Trigeminal neuralgia

Trigeminal neuralgia (TN) is the most common facial neuralgia, and is considered to be one of the most painful conditions to affect patients. The rate of occurrence of TN in men and women is 2.5 and 5.7 per 100,000 per year respectively. TN is generally characterized by lancinating, unilateral, paroxysmal pain occurring in the distribution of the fifth cranial nerve. The diagnosis of TN is made clinically by excluding other possible causes of facial pain and is based on signs and symptoms from the patient history such as a trigger zone, typical unilateral lancinating paroxysms following neural disturbance, and a refractory period. Generally, TN can be diagnosed by the typical patient history, a negative neurologic exam, and response to a trial of carbamazepine. Imaging studies should be considered if the diagnosis is uncertain or neurologic abnormalities are noted. Most cases are caused by compression of the trigeminal nerve root, usually within a few millimeters of entry into the pons. In a few cases, TN is caused by a primary demyelinating disorder. The treatment modalities for the management of TN may be divided into medical, surgical, and gamma-knife radiosurgery. Generally, response to drug therapy is good, with over 80% of patients responding to some of the anticonvulsants. Percutaneous approaches to trigeminal gangliolysis are considered to have less associated risk and less cost than open surgical procedures. Three different techniques may be used to perform percutaneous destruction of the ganglion: percutaneous radiofrequency trigeminal gangliolysis (PRTG), percutaneous balloon microcompression (PBM), and percutaneous retrogasserian glycerol rhizotomy (PRGR). Open surgical procedures used in the treatment of TN include microvascular decompression of the trigeminal root and retrogasserian rhizotomy. Additionally, because both of these procedures have greater associated risks, morbidity, and mortality, they are customarily applied only to younger patients in good health. Stereotactic radiosurgery has been established as an alternative treatment for patients who do not respond to optimal medical management.

Multicenter comparative trial of the V-scope system for therapeutic ERCP

BACKGROUND AND STUDY AIMS

A new duodenoscope (the V-scope), with a modified elevator used in combination with a dedicated short guide wire, constitutes the V-system. This system is intended to allow fixation of the guide wire at the elevator lever, thereby enhancing the speed and reliability of accessory exchange over a guide wire during ERCP. The aim of this study was to evaluate the extent to which the V-system provides improved efficiency in comparison with conventional duodenoscope and guide wire combinations.

PATIENTS AND METHODS

This was an industry-sponsored multicenter randomized trial. Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) procedures in which treatment was anticipated were randomly assigned to the V-system or to a conventional duodenoscope and accessories used routinely in each center. The parameters recorded included the total case time, fluoroscopy time, catheter/guide wire exchange time, guide wire repositioning, loss of guide wire access, and success or failure of guide wire fixation when using the V-system.

RESULTS

Fifty patients were included, 22 in the conventional group and 28 in the V-system group. A total of 135 exchanges were carried out. The patients had up to six exchanges. The median exchange time was 19.4 s with the V-system and 31.7 s with the conventional systems ( P < 0.001). Guide wire repositioning was required less often in the V-system group ( P = 0.0005). The V-system effectively locked the guide wire in 63 of 71 exchanges (89 %). Loss of guide wire access occurred in two patients in the conventional group and four in the V-system group, attributable to failure to lock the guide wire early during the experience (no significant differences).

CONCLUSIONS

The V-system can effectively secure the guide wire during accessory exchange in ERCP and reduces the time required to exchange accessories. This may enhance overall efficiency during ERCP.

Scientific basis for the selection of absorbent underpads that remain securely attached to underlying bed or chair

The occurrence of pressure ulcers in patients is very high in certain high-risk groups. These special high-risk groups include elderly patients, patients with spinal cord injuries, or any individual with an impaired ability to reposition. Prevention of pressure ulcers is by far the best treatment of this condition, warranting certain interventions and preventive measures. One major risk factor to be minimized is the exposure of skin to moisture. Underpads are often used to protect the skin of patients who are incontinent. These products effectively absorb moisture and present a quick-drying surface to the skin. The construction of an underpad should accomplish three goals. First, its backing should have a low coefficient of friction to prevent frictional skin injuries. Second, an inner absorbent core should rapidly contain moisture and disseminate it throughout the entire pad. Third, the core and coverstock should successfully work together to retain moisture and prevent wet-back or fluid return. The purpose of this study was to determine the performance of three commercially available underpads in reducing the development of pressure sores in patients at high risk. In this study we selected three underpads that could be securely attached to either the underlying bed or the chair. The three performance parameters examined were absorbent capacity, wetback prevention, and holding security of the underpads. Measurements of these performance parameters can be easily replicated in other laboratories. The results of these studies provide a scientific basis for selecting and purchasing an underpad to prevent pressure ulcers in patients. In this comprehensive evaluation, we assess an absorbent underpad with polyethylene flaps and two absorbent underpads with adhesive. The absorbent capacity results showed Tranquility SlimLine Peach Sheet to be the most absorbent. The wet-back results showed Tranquility SlimLine Peach Sheet to be the only underpad with no wet-back, with no fluid returning through the coverstock. The Tranquility SlimLine Peach Sheet Underpad has four adhesive strips attached to each of the four ends of the underpad surface. These 5 cm long strips secure well to the seat of a wheelchair or chair. In contrast, they do not maintain secure attachment to a bed sheet, making the bed sheet vulnerable to urine or stool penetration. When the clinical staff used the Tuckable on the bed surface, they were all impressed by the secure fit of the plastic wings, which easily tucked around the mattress. The wings remained in place throughout the night. Realizing the stability of the Tuckable underpads, the clinical staff suggested that the Tuckable underpad be placed first on the bed, then the Tranquility SlimLine Peach Sheet can be placed on top of the Tuckable underpad, using the four adhesive strips to attach it to the surface of the Tuckable underpad. All of the staff were impressed that the adhesive strips remained securely attached to the Tuckable. This clinical decision was found to be very cost efficient, because the Tuckable could remain in place more than a week without changing. Even though we have developed a unique scientific basis for the selection of underpads for use on either chairs or beds, it can be a financial challenge to the patient or healthcare setting to use these products, because Medicare provides no reimbursement for underpads, an invitation to pressure ulcer formation. In the absence of responsible federal government policy, we are making recommendations for the selection of a cost-conscious and responsible company that sells incontinence products--Home Deliver Incontinent Supplies Co., Inc., (HDIS), Olivette, Missouri.

