Posttraumatic seizures

Posttraumatic epilepsy is one of the most clinically disturbing and, to date, difficult predictive factors associated with head trauma. The risk of developing seizures after head trauma depends on several factors. This article explores the mechanisms and biochemical effects of brain injury, their relationship to developing seizures, antiepileptic prophylaxis, and neuroprotective pharmacologic therapy.

Enzymic preparation of (3R-cis)-3-(acetyloxy)-4-phenyl-2-azetidinone: a taxol side-chain synthon

A key chiral intermediate [(3R-cis)-3-(acetyloxy)-4-phenyl-2-azetidinone (2)] for the semi-synthesis of paclitaxel (taxol; 5), an anti-cancer compound, was prepared by an enzymic process. The stereoselective enzymic hydrolysis of cis-3-(acetyloxy)-4-phenyl-2-azetidinone (1) to the corresponding (S)-(-)-alcohol (3) was carried out using various lipases. Lipase PS-30 (Pseudomonas cepacia) and BMS (Bristol-Myers Squibb) lipase (Pseudomonas sp. SC13856) catalysed hydrolysis of the undesired enantiomer of racemic compound 1, producing the (S)-(-)-alcohol (3) and the desired (R)-(+)-acetate (2). Reaction yields of > 96% and optical purities of > 99.5% were obtained. For a very efficient enzyme source (BMS lipase), a lipase fermentation using Pseudomonas sp. SC13856 was developed. In a fed-batch process using soybean oil, the fermentation resulted in 1500 units of extracellular lipase activity/ml. Crude BMS lipase (1.7 kg, containing 140,000 units/g) was recovered from the filtrate by ethanol precipitation. BMS lipase and commercially available lipase PS-30 were independently immobilized on Accurel polypropylene. These immobilized lipases were re-used (ten cycles) without loss of enzyme activity, productivity or optical purity of the product. The enzymic reaction process was scaled up to 75 and 150 litres using immobilized BMS lipase and lipase PS-30 respectively. From the reaction mixture, compound 2 was isolated in 88-90 mol% yield and 99.5% optical purity. A purity of 99.9 (area %) was demonstrated by g.c. for isolated compound 2.

Obtaining access in patients with indwelling vascular access devices

Chronic indwelling catheters are used increasingly for outpatient and inpatient therapy. Because more patients care for indwelling devices at home, indwelling lines are available to emergency department staff to draw blood and administer medications, blood products, and intravenous fluids. This article discusses the indications, complications, and methods of accessing chronic indwelling venous catheters.

Effect of the ingestion of heliotrope and copper on the concentration of zinc, selenium and molybdenum in the liver of sheep

Merino wethers were used to examine the effect of feeding heliotrope, with and without additional copper (Cu), on the development of clinical signs, lesions in the liver and concentration in the liver of Cu, zinc (Zn), selenium (Se) and molybdenum (Mo). The feeding of heliotrope reduced liver concentrations of Zn (P < 0.05) and Mo (P < 0.01), but Cu ingestion had no effect on these parameters. The concentration of Se in the liver was only increased when heliotrope was given with copper (P < 0.01); it had previously been shown that Cu and heliotrope ingestion is followed by an interaction which results in a marked increase in the concentration of Cu and the production of extensive lesions in the liver. The increase in liver Se may therefore have represented a passive or active response to liver necrosis, whereas effects on Zn and Mo represented specific metabolic disturbances attributable to heliotrope feeding.

Bovine glycogenosis type II: the molecular defect in Shorthorn cattle

The molecular defect in Shorthorn cattle affected with glycogenosis type II was studied. Polyclonal and monoclonal antibodies specific for bovine skeletal muscle acid alpha-glucosidase were raised and used to study the molecular and biochemical defect in seven affected animals. Cultured normal bovine fibroblasts pulsed and chased with [3H] leucine produced a 130 kDa precursor form of acid alpha-glucosidase which was processed via several 100 kDa intermediate forms to the 65 kDa mature form within 26 h. Fibroblasts from affected animals were labelled in vitro and were shown to produce a cross-reactive protein which was identified as the precursor form of the enzyme. The mature form of the enzyme was not found. The precursor form of the enzyme was demonstrated in Western blots of muscle tissue extracts from affected animals. Glycogenosis type II in Shorthorn and Brahman cattle must be caused by a different, independent maturation, since Brahman cattle lack the cross-reactive protein for acid alpha-glucosidase.

