Antimicrobial persistence of two alcoholic preoperative skin preparation solutions.

BACKGROUND: Normal skin flora and suboptimal skin antisepsis are the primary drivers of healthcare-associated infections (HAIs). Antimicrobial persistence of preoperative skin preparation is necessary to limit microorganisms on the skin and help minimize their entry into an incision or device-insertion site after application. AIM: To assess the antimicrobial persistence of two preoperative skin preparation solutions. METHODS: A randomized, single-centre, partially blinded, clinical study was conducted in 103 healthy volunteers to evaluate the persistent antimicrobial properties of BD ChloraPrep™ (2% w/v chlorhexidine gluconate [CHG] + 70% v/v isopropyl alcohol [IPA]) and BD PurPrep™ (8.3% w/w povidone-iodine [PVPI] + 72.5% w/w IPA) skin preparations out to 7 days and 96 h, respectively, on abdomen and groin testing sites. An additional 32 healthy volunteers participated in a neutralization procedure to ensure that the study recovery solution was non-toxic to microorganisms, and a spore-recovery procedure to demonstrate that microorganisms could be successfully recovered from the PVP-I+IPA film-forming product. FINDINGS: Both CHG+IPA and PVP-I+IPA produced a mean bacterial log10 reduction >2 and >3 on the abdomen and groin, respectively, 10 min after application. CHG+IPA maintained antimicrobial persistence out to 7 days post application, whereas PVP-I+IPA maintained antimicrobial persistence out to 96 h post application, the longest time-point selected for this product. CONCLUSION: CHG+IPA and PVP-I+IPA were both found to be effective, persistent antiseptic skin preparations. Overall, skin irritation was uncommon, and only one adverse event occurred following product application, which was not considered product-related but was considered procedure-related.

African Americans' views on research and the Tuskegee Syphilis Study.

The participation of African Americans in clinical and public health research is essential. However, for a multitude of reasons, participation is low in many research studies. This article reviews the literature that substantiates barriers to participation and the legacy of past abuses of human subjects through research. The article then reports the results of seven focus groups with 60 African Americans in Los Angeles, Chicago, Washington, DC, and Atlanta during the winter of 1997. In order to improve recruitment and retention in research, the focus group study examined knowledge of and attitudes toward medical research, knowledge of the Tuskegee Syphilis Study, and reactions to the Home Box Office production, Miss Evers' Boys, a fictionalized version of the Tuskegee Study, that premiered in February, 1997. The study found that accurate knowledge about research was limited; lack of understanding and trust of informed consent procedures was problematic; and distrust of researchers posed a substantial barrier to recruitment. Additionally, the study found that, in general, participants believed that research was important, but they clearly distinguished between types of research they would be willing to consider participating in and their motivations for doing so.

Key challenges and concepts in health risk communication: perspectives of agency practitioners.

The public demands that federal agencies provide information that is responsive to their fears and explains health risks clearly. In 1998 the Health Risk Communication Coordination Committee of the Agency for Toxic Substances and Disease Registry, a federal public health agency, conducted three focus groups with agency staff to identify current knowledge and understanding of health risk communication (HRC); HRC issues, problems, and best practices; and most appropriate HRC training content. The results indicate a need for clearer communications with communities, greater sensitivity to community concerns and fears, more balanced media coverage, and more accuracy in reporting, among other findings.

Understanding the perionychium.

The fingernail and toenail are unique to primates. The anatomy and physiology of the nail must be understood for nail care to be effective. The most common cause of deformity of the nail bed is trauma, which requires careful suturing and postoperative care if the desired results are to be achieved. Congenital anomalies, tumors, and infection can also cause nail deformities and can frequently be corrected or improved surgically.

Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis.

The records of 75 patients admitted with pyogenic flexor tenosynovitis at two academic centers were reviewed. The functional outcomes of patients who received intraoperative irrigation only (n = 20) and those that had both intraoperative irrigation and continuous postoperative irrigation (n = 55) were compared. There were no statistically significant differences between the outcomes in the two groups.

The management of cubital tunnel syndrome: a meta-analysis of clinical studies.

Despite extensive clinical experience in treating cubital tunnel syndrome, optimal surgical management remains controversial. A meta-analysis of 30 studies with accurate preoperative and postoperative staging was undertaken. Patients were staged preoperatively into minimum, moderate, and severe groups on the basis of clinical presentation. Treatment modalities included nonoperative management, surgical decompression, medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition. Statistical analysis using a standard SAS database with analysis of variance and chi-square tests was used to assess the efficacy of each therapeutic modality. For minimum-staged patients, all modalities produced similar degrees of satisfaction. However, total relief occurred most after medial epicondylectomy and least after anterior subcutaneous transposition. Patients treated nonoperatively had the highest rate of recurrence. For moderate-staged patients, submuscular transposition was most efficacious, whereas patients with nonoperative management fared the worst. Finally, for severe-staged patients, current therapeutic modalities were not consistently effective, with medial epicondylectomy producing the poorest operative result. This article reveals statistically significant differences in outcomes among therapeutic modalities, which may assist in treatment planning; it introduces standardized methods to aid in determining, analyzing, and communicating treatment outcomes.

Free nonvascularized composite nail grafts: an institutional experience.