Revolutionary advances in medical waste management. The Sanitec system

It is the purpose of this collective review to provide a detailed outline of a revolutionary medical waste disposal system that should be used in all medical centers in the world to prevent pollution of our planet from medical waste. The Sanitec medical waste disposal system consists of the following seven components: (1) an all-weather steel enclosure of the waste management system, allowing it to be used inside or outside of the hospital center; (2) an automatic mechanical lift-and-load system that protects the workers from devastating back injuries; (3) a sophisticated shredding system designed for medical waste; (4) a series of air filters including the High Efficiency Particulate Air (HEPA) filter; (5) microwave disinfection of the medical waste material; (6) a waste compactor or dumpster; and (7) an onboard microprocessor. It must be emphasized that this waste management system can be used either inside or outside the hospital. From start to finish, the Sanitec Microwave Disinfection system is designed to provide process and engineering controls that assure complete disinfection and destruction, while minimizing the operator's exposure to risk. There are numerous technologic benefits to the Sanitec systems, including environmental, operational, physical, and disinfection efficiency as well as waste residue disinfection. Wastes treated through the Sanitec system are thoroughly disinfected, unrecognizable, and reduced in volume by approximately 80% (saving valuable landfill space and reducing hauling requirements and costs). They are acceptable in any municipal solid waste program. Sanitec's Zero Pollution Advantage is augmented by a complete range of services, including installation, startup, testing, training, maintenance, and repair, over the life of this system. The Sanitec waste management system has essentially been designed to provide the best overall solution to the customer, when that customer actually looks at the total cost of dealing with the medical waste issue. The Sanitec system is the right choice for healthcare and medical waste professionals around the world.

Avian Flu Pandemic in the United States. The Sanitec Industry's Solution

On the basis of the extensive testing of the Sanitec Industries, Inc. waste management system by the North Carolina State University, the authors of this Editorial strongly recommend the immediate implementation of the Sanitec medical waste disinfection system throughout the United States to prevent the potential pandemic of the Avian Flu viral infection.

Physical Fitness Assessment: An Update

The American College of Sports Medicine (ACSM) gives the following definition of health-related physical fitness: Physical fitness is defined as a set of attributes that people have or achieve that relates to the ability to perform physical activity. It is also characterized by (1) an ability to perform daily activities with vigor, and (2) a demonstration of traits and capacities that are associated with a low risk of premature development of hypokinetic diseases (e.g., those associated with physical inactivity). Information from an individual's health and medical records can be combined with information from physical fitness assessment to meet the specific health goals and rehabilitative needs of that individual. Attaining adequate informed consent from participants prior to exercise testing is mandatory because of ethical and legal considerations.A physical fitness assessment includes measures of body composition, cardiorespiratory endurance, muscular fitness, and musculoskeletal flexibility. The three common techniques for assessing body composition are hydrostatic weighing, and skinfold measurements, and anthropometric measurements. Cardiorespiratory endurance is a crucial component of physical fitness assessment because of its strong correlation with health and health risks. Maximal oxygen uptake (VO2max) is the traditionally accepted criterion for measuring cardiorespiratory endurance. Although maximal-effort tests must be used to measure VO2max, submaximal exercise can be used to estimate this value. Muscular fitness has historically been used to describe an individual's integrated status of muscular strength and muscular endurance. An individual's muscular strength is specific to a particular muscle or muscle group and refers to the maximal force (N or kg) that the muscle or muscle group can generate. Dynamic strength can be assessed by measuring the movement of an individual's body against an external load. Isokinetic testing may be performed by assessing the muscle tension generated throughout a range of motion at a constant angular velocity. The ability of a muscle group to perform repeated contractions over a specific period of time that is sufficient to cause fatigue is termed muscular endurance. Musculoskeletal flexibility evaluations focus on the joints and associated structures, ligaments, and muscles that cross the joints. The sit-and-reach test and the behind-the-back reach test satisfy many of the criteria for physical assessment of musculoskeletal flexibility. A physical fitness assessment must be integrated into all activities of daily living, as well as the physician's examination, to assess and promote health.

