In vitro and in vivo detection of microbial gene expression in bioactivated scaffolds seeded with cyanobacteria.

Dermal replacement materials bioactivated with cyanobacteria have shown promising potential for wound regeneration. To date, extraction of cyanobacteria RNA from seeded scaffolds has not been described. The aim of this study was to develop a method to isolate total RNA from bioactivated scaffolds and to propose a new approach in determining living bacteria based on real-time PCR. Transgenic Synechococcus sp. PCC 7002 (tSyn7002) were seeded in liquid cultures or scaffolds for dermal regeneration in vitro and in vivo for 7 days. RNA was extracted with a 260/280 ratio of ≥2. The small subunit of the 30S ribosome in prokaryotes (16S) and RNAse P protein (rnpA) were validated as reference transcripts for PCR analysis. Gene expression patterns differed in vitro and in vivo. Expression of 16S was significantly upregulated in scaffolds in vitro, as compared to liquid cultures, whilst rnpA expression was comparable. In vivo, both 16S and rnpA showed reduced expression compared to in vitro (16S: in vivo Ct value 13.21 ± 0.32, in vitro 12.44 ± 0.42; rnpA in vivo Ct value 19.87 ± 0.41, in vitro 17.75 ± 1.41). Overall, the results demonstrate rnpA and 16S expression after 7 days of implantation in vitro and in vivo, proving the presence of living bacteria embedded in scaffolds using qPCR.

Treatment of keloids using 5-fluorouracil in combination with crystalline triamcinolone acetonide suspension: evaluating therapeutic effects by using non-invasive objective measures.

BACKGROUND: Intralesional 5-fluorouracil (5-FU) in combination with triamcinolone acetonide (TAC) has been recommended as a promising alternative for keloids not responding to silicone-based products, cryotherapy or intralesional corticosteroids alone. Although numerous studies support the efficacy of this regime, there is a lack of objective data. OBJECTIVES: In this study, we evaluate the therapeutic effect of four courses of intralesional 5-FU in combination with TAC (3 : 1) utilizing 3D analysis (PRIMOS®pico ), ultrasound and scar scales such as the Patient and Observer Scar Assessment Scales (POSAS) and the Dermatology Life Quality Index (DLQI). METHODS: Twenty-five patients with keloids were treated using 5-FU and TAC every 4 weeks. Objective assessments were performed and the scar scales administered at baseline, as well as during consecutive visits at 1- and 12-month follow-up (FU). Routine laboratory tests were performed at baseline and at 1-month FU. RESULTS: 3D PRIMOS and ultrasound measurements revealed highly significant and stable reductions in height (baseline mean score: 4.0 ± 1.7 mm, 1-month FU mean score: 1.5 ± 0.8 mm, 12-month FU mean score: 1.8 ± 0.9 mm, P = <0.0001), volume (baseline mean score: 1,105 ± 911.5 mm3 , 1-month FU mean score: 416.1 ± 218.1 mm3 , 12-month FU mean sore: 431.2 ± 253.6 mm3 , P = <0.0001, respectively) and penetration depth of keloids (relative reduction between baseline and 12-month FU of 74.4%, P = <0.0001). The POSAS and DLQI scales confirmed significant objective and subjective improvements in scar appearance in all categories. The life quality associated with keloid appearance improved from a 'moderate effect' to a 'small effect' throughout the course of the study. CONCLUSIONS: Results of this study confirm the efficacy and safety of the combination of 5-FU and TAC in keloids. Treatments were well tolerated and demonstrated stable results at 12-month FU.

Evaluation of a non-ablative, fractional 1565 nm laser for the improvement of striae distensae albae.