The pathology and trace element status of the toxic milk mutant mouse

The toxic milk (tx) mouse is a mutant in which copper metabolism is abnormal. Homozygous tx adults do not show overt signs of disease, but litters born to such parents are deficient in copper and die at about 2 weeks of age unless copper is provided. The results reported here clearly indicate that adults accumulate copper in the liver, kidney, spleen, brain, muscle, serum and red blood cells. The concentration of zinc is also elevated in liver, brain and muscle. In adult animals there is damage to hepatocytes with marked changes to the nuclei. Haemolysis occurs with subsequent deposition of haemosiderin in the kidney. This mutant provides a useful model for studies of the pathogenesis and treatment of copper toxicity in animals and man.

Effect of scrubbing and irrigation on staphylococcal and streptococcal counts in contaminated lacerations

We studied the effects of scrubbing with poloxamer 188 (SCR), irrigating with povidone iodine (PI), and scrubbing followed by irrigation (SCR-PI) on staphylococcal and streptococcal counts in inoculated guinea pig lacerations. PI irrigation and SCR-PI significantly lowered streptococcal counts (P < 0.05). Staphylococcal counts were not different from those in controls.

A radiographic comparison of short-arm cast and plaster and fiberglass wrist splints

Prepackaged plaster and fiberglass splints are used in many emergency departments. This study evaluated the effectiveness of short-arm cast (SAC), volar fiberglass wrist splint (FWS), and volar plaster wrist splint (PWS) in limiting wrist range of motion. Ten healthy male volunteers between the ages of 18 and 35 years were included. Each wrist on each volunteer was immobilized with SAC, FWS, and PWS. Wrist radiographs were taken with each appliance and angular motion measured by two radiologists. PWS performed better than FWS in flexion, extension, radial deviation, and ulnar deviation (all P < .05). PWS was not statistically different than SAC in limiting flexion, extension, or radial deviation, although SAC performed better in ulnar deviation (P < .05). PWS limits wrist motion more effectively than FWS and performs in a similar manner to SAC in flexion, extension, and radial deviation.

The hopes and hazards of health goals development

As part of the Edmonton Board of Health's centennial celebrations, health goals and objectives were developed for the city. The intensely collaborative process used to develop the goals and objectives is reviewed and critical activities such as communication, media and community involvement, committee membership, and implementation are discussed. It is hoped that the information will be useful for others who are developing health goals and objectives at the municipal level.

Effect of thiomolybdate and ammonium molybdate in pregnant guinea pigs and their offspring

Groups of eight guinea pigs and their offspring were given drinking water containing molybdenum as ammonium molybdate (AM) or thiomolybdate (TM) throughout and subsequent to pregnancy. All adult females had oestrous cycles and conception rates were unaffected. Fetal death was common in groups given the high dose of TM. The concentration of copper in liver was reduced in all groups at all ages except for pups killed at birth from animals given AM. The concentration of molybdenum was elevated in liver and kidney of all groups and was statistically significant in the majority. The concentration in plasma of copper, molybdenum and copper insoluble in trichloroacetic acid was elevated in all groups. Superoxide dismutase activity was significantly reduced in dams and six-week-old pups in which TM administration commenced before mating. Histological damage occurred in the pancreas of animals given AM or TM. The effects on the fetus and pancreas were considered to result from copper deficiency rather than molybdenum toxicity.

