Binding of natural latex proteins to cornstarch powder
The propensity of cornstarch to bind natural latex proteins was studied in detail in two recent publications. Three preparations of cornstarch: a) clean, unused dusting powder, b) cornstarch exposed to natural latex protein extracts and c) cornstarch extracted from powdered gloves, were evaluated for total protein levels (43) and for allergenic protein levels (43, 44). Unexposed cornstarch contained no allergenic proteins, while both natural latex exposed cornstarch preparations had a significant amount of allergenic proteins bound to the particles. The results of both studies clearly demonstrate that cornstarch indeed binds allergenic proteins, which can not be detached by simply washing the powder. These findings support the causal relationship between asthmatic reactions in individuals with natural latex allergy and the exposure to airborne particles from NRL products.
Airborne glove powder as an allergen carrier
Several papers describe measurements of airborne particle levels in the environment with frequent use of NRL gloves. Airborne particles were collected through filters and analyzed for allergen content.
Airborne natural latex allergen levels were evaluated in the laboratories using either powdered gloves or powder-free gloves (45). This study showed much higher allergen levels ranging from 39-311 ng/m3 in laboratories where powdered gloves were used in comparison with the levels of less than 20 ng/m3 in laboratories where powder-free gloves were used. More detailed measurements of the airborne allergen were done in the operating rooms, comparing airborne allergen levels on days when high-allergen gloves were used with days when low-allergen gloves were used and finally with no surgery days (46). The median allergen level of 13.7 ng/m3 on high-allergen glove days was down to 1ng/m3 and 0.6 ng/m3 on low allergen glove days or no surgery days, respectively. In the environment where powdered gloves were used, large quantities of allergen could also be collected from personnel lab coats and scrub suits (47).
These studies demonstrate that the level of airborne allergen is directly related to the frequency of powdered glove usage in particular areas and to the level of allergen/powder on the gloves used.
Respiratory problems in natural latex allergic individuals
A number of published papers provide direct evidence that natural latex protein allergens, bound to corn starch particles are a cause of respiratory allergic reactions and asthma like attacks. This has been documented by the bronchial provocation test, performed by exposing allergic individuals to inhalation from powders on NRL gloves. A change in the Forced Expiration Volume (FEV), a measure of pulmonary function, is an indication of intensity of the reaction to allergen.
Patients who developed rhinitis, conjunctivitis and dyspnea when in the operating room theater or in other hospital environments with a heavy use of NRL gloves, were evaluated for natural latex allergy (medical history, specific IgE antibodies, skin test). After positive diagnosis of existing allergy to natural latex proteins, patients underwent the bronchial provocation test with airborne powder particles from NRL gloves. Test subjects were asked to handle powdered NRL gloves and powdered non-NRL gloves while their respiratory functions were monitored. They could handle up to 20 pairs of non-NRL gloves inhaling the powder particles, without any respiratory symptoms, while the same individuals, after handling as few as one pair of NRL gloves started to develop airway resistance (48). Furthermore, the preparation of glove powder from NRL gloves tested by bronchial provocation test and skin test, demonstrated positive reactions in both cases (49). In another study, a provocation test with clean cornstarch that has not been in the contact with a natural latex product did not provoke any respiratory reaction, while in the same individuals, powder from NRL induced asthmatic reaction (50). The control individuals with no natural latex allergy, did not develop any symptoms during provocation with allergenic powder.
In a more recent well controlled study (51), the bronchial provocation test was performed with the extracts from powder-free surgical gloves, from powdered surgical gloves and with a clean cornstarch powder extract. A clean cornstarch powder caused no bronchial reaction in sensitized subjects. Exposure to a nebulized powder-free NRL surgical glove extract induced immediate bronchoconstriction in two of four tested subjects. However, when nebulized powdered glove extract was tested, a 1:10 dilution of the extract induced bronchoconstriction in all four tested subjects and the intensity of the reaction was the same as with undiluted powder-free glove extract.
A recent study from Belgium (52) revealed that 4.7% of hospital personnel were allergic to natural latex, confirmed by medical history and skin testing. Allergic individuals were pretested for bronchial responsiveness and then exposed to the provocation test with powdered NRL gloves. A total of 58% of allergic participants or 2.6% of the entire surveyed population developed an asthmatic reaction, while the provocation with vinyl glove powder did not cause any change in bronchial functions.
In summary, the studies reviewed above lend support to the conclusion that airborne glove powder may represent a threat to individuals allergic to natural latex proteins. Avoidance of use of natural latex products by such individuals may provide insufficient protection from natural latex proteins if they are in the environment of powdered glove use. Since there is not current safe and effective therapy for natural latex allergy, avoidance of all sources of natural latex allergen is the only available therapeutic option.
Role of glove powder in irritation and contact dermatitis development
Another issue that has to be addressed is a possible causal relationship of glove powder with the irritation and contact dermatitis development.
It is known that cornstarch used for donning is a strong absorbing powder and has a tendency to cause dryness of the skin leading to cracking and itching. A compromised epithelium can have serious health consequences. Not only that barrier properties for infectious agents are reduced, but also in this case, chemicals used in the production of NRL gloves and natural latex proteins can penetrate a damaged skin enhancing chances of development of both Type IV and Type I allergy. Skin reactions to glove powder have been observed and interpreted as irritant reactions (53). The major factors influencing elicitation of irritant dermatitis are dose and exposure time, and termination of exposure is the cure. Therefore, in the case of NRL gloves, a prolonged contact with glove powder may have serious impact on the user skin condition.
There are no data that directly implicate cornstarch powder as a cause of allergic contact dermatitis up to now. However, it has been reported that nonimmune proinflammatory agents can augment the response to contact sensitizers (54). This augmentation occurs with subthreshold doses of both irritants and allergens and therefore, individuals that may have not presented symptoms of either reaction, can still react in case of a combined exposure (55).
These published data (although limited) and clinical experience implicate that cornstarch powder on the NRL gloves, in addition to its role in Type I allergy, may also be a contributing factor in the development of irritation and Type IV allergy.
Author: Vesna Tomazic
IV. Medical Device Reporting (MedWatch) Database
FDA's adverse event databases rarely contain event text or coded information that would allow for comprehensive, automated tallies of reported medical glove related events. Reports cannot differentiate between events associated with either Type I or Type IV hypersensitivity reactions, including reactions to powder-free vs. powdered glove products. However, based on a review of all reports, it is possible to provide the following information summary.
As of August 27, 1997, 2,501 voluntary and mandatory incident reports involving natural rubber latex containing medical gloves have been entered into FDA's adverse event database. A review of database information indicates that approximately 1,550 or 62% of these medical glove related reports allege the occurrence of adverse events that involve allergic reactions, including anaphylaxis. The text of these reports indicate the occurrence of either skin reactions (Type IV or Type I) or systemic (type I) allergic reactions of one or more health care professionals or patients to medical gloves.
Approximately 100 or 4% of medical glove related adverse event reports allege specific glove powder residue complaints. These reports raise concerns regarding granuloma formation, general concerns regarding infection risk associated with powder content, low powder content making donning difficult, contamination with unidentified debris or insect parts, mold growth, and high levels of powder on gloves labeled as "powder-free." A glove powder related death report was submitted in 1986 under the procode for surgeons' gloves. The reporter, a manufacturer, indicated that a physician had questioned the role that glove powder could have played in the death of a patient who experienced post-operative peritonitis related complications.
The remaining 851 (33%) reports are primarily related to concerns regarding product barrier integrity. However, it should be noted that problems with degradation of the desirable physical properties of medical gloves has also been associated with powder-free glove manufacturing processes such as chlorination.
