Diatoms in maggots; a potential tool for drowning diagnosis - A preliminary study.

Advanced putrefaction causes extensive loss of soft tissue, rendering it difficult to use the diatom test as a reliable diagnostic tool for drowning investigations. A positive diatom test in carrion insect larvae may provide significant assistance in overcoming the challenge of decomposition. The studies determined the utility of diatom test in carrion larvae on severely decomposed bodies. A modified acid digestion method involving nitric acid, K2Cr2O7 and HCl, was used to digest the blowfly larvae feeding on piglet carrion previously drowned in freshwater and sea water, respectively. Extracted diatom frustules were analysed and characterised using light microscopy coupled to a digital camera. Diatoms recovered from maggots on sea-drowned piglets were similar to diatoms from sea water (drowning medium). Centric diatoms recovered in maggots were higher (200 ± 60 diatoms/ mL) than pennate diatoms (80 ± 20 diatoms/mL). Isolated diatoms common to both maggots and water samples included Coscinodiscus sp. and Navicular spp. Albeit, there were no diatoms recovered from maggots on freshwater-drowned piglets. The findings of this study suggest that the diatom test is still a reliable diagnostic tool to determine if drowning was involved in the death of a fully decomposed body. This is the first study that isolated diatoms from maggots feeding on drowned bodies. It serves as the basis for further research into the utility of maggots for drowning investigations.

Outpatient healthcare utilization among incident cases of systemic sclerosis: results from a population-based US cohort (1988-2016).

OBJECTIVE: Systemic sclerosis (SSc) is a complex, heterogeneous connective tissue disease with multiorgan dysfunction. This study aimed to compare healthcare utilization among incident cases of SSc versus age- and gender-matched comparators. METHOD: A population-based cohort of physician-diagnosed patients with SSc in Olmsted County, MN, USA, from 1 January 1988 to 31 December 2016 was assembled. A 2:1 cohort of age- and gender-matched non-SSc subjects was randomly selected for comparison. Patients were followed until death, migration from Olmsted County, or 31 December 2017. Outpatient utilization data were obtained beginning 12 months before the SSc incidence/index date and compared using negative binomial and multinomial models. Services were summarized as visit-days to avoid overestimation of services provided. RESULTS: The study included 69 incident SSc cases and 138 non-SSc comparators (mean ± sd age 57 ± 16 years at diagnosis/index, 90% female). Patients with SSc had higher utilization of outpatient physician, laboratory, and combined radiology visit-days annually for the year before and for each of the first 5 years after diagnosis than comparators. Among patients with SSc, healthcare utilization was highest during the year of SSc diagnosis. Rate ratios comparing utilization in patients with and without SSc ranged from 1.8 to 3.0 for all comparisons. CONCLUSION: Higher utilization of outpatient physician, laboratory, and radiology visit-days was observed among patients with SSc compared to non-SSc subjects throughout 5 years of disease duration, indicating high and continued care needs in this patient population. The highest utilization of services among SSc patients occurred during the year of SSc diagnosis.

Adult tetanus in Accra, why the high mortality? An audit of clinical management of tetanus.

BACKGROUND: Tetanus is a life threatening infection relatively uncommon in the developed countries but occurs frequently in developing countries with case fatality rates of 40-60 %. Recent review of adult tetanus at the Korle-bu Teaching Hospital showed a high case fatality of 50%. In order to determine the factors underlying this high case fatality we conducted a retrospective clinical audit of the clinical management of adult tetanus admitted in 1994 to 2001 to the Korle-bu Teaching Hospital. METHODS: Data extracted from the admission and discharge books of the Fevers' Unit of Korle-bu Teaching Hospital, Accra and patient case notes were examined and analysed. RESULTS: Case fatality rate (CFR) varied from 25 % in 1999 to 72.7% in 2001. There was no gender difference in the case fatality. There was no significant difference in the mean age of those who died and those who survived, however, the CFR rose with age. The presence of neck and a dirty wound were associated with increased CFR. The CFR correlated with the severity of tetanus and increased when an expected treatment action, wound debridement, administration of antibiotics and/or immunoglobulin, was not performed. The administration of anti-tetanus toxin was associated with an increased CFR. CONCLUSION: The high case fatality rate in Accra was due to inappropriate management with most of the patients not treated with immunoglobulin and antibiotics and had inadequate wound care.