BACKGROUND AND OBJECTIVE: Striae distensae (SD) represent therapeutically challenging forms of dermal atrophic scarring. In addition to topical ointments, medical needling and various energy-based devices, non-ablative fractional lasers have been suggested for their improvement. However, objective evaluations of their efficacy are widely missing. In this study, we aimed to assess the clinical improvement of SD albae after three treatments with a non-ablative fractional 1565 nm Er: glass laser by employing three-dimensional analysis and several questionnaires. METHODS: A total of 16 Caucasians suffering from SD albae were included in this prospective study. Every patient received three treatments - one every 4 weeks - using a non-ablative, fractional 1565 nm laser (two passes: 300 µbeams/cm2 , 40 mJ inside the SD; 150 µbeams/cm2 , 50 mJ inside the SD and within the surrounding area). Questionnaires (DLQI, POSAS), digital photography and three-dimensional analysis employing PRIMOS® software and VECTRA® camera system were taken at baseline, 1 and 6 months after the last treatment. RESULTS: Evaluation of objective measurements at 6-month follow-up (FU) showed a significant reduction in depth of atrophic lesions by 31.7% and less skin irregularities with Smax at baseline of 621.2 µm decreasing to 411.6 µm (P < 0.01, respectively). Improvement in objective measurements was supported by significant changes in patients' rating of skin appearance. POSAS patient total score declined from 33.5 points to 17.5 points throughout the study (P < 0.001). From baseline to 6-month FU, patients' life quality improved by 68.0% (DLQI score). Procedures showed no lasting negative side-effects and little to no down time. CONCLUSION: The use of a fractional non-ablative 1565 nm laser represents a safe approach for the treatment of SD albae. Clinically observed improvements were supported by significant data from objective measurements. The results achieved at 1-month FU represented at 6-month FU, showing stable clinical improvements.

The WST survival assay: an easy and reliable method to screen radiation-sensitive individuals.

An easy, fast and reliable method was developed to screen hundreds of Epstein-Barr virus-transformed cell lines (lymphoblastoid cell lines, LCLs) for radiation sensitivity that were generated from lymphocytes isolated from young lung cancer patients. The WST-1 test explores the metabolic activity of the mitochondria as an indicator for the vital status of cells. Cell proliferation as well as indirect cell death can be quantified by this method on a large scale in microtiter plates. Cell survival was measured at 24- and 48-h post-irradiation with 10 Gy ((137)Cs source) by the WST-1 assay and Trypan blue staining. To set up the experimental screening conditions and to establish a positive and a negative control, an ATM-mutated cell line from a radiation-sensitive ATM patient and an ATM proficient cell line from a healthy brother were compared. An optimal differentiation between the two cell lines was demonstrated for 10 Gy and 24- and 48-h cell growth after irradiation. Upon screening 120 LCLs of young lung cancer patients under these conditions, 5 of them were found to be radiation sensitive to a high degree of statistical significance. The results have been confirmed by a second laboratory by means of Trypan blue testing. The WST-1 test represents an efficient and reliable method by means of screening for radiation-sensitive cell lines.

The clinical practice of emergency medicine.

This article provides brief updates, pearls, and pitfalls on aspects of emergency practice that are dealt with routinely, including the application of diagnostic testing in the emergency department, ruling out subarachnoid hemorrhage, and the use of tympanic temperatures. Physician-patient and physician-physician communication skills are addressed. Finally, medicolegal and administrative topics, such as EMTALA, writing admitting orders, treating minors in the emergency department, and blood product therapy in Jehovah's Witnesses are also discussed.

Multiphasic anaphylaxis: an uncommon event in the emergency department.