Syneture stainless STEEL suture. A collective review of its performance in surgical wound closure

Syneture (division of U.S. Surgical, division of Tyco Healthcare, Norwalk, Connecticut, USA) STEEL sutures are monofilament stainless steel sutures composed of 316L stainless steel conforming to ASTM Standard F138 grade 2 (" Stainless steel bar and wire for surgical implant"). STEEL sutures meet all requirements established by the United States Pharmacopeia (USP) for nonabsorbable surgical sutures. Steel sutures are for use in abdominal wound closure, intestinal anastomosis, hernia repair, sternal closure, and skin closure. They are attached to the following types of surgical needles: Roto-Grip Needles and SCC Needle. The sutures and needles are packaged in a Mylar/Tyvek outer envelope. The purposes of this clinical review are two fold. First, we will report the performance of the Syneture STEEL suture product in the largest studies of suture performance ever reported in the literature. In addition, we will provide comprehensive information from the surgical literature that highlights the unique benefits of stainless steel sutures for the following wound closure techniques: sternal fixation, abdominal wound repair, inguinal hernia repair, and skin wound closure. Consorta Inc. (Rolling Meadows, Illinois), a leading healthcare resource management group purchasing organization, and Syneture, jointly with a clinician task force, designed a reproducible surgical evaluation program for needles and sutures in a large cooperative of healthcare systems. Because of the subjective nature of the more commonly used suture selection techniques, a nonexperimental observational study approach was designed to replace perception of performance characteristics with actual clinical experience. In a report involving 19 Consorta shareholder hospitals, they discussed the preliminary part (Phase I) of a large nonexperimental observational study of the clinical performance of surgical needles and sutures. Performance characteristics of the sutures and needles produced by Syneture that were evaluated in 3407 surgical procedures included packaging/ease of opening, needle strength and sharpness, tissue drag, knot security, tensile strength, clinically acceptable determinations, and clinically unacceptable determinations. In this preliminary study, the surgeons concluded that the needles and sutures were clinically acceptable in 98.1% of the evaluations. Armed with this favorable experience, we wanted to expand this observational study to an entirely new group of shareholder hospitals that had a larger number of participating hospitals (Phase I, 19 hospitals; Phase II, 42 hospitals). This more than doubling of hospital observational base dramatically increased the number of patients and performance evaluations. In the Phase II expanded program involving 42 hospitals, the number of patients (8939) and the number of evaluations (25,545) were more than twofold the preliminary study. In the phase I multicentric evaluation of Syneture surgical sutures, the performance of 9266 sutures was evaluated. Of these performance evaluations, 130 evaluations focused on Syneture STEEL sutures. The surgeons were especially pleased by the performance of this suture product, with 129 Syneture STEEL products being judged as clinically acceptable in their performance. Only one Syneture STEEL suture was judged to be unacceptable in its performance, resulting in a 99.2% acceptability rating. In the expanded phase II evaluation of Syneture suture products, the performance evaluation involved 25,545 surgical suture evaluations. The performance of Syneture STEEL sutures was judged in 215 cases. Of these product performance evaluations, 207 were judged to be clinically acceptable in their performance (96.3%). It is important to emphasize that the phase I and phase II observational studies evaluated the performance of other sutures besides monofilament steel sutures. These comprehensive suture and needle performance evaluations included the following additional sutures: Plain Gut, Mild Chromic Gut, Chromic Gut, DEXON II, DEXON S, MAXON, BIOSYN, SOFSILK, SURGILON, BRALON, MONOSOF, DERMALON, SURGIDAC, POLY-SORB, TI.CRON, SURGIPRO, SURGIPRO II, NOVAFIL, VASCUFIL, and FLEXON. Finally, we provide a collective review of the literature that shows the reliable performance of monofilament stainless steel sutures in the following wound closure techniques: sternal fixation, abdominal wound closure, inguinal hernia repair, and skin wound closure.

Rubella and congenital rubella (German measles)

Rubella, also known as German measles, is usually a very mild infection that can have devastating effects in certain instances. It is a pleomorphic RNA virus in the Togaviridae family of the genus Rubivirus. It typically causes a scarletiniform rash, cervical lymphadenopathy, and mild constitutional symptoms, but in older children and adults, especially women, it may be more severe, with joint involvement and purpuric rash. Infection during the first 12 weeks of pregnancy results in congenital infection and/or miscarriage in 80-90% of cases. The congenital rubella syndrome (CRS) involves multiple organ systems and has a long period of active infection and virus shedding in the postnatal period. For these reasons, the rubella vaccine program was instituted in 1969, and the incidence of rubella infection in the United States has since declined by 99%. Rubella has been recognized as a disease for approximately 200 years, and it has since been found that humans are the only natural reservoir for the rubella virus. Virus is present in nasopharyngeal secretions, blood, feces, and urine during the clinical illness, although patients with subclinical disease are also infectious. The virus is spread via oral droplets and is shed in the nasopharynx for approximately 7 days before and after the rash is visible. CRS includes a configuration of anomalies, including nerve deafness, cataracts, cardiac anomalies (usually pulmonary artery and valvular stenosis, and patent ductus arteriosis), and mental retardation, with late complications including diabetes, thyroid disease, growth hormone deficiency, and progressive panencephalitis. In 1969, the first rubella vaccine was licensed for use, and the Centers for Disease Control and Prevention (CDC) began its National Congenital Rubella Syndrome Registry. As required under the National Childhood Injury Act, all healthcare providers in the United States who administer any vaccine shall, prior to administration of the vaccine, provide a copy of the Vaccine Information Statements (VIS) produced by the CDC to the parent or legal representative of any child to whom the provider intends to administer such vaccine, or to any adult to whom the provider intends to administer such vaccine. Despite efforts to vaccinate children, CRS continues to occur in the United States. Hispanic infants have an increased risk of CRS. HIV-1infected children with a preserved immune system and MMR immunization had a good response to rubella vaccine. In contrast, those in more advanced categories for HIV infection responded poorly. Issues of risk, choice, and chance are central to the controversy over the MMR vaccine that erupted in the UK in 1998, and has continued into the new millennium. An important contribution to the MMR controversy has come from the parents of autistic children, some of whom reject the notion that this disorder is a random genetic misfortune and insist that it is, at least in part, the result of some environmental insult, such as MMR vaccinations.

