Acute Generalized Exanthematous Pustulosis in a Hemodialysis Patient.

Acute generalized exanthematous pustulosis (AGEP) is an uncommon skin condition that should be considered when evaluating patients with severe skin eruptions accompanied by systemic symptoms. We present a woman in her 70s with end-stage renal disease on hemodialysis who developed a generalized pruritic rash seven days after the administration of pre-procedure vancomycin and acetaminophen. Our patient underwent a biopsy with findings consistent with AGEP. This report highlights the need to consider AGEP in patients with severe cutaneous eruptions and systemic involvement. Prompt biopsy and blood cultures are essential to prevent misdiagnosis and treatment delays.

Custom, spray coated receive coils for magnetic resonance imaging.

We have developed a process for fabricating patient specific Magnetic Resonance Imaging (MRI) Radio-frequency (RF) receive coil arrays using additive manufacturing. Our process involves spray deposition of silver nanoparticle inks and dielectric materials onto 3D printed substrates to form high-quality resonant circuits. In this paper, we describe the material selection and characterization, process optimization, and design and testing of a prototype 4-channel neck array for carotid imaging. We show that sprayed polystyrene can form a low loss dielectric layer in a parallel plate capacitor. We also demonstrate that by using sprayed silver nanoparticle ink as conductive traces, our devices are still dominated by sample noise, rather than material losses. These results are critical for maintaining high Signal-to-Noise-Ratio (SNR) in clinical settings. Finally, our prototype patient specific coil array exhibits higher SNR (5 × in the periphery, 1.4 × in the center) than a commercially available array designed to fit the majority of subjects when tested on our custom neck phantom. 3D printed substrates ensure an optimum fit to complex body parts, improve diagnostic image quality, and enable reproducible placement on subjects.

Can double gloves improve surgeon-patient barrier efficiency?

The aim of this study was to compare double gloves (DGs) with single gloves (SGs) during orthopedic and trauma surgery in prevention of blood contact between patients and surgeons. DGs and SGs were collected after orthopedic operations, tested for size, site, and number of perforations. Medical records were reviewed for age, sex, type of operation, duration, and postoperative wound infection. Data were compared using t-test with level of statistical significance at P < 0.05. Five hundred seven operations yielded 1204 DGs and 830 pairs SGs. In DGs, perforations were detected in 220 outer glove and 39 inner glove (10.7%). In SGs, 226 perforations were detected (13.3%). The incidence of perforations in inner gloves of the double indicator glove was 1.6% (P < 0.001). During surgery, perforations were recognized in DGs in 67% compared with 12% in SGs (P < 0.005). This study confirms that DGs form an efficient barrier between patients and surgeons.

Double or single gloves: which is safer in pediatric orthopedic surgery.

BACKGROUND AND AIM: Surgical gloves should form an efficient barrier between surgeons and patients to prevent cross infection. Single gloves (SGs) have long been reported unsafe, and usage of double gloves (DGs) is still not universal. No study has reported the usage of DGs in pediatric orthopedic operations. The aim of this study was to assess the efficacy of DGs versus SGs in prevention of body fluid contact between patients and surgeons during pediatric orthopedic surgery. METHODOLOGY: After 150 pediatric orthopedic operations, DGs and SGs were collected and tested for perforations. Gloves were tested for size, site, and number of perforations among principal surgeons, assistant surgeons, and scrub nurses. Gloves were not changed during long surgical procedures and were changed only if perforations were identified and recorded. The DGs used were Maxitex Duplex, powder-free indicator gloves and the SGs were of Gammex-Ansell. One hundred unused gloves of each group were tested as controls. Medical records of the patients were reviewed for age, sex, type of operation, duration of operation, and any postoperative wound infection. The data were entered in database and analyzed using SPSS package. The data were compared between double and SGs using t test with a level of statistical significance at P less than 0.05. RESULTS: Five hundred twenty-six DGs and 316 SGs were tested. Forty-three perforations were detected in DGs (8.1%). Outer gloves were breached in 7.8% and inner in 0.3% as compared with SGs in which 28 (8.7%) were perforated. In DGs, 4% had multiple perforations compared with 11.9% in SGs. There was a statistical significance (P<0.001) when the perforations of inner gloves were compared with the SGs. None of the inner perforations were recognized during surgery, but the outer gloves of the DGs were recognized in 71% as compared with 9% in SGs (P<0.001). The majority of perforations were seen in the nondominant hand in surgeons and assistants hands, whereas scrub nurses had 85% of perforations in the dominant hand. The index finger was the site of perforations in DGs (53.4%; SGs, 43%). The inner gloves were breached only when the outer glove was found to be perforated. The duration of surgery had a direct impact on the number of perforations. There were no perforations in DGs in less than 60 minutes as compared with 3 (10.7%) in SGs. Between 60 and 120 minutes, the perforations in the DGs were 11, and in SGs, 21. During the study period, 4 patients had surgical site infection. Three were superficial and one deep-seated infection. In 3 patients with infection, the gloves were found to be perforated, and 1 patient with infection had no perforations in the gloves. CONCLUSION: Our study confirms that DGs are safer than SGs during pediatric orthopedic operations. In the event of nonavailability of DGs, SGs should be changed on an hourly basis during long procedures. Lastly, there exists a relationship between surgical site infection and glove perforations.