OBJECTIVE: To determine the rate of clinically significant recurrence of symptoms in patients treated for anaphylaxis in the ED. METHODS: Retrospective chart review of out-of-hospital, ED, and hospital records over 4.5-year period (July 1991 to December 1995) at a university hospital ED with an annual patient volume of 60,000. Subjects were ED anaphylaxis patients with > or = 2 of the following 3 organ systems involved: cutaneous, respiratory, and cardiovascular. The major outcome criterion was recurrence of symptoms after ED release. Recurrences were sought at the primary treatment hospital and at surrounding hospitals (radius of 75 miles from the primary institution) within a 7-day period from the initial visit. Review of the state death registry also was made to verify the absence of out-of-hospital deaths. RESULTS: The medical records of 1,261 allergic reaction patients were reviewed, with 67 (5.3%) cases of anaphylaxis identified. Symptoms and signs in patients during the ED phase included: dyspnea, 42 (63%); pruritus, 38 (57%); emesis, 27 (41%); throat/chest tightness, 25 (37%); orthostatic complaints, 12 (18%); urticaria, 47 (70%); circulatory shock, 32 (48%); upper airway angioedema, 7 (33%); stridor, 11 (16%); and bronchospasm, 20 (30%). Of the 67 patients, 93% had immediate resolution and remained asymptomatic for a mean time of 4.2 hours in the ED. Protracted reaction occurred in 5 cases (3 using beta-adrenergic blocking agents). For 19 (28%) patients admitted to hospital, the mean hospital length of stay was 63 hours. Only 2 (3%) recurrent cases were identified, both manifested solely by urticaria. CONCLUSION: Recurrent anaphylactic reactions were rare, occurring in 3% of cases and without life threat in this patient population. Selective outpatient management of patients with severe anaphylactic reactions that promptly respond to therapy with complete, rapid resolution may be reasonable. Further study of this medical emergency is required to develop criteria to guide the choice of an outpatient disposition.

Acute hypoglycemia masquerading as head trauma: a report of four cases.

Hypoglycemia, a commonly encountered metabolic emergency, is most often easily diagnosed and rapidly treated with satisfactory patient outcome. If not recognized and treated promptly, hypoglycemia may cause irreversible central nervous system injury; it rarely results in death. The classic presentation of hypoglycemia, a patient with diabetes mellitus on medical therapy (Insulin or oral hypoglycemic agents) who presents with an altered sensorium, is frequently seen in the emergency department (ED). Less often, patients with this metabolic emergency present to the ED in a manner suggestive of a situation other than hypoglycemia. Patients may present with seizure activity or focal neurological deficits, leading the physician to treat a primary neurological syndrome and not immediately recognize the primary cause of the problem. Alternatively, patients with hypoglycemia will present to the ED with an altered mental status after a traumatic event. The physician may again assume that the alteration in consciousness has resulted from a head injury and not a metabolic disorder. Four cases are presented in which the medical history of the event (i.e., trauma) suggested head injury as an explanation of the presentation when, in fact, hypoglycemia was responsible for the altered sensorium. The diagnosis of hypoglycemia is easily made with the performance of a bedside screening test which can be subsequently confirmed by laboratory blood analysis. It is imperative that emergency physicians consider hypoglycemia in all patients with any mental status abnormality, focal neurological deficit, or seizure activity, even when the findings seem to be explained initially by other etiologies.

Fatal pneumococcal septicemia in a patient with a connective tissue disease.

Fulminant pneumococcal sepsis is a rare but life-threatening illness usually occurring in patients with known splenic absence (postsplenectomy) or dysfunction (sickle cell anemia). Several medical illnesses, not typically recognized as being associated with abnormal spleen function, may be complicated by fulminant pneumococcal sepsis. We report a case of fatal pneumococcal sepsis in a patient diagnosed with mixed connective tissue disease who likely had systemic lupus erythematosus and unsuspected splenic fibrosis. Medical illnesses associated with functional asplenia, hematological findings suggesting splenic dysfunction, and confirmatory tests of hyposplenism are discussed.

Abdominal pain in the ED: stability and change over 20 years.