Difficult wounds: an update

The purpose of this collective review is to describe revolutionary advances in the treatment of Gardner's syndrome (GS), pseudofolliculitis barbae, nasal septal perforation, factitious wounds, and hidradenitis suppurativa (HS). Gardner's syndrome or familial polyposis has various manifestations that appear to be controlled by a single genetic locus. Apart from the large bowel adenomas, which are always present, a common extracolonic symptom of Gardner's syndrome is the occurrence of epidermal cysts. These cysts can be seen before the intestinal polyps are evident. Because epidermal cysts in patients with Gardner's syndrome are always benign, we excise these cysts using incisions that are commonly used for rhytidectomy. Pseudofolliculitis barbae, a pseudofolliculitis caused by ingrown hairs, effects 85% of blacks who shave their beards. When this disease is allowed to progress to keloid formation, we use a surgical approach that includes excision of the keloidal scar, meticulous debridement of all residual ingrown hairs in the underlying wound, and coverage of the defect with a split-thickness skin graft. More recently, laser therapy has revolutionized the treatment of pseudofolliculitis barbae and has enabled a cure for the first time for those plagued with this disorder and for whom a beardless face is acceptable. Nasal septal perforation is a well recognized complication of septal surgery. Other iatrogenic causes of perforation include cryosurgery, electrocoagulation for epitaxis, nasotracheal intubation, or nose packing. In recent years drugs such as cocaine account for an increasing number of perforations. It has only been with the use of an external approach for the repair of the nasal septal defect that surgical closure has become easier and more reliable. The external approach allows for greater surgical closure and enables the surgeon to use both hands with the aid of binocular vision to mobilize and suture local mucosal advancement flaps and the intraseptal connective tissue grafts. More recently, surgeons have repaired large septal perforations with a radial forearm free flap. Because of its availability and deep emotional significance, the skin is a common site for self-destructive behavior with the development of factitious skin wounds. When suspected, psychiatric care must proceed immediately. Second, the ulcer can then be healed by appropriate techniques and wound repair. It is important to emphasize that the treating physician must first confront the patient, and then a psychiatrist should provide appropriate psychotherapy. Hidradenitis suppurativa is an inflammatory disease of the skin and subcutaneous tissue that occurs in apocrine-gland-bearing areas distributed in the axilla, mammary nipple areola, mons pubis, groin, scrotum, perineum, perianal region, and umbilicus. The condition has an insidious onset. The susceptibility of women's axillary skin to hidradenitis suppurativa may be related, in part, to the practice of axillary removal of hair with a safety razor. Consequently, the use of safety razors must be avoided and replaced with the use of an electric razor. The method of treatment will vary with the stage of the disease. Treatment of the chronic stage of axillary hidradenitis suppurativa is primarily surgical. More recently, carbon dioxide laser treatment, with healing by secondary intention, is proving to be a rapid, efficient, and economic treatment of this difficult wound.

Precise formulation and evidence-based application of resource-constrained triage

OBJECTIVES

To develop a precise mathematical formulation of resource-constrained triage, denoted the Sacco triage method (STM), to develop an evidence-based application to blunt trauma, and to compare the STM with the simple triage and rapid treatment (START) method.

METHODS

Resource-constrained triage is modeled mathematically as a classic resource allocation problem. The objective is to maximize expected survivors given constraints on the timing and availability of resources. The model incorporates estimates of time-dependent victim survival probabilities based on an initial assessment and expected deterioration. For application to blunt trauma, an "RPM" score, based on respiratory rate, pulse rate, and motor response, was used to predict survivability. Logistic function-generated survival probability estimates for scene values of RPM were determined from 76,459 blunt-injured patients from the Pennsylvania Trauma Outcome Study (PTOS). The Delphi method provided expert consensus on victim deterioration rates, and the model was solved using linear programming. STM was compared with START across various criteria of process and outcome. Outcome was measured by expected number of survivors in simulated resource-constrained casualty incidents.

RESULTS

In this mathematical simulation, RPM was a more accurate predictor of survivability from blunt trauma than the Injury Severity Score and the Revised Trauma Score, as measured by calibration and discrimination statistics. STM resulted in greater expected survivorship than START in all simulations.

CONCLUSIONS

Resource-constrained triage is modeled precisely as an evidence-based, outcome-driven method that maximizes expected survivors in consideration of resources. The lifesaving potential and operational advantages over current methods warrant scrutiny and further research.

Use of treated woods in roof assembly

On February 12, 2002, the US Environmental Protection Agency (EPA) announced a voluntary decision by industry to move consumer use of treated lumber products away from a variety of pressure-treated wood that contains Arsenate (As) by December 31, 2003, in favor of new alternative wood preservatives. It is the purpose of this report to outline legislative efforts to ban the use of chromated copper arsenate (CCA)-treated wood for residential roofing in the State of Oregon. At the time that the legislation was introduced, it was coincidental that the National Roofing Contractors Association (NRCA) recommended that CCA-treated wood should not be used in residential roofing. A summary of the report is included in this review. Finally, we discuss some of the potentially harmful environmental hazards of wood preservatives on the environment. In addition to the toxicity of pressure-treated wood on our environment, we point out that wood as well as pressure-treated wood assemblies are highly flammable. Consequently, we recommend the use of residential roofing systems that have Class A fire protection for the homeowner. Because residential roof fires remain a life-threatening danger to residential homeowners in the United States, we describe a national fire prevention program for reducing residential roof fires by use of an Underwriters Laboratories Inc. (UL) and National Fire Protection Association Class A fire-rated roof system.