Author: Sharon Dillard
Appendix C
Alternatives to Glove Powder
As discussed in previous sections of this report, glove powder has been implicated in the post-operative formation of adhesions, and in some instances, in granuloma formation. Also as discussed previously, natural latex allergens bound to airborne glove powder are known to cause respiratory problems for natural latex allergic individuals. Although the use of glove powder as a dusting lubricant is very common, there are other alternatives available. This section discusses several alternatives to powdered NRL gloves.
Chlorinated natural latex rubber (NRL) gloves
Although lubrication of the NRL glove surface can be accomplished with various dusting powders, the powder can be rubbed off and become airborne during use. A more permanent method of reducing surface drag in natural rubber latex products is known as halogenation. When carried out using chlorine as the active element - as is commonly done with NRL gloves - the process is called chlorination.
Chlorination of the NRL gloves is performed by immersing the gloves in a dilute solution containing free chlorine ions. The chlorine reacts with the natural rubber surface to reduce the natural tackiness of the natural latex, hence eliminating the need to add a dusting powder to the glove. After immersion of the glove into the dilute chlorine solution (usually between 0.050.30%), the gloves are washed in water, dipped in a neutralizing solution (e.g., 1% ammonia solution), rinsed again, and then dried (56). This extra washing performed during and after chlorination greatly reduces the level of extractable latex proteins in the product. Some latex proteins are even converted to insoluble forms during chlorination itself (57).
One significant drawback to using chlorinated NRL gloves is that some of the mechanical and physical properties of the natural latex are compromised. Woods et al (58) states that the chlorination process adversely affects shelf life, grip and in-use durability of the glove. In addition, strong odors may be present in chlorinated gloves, as well as possible skin irritants.
An FDA study of the effects of elevated temperature on the tensile strength of NRL gloves showed very dramatic results for powder-free examination gloves that are believed to have been chlorinated. Various styles of NRL gloves were placed in paper envelopes and oven-aged in air for 7, 14, and 21 days at 70º Celsius, and then subjected to tensile testing per ASTM D 412. (Accelerated aging in the laboratory at 70º C is common for NRL gloves, and is one of two recommended temperatures for aging of gloves in ASTM D 3577 and ASTM D 3578.) Five of seven powder-free styles exhibited dramatic decreases in tensile strength after just 7-14 days at 70º C, with total decreases in tensile strength ranging from 70% to over 90% at 21 days of aging. Although the details of the manufacture of these five styles are proprietary, it is believed that all were chlorinated. In contrast, almost half of the powdered gloves subject to the same conditions showed no statistically significant decrease in tensile strength, while the remaining powdered gloves decreased a moderate 10 to 25% by 21 days of exposure (59). A progress report from an ongoing federalstate contract study on NRL exam gloves recently indicated similar results: extreme degradation of chlorinated exam gloves observed after 14 to 21 days of aging at 70º C (60).
Slight variations in the chlorination process are known (56, 61, 62). For example, variations in solution strength, immersion time, neutralizing agents, time elapsed between chlorination and neutralization, drying temperature and drying time can all influence the effects of chlorination. Aziz (56) tested gloves chlorinated with 0.01%, 0.03%, 0.05%, 0.1% and 0.3% chlorine solutions. For unaged samples, tensile strength was maintained from 1 to 20 minutes of chlorination time for all samples except those chlorinated with the 0.3% solution, in which tensile strength decreased by approximately 25%. For samples aged 7 days at 70º C, original tensile strength decreased slightly for up to 20 minutes of chlorination, except for the 0.3% samples, where the tensile strength decreased by roughly 50% for 20 min. of chlorination. For samples aged 22 hours at 100º C, original tensile strength was maintained only for the 0.01% solution. The strengths of the remaining samples decreased 50-95% after only 2-6 minutes of chlorination.
Aziz also showed the higher concentrations of chlorine lead to microscopic cracks in the surface of the natural rubber latex. Chlorination time and solution strength also affect the color of the finished product (longer times and higher concentrations lead to a more yellow product). Thus, in order to avoid the potential negative effects of chlorination, chlorine concentrations and immersion times should be carefully chosen.
Synthetic polymer linings
Another alternative to powdered gloves is a NRL glove having a synthetic polymer lining on the internal surface of the glove. The slippery surface of such a lining facilitates donning of the glove. Synthetic polymer coatings may be made of a hydrogel, silicone, or another polymer. It appears that no shelf-life data exist to substantiate the long-term barrier properties of synthetic polymer-coated NRL gloves.
In the case of hydrogel polymer linings, the NRL glove is dipped into a solution of the hydrogel prior to the final curing stage of glove manufacture. The hydrogel lining is physically bonded to the natural rubber latex (58) and lies on the internal skin-contacting surface of the finished product. Due to its low coefficient of friction, the hydrogel lining facilitates donning with either wet or dry hands (63, 64, 65).
Other approaches
From the late 1800s to the mid-twentieth century, surgeons used water as the primary lubricating agent when donning gloves. The protective rubber gloves utilized at that time were designed for multiple use, and thus were pulled onto wet hands after being "sterilized" [sic] in boiling water (58, 63, 66). Water is not an effective glove lubricant for today's thin, close-fitting NRL gloves.
Glove liners in the form of cotton or nylon stretch gloves, or liners made of materials designed to resist puncture, are sometimes worn underneath NRL gloves, between the bare skin and the glove. Although liners are not used to facilitate donning, they will provide a layer of protection to the user, and thus reduce the risk of skin irritation. They also reduce discomfort due to hand sweating. Gloving creams are sometimes used to facilitate the donning of gloves and at other times, are used to reduce the wearer's potential for skin irritation. However, if used with powdered gloves, such glove liners and creams will do nothing to eliminate the occurrence of airborne natural latex allergens.
Gloves made from materials other than natural rubber latex (e.g., synthetic rubbers or other synthetic polymers) are available, but none possess the unique mix of properties (high elasticity and tensile strength, excellent film-forming characteristics) found in NRL gloves (57, 66). Gloves made from some of these alternative materials, such as plasticized PVC, include high levels of chemical additives which may cause skin irritation and/or allergic reactions (66, 67). Furthermore, the barrier properties of alternative glove materials must be thoroughly examined prior to their selection for use.
Chlorination of NRL gloves is a common alternative to the use of glove powder. Chlorination has an adverse affect on various mechanical and physical glove properties, which may affect shelf-life. Thus, the chlorination process should be tightly controlled. Gloves made of synthetic materials are available, but none possess the unique mix of physical properties offered by natural rubber latex. Synthetic polymer-coated gloves are another possibility, but as is the case with both NRL and non-NRL gloves, it appears that little or not shelf-life data exist in the current literature to substantiate the long-term barrier properties of this type of medical glove.
Author: Donna Walsh
Appendix D
Glove Market Availability
In 1996, the U.S. imported 20.8 billion medical gloves, 62% of which came from Malaysia. Since 1991, the number of medical gloves imported into the U.S. has increased by 247%. See the table below provided by the Division of Small Manufacturers Assistance (DSMA).
|Sri Lanka
|Total Imports
|% Increase
* Number of imports not enough to be included in top seven countries in this table.
These numbers include medical gloves of all types: NRL, powder-free NRL, and non-NRL. In 1996, the distribution by type was 90% NRL and 10% non-NRL. Of the 90% natural rubber latex, 20-25% were powder-free latex and chlorinated. Only a small number of manufacturers are using a process other than chlorination to produce powder-free gloves.