Abdominal pain (AP) is a common presenting complaint in emergency department (ED) patients. A 1972 study reported that unsupervised surgical residents in a university hospital ED were unable to make a specific diagnosis in 41% of 1,000 AP patients. In the intervening time, ED availability of diagnostic technology has increased, and the reference hospital acquired full-time emergency medicine (EM) faculty. To assess what changes occurred in the evaluation and epidemiology of AP, a similar study was done at the same hospital. The study design was a review of records of 1,000 consecutive ED patients with AP seen in 1993 at a 58,000-visit public Level I trauma center ED. The percentage of ED patients (4% to 5%) with AP was unchanged. Frequency of hospital admission dropped from 27.4% (1972) to 18.3% (1993). There was marked increase in the specificity of diagnoses, with only 24.9% in 1993 diagnosed as undifferentiated abdominal pain (UDAP). There were eight cases of missed appendicitis in 1972 and none in 1993. One 1993 patient with acute cholecystitis was initially misdiagnosed as having UDAP. Advances in technology and EM faculty presence were temporally associated with improved diagnostic accuracy in patients with AP in a university hospital ED. As compared with 20 years ago, fewer patients required hospitalization, more were assigned a specific diagnosis, and there were fewer cases of missed surgical disease.

Referral and consultation in emergency medicine practice.

Since emergency physicians (EPs) frequently initiate referrals and consultations, accept patients in referral, and may provide consultation services, it is imperative that EPs fully understand these processes. Such an understanding improves communication and facilitates professional interactions and patient care. There is little published information concerning the significance and practice of referrals and consultations as they pertain to the EP. This article addresses referrals and consultations in relation to EPs. Specific recommendations are made for consultation initiation and execution. The dynamics and ethical/legal issues associated with initiating and accepting referrals and consultations are discussed.

A prospective evaluation of benzocaine-associated methemoglobinemia in human beings.

STUDY OBJECTIVE: This study determined the frequency and severity of benzocaine-associated methemoglobinemia in routine clinical use. DESIGN: Prospective, crossover, convenience study. SETTING: Gastroenterology clinic at a US Army medical center functioning as a community hospital and tertiary referral center. PARTICIPANTS: Healthy adult volunteers and patient volunteers undergoing an upper gastrointestinal endoscopic procedure. INTERVENTIONS: Baseline methemoglobin levels were measured. Subjects then received a 2-second spray of benzocaine to the oropharynx. Venous blood for methemoglobin analysis was collected 20, 40, and 60 minutes after benzocaine dosing and analyzed using a co-oximeter. RESULTS: A statistically significant (P < .05) increase in methemoglobin level between baseline (0.8 +/- 0.2%) and 20-, 40-, and 60-minute measurements (0.9 +/- 0.2%) was identified using one-way analysis of variance followed by Fisher's protected least-squares difference. CONCLUSION: A 2-second spray of 20% benzocaine applied to the oropharynx of human beings induces a statistically significant, but clinically insignificant, increase in methemoglobin levels.

Comparison of sinus x-rays with computed tomography scans in acute sinusitis.

OBJECTIVE: To determine the sensitivity and specificity of sinus x-rays of patients clinically diagnosed as having acute sinusitis. METHODS: Thirty consecutive adult, nonpregnant emergency department (ED) patients clinically diagnosed as having acute sinusitis and meeting study criteria were entered into the study. Sinus x-rays were obtained immediately after study entry and sinus computed tomography (CT) scans were done within 72 hours. Radiologic criteria for sinusitis were defined as more than 3 mm of mucoperiosteal thickening (MPT), an air/fluid (A/F) level, or opacification. All films were read in a blinded fashion [CT scans by two radiologists and plain film by two emergency medicine (EM) staff members and the same radiologists]. A third radiologist 'interpreted Ct scans when the initial radiologists disagreed. RESULTS: Sinus CT scans were obtained for 29 of 30 patients. Radiologists interpreted 28 of 29 CT scans identically, with 21 being positive for sinusitis. Sensitivity and specificity of x-rays were 57% and 88%, 62% and 88%, 67% and 75%, and 48% and 100% for the two radiologists and the two EM physicians, respectively. Four ethmoid, five frontal, and five sphenoid sinuses were opacified or had A/F levels on CT scan. No ethmoid, frontal, or sphenoid sinus was interpreted as being opacified or having an A/F level on plain film. Sensitivity and specificity of maxillary sinus opacification or A/F level on x-ray were 70% and 100%, and 70% and 100%, and 70% and 96%, and 70% and 96% for the two radiologists and the two EM physicians, respectively. Mean concordances (kappa) of x-ray and CT scan interpretations for the four reviewers were 0.34 (range, 0.30-0.39) for the diagnosis of sinusitis and 0.77 (range, 0.74-0.79) for maxillary sinus opacification or A/F level. CONCLUSIONS: Sinus x-rays are less sensitive than sinus CT scans for demonstration of radiographic changes consistent with acute sinusitis. Sinus plain films may not be reliable enough to assist with clinical decision making. If severity of patient illness requires diagnostic certainty, more sensitive imaging studies, such as CT scans of the sinuses, should be considered.