Modern concepts of treatment and prevention of lightning injuries

Lightning is the second most common cause of weather-related death in the United States. Lightning is a natural atmospheric discharge that occurs between regions of net positive and net negative electric charges. There are several types of lightning, including streak lightning, sheet lightning, ribbon lightning, bead lightning, and ball lightning. Lightning causes injury through five basic mechanisms: direct strike, flash discharge (splash), contact, ground current (step voltage), and blunt trauma. While persons struck by lightning show evidence of multisystem derangement, the most dramatic effects involve the cardiovascular and central nervous systems. Cardiopulmonary arrest is the most common cause of death in lightning victims. Immediate resuscitation of people struck by lightning greatly affects the prognosis. Electrocardiographic changes observed following lightning accidents are probably from primary electric injury or burns of the myocardium without coronary artery occlusion. Lightning induces vasomotor spasm from direct sympathetic stimulation resulting in severe loss of pulses in the extremities. This vasoconstriction may be associated with transient paralysis. Damage to the central nervous system accounts for the second most debilitating group of injuries. Central nervous system injuries from lightning include amnesia and confusion, immediate loss of consciousness, weakness, intracranial injuries, and even brief aphasia. Other organ systems injured by lightning include the eye, ear, gastrointestinal system, skin, and musculoskeletal system. The best treatment of lightning injuries is prevention. The Lightning Safety Guidelines devised by the Lightning Safety Group should be instituted in the United States and other nations to prevent these devastating injuries.

Treated wood preservatives linked to aquatic damage, human illness, and death--a societal problem

On February 12, 2002, the US Environmental Protection Agency (EPA) announced a voluntary decision by industry to move consumer use of treated lumber products away from a variety of pressure-treated wood that contains arsenate (As) by December 31, 2003, in favor of new alternative wood preservatives. Chromated copper arsenate (CCA) is a chemical mixture consisting of three pesticidal compounds (As, chromium, and copper) registered for wood preservative uses. CCA is injected into wood by a process that uses high pressure to saturate wood products with the chemical. Only people who have received the proper safety training should use CCA to treat wood products. Around the home, CCA-treated wood is commonly used for decks, walkways, fences, gazebos, boat docks, and playground equipment. Other common uses of CCA-treated wood include highway noise barriers, sign posts, utility posts, and retaining walls. As of January 1, 2004, the EPA is no longer allowing CCA products to be used to treat wood intended for any of these residential uses. This decision will facilitate the voluntary transition to new alternative wood preservatives that do not contain As in both the manufacturing and retail sectors. To its credit, the EPA has developed consumer safety information sheets, hanging signs, end signs, and bin stickers that provide comprehensive information about the dangers of CCA-treated wood, use-site, and handling precautions. The EPA has not concluded that CCA-treated wood poses any unreasonable risk to the public or the environment. Nevertheless, As is a known human carcinogen and, thus, the EPA believes that any reduction in the levels of potential exposure to As is desirable. The toxicologic manifestations have been primarily related to the effects of As exposure from drinking water sources and include the following: acute poisoning incidents, cardiovascular effects, diabetes mellitus, and cancer. Understanding the biomethylation of As is central to elucidating its action as a toxin and a carcinogen. In humans as in many other species, inorganic As is enzymatically converted to the methylated products methyl As (MAs) and dimethyl As (DMAs). The aforementioned voluntary agreement to reduce the uses of CCA-treated wood does not include a ban on the use of CCA for residential roofing. A major reason that this wood product should be banned from residential roofing is that it does not provide a Class "A" fire-rated roof system, which markedly reduce the frequency of residential roof fires.

Cold injuries

Exposure to cold can produce a variety of injuries that occur as a result of man's inability to adapt to cold. These injuries can be divided into localized injury to a body part, systemic hypothermia, or a combination of both. Body temperature may fall as a result of heat loss by radiation, evaporation, conduction, and convection. Hypothermia or systemic cold injury occurs when the core body temperature has decreased to 35 degrees C (95 degrees F) or less. The causes of hypothermia are either primary or secondary. Primary, or accidental, hypothermia occurs in healthy individuals inadequately clothed and exposed to severe cooling. In secondary hypothermia, another illness predisposes the individual to accidental hypothermia. Hypothermia affects multiple organs with symptoms of hypothermia that vary according to the severity of cold injury. The diagnosis of hypothermia is easy if the patient is a mountaineer who is stranded in cold weather. However, it may be more difficult in an elderly patient who has been exposed to a cold environment. In either case, the rectal temperature should be checked with a low-reading thermometer. The general principals of prehospital management are to (1) prevent further heat loss, (2) rewarm the body core temperature in advance of the shell, and (3) avoid precipitating ventricular fibrillation. There are two general techniques of rewarming--passive and active. The mechanisms of peripheral cold injury can be divided into phenomena that affect cells and extracellular fluids (direct effects) and those that disrupt the function of the organized tissue and the integrity of the circulation (indirect effects). Generally, no serious damage is seen until tissue freezing occurs. The mildest form of peripheral cold injury is frostnip. Chilblains represent a more severe form of cold injury than frostnip and occur after exposure to nonfreezing temperatures and damp conditions. Immersion (trench) foot, a disease of the sympathetic nerves and blood vessels in the feet, is observed in shipwreck survivors or in soldiers whose feet have been wet, but not freezing, for long periods. Patients with frostbite frequently present with multisystem injuries (e.g., systemic hypothermia, blunt trauma, substance abuse). The freezing of the corneas has been reported to occur in individuals who keep their eyes open in high wind-chill situations without protective goggles (e.g., snowmobilers, cross-country skiers).

