Traumatic ulnar translocation of the carpus: early recognition and treatment.

This study evaluated the clinical outcomes and radiographic features of surgically treated traumatic ulnocarpal translocation in nine patients (ten cases). All ligament and fracture repairs were completed within 2 months of injury. Seven cases were examined at a mean of 6.5 years, and information in three cases was obtained from medical records at a mean of 13 months after injury. At final evaluation, the mean disabilities of the arm, shoulder, and hand score was 6 (range, 0-16), and the mean Mayo modified wrist score was 76 (range, 40-100). Ulnocarpal translocation was evident in nine of the injured wrists, six of which showed arthritis, and in four of the uninjured wrists. Ulnar variance measured negative in nine cases and neutral in one case. Pre-existing medial alignment of the carpus and ulnar minus variance may predispose to traumatic ulnocarpal translocation. Early injury repair does not assure restoration of radiocarpal alignment or prevent joint deterioration; however, these changes do not always portend a suboptimal result.

Mycotic aneurysm in a free flap.

A 41-year-old man developed a 3 x 4 cm wound after corrective osteotomies of his distal tibia and fibula. The wound was debrided and covered with a free gracilis muscle flap. Seven days after flap transfer, the arterial pedicle ruptured adjacent to the anastomosis. Attempted repair of the aneurysm failed and the graft was subsequently debrided. Intraoperative wound cultures grew Pseudomonas and Enterobacter cloacae, which were attributed to formation of the aneurysm.

Adherence to Universal (barrier) Precautions during interventions on critically ill and injured emergency department patients.

In a study undertaken to determine compliance with Universal Precautions, we observed 129 personnel performing 1,274 interventions on 151 consecutive critically ill and injured patients in an emergency department setting in July 1988. Barrier precautions were fully adhered to 44.0% of the time. During interventions in patients with profuse bleeding, adherence was only 19.5% in contrast to 44.7% for those who were not bleeding. Adherence was 56.4% during minor interventions but only 16.7% during major procedures. Adherence rates varied among health care providers: residents, 58%; emergency staff physicians, 38%; consultant physicians, 43%; emergency nursing staff, 44%; paramedics, 8%; radiology technicians, 14%; and housekeeping, 91%. In a follow up questionnaire that ascertained reasons for lack of compliance, 47% of providers indicated that there was not always sufficient time to put on protective material, 33% felt that precautions interfered with skillful performance of procedures, and 23% stated that materials were uncomfortable. Only 2.7% felt that Universal Precautions did not work. Since there is no proven postexposure prophylaxis for human immunodeficiency virus, Universal Precautions must be rigorously followed until such time as they are shown not to be effective or an alternate approach is developed. Strategies to improve compliance and improvements in barrier technology need to be developed.

Regulation of the RAD2 gene of Saccharomyces cerevisiae.

Regulation of the DNA damage-inducible RAD2 gene was investigated in yeast cells transformed with centromeric plasmids containing RAD2-lacZ fusion constructs. Deletion analysis defined several regions in the 350bp region upstream of the translational start codon which are required for induction of beta-galactosidase activity. No deletions resulted in constitutively enhanced expression. We therefore conclude that induction of RAD2 by DNA-damaging agents is positively regulated. Two domains required for induction have a similar sequence and are located approximately 70 and approximately 140bp upstream of the major transcriptional start site. Four other sequence domains required for induction contain uninterrupted poly(dA) poly(dT) stretches 9-13bp long. Deletion of some of these AT-rich domains also affects constitutive expression of RAD2. Expression of RAD2 is not cell-cycle-regulated in mitotic cells. However, meiosis is accompanied by increased steady-state levels of RAD2 mRNA in the absence of DNA damage. This enhanced transcription is not dependent on the presence of upstream sequences required for regulation of induction by DNA damage. Increased steady-state levels of RAD2 mRNA are induced by cycloheximide in asynchronously dividing populations of cells, but not in non-replicating cells arrested in G1 phase of the cell cycle. Following exposure to u.v. irradiation induction is also dramatically reduced in non-replicating cells.

Human immunodeficiency virus infection in emergency department patients. Epidemiology, clinical presentations, and risk to health care workers: the Johns Hopkins experience.

In a study to assess the impact of the human immunodeficiency virus epidemic on The Johns Hopkins Hospital Emergency Department, we found 152 (6.0%) of 2544 consecutive patients to have human immunodeficiency virus infection, an absolute increase of 0.8% from the previous year. Of the 57 patients with a known history of infection, 49.1% had no insurance vs 36.0% of seronegative patients. Infected patients were three times more likely to be admitted as seronegative patients. Overall, health providers followed universal precautions during 44.0% of interventions. In patients with profuse bleeding, adherence fell to 19.5%. The most common reasons given by providers for not following precautions were insufficient time to put on protective attire and interference with procedural skills. We conclude that the human immunodeficiency virus epidemic has a major impact on emergency services and that strategies need to be developed for appropriate use of emergency resources and also for maximizing provider protection.

A yeast excision-repair gene is inducible by DNA damaging agents.

Plasmids containing various RAD-lacZ gene fusions were integrated into the chromosome of haploid yeast cells. These integrant strains were tested for expression of Escherichia coli beta-galactosidase after treatment with agents that damage DNA or interfere with normal DNA replication. We did not observe induction of single-copy RAD1-lacZ or RAD3-lacZ fusion genes under the experimental conditions used. However, exposure of cells containing an integrated RAD2-lacZ fusion gene to UV-radiation, gamma-radiation, 4-nitroquinoline 1-oxide, or nalidixic acid resulted in 4- to 6-fold enhanced expression of beta-galactosidase. Induction of the RAD2 gene after treatment of untransformed cells with 4-nitroquinoline 1-oxide was confirmed by direct examination of RAD2 mRNA. Lower levels of induction (approximately equal to 50%) were observed after treatment of cells with other chemicals. Induction of the RAD2-lacZ fusion gene was also observed in cells transformed with single-copy and multicopy autonomously replicating plasmids.

Molecular approaches to the study of nucleotide excision repair in eukaryotes.

Very little is known about the molecular mechanism of nucleotide excision repair in eukaryotes. Studies on human cells have been stimulated by the availability of excision repair-defective cell lines from patients suffering from the autosomal recessive disease xeroderma pigmentosum (XP). Such studies have contributed significantly to an understanding of the genetic complexity of excision repair in human cells. However, to date, no human excision repair genes or gene products known to complement the repair defect in XP cells have been isolated. The yeast Saccharomyces cerevisiae is an interesting model for exploring the molecular mechanism of nucleotide excision repair in eukaryotic cells. As is true in human cells, multiple yeast genes are involved and at least five genes are required for the specific incision of UV-irradiated DNA in vivo. These five genes have been isolated by molecular cloning and the nucleotide sequences of four of them have been determined. Each of these cloned genes is being used for overexpression of protein.