Accidental Mycobacterium bovis infection in a veterinarian.

CASE: A veterinarian developed tenosynovitis and secondary carpal tunnel syndrome following accidental inoculation of Mycobacterium bovis during the necropsy of a tuberculous possum from Westland, New Zealand. CLINICAL RELEVANCE: M. bovis infection is a zoonotic disease, and occupational exposure to tuberculous animals places people at risk of contracting the disease. CONCLUSIONS: Adhering to safe work practices reviewed in this article is important to minimise the risk of infection to people handling tuberculous animals.

Paraquat poisoning in a burn patient.

Paraquat is a bipyridyl compound widely used as a contact herbicide. Since its introduction in 1962, hundreds of deaths have occurred, usually after suicidal or accidental ingestion. Death after dermal absorption of paraquat is uncommon, but has occurred after either contact with undiluted paraquat, disruption of skin integrity, or prolonged exposure. It is the purpose of this case report to describe a patient who had fatal dermal paraquat absorption after a crop-dusting accident in which he sustained 37% TBSA burns. After 9.5 hours of cutaneous exposure, a paraquat level of 0.169 mg/ml was obtained at 20 hours, the standard lethal dose at 16 hours being 0.16 mg/ml. In light of the apparently irreversible pathophysiology of paraquat poisoning with plasma levels as low as 3 mg/L, prevention and early intervention are the best treatments. Our patient may have survived an otherwise routine thermal injury had his wounds been aggressively irrigated in the field.

New assistive technology for passive standing.

The anesthetic skin of patients with spinal cord injuries makes these patients a high-risk population for burn injuries. Innovations in rehabilitation engineering can now provide the disabled with mechanical devices that allow for passive standing. Passive standing has been shown to counteract many of the effects of chronic immobilization and spinal cord injury, including bone demineralization, urinary calculi, cardiovascular instability, and reduced joint range of motion and muscular tone. This article will describe several unique assistive devices that allow for passive standing and an improvement in daily living for people with disabilities.

"Scientific basis of wound closure techniques." Evaluation of a new training program.

A formal training program in wound repair entitled "Scientific Basis of Wound Closure Techniques" has been developed and is accredited by the Dannemiller Memorial Educational Foundation. This course is now available at no cost to medical schools, residencies, and continuing education programs for graduate physicians. A manual with its complementing videotape allow the course participant to gain the necessary psychomotor skills to repair wounds. Evaluation of the course taken by third-year medical students and first-year residents demonstrates a high level of satisfaction. After instituting the course, there was a noticeable change in the types of barriers, instruments, and wound closure techniques practiced in our emergency department.

Asymptomatic jaundice after fasting: a diagnostic dilemma.

An 18-year-old female with asymptomatic jaundice presented to the emergency department after fasting. She was referred to the regional medical center for evaluation and treatment. The diagnosis of Gilbert's syndrome was made by fractionation of serum unconjugated and conjugated bilirubin fraction by alkaline methanolysis, followed by thin-layer chromatography and analysis of fasting-state levels of cholyl conjugated bile acids. Methods for diagnosing this disorder are discussed.

Molten metal burns: further evidence of industrial foundries' failure to comply with Occupational Safety and Health Administration regulations.

The purpose of this report is to describe another case of a molten metal burn to the foot of a foundry worker. The foundry in which he worked failed to comply with Occupational Safety and Health Administration regulations with regard to protective apparel. This injury could have been prevented with annual, unscheduled inspections by the Occupational Safety and Health Administration and with enforcement of additional regulations regarding protective apparel.

Metacarpophalangeal joint dislocation: indications for open surgical reduction.

In complex dislocations of the metacarpophalangeal joint, the volar plate is separated from the proximal phalanx and the metacarpal head is entrapped within surrounding tissue structures. These complex dislocations must be managed by open surgical reduction to reduce the dislocation and realign the volar plate. A 58-year-old male presented to the emergency department with a complex dislocation of the metacarpophalangeal joint of the left little finger, which was successfully treated by open reduction in the operating room. The indications for open reduction of metacarpophalangeal joint dislocations are reviewed.

A new silver sulfadiazine water soluble gel.

Silver sulfadiazine is the most commonly used topical antibacterial agent for the treatment of burn wounds. It has many clinical advantages, including a broad spectrum of antimicrobial activity, low toxicity, and minimal pain on application. The current formulation of silver sulfadiazine contains a lipid soluble carrier, polypropylene glycol, that has certain disadvantages, including pseudo-eschar formation and the need for twice daily application. The purpose of this investigation was to describe a new formulation of silver sulfadiazine in a water soluble gel, poloxamer 188. The antibacterial activity of this new gel has been compared to that of the commercially available silver sulfadiazine cream by in vitro and in vivo testing. The results of the in vitro antibacterial testing of these two different agents demonstrated the superiority of the new gel formulation. In experimental wounds, the antibacterial activity of the gel and the commercially available silver sulfadiazine cream were not significantly different when applied once a day. The antibacterial activity of the gel when applied once a day was comparable to that encountered by twice daily applications of the silver sulfadiazine cream by experimental wounds. The major advantage of this gel was its ease of application and removal that is attributed to its water solubility.