An organized approach to trauma care: legacy of R Adams Cowley

The organized approach to caring for trauma patients was introduced into the civilian setting by the innovative pioneer, R Adams Cowley. His system in Maryland has the following 11 components: (1) a State Police Aviation Division that transports patients throughout the State; (2) trained paramedics at the scene of the accident as well as on the helicopter, who will stabilize the patients en route to the Shock Trauma Center; (3) one central dispatch communication center in Baltimore that coordinates information between paramedics and the Trauma Center; (4) a Shock Trauma Center with a helicopter landing zone near the building; (5) trained trauma nurses and trauma technicians to transfer the patient from the helicopter by stretcher to the resuscitation area; if there is a special complication, such as an airway problem, the anesthesiologist and or trauma surgeon may meet the helicopter on the roof as well; (6) trauma surgeons, board-certified in surgery, with a certificate of added qualification in surgical critical care, to treat the critically ill trauma patients in the resuscitation area; (7) a CT scan and portable X-ray units in the admission area that aid in the diagnosis of the injury; (8) operating rooms adjacent to the admission area for repair of trauma injuries; (9) a surgical intensive unit to care for the trauma patient; (10) a team of specialty physicians trained in a wide variety of specialties who work as a multidisciplinary unit caring for the hospitalized patient; and (11) an ambulatory outpatient unit that allows the patient to be followed in the center after discharge. Dr. R Adams Cowley incorporated each of these 11 components for an organized trauma center into Maryland. In recognition of his landmark contributions to trauma, the eight-story Shock Trauma Center was named the R Adams Cowley Shock Trauma Center. There is growing evidence that this organized system in trauma care seen in Maryland must be replicated in every state in our nation. The results of the Health Resources and Services Administration Report in 2002 show serious limitations in our nation's organized approach to emergency and trauma care. This report indicates that many Americans do not have access to well-trained pre-hospital emergency personnel. Between 10 and 15% of the US population does not have access to basic emergency medical and communication services. Moreover, the presence of key trauma system components continues to vary throughout the country, most likely because of growing economic constraints. Emergency communication systems remain fragmented, and adequate training programs and protective equipment for health personnel remains notably absent. The threat of inadequate funding for the state manifests itself in the consistent uneasiness regarding the recruitment and continued retention of trauma care providers. Federal authorities must devise national emergency medical and organized trauma programs to save the lives of injured Americans.

Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems

Occupational back pain in nurses (OBPN) constitutes a major source of morbidity in the health care environment. According to the National Institute for Occupational Safety and Health (NIOSH), occupational back injury is the second leading occupational injury in the United States. Among health care personnel, nurses have the highest rate of back pain, with an annual prevalence of 40-50% and a lifetime prevalence of 35-80%. The American Nursing Association believes that manual patient handling is unsafe and is directly responsible for musculoskeletal disorders encountered in nurses. It has been well documented that patient handling can be done safely with the use of assistive equipment and devices that eliminate these hazards to nurses that invite serious back injuries. The benefit of assistive patient handling equipment is characterized by the simultaneous reduction of the risk of musculoskeletal injury to the nursing staff and improvement in the quality of care for patient populations. To understand the cause of disabling injuries in health care workers, several factors must be considered, including the following: (1) anatomy/physiology of the back, (2) risk factors, (3) medical legal implications, and (4) prevention. Among nurses, back, neck, and shoulder injuries are commonly noted as the most prevalent and debilitating. While mostly associated with dependant patient care, the risk for musculoskeletal injury secondary to manual patient handling crosses all specialty areas of nursing. The skeletal defects of an abnormal back make the back more susceptible to occupational injury, even under normal stress conditions. Workers compensation guidelines for occupational back injury differ in public and private health care sectors from state to state. Nursing personnel should be reminded that the development of back pain following occupational activities in the hospital should be reported immediately to the Occupational Health Department. A nurse's failure to report OBPN immediately has resulted in numerous denials of claims for rehabilitation and compensation that nurses deserve. Experts believe that training in proper body mechanics does not prevent back injury. Consequently, focus has been placed on other innovative injury prevention programs, including the use of engineering controls as well as the "lift team" method. Ergonomics involves the use of mechanical devices (e.g., walking belt and mechanical hoist) to aid in patient lifting and transferring tasks. Guldmann Inc. has devised ceiling lift systems and slings during the past 20 years. They have successfully completed thousands of installations worldwide, covering a wide range of challenging conditions and complex environments. The Guldmann ceiling-mounted hoist system consists of a wide range of lifting units, rail components, and a complete assortment of lifting slings and accessories. Its sling is made of polyester, which is characterized by its strength and elasticity. It retains its shape and is dirt repellent and easy to maintain. The Guldmann network has one of the largest and indisputably most experienced group of certified installers in the United States. The "lift team" method was devised to remove nursing personnel from the everyday task of moving patients. This type of intervention assumes that lifting is a specialized skill to be performed only by expert professional patient movers who have been thoroughly trained in the latest lifting device techniques.

