Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I.

BACKGROUND AND OBJECTIVES: This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION: The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION: On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part II.

BACKGROUND AND OBJECTIVES: During the last four decades, our research team has devised advances in wound repair that are highlighted in Part II of this collective review. DISCUSSION: There are several different methods to provide an accurate and secure approximation of the skin edges-sutures, tapes, staples, and tissue adhesives. Ideally, the selection of the wound closure technique will be based on the biologic interaction of the materials employed, tissue configuration, and biomechanical properties of the trauma wound. Selection of the appropriate wound dressing is another important consideration in the management of the trauma wound. CONCLUSION: On the basis of the comprehensive research and clinical studies, we have individualized the wound closure techniques for traumatic wounds so that healing can be achieved with more aesthetically pleasing scars.

Modern concepts of the diagnosis and treatment of psoriasis.

Psoriasis is a papulosquamous skin disease that is recognized as one of the most common immune-mediated disorders. At least nine chromosomal psoriasis susceptibility loci have been identified. It is important to emphasize that management of psoriasis begins with identification of the extent of the cutaneous disease. There are three clinical forms of psoriasis, to include psoriasis vulgaris, pustular psoriasis, and erythrodermic psoriasis. Treatments currently available are topical agents used predominantly for mild disease and for recalcitrant lesions in more severe disease, phototherapy for moderate disease, and systemic agents, including photochemotherapy, oral agents, and newer injectable biological agents, which have revolutionized the management of severe psoriasis.

Scientific documentation of the relationship of vitamin D deficiency and the development of cancer.

It is well known that vitamin D plays a key role in calcium homeostasis and is important for optimal skeletal growth. The major function of vitamin D is to enhance the efficiency of calcium absorption from the small intestine. Most physicians relate vitamin D deficiency to disorders of skeletal muscle. Vitamin D deficiency in children can manifest itself as rickets. In adults, vitamin D deficiency results in osteomalacia. Because most physicians do not appreciate the role of vitamin D deficiency in predisposing the development of cancer, we have written this important report as a wake-up call to physicians and other healthcare workers in documenting the relationship of vitamin D deficiency and cancer. Epidemiological data show an inverse relationship between vitamin D levels and breast cancer incidence. In addition, there is a well-documented association between vitamin D intake and the risk of breast cancer. Low vitamin D intake has also been indicated in colorectal carcinogenesis. A vitamin D deficiency has also been documented in patients with prostate cancer, ovarian cancer, as well as multiple myeloma. Larger randomized clinical trials should be undertaken in humans to establish the role of vitamin D supplementation in the prevention of these cancers.

Revolutionary advances in the prevention of demyelinating diseases.

This collective review focuses on three major factors that influence the incidences of multiple sclerosis (MS) to include ultraviolet radiation (UVR), vitamin D3 supplementation, and vitamin D receptor gene (VDRG) polymorphisms. In general, the rate of MS increases with latitude. Individuals tend to carry their original risk with them if they migrate to a different latitude after adolescence. It is important to emphasize that UVR increases the synthesis of vitamin D3, which has a known immune suppressant action via the VDRG. Clinical studies have pointed out that vitamin D deficiency may exacerbate the development of MS. Because vitamin D3 is an inhibitor of MS, providing supplemental D3 for individuals at risk for MS should be mandatory. There is unanimous agreement that exposure to UVR and vitamin D3 supplementation can reduce the incidence of MS. Although there is debate regarding the association of MS with the use of silver mercury fillings, there is general agreement throughout the world that there is a need for dental-patient informed-consent brochures for all dentists who use dental restoration materials. For the dentists who remove silver mercury amalgam from their patients, there is a uniform international agreement that all dental offices should use reliable debris collection devices that prevent pollution of our environment.

Dangers of cornstarch powder on medical gloves: seeking a solution.

This article reviews information on the hazards of cornstarch powder on medical gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques without dusting powder. It has been well documented that these powders on gloves present a health hazard to patients and health care workers by 5 different mechanisms. First, the glove cornstarch has documented detrimental effects on wound closure techniques. Second, this powder potentiates wound infection. Third, cornstarch induces peritoneal adhesion formation and granulomatous peritonitis. Finally, these powders serve as carriers as latex allergen and they precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powder have caused the United Kingdom and Germany to ban cornstarch powder on medical gloves over 10 years ago.

Citizen's Petition to Food and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence.