Malaysia is the largest producer of natural latex worldwide. Over 90% of all patient examination gloves are made from natural latex, and it is estimated that up to 80% of NRL patient examination gloves consumed in the U.S. are manufactured in Malaysia (68). The Association of Malaysian Medical Industries (AMMI) represents Malaysian and multinational companies involved in the development and manufacture of medical devices, products, equipment and services in Malaysia for the health care community worldwide. The Malaysian Rubber Glove Manufacturers' Association (MRGMA) specifically represents the NRL glove manufacturers. According to the AMMI and MRGMA, any significant increase in the numbers of medical gloves available for importation is not likely. However, a shift in the types of gloves (powdered to powder-free) is already occurring.
In June 1997 as a result of the NIOSH alert, five questions regarding current and future availability of medical gloves to the U.S. were posed to the entire 20 company AMMI membership, nine of which were glove-only manufacturers, also members of MRGMA. The responses were compiled and presented to CDRH by an AMMI executive and MRGMA member at a subsequent June meeting. The questions and AMMI responses follow. Wherever appropriate, supplemental supporting documentation is included.
What is your current monthly and/or annual capacity for manufacturing NRL and powder-free NRL medical gloves for the U.S.?
The total capacity from Malaysia in 1996 was 13 billion (including 10% non-NRL) pieces. This capacity will not change significantly. The projected Malaysian industry trend is to shift the ratio of powdered (P) to powder-free (PF) natural rubber latex. AMMI and MRGMA project this shift to be rapid as indicated below.
P to PF Latex 12 months ago 80:20 6 months ago 75:25 today (June 1997) 65:35 12 months from now 50:50
How do these numbers compare to distribution outside the U.S.?
The ratio of Malaysian medical gloves for U.S. distribution to the rest of the world is 70:30. Partly due to volume and purchasing requirements, other countries are more willing to pay the higher prices of powder-free NRL gloves. As a comparison to the P to PF ratio above, the ratio in the United Kingdom is:
P to PF Latex 3 months ago 75:25 today (June 1997) 55:45 12 months from now 40:60
If there was a request by the U.S. health care community to produce a larger quantity of powder-free medical gloves, how quickly could this increase occur and by what percent?
If the U.S. health care community could bear the "current market price" of gloves, the powder-free glove supply to other parts of the world could be significantly shifted to the U.S. Demand for powdered gloves has already dropped worldwide. One constraint to any possible shift is long-term contracts. Half or 50% of glove manufacturers have long-term contracts that stretch 6-12 months. Unless the U.S. price warranted, these contracts would not be re-negotiated.
The lines producing powder-free NRL gloves are currently working to capacity. Conversion of lines is expensive and requires 12-18 months before realizing an increased capacity. Some of the obstacles include acquiring chlorinators, which are backlogged worldwide, and water treatment enhancements. It is doubtful that the industrial process would shift to greater than 60% powder-free vs. 40% powdered NRL. Any greater erosion from powdered would be made up by a shift to non-NRL. Ten percent of the current Malaysian market is non-NRL and is growing. Although non-latex technology is not yet equal to that of natural rubber latex, glove manufacturers are attempting to perfect the nonlatex process and anticipate future increases in the nonlatex market.
However, additional FDA staff research found that non-NRL gloves, other than vinyl, are considerably more expensive than NRL gloves.
Glove Prices to Hospitals (69)(in U.S. dollars per box of 100 pieces) Exam Vinyl Natural Rubber Latex (NRL) Synthetic Rubber Synthetic Polymer Powdered 3.50 3.90 8.00 12.00 Powder-free 4.20 5.80 10.00 15.00 % of Increase for Powder-free Product 20% 49% 25% 25%
For the powdered gloves, NRL costs are 11.4% higher than vinyl but synthetic rubber is 128.5% higher than vinyl and 105% higher than NRL. For powder-free gloves, NRL costs are 39% higher than vinyl but synthetic rubber is 138% higher than vinyl and 72.4% higher than NRL. Moving to a synthetic glove is currently cost prohibitive for U.S. hospitals.
Although vinyl gloves are less expensive than NRL, research indicates they are not necessarily the best alternative. Both NRL and vinyl patient examination gloves provide protection against microorganisms; however, it has been demonstrated that NRL is preferred to vinyl for more effective and durable barrier qualities (70, 71). NRL is pliable allowing for natural molding for more appropriate fit and has the ability to reseal when tiny punctures occur. In general, NRL provides comfort to the wearer, adequately protects against microorganisms, and provides adequate barrier effectiveness when used for medical and nursing procedures (70). Consequently, NRL is still the barrier of choice in the U.S.
Would an increased volume impact importation/distribution to the U.S.? If so, what obstacles may you encounter?
U.S. entry requirements can be a problem for glove manufacturers which result in delays and, in some cases, a barrier too costly to pursue. Some specific obstacles which act as a deterrent are:
- 510(k) requirement of biocompatibility testing. There are very few laboratories available to conduct the testing causing a current 2-4 month backlog. It would be helpful if a "contingent" 510(k) approval could be granted while biocompatibility testing is being conducted. This would allow the manufacturer the opportunity to recoup some of the start-up expenses. It is cost prohibitive for a manufacturer to maintain the facility without any return, even for a relatively short period of time.
- 510(k) processing time. The current 90 days is all the manufacturers can afford. It would be an obstacle if an increase in 510(k) applications would cause a backlog.
- Regulatory expenses. Other countries are offering prices comparable or greater than those offered by the U.S. To avoid U.S. regulatory expenses/hassles, glove manufacturers are strongly inclined to direct their products to markets they can enter without delay or added costs.
What would be your special concerns and/or difficulties producing a larger quantity of powder-free NRL medical gloves, if any?
Barrier integrity is the main concern for medical gloves and glove manufacturers. Producing a product that will consistently meet water leak tests is of special concern. However, the current anxiety over natural latex allergy is resulting in a shift to materials and/or processes that may compromise barrier integrity. In a shortage situation, or even a perceived shortage situation, inconsistent quality suppliers may seize the opportunity to move into the U.S. market. This will result in poor barrier products entering the U.S., much as they did in 1988-89 when demand rapidly increased because of concern regarding universal precautions.
Producing a product that will have acceptable shelf life (one-year) is another special concern and/or difficulty. Powder-free technology is not easy and chlorination contributes to the difficulty. Most powder-free gloves are chlorinated and suppliers of auxiliary equipment are already back-ordered at least six months. However, chlorination is not the only process for producing powder-free NRL gloves. More emphasis needs to be placed on other processes which may help improve shelf life.
In summary and based on additional investigation, comprehensive labeling, including warnings and precautions, added to all medical NRL gloves would not be significant. The health care community is largely aware of natural latex allergenicity and has been making appropriate adjustments. The demand for more powder-free or lower protein gloves will most likely increase, and as refinement in other manufacturing processes improve and lower protein NRL is developed, the shift will be toward medical gloves other than chlorinated powder-free.
Author: Carol Herman
- Ellis H: The hazards of surgical glove dusting powder. Surgery, Gynecology & Obstetrics, Vol 171: 521527, 1990.
- Beck WC, Beezhold DH: Starch Glove Powder should follow talc into limbo.
- Carlson and Fay: [Letter.] J Amer Coll Surgeons; 178: 185186, 1994. Feb 1995. AORN Journal 61:317, 1995.
- Zaza S, Reeder JM, Charles LE, Jarvis WR: Latex sensitivity among perioperative nurses. AORN Journal, 60: 806812, 1994.
- Edlich RF: A plea for powder-free surgical gloves. The J Emerg Med 12:6971, 1994.
- Hunt TK, Slavin JP, Goodson WH: Starch powder contamination of surgical wounds. Arch Surg, 129: 825828, 1994.