Consultation and referral patterns from a teaching hospital emergency department.

The objective of this study was to describe consultation and referral patterns from a military emergency department (ED). The design of the study consisted of a prospective analysis of consultations and referrals from Madigan Army Medical Center ED during April 1990, an Army Medical Center with multiple residencies, including emergency medicine (EM). Patient population included active and retired military personnel, their families, and civilian emergency medical system-transported patients. ED visits averaged 60,000 per year. The overall rate of consultation and referral was 39.9%; 10.7% were consultations, whereas 29.2% were referrals. PGY-2 and -3 EM residents consultation rates were higher than average. Of all ED visits, 19.7% resulted in consultations or referrals to surgical services, 13.6% to medical services, and 2.8% to pediatrics. ED patients frequently are referred to or result in consultations with non-EM physicians. Differences in consultation by level of training and the impact of consultation on consulting services both deserve further investigation. Review of EM resident use of consultation and referral may focus evaluation of ED care in teaching hospitals.

Topical anesthetic-induced methemoglobinemia in sheep: a comparison of benzocaine and lidocaine.

Benzocaine induces methemoglobin (MHb) in several species, whereas lidocaine may increase MHb in cats and human. Elevated MHb (greater than 20%) in sheep after benzocaine exposure was recently recognized. MHb decreases blood oxygen-carrying capacity which can complicate interpretation of experimental data. Sheep are used in research which requires tracheal intubation and blood gas analysis. Since benzocaine and lidocaine are used to provide local anesthesia prior to intubation, we compared MHb production by sheep after exposure to these drugs. A dose-response relationship between benzocaine and MHb was investigated. Eight crossbred Dorset ewes were dosed intranasally with benzocaine for 2 sec or with 40 mg of lidocaine in a randomized crossover design. Sheep with elevated MHb after the 2-sec benzocaine dose were later dosed with benzocaine intranasally for 10 sec. MHb levels were measured periodically on a CO-Oximeter. A quantitative MHb response to an indirect MHb former, p-aminopropiophenone (PAPP), by each sheep was determined 15 min after PAPP (0.6 mg/kg iv). MHb levels remained at baseline (1-2%) after lidocaine exposure in all sheep, as well as in four sheep (nonresponders) after the 2-sec benzocaine dose. Four sheep (responders) demonstrated 16.5-26.4% MHb after the 2-sec benzocaine dose. The responders formed 38.2-50.5% MHb after the 10-sec benzocaine dose. All responders developed high MHb after PAPP, while nonresponders developed slightly elevated MHb after PAPP. An N-hydroxy metabolite of benzocaine is the likely active MHb-forming substance. Benzocaine should be replaced by lidocaine when local anesthesia of the nasal or oropharyngeal region in sheep is required.

Blunt laryngeal trauma associated with shoulder harness use.

A case of blunt laryngeal trauma secondary to use of a shoulder harness is presented. The patient, restrained with a lap and shoulder belt, was the occupant of an automobile involved in a rear-end collision. She presented with left anterior neck pain and two hours later developed hoarseness and hemoptysis. A laryngeal laceration, identified by laryngoscopy, was surgically repaired after tracheostomy. The patient had an uncomplicated hospital course and uneventful recovery.