The effect of scrubbing and irrigation with normal saline, povidone iodine, and cefazolin on wound bacterial counts in a guinea pig model

This study examines the effects of povidone iodine, normal saline, and cefazolin alone and after scrubbing on bacterial counts in contaminated animal lacerations. Twelve albino guinea pigs each received four lacerations inoculated with a standard inoculum of Staphylococcus aureus. Twelve hours after inoculation, each wound was biopsied to ensure contamination and then either treated or left as an untreated control. One wound on each animal was an untreated control. The remaining three lacerations on six pigs were irrigated with cefazolin (CZ) solution, normal saline, or 1% (wt/vol) povidone iodine solution (PI). Three lacerations on another six pigs were treated with 20% poloxamer 188 scrub (scrub) alone, scrub followed by PI irrigation (SCR/PI), or scrub followed by CZ irrigation (SCR/CZ). Quantitative bacteriology was performed on tissue biopsies 2 hours (time 1), 7 hours (time 2), and 12 hours (time 3) after irrigation. Posttreatment counts for PI, CZ, and normal saline irrigation were not different from control or one another (P > .05). Bacterial counts for SCR/PI were significantly lower than control (P < .05) for all posttreatment biopsies (1.8 to 2.9 mean log(10) decrease). SCR/CZ was significantly lower than control (P < .05) at times 2 and 3 only (1.7 to 2.0 mean log(10) decrease). In this guinea pig model, cleansing 12-hour-old lacerations contaminated with S aureus using SCR/PI or SCR/CZ significantly reduced bacterial counts over 12 hours.

Mesothelioma in horses

Pleural mesothelioma and pericardial mesothelioma with spread to the pleural cavity were diagnosed in 2 horses. Clinical signs included respiratory distress, depression and pleural pain. The affected body cavities contained copious, serous effusions containing very large neoplastic mesothelial cells with densely-staining cytoplasm, hyperchromic nuclei and prominent, often multiple, nucleoli. Ultrastructurally, the neoplastic cells appeared as solid aggregates, with profuse microvillous borders and neolumen formation. Cytological examination, together with confirmative ancillary diagnostic tests, including electron microscopy and immunocytochemistry, may be used to obtain an ante-mortem diagnosis of mesothelioma.

Current and future trends in wound healing

New adjuncts to outpatient wound care focus on diminishing infection rates and improving the speed and effectiveness of laceration repair. This article provides an overview of growth factors, proteolytic enzymes, topical antimicrobial agents, and new materials that facilitate wound closure. Also, the pathophysiology of surface wound repair is summarized.

The effect of copper and heliotrope on the composition of bile in sheep

The effects of interrupting the enterohepatic circulation (EHC) of bile salts for seven hours and of feeding copper and heliotrope alone and combined for 13 weeks, on bile flow and excretion of copper, zinc, iron and alpha-mannosidase were studied in sheep. Interruption of EHC reduced bile flow rate and increased the concentration of copper, zinc, iron and bile acids while alpha-mannosidase's activity remained stable. Changes in concentration were related to changes in bile volume for copper and zinc only. Total output per hour was not changed. Biliary concentration of copper correlated with alpha-mannosidase's activity in control sheep and those given copper or heliotrope, supporting the hypothesis that lysosomes are involved in biliary secretion of copper in sheep. Increasing the intake of copper increased the rate of excretion of copper in bile. Copper output was lower when heliotrope was fed alone.

Steroids for the treatment of corrosive esophageal injury: a statistical analysis of past studies

Caustic esophageal injury causes substantial morbidity and mortality. However, the use of corticosteroids to treat this problem has been evaluated in a limited number of studies because adequate sample size is difficult to obtain. We analyzed 361 subjects with corrosive esophageal injury derived from 10 retrospective and three prospective publications. We divided cases into those treated with corticosteroids and antibiotics (T) and those that received neither modality (NT) based on inclusion and exclusion criteria. Forty-one percent of NT cases developed esophageal stricture and 19% of T cases developed this complication (P less than .01). There were no reported strictures among 72 first-degree esophageal burns (combined T and NT cases). The T group contained 54 strictures among 228 patients (24%) with either second- or third-degree burns. The NT group of 25 patients with the same burn severity suffered 13 strictures (52%) (P less than .01). Reports of death and gastrointestinal hemorrhage did not increase among steroid-treated patients. We do not recommend corticosteroid therapy for first-degree esophageal injuries. However, this therapy may be useful in preventing strictures among patients with second- or third-degree corrosive esophageal burns.