- Giercksky KE, Qvist H, Giercksky TC, Warloe T, Nesland JM: Multiple glove powder granulomas masquerading as peritoneal carcinomatosis. J Amer Coll Surgeons, 179: 299304, 1994.
- Risberg B: Adhesions: Preventive Strategies. Eur J Surg, 163: (Suppl 577: 3239, 1997.
- Holmdahl L, Risberg B, Beck DE, Burns JW, Chegini N, diZerga GS, Ellis H: Adhesions: Pathogenesis and PreventionPanel Discussion and Summary. Eur J Surg, 163 (Suppl 577) 5662, 1997.
- Luijendijk RW, cdLange DCD, Wauters CCAP, Hop WCJ, Duron JJ, Pailler JL, Camprodon BR, Holmdahl L, vanGeldorp HJ, Jeekel J: Foreign material in postoperative adhesions. Annals of Surg, 223: 242248, 1996.
- Becker JM, Dayton MT, Fazio VW, et al: Prevention of postoperative abdominal adhesions by a sodium hyaluronate based bioresorbable membrane: a prospective randomized double blind multicenter study. J Am Coll Surg, 1996 183: 297306.
- Hunt TK: Can adhesions be prevented? J Amer Coll Surgeons, 183: 406407, 1996.
- McEntee GP, Stuart RC, Byrne PJ, Leen E, Hennessy TP: Experimental study of starchinduced intraperitoneal adhesions. Br J Surg, 77: 113114, 1990.
- Ellis H: Pathological changes produced by surgical dusting powders. Ann R Coll Surg Engl, 76:58, 1994.
- Kang N, Griffin D, Ellis H: The pathological effects of glove and condom dusting powders. J Appl Toxicol, 12: 443449, (1992).
- Ruhl CM, Urbanic JH, Foresman PA, Cox MJ, Rodeheaver GT, Zura RD, Edlich RF: A new hazard of cornstarch, an absorbable dusting powder. The J Emerg Med, 12: 1114, 1994.
- Green MA, Lam Y, Moss RF: Starch, gloves, and extradural catheters. Br J Anesth, 75: 768770. 1995.
- Oh Y, Katz LJ, Spaeth GL, Wilson RP: Risk factors for the development of encapuslated filtering blebs. Ophthalmology, 101:629634, 1994.
- Schoen FJ: Tumorigenesis and Biomaterials, in Ratner, BD, Hoff,am AS, Schoen FJ, Lemons JE, Biomaterials Science, Academic Press, 1996, section 4.6.
- Tacke J, Schmidt A, Fartasch M, Diepgen TL: Occupational contact dermatitis in bakers, confectioners and cooks. Contact Dermatitis, 33:112117, 1995.
- Kanerva L, Toikkanen J, Jolanki R, Estlander T: Statistical data on occupational contact urticaria. Contact Dermatitis, 35: 229233, 1996.
- Van Meter BH, Aggarwal M, Thacker JG, Edlich RF: A new powder-free glove with a textured surface to improve handling of surgical instruments. The J Emerg Med, 13: 365368, 1995.
- Pavlovich LJ, Cox MJ, Thacker JG, Edlich RF: Ease of donning surgical gloves: an important consideration in glove selection. The J Emerg Med, 13: 353355, 1995.
- Kaczmarek RG, Moore RM, McCrohan J, et al: Glove use by health care workers: results of a tri-state investigation. Am J Inf Cont, 19:228-232, 1991.
- Kibby T, Akl M: Prevalence of latex sensitization in a hospital employee population. Annals of Allergy, 78:41-44, 1997
- Kaczmarek RG, Silverman BG, Gross TP, et al: Prevalence of latex-specific IgE antibodies in hospital personnel. Annals of Allergy, 76:51-56, 1996.
- Arellano R, Bradley J, Sussman G: Prevalence of latex sensitization among hospital employees occupationally exposed to latex gloves. Anesthesiology, 77:905-908, 1992.
- Lagier F, Vervloet D, Lhermet I, et al: Prevalence of latex allergy in operating room nurses. J Allergy Clin Immunol, 90:319-322, 1992.
- Yassin MS, Lierl MB, Fischer TJ, et al: Latex allergy in hospital employees. Ann Allergy, 72:245-249, 1994.
- Ownby DR, Ownby HE, McCullough JA, and Shafer AW: The prevalence of anti-latex IgE antibodies in 1000 volunteer blood donors [Abstract]. J Allergy Clin Immunol, 93:282, 1994.
- Baur X, Ammon J, Chen Z, Beckmann U, Czuppon AB: Health risk in hospitals through airborne allergens for patients presensitised to latex. Lancet, 342:1148-1149, 1993.
- Kujala V, Pirilä T, Niinimäki A, and Reijula K: Latex-induced allergic rhinitis in a laboratory nurse. J of Laryngology and Otology, 109:1094-1096, 1995.
- Field EA: The use of powdered gloves in dental practice: a cause for concern? J Dent, 25:209-214, 1997.
- Seggev JS, Mawhinney TP, Yunginger JW, and Braun SR: Anaphylaxis due to cornstarch surgical glove powder. Ann Allergy, 65:152-155, 1990.
- Ruëff F, Thomas P, and Przybilla B: Natural rubber latex as an aeroallergen in the general environment. Contact Dermatitis, 35:46-47, 1996.
- van der Meeren HLM and van Erp PEJ: Life-threatening contact urticaria from glove powder. Contact Dermatitis, 14:190-191, 1986.
- Assalve D, Cicioni C, Perno P, and Lisi P: Contact urticaria and anaphylactoid reaction from cornstarch surgical glove powder. Contact Dermatitis, 19:61-78, 1988.
- Seggev JS, Mawhinney TP, Yunginger JW, et al: Corn starch glove powder may cause anaphylaxis. Ann Allergy, 65:152-155, 1990.
- Fisher AA: Contact urticaria and anaphylactoid reaction due to corn starch surgical glove powder. Contact Dermatitis, 16:224-235, 1987.
- Orfan NA, Reed R, Dykewicz MS, Ganz M, and Kolski GB: Occupational asthma in a latex doll manufacturing plant. J Allergy Clin Immunol, 94:826-830, 1994.
- Vandenplas O, Delwiche J-P, and Sibille Y: Occupational asthma due to latex in a hospital administrative employee. Thorax, 51:452-453, 1996.
- Kujala VM and Reijula KE: Glove-related rhinopathy among hospital personnel. Amer J of Industrial Medicine, 30:164-170, 1996.
- Tomazic VJ, Shampaine EL, Lamanna A, Withrow TJ, Adkinson, Jr. NF, and Hamilton RG: Cornstarch powder on latex products is an allergen carrier. J Allergy Clin Immunol, 93:751-758, 1994.
- Beezhold D and Beck WC: Surgical glove powders bind latex antigens. Arch Surg, 127:1354-1357, 1992.
- Tarlo SM, Sussman G, Contala A, and Swanson MC: Control of airborne latex by use of powder-free latex gloves. J Allergy Clin Immunol, 93:985-989, 1994.
- Heilman DK, Jones RT, Swanson MC, and Yunginger JW: A prospective, controlled study showing that rubber gloves are the major contributor to latex aeroallergen levels in the operating room. J Allergy Clin Immunol, 98:325-330, 1996.
- Swanson MC, Bubak ME, Hunt LW, Yunginger JW, Warner MA, and Reed CE: Clinical aspects of allergic disease: Quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol, 94:445-451, 1994.
- Baur X and Jäger D: Airborne antigens from latex gloves. Lancet, 335:912, 1990.
- Jäger D and Baur X: Latex specific proteins as inhalative allergens causing bronchial asthma and shock during surgery. Clin Exp Allergy, 20 (abstract), 1990.