Better Trauma Care. How Maryland Does It

In March, 1970, the Maryland State Police, in cooperation with the University of Maryland, started the first statewide airborne transportation system. It was modeled after the army's success in Korea and Vietnam, where battlefield injuries were flown to front-line MASH units. The world's premier statewide medical aviation division was made possible through a cooperative effort between the Maryland State Police Aviation Division and Dr. R Adams Cowley at the University of Maryland Hospital as a public service to the citizens of the state. The Maryland Institute for Emergency Medical Services Systems (MIEMSS) has five components: (1) aircraft, (2) state troopers, (3) system communications (SYSCOM) center, (4) ambulance and fire emergency rescue, and (5) Level I adult and pediatric trauma centers and a regional burn center. The Maryland State Police Aviation Division now has 12 Aerospace Dauphin AS365N helicopters that operate out of eight fixed points throughout the state. Each helicopter has a two-person crew that consists of a pilot and a paramedic. Since 1993, the overall coordination of emergency medical services (EMS) has been under the purview of MIEMSS, an independent executive-level state agency that is governed by an appointed board and advisory council. To ensure stable funding for Maryland's world renowned emergency medical services (EMS) system, including med-evac helicopters, ambulances, fire equipment, rescue squads, and trauma units, a "surcharge" of $13.50 per year is collected with the automobile registration fee where applicable. The SYSCOM center in Baltimore coordinates the helicopter transport to the scene of the accident as well as referral to the specialty care facility: Adult Level I Trauma Center, Pediatric Level I Trauma Center, and Regional Burn Center. An on-the-scene evaluation of this exemplary emergency medical system in Maryland provides further convincing evidence of the performance of the Maryland State Police Aviation Division as they transported an injured child to the Johns Hopkins Pediatric Level I Trauma Center. It is our belief that the model emergency medical system in Maryland, if replicated throughout our nation, would save the lives of the critically injured.

Modern Concepts of Treatment and Prevention of Electrical Burns

Electric injuries account for 1,000 deaths in the United States, with a mortality rate of 3--15%. As the widespread use of electricity and injuries from it increase, all health professionals involved in burn care must appreciate its physiological and pathological effects as well as management of electrical current injury. Electric current exists in two forms: alternating current and direct current. The effects of electricity on the body are determined by seven factors: (1) type of current, (2) amount of current, (3) pathway of current, (4) duration of current, (5) area of contact, (6) resistance of the body, and (7) voltage. Electrical accidents can be divided into less than 1,000 V (low-voltage accidents) and greater than 1,000 V (high-voltage accidents). In any electrical accident, the witness must turn off the power source and initiate treatment at the scene of the injury. Low-voltage electric burns almost exclusively involve either the hands or oral cavity. Surgical treatment will vary with the severity of the injury. Burns caused by contact with a high-voltage alternating electric circuit conforms to two types: burns from an electric arc and burns from an electric current. High-voltage electric current injuries have a wide variety of systemic manifestations, including neurologic complications, cardiovascular and pulmonary manifestations, vascular damage, and abdominal, bone, eye and joint complications. An organized approach to the management of these complications is outlined in this article. The best treatment of burn injuries remains prevention. Because the majority of burn injuries are due to occupational electrical injuries, the regional burn centers must work effectively with industry to prevent these potentially life-threatening accidents.

Modern Concepts of Treatment and Prevention of Chemical Injuries

Chemical injuries are commonly encountered following exposure to acids and alkali, including hydrofluoric acid, formic acid, anhydrous ammonia, cement, and phenol. Other specific agents that cause chemical burns include white phosphorus, elemental metals, nitrates, hydrocarbons, and tar. Even though there are more than 65,000 chemicals available on the market, and an estimated 60,000 new chemicals produced each year, the potential deleterious effects of these chemicals on humans are still unknown. The Superfund Amendments and Reauthorization Act contains extensive provisions for emergency planning and the rights of communities to know about toxic chemical releases. Since 1990, the Agency for Toxic Substances and Disease Registry (ATSDR) has maintained an active, state-based Hazardous Substances Emergency Events Surveillance (HSEES) system to describe the public health consequences risked by access to hazardous chemicals. Most chemical agents damage the skin by producing a chemical reaction rather than hyperthermic injury. Although some chemicals produce considerable heat as a result of an exothermic reaction when they come in contact with water, their ability to produce direct chemical changes on the skin accounts for the most skin injury. Specific chemical changes depend on the agent, including acids, alkalis, corrosives, oxidizing and reducing agents, desiccants, vesicants, and protoplasmic poisons. The concentration of toxic agent and duration of its contact primarily determine degree of skin destruction. Hazardous materials (hazmats) are substances that may injure life and damage the environment if improperly handled. HAZMAT accidents are particularly dangerous for responding personnel, who are in danger from the moment of arrival on the scene until containment of the accident. Consequently, the Superfund Amendment and Reauthorization Act mandates community preparedness for dealing with hazmat accidents. Paramedics and members of the hazmat response team (usually firefighters) must work together to identify toxic chemicals and assess hazardous environments. The contingency plan for hazmat management can be divided into two parts: initiation of the site plan and evacuation. In coping with hazmat incidents, two distinct goals must be achieved concomitantly. First, hazmats must be contained, fire and explosions must be extinguished, and the site eventually must be cleaned. Second, those exposed to hazmats must be treated at the scene of contamination as well as in the hospital and rehabilitation setting.

Devastating Injuries in Healthcare Workers: Description of the Crisis and Legislative Solution to the Epidemic of Back Injury from Patient Lifting

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.