Jejunoileal causes of overt gastrointestinal bleeding: diagnosis, management, and outcome.

Major bleeding from the small intestine is uncommon and difficult to localize. We examined its etiologies and assessed available diagnostic and therapeutic approaches. The records of all adults undergoing operation for small intestinal hemorrhage over a 10-year period (1/89-12/98) were reviewed. There were eight men and four women with a mean age of 54 years. Six patients presented with arteriovenous malformations. Preoperative diagnosis was by endoscopy (three of six), scintigraphy (two of two), and/or angiography (two of six). Intraoperative panendoscopy was used for localization in 5 cases. Three other patients had tumors (leiomyoma, leiomyosarcoma, and adenocarcinoma) by CT scan (two) and/or scintigraphy (two). All were resected but one patient died of recurrence. Two patients underwent resection of a Meckel's diverticulum, one after angiographic diagnosis. Another patient with Crohn's disease had a positive angiogram and colonoscopy before resection. There were no operative deaths but major morbidity occurred in five patients (42%) and hospitalization averaged 17 days. We conclude that jejunoileal lesions are a rare cause of intestinal bleeding but can be associated with substantial morbidity. Arteriovenous malformations and tumors remain the most common causes. An accurate diagnosis and definitive management depend on selective preoperative imaging and judicious operative exploration.

A cost analysis of diabetic lower-extremity ulcers.

OBJECTIVE: Our objectives were to 1) estimate the prevalence of diabetes and diabetic lower-extremity ulcers in the Medicare population, 2) characterize Medicare population-specific costs for lower-extremity ulcer episodes, and 3) evaluate potential cost savings associated with better healing of lower-extremity ulcers. RESEARCH DESIGN AND METHODS: Prevalence and costs of diabetic lower-extremity ulcers were obtained by an analysis of Medicare claims data from 1995 and 1996 Standard Analytic Files (5% sample). RESULTS: Medicare expenditures for lower-extremity ulcer patients were on average 3 times higher than those for Medicare patients in general ($15,309 vs. $5,226). Lower-extremity ulcer-related spending accounted for 24% of total spending for lower-extremity ulcer patients. Most of the ulcer-related costs accrued on the inpatient side (73.7%); proportionately smaller amounts went to physicians and nursing home facilities. To determine the potential effect of better diabetic ulcer management, a model was created that estimated the impact on costs with improved healing rates. Improving the 20-week healing rate from 31 to 40% would save Medicare $189 per episode. CONCLUSIONS: Lower-extremity ulcers cost the Medicare system $1.5 billion in 1995. Any wound care intervention that could prevent even a small percentage of wounds from progressing to the stage at which inpatient care is required may have a favorable cost effect on the Medicare system.

Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries.

OBJECTIVE: To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receive Medicaid assistance and those who do not receive such aid. DATA SOURCES AND COLLECTION: 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration. STUDY DESIGN: We analyzed out-of-pocket spending through a Medicare Benefits Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well as indirect tax payments toward health care financing. PRINCIPAL FINDINGS: Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. The 75 percent of beneficiaries with incomes between 100 and 125 percent of the poverty level who were not enrolled in Medicaid spent an estimated 30 percent of their income out-of-pocket on health care if they were in the traditional program and about 23 percent of their income if they were enrolled in a Medicare HMO. Average out-of-pocket spending among fee-for-service beneficiaries varied depending on whether beneficiaries had Medigap policies, employer-provided supplemental insurance, or no supplemental coverage. Those without supplemental coverage spent more on health care goods and services, but spent less than the other groups on prescription drugs and dental care-services not covered by Medicare. CONCLUSIONS: While Medicaid provides substantial protection for some lower-income Medicare beneficiaries, out-of-pocket health care spending continues to be a substantial burden for most of this population. Medicare reform discussions that focus on shifting more costs to beneficiaries should take into account the dramatic costs of health care already faced by this vulnerable population.

The spine in sickle cell disease.