- Marcos C, Lázaro M, Fraj J, Quirce S, de la Hoz B, FernándezRivas M, and Losada E: Occupational asthma due to latex surgical gloves. Ann Allergy, 67:319-323, 1991.
- Pisati G, Baruffini A, Bernabeo F, and Stanizzi R: Bronchial provocation testing in the diagnosis of occupational asthma due to latex surgical gloves. Eur Respir J, 7:332-336, 1994.
- Vandenplas O, Delwiche J-P, Evrard G, Aimont P, van der Brempt X, Jamart J, and Delaunois L: Prevalence of occupational asthma due to latex among hospital personnel. Am J Respir Crit Care Med, 151:54-60, 1995.
- Heese A, Hintzenstern J, Peters K-P, Koch HU, and Hornstein OP: Allergic and irritant reactions to rubber gloves in medical health services. J Am Acad Dermatol, 25:831839, 1991.
- Garioch J, Biagioni P, Forsyth A, Baillie A, MacPherson D: Infrared thermography of the allergic response to nickel. Br J Dermatol, 121:41, 1989.
- McLelland J, Shuster S, and Matthews JNS: Irritants increase the response to an allergen in allergic contact dermatitis. Arch Dermatol, 127:1016-1019, 1991.
- Aziz NAA: Chlorination of gloves. Paper No. 5 of the Latex Protein Workshop of the International Rubber Technology Conference, June 1993, Kuala Lumpur, Malaysia.
- Mellstrom GA and Boman AS in Protective Gloves for Occupational Use, CRC Press, Boca Raton, FL, 1994, chapter 3.
- Woods JA, Morgan RF, Watkins FH, and Edlich RF: Surgical glove lubricants: from toxicity to opportunity. J Emerg Med, 15(2), 209220 (1997).
- Walsh DL, Chwirut DJ, Kotz R, and Dawson J: Environmental Degradation of Latex Gloves: The Effects of Elevated Temperature on Tensile Strength. DMMS Report #9605. FDA, Rockville, MD.
- Progress report from subcontractor to FDA study. July 17, 1997.
- Natural Rubber Technical Information Sheet L17. 1977 Latex Series of the Malaysian Rubber Producers' Research Association, England.
- Gorton ADT: Natural rubber gloves for industrial use. NR Technology, Vol. 15, Part 1, 1984.
- Fisher MD, Neal JG, Kheir JN, Woods JA, Thacker JG, and Edlich RF. Ease of donning commercially available powder-free surgical gloves. J Biomed Mater Res, 33(4), 291295 (1996).
- James MH, Bratby DM, Duck R, Podell HI, Goldstein A, and Blackley DC: Dipped rubber article. US Patent No. 4,499,154 (1985).
- Nile JG, Gromelski SJ, Brain AA, and Hardwick ST: Surgeon's glove having improved donning properties. US Patent No. 5,570,475 (1996).
- Phillips P: on http://www.smtl.co.uk/MDRC/Gloves/jowcpaper96; 1996.
- Estlander T, Jolanki R, and Kanerva L in Protective Gloves for Occupational Use, CRC Press, Boca Raton, FL, 1994, chapter 16.
- Safeskin Company Report. INVESTEXT, Thomson Financial Services, Boston, MA, January 10, 1994, p.4, from Smith Barney Shearson. Online. Dialog.Investext.545.
- Glove Prices to Hospitals. Malaysian Rubber Glove Manufacturers' Association, August 1997.
- Korniewicz D: Barrier Protection of Latex. Immunology and Allergy Clinics of North America, 15/1:123-137, 1995.
- Korniewicz D, Kirwin M, Cresci K, et al: In-use comparison of latex gloves in two high risk units: Surgical intensive care and acquired immunodeficiency syndromes. Heart Lung, 21:81-84, 1992.
CDRH Glove Powder Working Group:
|Terrell Cunninghan
|Sharon Dillard
|John Farnham
|Carol Herman
|Delon Hull
|Ron Kaczmarek
|Chiu Lin
|Andrew Lowery
|Katharine Merritt
|John Stigi
|Mel Stratmeyer
|Vesna Tomazic
|Donna Walsh


text:
Alexand and Katherine have travelled to Alexand's home village to get married. (As Alexand has a very large family, who couldn't afford to travel to India, and none of Katherine's family replied to the invitations) Alexand's younger brother, Farokh is one of the guests. Heyem is Alexand's "best Woman," much to her delight. Even Alexand's mother Inajda has managed to find time from her very busy military schedule to be there. Unfortunately Farokh sees through what should be a happy occasion to things disintegrating beneath. (From left to right: Inajda Rekaya, Jarad Vijay, Farokh Merek, Katherine De Somme, Alexand Merek and Heyem Merek.) CLICK HERE for next chronological story.
Posts Tagged 'wedding'
Unbound Boxes Limping Gods: Disconnected Stories. Issue # 65: Farokh Merek Part 2
Posted in Art, Blogs, Books, Experimental, Experimental short story, graphic novel, Illustrated Short Story, Story Book Characters, Writing, tagged Alexand Merek, Eric Mehmed, Farokh Merek, Heyem Merek, Inajda Rekaya, Jarad Vijay, Katherine De Somme, love, same sex marriage, Unbound Boxes Limping Gods, wedding on December 26, 2012 | 26 Comments »
Behind the Writing
Who wrote this?
Blog Stats
- 91,157 hits
Featured Characters
Coming soonForthcoming releases, Issue # 272: The Factory (Wednesday 7th December) Issue # 273: The Factory Part 2 (Wednesday 14th December) Issue 274: The Factory Part 3 (Wednesday 21st December) Issue 275: Juba Apfvarzian Part 4 (Wednesday 28th December) Issue 276: Project Ghost Ship Part 5 (TBA) Issue 277: Project Ghost Ship Part 6 (TBA) Issue 278: Amanojuko Immortalis Part 2 (TBA) Issue 279: Amanojuko Immortalis Part 3 (TBA) Issue 280: Day 2 (TBA) Issue 281: Anesidor Sumian Part 3 (TBA) Issue 282: Amanojuko Immortalis Part 4 (TBA) Issue 283: Amanojuko Immortalis Part 5 (TBA) Issue 284: Amanojuko Immortalis Part 6 (TBA) and Amanojuko Immortalis Part 7 (TBA)
From Salt Publishing
Fun Stuff
What is this?Unbound Boxes Limping Gods is the first in a series of speculative fiction manuscripts. These short stories feature some of the characters in a time set before the novels.
So many stories! Where do I begin?Go to the Story timelines tab at the top, and you can read all the stories in order of time. You'll find them gradually connecting together.
Follow me on twitter
- @Inessa_ie Thank you! 22 hours ago
Unbound Boxes Facebook Page
About The Characters
Unbound Boxes on Flickr
More Photos
The blurb for Unbound Boxes Limping Gods(Set in 4041, the first book begins on Christmas Island, Japan.) Alexand Merek is a woman who treasures "Bad Things," and delights in music. She has done something stupid, placing those she loves in danger. Women like her are not welcome in the ordinary world, where women who play piano and dance with wives are placed into, "The Bad Thing Box." Alexand must fight to bring her lost family back together to save them from an unimaginable fate. (If you would like to see this book published, please press the follow button. The writer gives life to a story, but the reader keeps it alive.)