Search for a scientific basis for continuous suture closure: a 30-yr odyssey.

Continuous percutaneous and dermal suture closures have an important role in the approximation of long, linear lacerations in the emergency department. This report documents the scientific basis for these continuous closure techniques. In addition, a detailed description of these surgical closure techniques is presented.

Technical considerations in knot construction. Part II. Interrupted dermal suture closure.

The purpose of this study was to identify the optimal knot construction for interrupted dermal sutures. A synthetic braided absorbable suture, sizes 3-0 and 5-0, was selected for this evaluation. With reproducible mechanical performance tests, we determined that the construction of secure knots without ears required one additional throw as compared with secure knots with 3-mm ears. The direction of applied tension did not alter knot security, with the exception of granny knots, which required an extra throw when tension was applied parallel to the suture loop. Because interrupted dermal knot construction is accomplished without knot ears and with an applied tension parallel to the wound, one additional throw must be added to the knot to ensure knot security.

Industrial high-voltage electrical burn of the skull, a preventable injury.

Deep burns of the scalp and skull are often caused by high-voltage electrical injuries. Patients with such injuries should be referred to regional burn centers that are prepared to excise necrotic burn tissue and cover the devitalized bone with a well-vascularized flap. Strategies for prevention of these electrical burns are discussed.

Technical considerations in knot construction. Part I. Continuous percutaneous and dermal suture closure.

The purpose of this investigation was to determine the security of the square knot tied with one looped end and one free end versus the security of the square knot tied with two free ends. Size 4/0 and size 6/0 monofilament nylon, polypropylene, and Biosyn sutures were selected for this evaluation. The mechanical performance of these sutures was judged according to knot breakage force and number of throws required to attain security. Knots with one looped end and one free end require more throws to ensure knot security than do knots constructed from two single suture strands of comparable sizes and types of sutures.

Evaluation of a new external condom catheter system.

The purpose of this study was to perform a biomechanical performance study and a clinical trial on a new external condom catheter system. The biomechanical performance study demonstrated that the vented connector failed following exposure to urine for 14 days. In addition, angulation of the inlet adapter of anti-reflux valve of the urinary leg bag to an angle of 35 degrees (+/-5 degrees) caused complete obstruction of urinary flow. A clinical trial of the new condom catheter with its inner flap revealed twisting of the catheter that interrupted urinary flow in four of ten patients. This catheter twisting was not observed in condom catheters without inner flaps. Furthermore, this new system is not easily applied or removed by patients with neurosensory deficits or musculoskeletal weakness. Design modifications of the vent within the connection tubing, the anti-reflux valve in the collection bag, the condom catheter with its inner flap, as well as the leg bag attachments should remarkably improve the performance of this new urinary drainage system.

Biomechanical performance of a braided absorbable suture.

Lactomer and Polyglactin 910 sutures are both made of copolymers of lactide and glycolide. Biomechanical performance tests demonstrated superior handling characteristics of the Lactomer sutures. Using sutures comparable in size and knot construction, the Lactomer sutures exhibited knot holding force superior to the Polyglactin 910. Moreover, the low knot rundown forces encountered by the Lactomer sutures facilitated construction of secure knots that failed by breakage rather than by slippage.

Commentary: obstacles to scientific discovery.

Over the last two centuries, obstacles to scientific discovery frequently have been encountered by visionary scientists. From Semmelweis to Marshall, many scientists have faced rigid and nonintellectual academic environments that refused to recognize innovative advances. Their heroic journeys should be a constant reminder to us to create an academic environment that fosters intellectual freedom.

Rapid changes in the range limits of scots pine 4000 years ago.

Paleoecological data provide estimates of response rates to past climate changes. Fossil Pinus sylvestris stumps in far northern Scotland demonstrate former presence of pine trees where conventional pollen evidence of pine forests is lacking. Radiocarbon, dendrochronological, and fine temporal-resolution palynological data show that pine forests were present for about four centuries some 4000 years ago; the forests expanded and then retreated rapidly some 70 to 80 kilometers. Despite the rapidity of this response to climate change, it occurred at rates slower by an order of magnitude than those necessary to maintain equilibrium with forecast climate changes attributed to the greenhouse effect.