BACKGROUND: During the last 25 years, scientific experimental and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic in the world. Realizing the dangers of cornstarch on examination and surgical gloves, Germany's regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1997. In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch. DISCUSSION: Realizing the dangers of cornstarch-powdered gloves, many hospitals and clinics in the United States have banned the use of cornstarch-powdered examination and surgical gloves. Hospitals that have banned cornstarch in their examination and surgical gloves have noted a marked reduction in the latex allergy epidemic in their facilities. Realizing the dangers of cornstarch-powdered examination and surgical gloves, Dr Sheila A. Murphey, branch chief, Infection Control Devices Branch, Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices Office of Device Evaluation, Center for Devices and Radiological Health of the Food and Drug Administration (FDA), recommended that a Citizen's Petition be filed to the FDA to ban cornstarch on surgical and examination gloves. CONCLUSION: The 12 authors of this report have attached the enclosed petition to the FDA to ban the use of cornstarch on all synthetic and latex examination and surgical gloves used in the United States.

Modern concepts in the diagnosis and treatment of vitamin D deficiency and its clinical consequences.

It is the purpose of this comprehensive report to outline a revolutionary strategy to prevent vitamin D deficiency in our nation. Vitamin D is a unique vitamin. Its metabolic product, calcitriol, is a profound secosteroid hormone that has impact on over 1000 genes in the human body. Recent clinical research has implicated vitamin D deficiency as a major factor in the etiology of rickets, a wide variety of cancers, as well as hypertension, stroke, heart attack, diabetes, bone fractures, periodontal disease, and even multiple sclerosis. There are two forms of vitamin D utilized in the human body: D2 and D3. Measurement of 25(OH)D is the most reliable method of detecting vitamin D deficiency. Several methods, including high-performance liquid chromatography (HPLC), chemoluminescence, and radioimmunoassay (RIA), have been developed for the measurement of total 25(OH)D levels. Prevention and treatment of vitamin D deficiency is accomplished by regulated sun exposure as well as vitamin D, supplementation. This information describing our plan to prevent vitamin D deficiency in the patients and employees of Legacy Health System is a landmark accomplishment that should be replicated in every healthcare setting in our country to prevent vitamin D deficiency.

Revolutionary advances in the diagnosis and treatment of Familial Adenomatous Polyposis.

During the last 25 years, there have been revolutionary advances in the treatment of Familial Adenomatous Polyposis (FAP). The purpose of this article is to describe the pathophysiology, genetic testing, surveillance, surgical interventions, and psychosocial issues. The genetic defect in FAP is germline mutation in the adenomatous polyposis coli (APC) gene. Syndromes once thought to be distinct from FAP are now recognized to be part of the phenotypic spectrum of FAP. Syndromes with a germline mutation in the APC gene include FAP, Gardner syndrome, Turcot syndrome, and Attenuated Adenomatous Polyposis Coli (AAPC). FAP is a germline mutation in the APC gene with onset of florid polyposis in childhood and development of colorectal cancer by age 30. Colectomy is advised because of the high risk of developing colorectal cancer. AAPC is a variant of this condition with later age of onset and milder clinical phenotype. However, colectomy is advised once polyposis develops and polyps cannot be managed endoscopically. Despite the unique advances in genetic testing, psychosocial management of these syndromes remains to be a challenging problem.

Breast cancer and ovarian cancer genetics: an update.

The purpose of this report on breast cancer and ovarian cancer genetics is to review the evidence for the efficacy of surveillance for early detection, bilateral prophylactic mastectomy, prophylactic oophorectomy, and chemoprevention in preventing breast cancer and improving survival of BRCA1 and BRCA2 carriers. This collective review highlights radiologic screening of patients with this genetic predisposition for cancer as well as discusses cancer risk reduction strategies and reproductive concerns in female BRCA1/2 mutation carriers. It has now been well documented that magnetic resonance imaging (MRI) of the breast has a higher sensitivity than mammography for the diagnosis of breast cancer in patients predisposed to breast cancer. We also emphasize that a new diagnostic device, molecular breast imaging (MBI), is now available and may be as sensitive as MRI. To date, this exciting technology, MBI, has not been used in studies of patients with BRCA1/2 genes. We also discuss in more detail the unique psychological ramifications of female BRCA1/2 mutation carriers. These women face unique choices regarding management of their high risk for breast and ovarian cancer that impact their reproductive options. Despite their high levels of concern, few female BRCA1/2 mutation carriers consider assisted reproduction technologies such as pregnancy surrogate, cryopreservation of oocytes or embryos, or implantation genetic diagnosis to select embryos without BCRA1/2 mutation. Further research must be undertaken to explore the risk management of patients with inherited cancer predisposition and to incorporate these preferences into clinical care.