This is for you Dad.My stories and my world are dedicated to you, Dad. You died before I was old enough to know who you were. I will try to find you in my stories, to go to places far away from this world, to search for you. Maybe one day I'll know you again. Until then I'll keep writing. I'll never forget you. Cheryl
Micro Story Archive
I feed on FeedbackYou are very welcome to leave comments. I would love to hear what you think of the stories and characters. Your constructive criticism is very much appreciated and very rarely put in my spam box! Thank you for reading. Cheryl

subset: commoncrawl


text:
Arbors Records
The resulting issues have presented some of the more interesting efforts in mainstream swing over the past few years. Seventyish clarinetist Bob Wilber teamed up with the young Tuxedo Big Band from Toulouse, France for two revelatory albums of unrecorded charts from Benny Goodman's book. Wry pianist/songwriter Dave Frishberg has recorded several times for the label, the most recent effort being a live session at Jazz at Lincoln Center. Octogenarian clarinet legend Buddy DeFranco, almost hours after his successful JVC-New York festival appearance last year, hit the studio with John Pizzarelli's trio and former Count Basie drummer Butch Miles. Cornetist Ruby Braff played some of his last dates for founder Mat Domber's microphones, while the criminally underrecorded cornetist Warren Vache Jr. has a new Arbors release with pianist Bill Charlap and saxophonist Harry Allen.
While the economic realities of the music business work against bigger labels giving exclusive contracts to artists, it works in Arbors' favor, making the likes of Telarc's Pizzarelli and Blue Note's Charlap available as sidemen.
"Very few musicians have contracts that would prohibit them from at least being sidemen on a record, or would require them to work exclusively for a particular company," Domber said. "So we've been very fortunate in that we've recorded with musicians who have major recording contracts but who can appear as sidemen."
The story of how a lawyer who also worked in real estate became a 21st century Norman Granz is not all that unusual for independent jazz labels: he was a fan first and an entrepreneur second.
"As a kid, I really took a fancy to [guitarist] Eddie Condon, [clarinetist] Pee Wee Russell and [cornetist] Mugsy Spanier," Domber said. "Even before I was the drinking age, my father would bring me down to Nick's and I'd would listen to the music. I went to the Commodore music shop. I really started at an early age listening to the music."
Later in life, on a business trip in the late '60s Domber struck up a friendship with Rick Fay, a Los Angeles-based reedman who had been performing at Disneyland. When Fay was later transferred to Florida's Disneyworld, he invited Domber to hear him at an off-park gig. "After the performance, I asked Rick if I could buy some of his records. He said, 'I never recorded.' I said, 'You've been in the business for 40 years and you've never recorded? Would you like to?' That was how I got into the music business."
That first album, Rick Fay's Hot 5: Live at Lone Pine , named after the studio where it was recorded in 1989, became Domber's entre to recording business when he discovered that if he wanted to get it distributed properly, he'd have to have other recordings to accompany it. Fay introduced Domber to Dan Barrett, a trombone player who had worked with him when he was 16 years old, and the former Concord Records artist came to Arbors.
Domber then set about getting his friend Fay more attention by presenting him at a St. Petersburg jazz concert and ended up hiring the legendary bassist Bob Haggart who lived nearby. Haggart "was a guy who liked to play. And if you had the right group and the musicians who he respected, he was delighted. The money wasn't that important to him, but it was the chance to play."
"One thing led to another, and we've got over 200 CDs that we've recorded, growing without any plan," Domber said. While he still considers his audience a "niche market", last year Arbors albums were five of the top ten recordings voted by Britain's Jazz Journal International critics.
"I still consider myself a jazz fan and not a musical entrepreneur. I sort of approach even our record business as a jazz fan. I'm more interested in the kind of music that I enjoy, the kind of musicians that I enjoy," Domber said.


text:
« Back to Author Index
Don Schreiber .
Don Schreiber
Don Schreiber .
Articles by this Author
Pages: ←1→
Stock Strategies »
Basic Ratios for Building a Dividend-Based Stock Portfolio
Stock prices rise and fall. But there is one constant in stock investing, and that is dividends, which arrive every quarter. How do you build a portfolio of solid dividend-paying stocks? The building blocks you need to get started.
May 2005 | Journal
Pages: ←1→


text:
Black River & Western #60 getting ready to leave Flemington with the Candy Cane Limited.
BR&W #60, runs around its train at Flemington, after returning from Ringoes with the Candy Cane Limited.
The crew from BR&W #60 inspecting and oiling her between trips. In a few minutes, #60 will be departing, on her last round trip of the day between Flemington and Ringoes.
BR&W #60 runs around it's train at Flemington after arriving from Ringoes, N.J. In a few minutes #60 will be ready for it's return trip to Ringoes.
Black River & Western #60 waits for passengers to board for the 11:30 trip out of Flemington.
Traveling east from Flemington, NJ, BR&W #60, no stranger to snow with a rich Colorado Great Western heritage, brings an excursion train past "Hogstown Station" while en route to Ringoes... (more)
Built in 1865, the original CNJ station in Flemington, NJ still stands and serves as a a bank located about a 1/4 mile east of a shack that the BR&W uses at the terminus of it's regular tourist tr... (more)
All aboard! BR&W #60 prepares for departure from Flemington, NJ in the midst of a Winter storm. Destination, Ringoes, NJ.
A grandfather and his grandson look on as the crew gets their train ready to depart Flemington for Ringoes.
Built in 1939, Lehigh Valley 112, runs around its train at Flemington. The 112 will make a couple more trips during the day, between Flemington and Ringoes, for the start of another season of excu... (more)
2013 or…? Crew gives #60 a quick look before departing at 1:00pm for the North Pole (Ringoes). She would run a hot axle later that week.
Black River & Western has recently returned steam engine #60 back to service and used the engine for their opening weekend of Santa Trains. Here, the engine waits for its next run as a crowd gat... (more)
The colors of Fall have come to Flemington adding to the lure of a ride through the backwoods of Central Jersey by steam.
A father /daughter team take in the action as the crew boards BR&W #60 for a trip to the corn maze.


text:
Watch Featured Movies
Flash 28: Short news report about the Valladolid XIIIth Cinema Week, with the participation of famous people.
|IMDB: N/A Metascore: N/A RT: N/A
|December 01, 1979
|Documentary Short
|Felix Martialay
|Josep Maria Forn Samuel Fuller
Flash 28 Links
Streaming films is becoming more risky every day. We strongly urge our users to use a VPN to make themselves anonymous while streaming films and TV shows online. Using a VPN ensures that your ISP, the government and the NSA can't spy on you or block any streams. They will not be able to see ANY of your online activity. Protect Your Privacy with a Free VPN
|Version 1
|2232 views
|Report Broken
|Version 2
|17628 views
|Report Broken
|Version 3
|12562 views
|Report Broken
This movie may be available for download - Click here to try
|= Low Quality
|= Medium Quality
|= High Quality
|How do I watch these?
Sponsored Content
Flash 28 Comments
Post a Comment
Flash 28 Reviews
Support the Site
Site Updates and News
|Follow @real_1channel
Did you know you can use Primewire.org and Primewire.is to access this site? Well, now you do.
Check out the personalized TV Schedule.
Primewire Trivia
Latest Comments
neildammit : Man, this is tense.
Christmas List
visnja : The main actress acts, speaks and thinks like a 10-year-old. I found that very a ...
uzukiichan : omgggggg the ending
waadfrelle : This 45 minute two elimination ep went to fast for me, why this programming? The ...
The Vampire Diaries
wayney85 : oh dear ric you just signed a death warrant haha!
Shameless (US)
DestructoDoll : Oh, my God! I literally screamed at 7 am while people were still sleeping becaus ...