Bone changes in sickle cell disease occur due to marrow hyperplasia, tissue ischaemia and infarction due to vaso-occlusion. Between 1982 and 1991 thirty four patients were treated in the Orthopaedic and Neurosurgery Departments of the Kind Fahd University Hospital, Al-Khobar, with spinal complications due to sickle cell disease. There were 21 males and 13 females aged between 4 and 28 years (mean 17.4 years). Structural changes in the vertebral bodies due to marrow hyperplasia occurred in 44% of the patients. Avascular necrosis leading to collapse of the vertebral bodies was seen in 9 (27%) patients. Infective spondylitis was the most serious complication seen in 8 (24%) patients; the majority needed anterolateral decompression and bone grafting. The spine is often affected in sickle cell disease and aggressive treatment with close follow-up is required to avoid disabling complications.

The scud missile disaster in Al-Khobar, Saudi Arabia, 1991: the orthopaedic experience.

The orthopaedic experience of the scud missile disaster in Al-Khobar, Saudi Arabia during the Gulf war is reviewed. This was by far the most severe of 70 scud attacks. The majority of casualties had 'orthopaedic' injuries, fractures and soft tissue lacerations of the extremities and the back. Our experience confirmed the importance of the principles of planning triage beforehand and open wound treatment with secondary suture. Repeated ward rounds with reassessment of the patients proved beneficial. The ready availability of hospital beds in high-risk situations of regional war highly facilitated the management of mass casualties.

McMurray's test tested.

We studied the validity of McMurray's test for a torn meniscus in 93 patients. The clinical test results were compared with arthroscopic and/or arthrotomy findings as reference. The clinical test had a sensitivity of 58.5%, a specificity of 93.4%, and the predictive value of a positive result was 82.6%. The test therefore seems to be of limited value in current clinical practice.

Weight and height of Saudi children six to 16 years from the eastern province.

Measurements of weight and height of 21,638 Saudi boys and girls ages six to 16 years from the Eastern Province were taken. It was observed that the occurrence age of children could only be made out in Hegira years, as age is recorded by parents and at schools by the Hegira calendar. Age is a crucial factor in studies such as this and for valid comparison with any international reference standard, the latter must be adapted to the Hegira calendar year. Curves for weight and height percentiles for age have been constructed and compared with the Hegira adaptation of the NCHS growth standard.

The role of computerised tomography in the management of spinal tuberculosis.

Computerised axial tomography of the spine has been carried out in 56 patients with spinal tuberculosis; the extent of the bone and soft tissue involvement, spinal canal encroachment and neural compression were demonstrated. This accurate information made it possible to lay down guide lines for conservative and surgical management.

Congenital brachial palsy in the eastern province of Saudi Arabia.

The clinical features of 57 patients (31 males, 26 females) with congenital brachial palsy seen at the King Fahd Hospital of the University over a 5-year period are described. Delivery was difficult in 32 (56%), 20 (35%) were large babies (birth weight greater than 3,600 g), and 20 deliveries required either forceps or vacuum extraction. The presentation at delivery was vertex in 45, breech in five, and shoulder in four. Associated injuries or features, encountered in 14 cases, were fractures of the clavicle and humerus (six cases each), and skull fracture and Horner's syndrome in one patient each. The right and left sides were involved in 31 and 24 cases, respectively, and both sides in only two cases. All the muscle groups of the affected limb were most commonly involved (40%), and hand muscles alone were affected in only one patient. Although 60% of the cases presented late to the hospital, functional recovery was observed in 63%. The major predisposing factors identified in this study were technically difficult deliveries, large infants, and breech or shoulder presentation with assisted delivery. It is suggested that early identification of these factors and improvement in obstetric care of both the mothers and babies during delivery would reduce the incidence and severity of this disability.

Tuberculosis of the arch of the atlas. Case report.

This rare case of tuberculosis of the arch of atlas illustrates the potential difficulties in making a clinical diagnosis of tuberculosis of the upper cervical spine. Plain roentgenograms may not demonstrate an early lesion of the neural arch, and CT is a valuable adjunct. The use of a halo vest proved a successful alternative to operation in conferring stability to the spine during healing.

Squamous cell carcinoma in chronic osteomyelitis. Report of a case and review of the literature.

Malignant change at the site of a chronic osteomyelitis, a rare condition, is reported in a 45-year-old man, along with a review of the literature. This patient with a 30-year history of chronic osteomyelitis of the right femur and an intermittently discharging sinus had a large abscess in the lower thigh. The abscess was drained, and an ulcer developed at the mouth of the sinus tract. Soon afterward, he sustained a pathologic fracture through the lower femur. Biopsy specimens of the ulcer showed a well-differentiated squamous carcinoma. An amputation was performed at the level of the proximal 10 cm of the femur. The patient remains well 18 months later with no clinical or radiologic evidence of metastases. Changes in character of a previously innocuous osteomyelitis sinus tract should arouse suspicion of neoplastic transformation. Biopsy of various depths of the sinus tract, including the bone marrow, is essential. Early amputation for squamous cell carcinoma is indicated and offers a good prognosis.