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.

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.

Delusions of parasitosis.

BACKGROUND: Delusions of parasitosis (DP) is a rare psychiatric disorder in which the patient has a firm belief that she or he is infected by parasites. Although it is a psychiatric disorder, these patients often present to an emergency physician because they are convinced that they have a severe skin problem. TREATMENT: Patients with DP often reject psychiatric referral. The diagnosis of DP can usually be made based on history alone. However, it is important that the patient does not have an organic skin disorder and that the delusion is not secondary to another mental or physical illness. The current treatments of choice are the antipsychotic medications risperidone and olanzapine. CONCLUSIONS: In our experience, patients with DP seen in the emergency department who are suspected of having this condition can be a challenging diagnostic and treatment problem because they usually do not have health insurance. Consequently, we find it difficult to get dermatologic and psychiatric consultation to treat their illness.

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.

The food and drug administration agrees to classify mercury fillings.

In the United States Court of Appeals of the District of Columbia Circuit, the Appellants Mom's Against Mercury, Connecticut Coalition for Environmental Justice, Oregonians for Life, California Citizens for Health Freedom, Kevin J. Biggers, Karen Johnson, Linda Brocato, R. Andrew Landerman, and Antia Vazquez Tibaul filed a petition for review of Regulatory Inaction by the Food and Drug Administration (FDA). On Monday June 2, 2008, the lawsuit was settled with the FDA after it agreed to classify mercury fillings. During its negotiation session with the Appellants, the FDA indicated that it would change its website on mercury fillings. The FDA no longer claims that no science exists about the safety of mercury amalgam or that other countries have acted for environmental reasons only. On its website, the FDA now states the following: "Dental amalgams contain mercury, which may have neurotoxic effects on the nervous systems of developing children and fetus." The FDA also states that "Pregnant women and persons who may have a health condition that makes them more sensitive to mercury exposure, including individuals with existing high levels of mercury bioburden, should not avoid seeking dental care, but should discuss options with their health practitioner." The FDA decision to classify mercury fillings is a reflection of the legislations enacted in Europe and Canada that highlight the neurotoxic effects of mercury fillings.

Legislation and informed consent brochures for dental patients receiving amalgam restorations.

In 2008, Norway banned the use of mercury for amalgam restorations. Four states in the United States have developed Informed Consent Brochures for amalgam restorations that must be given to their dental patients. The authors describe a patient who had a large cavity in his left lower molar tooth no.18 that had to be removed by an oral surgeon. When the patient went to the oral surgeon, the surgeon told the patient that he would replace the carious tooth with a gold implant. He was not given an Informed Consent Brochure regarding dental restorative materials. The oral surgeon extracted the carious tooth, replacing the tooth with a supposed gold crown implant. On his yearly dental examination, his dentist took an x-ray of his dental implant and explained that the x-ray could not distinguish whether the implant contained either gold or mercury. Consequently, the dentist referred him to a dental clinic in which the dental implant could be removed without mercury contamination of the patient's neurologic system during the extraction of the implant from the root canal. During the removal of the dental restoration, the dentist found build up expanding into the root canal that had a black color. The crown and underlying tooth were sent to ALT BioScience for analysis. Elemental analysis of the crown and underlying tooth confirmed the presence of mercury in the restoration. The patient should have been given an Informed Consent Brochure by the dentist that described the dental restoration that was used in the dental implant.