Upper extremity injection of household insecticide: a report of five cases.

Self-injection of household insecticide into the upper extremity in 5 patients is reported. All patients had mental problems, such as depression, substance abuse, or both. Four of the 5 cases were suicide attempts. Household insecticides can be divided into 3 categories based on the main chemical component. The hydrocarbon vehicle used in these insecticides, however, is poorly cleared by the local tissues and is responsible for fever, leukocytosis, and liquifaction necrosis. The focus for the hand surgeon is recognition and early and frequently repeated debridement. Psychiatric treatment and hand therapy are required.

Free flaps for soft tissue coverage in the hand and fingers.

With mastery of conventional methods, free flaps are indicated in selected cases for coverage of the hand and fingers. Careful preoperative planning, delicate intraoperative management, and postoperative physiotherapy are the mainstays for success in functional recovery and aesthetic result. Thin flaps of good vascularity are favored for coverage of the hand and finger. For hand surgeons, the lateral arm fasciocutaneous or fascia flap, toe flaps, and the latissimus dorsi flap seem to be the easiest and most useful free flaps applicable to most situations.

Transmission electron microscopic pathoanatomy of congenital trigger thumb.

Previous studies of trigger digits in children have been limited to gross morphology and light-microscopic histology. Nine children with 11 trigger thumbs formed a preliminary study group for electron-microscopic evaluation of tendon nodules and A-1 pulleys. This pathoanatomic investigation was not previously reported. Comparison was made with light-microscopic sections. Large amounts of mature collagen was observed. Fibroblasts with prominent rough endoplasmic reticulum were present. No degenerative or inflammatory changes were noted in either tendon or sheath. We believe that although the etiology of trigger digits is still uncertain, an infectious, inflammatory, or degenerative process is unlikely.

Coordinating activities between NOAA and other agencies.

The Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA) and the National Oil and Hazardous Substances Pollution Contingency Plan (NCP) mandate protection of public health, welfare, and the environment at Superfund hazardous waste sites. The NCP requires lead response agenciesto integrate baseline risk assessments into the remedial process that "assess threats to the environment." EPA policy statements direct regional offices to perform thorough, consistent ecological risk assessments, and stress the importance of coordination and technical consultation with the natural resource trustees. As a Federal natural trustee, the National Oceanic and Atmospheric Administration's (NOAA) role and responsibilities within the CERCLA process also are defined and mandated by Federal law. NOAA is responsible for identifying sites in the coastal zone that may affect natural resources, evaluating injury to trust resources, and providing technical advice on assessments and remedial and restoration alternatives. Statutes require lead cleanup agencies and trustee agencies to notify and coordinate with each other during CERCLA response. Over the past ten years, NOAA has gained valuable experience and technical expertise in environmental assessments and in evaluating contaminated aquatic environments. NOAA fulfills its responsibilities through an effective network of Coastal Resource Coordinators (CRCs) who can rapidly respond to local technical requirements and priorities, and coordinate effectively with technical and trustee representatives. In addition to CRCs, an interdisciplinary support group provides technical expertise in the scientific disciplines required to respond to the needs of regional activities. NOAA provides CRCs to coastal EPA regional offices for technical support, and to act as liaisons with Federal and state natural resource trustee agencies. The CRCs help EPA and other lead response agencies identify and assess risks to coastal resources from hazardous waste sites and to develop cost-effective strategies to minimize those risks. Notification of trustees of potential natural resource injuries and coordination of subsequent investigations helps Federal and state trustees to carry out their responsibilities effectively. Trustees' early involvement in the scoping of ecological risk assessments ensures that assessments and the entire remedial process adequately evaluate the risk to trust resources. Coordination throughout the process makes it easier to develop cost-effective and protective remedies that enhance the recovery of natural resources. Examples of NOAA's successful coordination and cooperative ecological risk assessments will be presented in brief case studies for both EPA and Department of Defense (DOD) lead sites.

Diminished adrenocorticotropin response to insulin-induced hypoglycemia in nondepressed, actively drinking male alcoholics.

Although changes in hypothalamic-pituitary-adrenal axis function have frequently been reported in alcoholics, the majority of studies have used recently detoxified subjects in whom abstinence phenomena and clinical depression may contribute to observed stress axis alterations. To isolate the primary effects of alcohol dependence on the stress axis, the ACTH and cortisol responses to insulin-induced hypoglycemia were measured in seven actively drinking male alcoholics recruited from the general public through a newspaper advertisement along with eight age-matched male controls. The alcoholic subjects met current American Psychiatric Association diagnostic criteria for alcohol dependence, were stably employed, and had no concurrent psychiatric disorders, cognitive impairment, or psychometric evidence of depression. While relatively young (30.0 yr; range, 22-48 yr), they had lengthy histories of alcohol-related problems (11.9 yr; range, 5-30 yr). Insulin administration resulted in similar nadirs in blood sugar in both alcoholic and control groups. However, the plasma ACTH response was markedly blunted in the alcoholics (P = 0.040, by Mann-Whitney U test). There was a nonsignificant trend toward increased cortisol levels in the alcoholic group. The findings suggest that altered hypothalamic-pituitary-adrenal axis function in alcoholics is a primary results of chronic ethanol exposure rather than a confounding effect of clinical depression or recent detoxification.

Phialophora richardsiae infection mimicking a soft tissue mass of a finger.

Phialophora richardsiae was discovered in an index finger mass which was thought to be a residual of a steroid injection for tendinitis of the extensor tendon. A case report is presented.

Aspiration curettage for asymptomatic patients receiving estrogen.

Recent epidemiologic data suggest that patients treated with exogenous estrogens have an increased risk of developing endometrial carcinoma and support the concept that patients taking estrogens must be monitored with special vigor. The hypothesis that endometrial aspiration curettage might be an appropriate modality to accomplish adequate surveillance was tested from January 1, 1976, to January 1, 1977, on a group of 208 consecutive patients undergoing hormonal replacement therapy. Although no patient in the test group experienced abnormal or unusual bleeding, focal adenomatous hyperplasia or a more severe lesion was found in 16.0% of the specimens. Among these were 4 cases of endometrial adenocarcinoma and 2 of atypical adenomatous hyperplasia. This study demonstrated that routine endometrial aspiration curettage of patients receiving exogenous hormone replacement therapy can not only help diagnose very early lesions which are amenable to definitive and completely corrective treatment, but also can uncover significant endometrial pathology before it becomes symptomatic. It further suggests the possibility that the incidence of such pathology among this category of patients might be higher than previously suspected.

Successful quadruplet pregnancy following ovulation induced with human menopausal gonadotropin and human chorionic gonadotropin.

PIP: A case report of a quadruplet pregnancy that followed the induction of ovulation by human chorionic gonadotropin and human menopausal gonadotropin is presented. Examination revealed 4 separate placentas, indicating development from 4 different ova. The infants all did well at term, with no signs of respiratory distress syndrome, and have developed normally. Early diagnosis by ultrasonography and complete early bedrest are important for fetal survival. Hospitalization at Week 27-28 of pregnancy is essential, and a complete, competent staff able to handle high-risk patients should be available. Intravenous ethanol infusion is useful during early labor. The patient must be carefully observed for postpartum hemorrhage and should be followed in the recovery room for 24 hours.^ieng