text:
Twain Harte, CA – May 22, 2013 – Exato Game Studios and Reverb Publishing announced today that Guncraft is the latest mystery addition to Groupees "Be Mine 8 Game + Charity Bundle," available now at Groupees.com/bm8. Guncraft can be unlocked as an additional option for gamers who contribute $5.00 or more, allowing cost-conscious consumers an even better way to access the most anticipated voxel-based shooter of 2013. It has never been a better time to "Block and Load" with Guncraft .
In addition, Exato Game Studios is pleased to announce the first of many future Guncraft Map Contests, allowing those in the Beta to put their level building skills to the test, to see who can create the best battlefields around. Open to paid and Beta members, the contest begins with levels inspired by board games. More information can be found at the Exato Game's website here.
Guncraft fans can vote for the game on Valve's Steam Greenlight, ( steamcommunity.com/sharedfiles/filedetails/?id=94212175), which enables community members to vote for games that they'd like to see available on the service. Vote today!
# # #
About Exato Game Studios
Exato Game Studios was founded on the premise of creating indie games of the highest caliber. Its first title, Guncraft, aims high in its grand goals of pushing the envelope, by offering one of the most diverse, user-driven, and customizable first-person shooters to ever be created.
About Reverb Publishing
Launched in 2010, Reverb Publishing offers digital publishing to independent game developers, combining production and business development support paired with the proven public relations and marketing agency expertise from its parent company, Reverb Communications. Reverb's unique model is form fitted for studios, ensuring they receive the majority of the game's revenue and maintain ownership of their titles while Reverb handles non-developmental tasks including production support, navigating QA, and preparing for product submission.
For more information about Reverb Publishing, please visit www.reverbpublishing.com.


text:
You are currently using an unsupported web browser.
We support the latest versions of these browsers:
If you have any problems while attempting to download a browser, you should contact your organization's system administrator.
For any questions related to Cvent, feel free to contact our Customer Care team.
You must be logged in to view contact information for this supplier. Sign up for a free Cvent account today.
The Occidental Grand Nuevo Vallarta features multifunctional conference facilities ideally suited for hosting anywhere from 50 to 175 people. It's excellent location, exceptional amenities and executive suites make it perfect for corporate functions.
Nestled between the Sierra Madre Mountains & Banderas Bay, CasaMagna Marriott Puerto Vallarta Resort & SPA offers 8,000 square feet of versatile and flexible meeting and event space along with 409 luxurious guest rooms.
Nestled in a captivating setting on one of the world's most alluring beaches, The St. Regis Punta Mita Resort promises to offer an experience that transcends ordinary travel, immersing guests in unsurpassed luxury.


text:
Council wants permanent place to meet
Marietta City Council members met as a committee of the whole Wednesday to discuss the possibility of developing a permanent space where council and committee meetings could be located.
Current council committee sessions are held in the second floor conference room at 304 Putnam St., while the twice-a-month regular council meetings are conducted in the community building at Lookout Park on Harmar Hill.
"My main objection to Lookout Park is that it's too remote," said council president Walt Brothers. "I would rather have a location closer to the downtown area."
Neither of the current meeting locations is easily accessible for people with disabilities, and committee meetings in the room at 304 Putnam St. are often overcrowded, forcing some attendees to stand or sit outside the room in an adjacent hallway.
Current preliminary plans for renovation of Marietta's City Hall building show a city council chambers or general meeting area located in the basement, but council members on Wednesday did not support that location, noting access to the basement room would be difficult for the general public.
The possibility of creating council chambers in the renovated National Guard Armory was also negated due to cost liabilities for the city.
"It looks like we're coming down to a room in the basement of the new municipal court building (on the corner of Third and Butler streets) or a location on the first floor of the building across the way (at 308 Putnam St.)," Brother said.
City engineer Joe Tucker said he had discussed the potential location of city council chambers in the above-ground basement area of the municipal court with Judge Janet Dyar Welch.
"I didn't want to spend time working on plans for that area if it's not going to be acceptable to the judge," Tucker said. "But she was pretty busy at the time and said she would have to take some time to think about it."
Brothers noted the ground floor of 308 Putnam St., which currently houses the city auditor and treasurer's offices, would be available for a council chamber after those offices move to the city hall building once renovations are completed there.
"I think we should look at both of those locations," he said. "But I would look at the municipal court location first."
Councilman Tom Vukovic, D-4th Ward, said if 308 Putnam is selected it would require renovation of that building as well as a new roof, which would be costly.
Tucker agreed.
"The financial analysis would favor the municipal court area," he said. "Then the city could sell 308 Putnam and not be burdened with future operation and maintenance costs there."
Brothers said he would approach Welch about the possibility of locating the chambers at the municipal court site.
In other business Wednesday, Tucker suggested that members of council's streets and transportation committee consider developing a right of way ordinance that would govern use of city rights of way by utility companies.
"Around 2005 or 2006 we started talking about a right of way ordinance, and in 2009 council hired City Communications Consultants Ltd. of Columbus to do an assessment and help develop a draft ordinance," he said. "When we got to the point of a final draft there were concerns about how the ordinance would be implemented, and one concern was how to track the time the city would have to spend checking on utilities working in the right of way."
The issue was shelved at that time, but Tucker said now may be a good time to reconsider the ordinance as the city's New World software, currently being installed, has a time-tracking component that would enable the city to keep record of time spent on right of way issues.
"The public right of way is a city asset, and a lot of utility companies use that asset," he said. "We need to do a much better job of managing our right of way, and costs should be recovered from companies operating in those areas."
Tucker said utility companies would not be in favor of a right of way ordinance, but as a home rule municipality the city has the right to set such regulations.
The committee members agreed, and Tucker said he would arrange for David Haney, managing principal with City Telecommunications, to meet with the committee in the next couple of weeks to review the originally-proposed ordinance and discuss how the city should proceed.
Also on Wednesday, Eric Lambert, project manager with the city engineering department, said the department would like to conduct a citywide needs assessment of stormwater issues.
"We usually address stormwater needs as part of our streets projects," he said, but added that stormwater should be considered as a separate issue with its own source of funding.
"We want to define our stormwater problems citywide," Lambert said.
Tucker said stormwater issues are one of the concerns that upset city residents the most.
"We have stormwater problems all over the city," he said. "But we're addressing those as a knee-jerk reaction. And we do not track how much the city spends on stormwater issues, although those repairs eat into our streets fund."
A professional needs assessment of the city's stormwater issues could cost between $25,000 to $50,000, Tucker said, adding that he is not suggesting that the study be done this year.
"But I would like to see that cost built into our budget and get council's backing for this assessment," he said.
Asked how an annual stormwater line item in the city budget would be funded once the analysis is completed, Tucker noted that many cities-including Williamstown just across the river-assess a stormwater user fee that's collected through the water and sewer bills of residents and businesses.
But Vukovic questioned that idea.
"How do you convince the community that this is the right thing to do when we've been getting by for years without such a fee?" he asked. "How do you sell this idea to the public?"
Tucker said doing a stormwater needs analysis would not mean that a fee would have to be assessed, but it would show what costs the city would face to address stormwater concerns.
"But it's expensive to deal with these problems on a reactionary basis as we do now," he said. "And it's not a good way to manage our assets."
Tucker said he would pursue funding to help pay for the needs assessment if the committee members want him to proceed with the proposal.
"I think we're all for that," said streets committee chairman Denver Abicht, D-at large.


text:
The Style Gallery is a great new way for you to view, love, and share outfit photos. It's meant to showcase
all the expressive, creative, and inspirational personalities of our community!
Love you too!
Your email has been sent!