Outpatient wound preparation and care: a national survey

STUDY OBJECTIVE

To sample the practice styles of emergency physicians caring for acute traumatic wounds.

DESIGN

Written survey.

SETTING

US emergency departments obtained from the American College of Emergency Physicians mailing list.

SUBJECTS

Randomly selected ACEP members.

MAIN RESULTS

One hundred fifty-one of 285 (53%) survey mailings were returned. Eighty-six percent of respondents were primarily clinicians, and the majority (61.6%) worked in EDs with annual patient visits between 21,000 and 50,000. The majority of respondents (64.2%) were certified by the American Board of Emergency Medicine. Nineteen percent managed wounds based on provider preference despite the existence of written wound management protocols. We identified a variety of practices that are contrary to current literature and textbook recommendations. Fifty-eight (38%) soaked wounds, whereas 21% used either 10% povidone iodine or hydrogen peroxide to cleanse wounds. One hundred one (67%) scrubbed the entire wound surface using, among other methods, cotton gauze (59%) or a coarse, bristle-laden sponge (38%). Forty (27%) irrigated wounds using techniques that have not been proven to deliver the 5 to 8 psi necessary for adequate tissue cleansing. Delayed primary closure, a treatment option for lacerations at increased risk for infection, was infrequently or never practiced by 76% of respondents. All respondents administered IV antimicrobials at least occasionally for simple outpatient lacerations.

CONCLUSION

Methods of preparing, treating, and following outpatient wounds vary among emergency physicians, and these results support the idea that no de facto standard of care exists for this clinical problem. Outpatient wound care techniques routinely practiced (ie, soaking, scrubbing, use of full-strength hydrogen peroxide or full-strength povidone iodine) may be harmful based on limited animal and human research, whereas other proven techniques (ie, delayed primary closure) are infrequently practiced by many emergency physicians.

Xiphodynia: a report of three cases

Xiphodynia is an uncommon musculoskeletal disorder that mimics a number of common abdominal and thoracic diseases. We report three cases of xiphodynia. The diagnosis is suggested when a given patient's chest or abdominal discomfort is completely or almost completely reproduced with light pressure on the xiphoid process. Local injection with an anesthetic-steroid combination is frequently curative. No more than 5 to 7 mL of solution should be injected, and results are variable when several trigger points are found on the anterior chest wall. Tack hammer deformity of the xiphoid, another cause of xiphoid pain, has been successfully treated with surgical excision.

Alkalinity of non-industrial cleaning products and the likelihood of producing significant esophageal burns

Alkaline cleaning products are a cause of serious esophageal injury. Over time, legislation has diminished the concentration of many such non-industrial solutions and solids; however several products presently do not list either the pH or relative concentrations of alkaline constituents. This study measures the pHs of several non-industrial cleaning products containing either ammonium chloride, sodium hydroxide, or potassium hydroxide. Three pH measurements were performed on each of 10 non-industrial alkaline cleaning products (eight liquid, two solid). Two 0.1% ammonium chloride solutions had pHs of 12.06 +/- 0.00 and 12.06 +/- 0.01, whereas a pH of 12.43 +/- 0.00 was recorded in a 0.2% ammonium chloride solution. Concentrations of sodium hydroxide and potassium hydroxide were listed on only one of five liquid cleaning product labels. The pHs for these five products varied between 12.83 +/- 0.009 and 13.5 +/- .0.2. The pHs of three sodium hydroxide solutions differed from values reported in Micromedex (Micromedex Inc, Denver CO) by up to 0.32 pH units. Ten percent (v/v) solutions of two solid lye products had pHs of 13.62 +/- 0.008 and 13.74 +/- 0.02. The investigator found that selected non-industrial cleaning products, including ammonia solutions, retain the ability to cause clinically important esophageal damage.