Iatrogenic nerve injury with the Russell-Taylor humeral nail.

The first consecutive 51 humeral shaft fractures treated with the Russell-Taylor intramedullary nail at Glasgow Royal Infirmary were reviewed in a retrospective study. There were eight iatrogenic nerve injuries- three to the radial nerve which settled spontaneously and five to the lateral cutaneous nerve of forearm of which three have failed to recover completely. The authors feel that the insertion of the distal interlocking screw in the antero-posterior direction puts this nerve at risk. We believe that iatrogenic injury to the lateral cutaneous nerve of forearm during humeral nailing has not been previously reported.

Characteristics of adult tetanus in Accra.

BACKGROUND: Tetanus is a life threatening infection with an estimated annual global incidence of about 1 million cases and a mortality of 50%. It is very common in developing countries. The prevalence in Ghana is not known, however, cases continue to be admitted in hospitals in the country. This retrospective study was undertaken to define the characteristics of cases of tetanus in adults admitted to the Korle-bu Teaching Hospital, Accra, Ghana, from 1 January 1994 to 31 December, 2001. METHODS: Information was extracted from the admission and discharge registers of the Isolation Unit of Korle-bu Teaching Hospital, Accra and case notes were examined and analysed. RESULTS: There were 158 (76.6%) males) cases of tetanus with mean age of 32.7 +/- 15.0 years. The peak age was in the 20-29 year group. Admission rate was lowest during the raining season months of June-August. Traumatic injury occurred outdoors (56.9%) and was caused by deep prick (24.3%), or cut (16.2%). The most common site of injury was on the lower (44.6%) limbs. The time interval between injury and admission was 8.3 +/- 22.4 weeks (range 1-156 weeks) and the duration of symptoms was 2.9 +/- 2.7 days (range 1.0-21.0 days). The most common presenting features were locked jaw (82.4%), general spasm (62.2%), presence of a wound (53.7%) and neck stiffness (50.0%). Hospital admission was 11.4 +/- 11.6 (range 0-53) days. The case mortality was 50% (79/158). CONCLUSION: These results confirm that adult tetanus is still very prevalent in Ghana and is occurring in a younger age group compared to that in the developed countries. The case mortality is still very high.

Bier's block: a change of injection site.

Bier's block or intravenous regional anesthesia is a well-proven technique that is useful in the traumatic setting to provide upper limb anesthesia in the manipulation of distal radial fractures. In this situation, the traditional injection site in the dorsum of the hand can present difficulties with subsequent plaster application and with venous access caused by swelling or pain. One hundred patients were randomly allocated into two groups of 50. The first group was injected into the dorsum of the hand and the second into the antecubital fossa, in each case on the injured side. Effectiveness of anesthesia at both the fractures site and the cuff was assessed using a visual analog scale. Results analyzed using Student's t test, showed no difference in anesthesia between the two groups. In addition, there were fewer technical problems associated with venous access and subsequent plaster application in the antecubital fossa group.

Crush syndrome: a hazard of prolonged bus journeys.

Compartment syndrome is a devastating condition, with a high morbidity if it goes unrecognised. We describe a case that progressed to muscle ischaemia and crush syndrome in a man undergoing a prolonged bus journey while under the influence of alcohol--an unusual presentation whose outcome is dependent on early recognition.

Caveat surgeon: do orthopaedic surgeons take adequate precautions against blood-borne viral infections, in particular the human immunodeficiency virus (HIV)?

One year ago the British Orthopaedic Association issued guidelines for the prevention of cross-infection with special reference to HIV and the hepatitis viruses. We were interested to establish whether the guidelines were being widely applied and whether they had changed general orthopaedic practice. We distributed a questionnaire to Scottish Orthopaedic Fellows, Associates of the BOA, and orthopaedic trainees. With a 70 per cent return rate, it would appear that the recommendations are not adhered to in full. Of respondents, 84 per cent were immunized or undergoing immunization against hepatitis B. In all, 30 per cent were operating on high-risk patients on a monthly basis, 60 per cent thought that their current practice was low risk, and only 15 per cent thought that their future practice would be high risk; 81 per cent were concerned and yet only 60 per cent had altered their practice. It is of some concern that orthopaedic surgeons may not take the threat of HIV cross-infection seriously enough and do not consider precautions mandatory. Further pressure and support from the BOA may be necessary to encourage a change in orthopaedic practice as the threat of HIV is increasing.