Named after one of our favorite fashion blogs, this dress from BB Dakota is sure to make you the biggest little sensation in the world! If, on any particular day, you can't risk taking a gamble on your get-up, then giddy-up into this winning twofer. This frock is composed of a racerback top the shade of coral you might find coloring the sky during a high desert valley sunset, and a streaky, Impressionistic floral print skirt that gathers up into a paper bag-style waist and features a decorative button placket, a shaping tie, and deep pockets convenient for stowing loot. Show your enthusiasm for fashion when you combine this dress with caged heels, a denim button-up shirt styled as a jacket, and a long, draping necklace, then hop in your Honda Civic to head out for a casual day of clothes shopping.
All measurements in inches.
Sorry this item isn't available anymore


text:
Visit the Brandon Pinch A Penny store, offering a wide array of swimming pool supplies: automatic pool cleaners, swimming pool chemicals, swimming pool equipment, swimming pool pump motors, swimming pool liners, swimming pool covers, above ground swimming pools, solar blankets & reels, patio accessories, swimming pool & spa maintenance equipment, swimming pool accessories, pool floats & games, spas & hot tubs, and much more!
This BRANDON Pinch A Penny store offers swimming pool equipment, automatic swimming pool cleaners, swimming pool heat pumps, gas heater installation and repairs, leak detection and pool refinishing, grills and smokers, swimming pool cleaning service, pool stain removal chemicals and thousands of swimming pool supplies.
Pinch A Penny
212 East Brandon Blvd.813-689-2801
Brandon, FL 33511
Fax 813-681-6219
Located on the North side of Brandon Blvd. Between the Walk- In Clinic and Allied Tires.


text:
This wiki will shut down!
Please note that this wiki will be made read-only and eventually be taken offline.
A replacement is being discussed at https://github.com/awesomeWM/awesome-www/issues/7. We'd be happy to have more input for that discussion and volunteers who help us migrate the content of this wiki to its replacement.
Customizing GTK Apps
If you are used to GNOME, you might want to learn how to change your theme without using the GNOME Theme Manager. GTK apps first try to get their themeing information through an XSettings provider, such as gnome-settings-daemon or xsettings-kde, and in absence of these reverts to files, ~/.gtkrc for gtk2 apps, ~/.config/gtk-3.0/settings.ini for gtk3 apps.
Initial Setup[edit]
First, create a file called ".gtkrc-2.0" in your home folder, and put this line in it:
include '/home/<username>/.gtkrc.mine'
Next, create ".gtkrc-1.2-gnome2" and add the same line. Now create ".gtkrc.mine".
GTK Themes[edit]
To apply a theme, add this line to .gtkrc.mine:
gtk-theme-name = "Clearlooks"
replacing the example name with the name to the theme you want to use (probably in /home/<username>/.themes).
For GTK3 apps[edit]
create the file ~/.config/gtk-3.0/settings.ini with contents:
gtk-icon-theme-name = <icon-theme-name>
gtk-theme-name = <gtk-3-theme-name>
Icon Themes[edit]
To apply an icon theme, add this line to '.gtkrc.mine':
gtk-icon-theme-name = "Tango"
The name of the icon theme can be found in the index.theme file in the theme folder (probably in ~/.icons).
To change the fonts of GTK apps, add this to your '.gtkrc.mine' file:
style "schrift" { font_name = "DejaVu Sans 10" } widget_class "*" style "schrift" gtk-font-name = "DejaVu Sans 10"
To change the look of certain apps' toolbars (like gedit), add one of the following lines to your '.gtkrc.mine' file:
gtk-toolbar-style = GTK_TOOLBAR_ICONS #Only icons gtk-toolbar-style = GTK_TOOLBAR_TEXT #Only text gtk-toolbar-style = GTK_TOOLBAR_BOTH #Both icons and text gtk-toolbar-style = GTK_TOOLBAR_BOTH_HORIZ #Icons and text next to the icons
You can also change the size of the icons:
gtk-toolbar-icon-size = 16,16
There a few apps that you can use to change your theme without invoking gnome-settings-daemon:
- LXappearance (Support gtk2 and gkt3)
- gtk-theme-switch
- gtk-chtheme
- gnome-color-chooser
The following is an example '.gtkrc.mine' file:
################## # GTK # ################## include "/usr/share/themes/Clearlooks/gtk-2.0/gtkrc" ################## # FONTS # ################## style "schrift" { font_name = "Myriad Web 9" } widget_class "*" style "schrift" gtk-font-name = "Myriad Web 9" ################## # ICONS # ################## gtk-icon-theme-name = "Crashbit" ################## # TOOLBARS # ################## gtk-toolbar-style = GTK_TOOLBAR_ICONS


text:
This full website whois and analysis report on Dailytipsforgolf.com was ran on December, 10, 2016.
It is 6:13 AM CET when you ran this report for Dailytipsforgolf.com here on our website, IP-Adress.com. When it comes to Dailytipsforgolf.com, you can trust that if we have Whois information available for it, we will display it further below to assist in your research of Dailytipsforgolf.com. Feel free to run another Dailytipsforgolf related search, or start a new query.
Timestamp Confirmation:
The Whois report for Dailytipsforgolf.com was ran at 6:13 AM CET on December 10, 2016 and the information is provided below if available.
View comments on this Dailytipsforgolf whois website report below or add your own comment about Dailytipsforgolf.com.
Now you can review additional Whois data for Dailytipsforgolf.com below. Things like the status of Dailytipsforgolf, expiration date of Dailytipsforgolf.com, and Dailytipsforgolf name servers.
Don't forget that Dailytipsforgolf could have other domain extensions you might want to run a Whois search for and get further information about Dailytipsforgolf owned services.
|Hello guest sign up now!
Remaining lookups today: 16 (Get more)
My IP is: 220.127.116.11


text:
Check in from 14h / Check out prior to 10h
City Partner Hotel Szieszta: Find photos, reviews, information, amenities and compare prices for 3 stars hotels in Sopron, Hungary.
City Partner Hotel Szieszta is located in Sopron and offers outdoor tennis courts. It features a gym, as well as a steam bath, a playground and a sauna.
Hotel description
Rooms have a mini bar, heating and a private bathroom. There are also several rooms designed for families.
A satisfying breakfast is available every morning at Hotel Szieszta, and there are numerous cafés and eateries nearby.
Hunguest Szieszta Hotel Sopron provides a convenient place to discover the Fertorakos Mithraeum, as well as everything the local area has to offer. It is within a 20-minute walk of Sopron Vasutallomas, which allows for easy access in and around Sopron.
Hotel features
Mini Bar, TV, Billiards, En suite, Private Bathroom
Elevator / Lift, 24 Hour Reception, Conference Room(s), Safe-Deposit Box, Wake-up Service, Meeting Rooms, Bicycle Rental, Shops, Luggage Storage
Fitness Room/Gym, Massage / Beauty Centre, Tennis Courts, Sauna, Garden, Playground, Volleyball, Massage, Spa & Wellness Centre, Steam Bath
Private Toilet, Souvenirs/Gift Shop
Availability and Prices
Booking Site
Room Type
Per room
Per night
Per night
Users who viewed City Partner Hotel Szieszta also viewed these 3 stars Sopron hotels:
Palatinus Hotel
Új utca 23, Sopron
Új utca 23, Sopron
Rosengarten Hotel & Restaurant
Lackner Kristóf utca 64, Sopron
Lackner Kristóf utca 64, Sopron
Balf Camping and Hotel
Sopron-Balf, Furdo sor 59-61., Sopron
Sopron-Balf, Furdo sor 59-61., Sopron
Search hotels
based on
0 reviews
Nearest hotels
- Füzi Panzió
209 m
- Anna Panzió Sopron
219 m
- Hotel Fagus
362 m