Vaccine Information Statements. Revolutionary but Neglected Educational Advances in Healthcare in the United States

The purpose of this report is to provide further information about vaccine information statements (VISs) that are revolutionary but neglected educational advances in the United States. Because the use of VISs is mandated by the Federal Government in every individual being immunized, it is the goal of this report to further awaken health professionals and society to the mandatory use of these superb educational statements. With the passage of the National Childhood Vaccine Injury Act of 1986, the Federal Government required that VISs would be given to all vaccine recipients. As of September 2001, the VISs that must be used are diphtheria, tetanus, pertussis, (DTaP); diphtheria, tetanus (Td); measles, mumps, rubella (MMR); polio (IPV); hepatitis B; Haemophilus influenzae type b (Hib); varicella; and pneumococcal conjugate. Copies of the VISs are available at www.cdc.gov/nip/publications/VIS. The National Childhood Vaccine Injury Act of 1986 mandated that all health care providers report certain adverse events that occur following vaccination. As a result, the Vaccine Adverse Events Reporting System (VAERS) was established by the FDA and the Centers for Disease Control and Prevention (CDC) in 1990. In order to reduce the liability of manufacturers and healthcare providers, the National Childhood Vaccine Injury Act of 1986 established the National Vaccine Injury Compensation Program (NVICP). This program is intended to compensate those individuals who have been injured by vaccines on a no-fault basis. While the use of VISs has been mandated since 1996, a national survey of private practice office settings has revealed that many immunized patients do not receive the VISs. When these forms were used, physicians rarely initiated discussions regarding contraindications to immunizations or the National Vaccine Injury Compensation Program. Fortunately, the state boards of medical examiners, like the one in Oregon, are taking a strong stand for the use of VISs, with the warning that failure to use a VIS may result in disciplinary action. Our nation and practicing physicians must be awakened to the importance of the use of VISs to ensure that every vaccinated individual receives this statement at the time of vaccination.

Bacterial Diseases of the Skin

When considering common bacterial diseases of the skin, rather distinct clinical responses to a variety of bacterial infections have been identified. In these cases, it is the specific site of infection and the attendant inflammatory responses that provide the characteristic clinical picture. When the pyoderma extends just below the stratum corneum, it is called impetigo. Nonbullous impetigo is the most common pediatric skin infection. It usually starts in a traumatized area. The typical lesion begins as an erythematous papule, after which it becomes a unilocular vesicle. When the subcorneal vesicle becomes pustular, it ruptures and eventually becomes a yellow, golden crust that is a hallmark of the disease process. Bullous impetigo is a less common form of impetigo, accounting for fewer than 30% of all impetigo cases. It occurs in infants and is characterized by rapid progression of vesicles to the formation of bullae measuring larger than 5 mm in diameter in previously untraumatized skin. Treatment of nonbullous impetigo must include intervention against the pathogen as well as improvements in the hygiene and living conditions of the patient. A fundamental tenet is to debride the crust (scab) from the wound surface using poloxamer 188. If the lesions are not widespread, topical mupirocin is the treatment of choice. Treatment of bullous impetigo is similar, except that the local cleansing and topical antibiotic must be complemented by systemic antibiotics if there is evidence of disseminating infections. Ecthyma is usually a consequence of failure to treat effectively impetigo. The untreated infection extends deep into the tissue in shallow ulcerations that often heal without scar. Treatment for ecthyma usually requires systemic antibiotics against either staphylococcus or streptococcus. Folliculitis is a pyoderma located within a hair follicle, secondary to follicular occlusion by keratin, overhydration, or either bacterial or fungal infection. Folliculitis may be divided into either a deep or a superficial type. In the superficial type, the pustule is located at the opening of the hair follicle. In the deep form, the infection may extend beyond the confines of the hair follicle, becoming a furuncle or boil. Carbuncles are aggregates of interconnected furuncles that drain through multiple openings of the skin. Treatment of folliculitis must include searching for and avoiding any factors predisposing to infection. If topical antibiotic therapy is ineffective in controlling the infection, surgical drainage of the infected skin abscess will be necessary. Paronychia is the most common bacterial infection of the hand, which often requires surgical incisional drainage. Similarly, a felon that is an infection of the distal pulp of a finger usually requires surgical drainage. Finally, cellulitis is an acute inflammatory reaction involving the skin and underlying subcutaneous tissue. It usually starts as erysipelas and may advance to lymphangitis, lymphadenitis, or gangrene,which will respond to life-saving interventions in the hospital that usually include systemic antibiotic treatment as well as surgical intervention.

Massive Soft Tissue Infections: Necrotizing Fasciitis and Purpura Fulminans

Necrotizing fasciitis and purpura fulminans are two destructive infections that involve both skin and soft tissue. Necrotizing fasciitis is characterized by widespread necrosis of subcutaneous tissue and the fascia. Historically, group A beta-hemolytic streptococcus has been identified as a major cause of this infection. However, this monomicrobial infection is usually associated with some underlying cause, such as diabetes mellitus. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is polymicrobial. The diagnosis of necrotizing fasciitis must be made as soon as possible by examining the skin inflammatory changes. Magnetic resonance imaging is strongly recommended to detect the presence of air within the tissues. Percutaneous aspiration of the soft tissue infection followed by prompt Gram staining should be conducted with the "finger-test" and rapid-frozen section biopsy examination. Intravenous antibiotic therapy is one of the cornerstones of managing this life-threatening skin infection. Surgery is the primary treatment for necrotizing fasciitis, with early surgical fasciotomy and debridement. Following debridement, skin coverage by either Integra Dermal Regeneration Template or AlloDerm should be undertaken. Hyperbaric oxygen therapy complemented by intravenous polyspecific immunoglobulin are useful adjunctive therapies. Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin; it is rapidly progressive and accompanied by vascular collapse. There are three types of purpura fulminans: neonatal purpura fulminans, idiopathic or chronic purpura fulminans, and acute infectious purpura fulminans. Clinical presentation of purpura fulminans involves a premonitory illness followed by the rapid development of a septic syndrome with fever, shock, and disseminated intravascular coagulation. The diagnosis and treatment of these conditions is best accomplished in a regional burn center in which management of multiple organ failure can be conducted with aggressive debridement and fasciotomy of the necrotic skin. The newest revolutionary advancement in the treatment of neonatal purpura fulminans is the use of activated protein C.