Free, nonvascularized composite nail grafts have been reported as a successful method to reconstruct nail deformities due to congenital anomalies or traumatic defects. The authors performed a decade review of their experience with nine patients who had had 10 free, nonvascularized composite nail grafts. Patient demographics, mechanism of injury, timing, site of reconstruction, and amount of nail to be replaced were all recorded. Results of nail growth in reconstructed nails were judged as excellent, good, fair, or poor on the basis of the appearance of the nail. The majority of reconstructed nails had half or more of the nail bed replaced. The 10 cases (mean follow-up of 1.8 years) that were reported had two excellent, three good, two fair, and three poor outcomes. There was no apparent relation between the successful outcome of the procedure and patient age, timing of reconstruction, or amount of nail bed replaced. Although the authors' experience suggests the unpredictable nature of this type of graft, it should be considered for patients who desire nail reconstruction and are not candidates for ablative or vascularized nail complex transfer procedures.

Correction of pincer-nail deformity using dermal grafting.

Pincer-nail syndrome has been described as distortion in the shape of the nails with excessive transverse curvature of the plate that increases from proximal to distal, leading to pinching and loss of soft tissue in the affected digit, resulting in severe pain. Many treatments have been recommended, but an effective long-term method that preserves the nail matrix has not been described. A method of dermal grafting under the nail matrix is described, and the results of treatment of six digits are reported. Five women and one man with an average age of 52 were treated. The affected digit was the thumb in four patients and the great toe in two patients. Follow-up averaged 25 1/2 months. The results were good in all cases with only one side of one nail remaining slightly curved. Pain was relieved in all cases, and complete adherence of the new nail plate occurred. Dermal grafting seems to provide excellent long-term treatment of the pincer-nail deformity with preservation of the nail matrix.

Fingertip reconstruction with flaps and nail bed grafts.

We retrospectively reviewed the cases of 14 fingertips reconstructed with a combination of local or regional flaps and nail bed grafts, some of which were placed wholly or partially over a de-epithelialized flap. Most of the fingertips sustained a crushing injury and were reconstructed at the time of the injury. Soft tissue coverage was provided by palmar V-Y flaps in 6 cases, thenar flaps in 4, lateral V-Y flaps in 2, a Moberg flap in 1, and a cross-finger flap in 1. Split toenail bed grafts were used in 6 cases, full-thickness nail bed grafts from the amputated part in 6, and split nail bed grafts from the injured digit in 2. There was 1 partial graft loss and 1 partial flap loss. The remaining cases had completely successful grafts and good soft tissue healing. Subsequent nail growth and adherence were good in all but the 1 digit requiring secondary composite grafting.

Consent for adolescent vaccination: issues and current practices.

To identify and describe implementation of state-level informed consent requirements for adolescent immunizations, current state regulations on informed consent and immunization services for children and adolescents were identified through the LEXIS-NEXIS legal data base. Regulations were coded for informed consent characteristics, consent exemptions, and current immunization requirements. State immunization program directors, project managers, and state hepatitis coordinators were surveyed to catalogue how regulations were implemented and document new policies or regulations under consideration. Parental consent for immunizations is standard practice in 43 states. Most states (n = 34) require separate consent for each injection when more than one injection is required to complete a vaccination, but only for a limited number of medical procedures. Nine states allow adolescents to self-consent for hepatitis B vaccination in sexually transmitted disease clinics and family planning clinics as part of the exemption for minors' receipt of sexual health services. Most states require consent for vaccination services provided to adolescents. Parental consent requirements are a potential barrier to vaccinating adolescents in some settings.

Repair of a long-standing coccygeal hernia and open wound.

Coccygectomy is a rarely used treatment for coccygodynia because of its high failure rate and various complications, such as bowel herniation, as seen in our patient. The limited number of literature articles available on coccygectomy discussed the few successes but failed to mention the complications and treatment of such. As a result of coccygectomy, our patient suffered from bowel herniation, unsuccessfully treated twice with prosthetic mesh. Bilateral gluteus maximus muscle flaps plicated in the midline reduced our patient's hernia successfully. This procedure appears to be an effective treatment for this postcoccygectomy complication.

Nipple-areolar perfusion and reduction mammaplasty: correlation of laser Doppler readings with surgical complications.

Clinical assessment of nipple-areolar perfusion by color, capillary refill, and temperature during and after reduction mammaplasty is generally satisfactory. However, the estimation of vascular perfusion in patients with very large breasts or dark-skinned women is difficult. If marginal perfusion of the nipple-areolar areas is undetected, necrosis is likely. To this point, no studies have tested the ability of the laser Doppler perfusion monitor to give absolute alarm values that would suggest marginal perfusion in the nipple-areola following reduction mammaplasty. We therefore completed a prospective study of areolar perfusion during surgery and for up to 24 hours following reduction mammaplasty. Fifty-four patients were studied and data collected from 104 breasts. Laser Doppler perfusion was measured with a LASERFLO BPM2 Blood Perfusion Monitor (Vasamedics, St. Paul, Minn.). Perfusion values were recorded for each breast following anesthesia but prior to the incisions, at the end of surgery, and every 2 hours for 24 hours. Patients were divided into three groups according to their follow-up results: no complications (92 breasts), minor complications (9 breasts), and patients with tissue necrosis (3 breasts). The no complications group had a perfusion of 4.8 ml/min/100 gm following the reduction procedure, while the minor complications and tissue necrosis groups had average perfusions of 1.4 and 0.8, respectively, immediately after incision closure. The average tissue removed from each group was 811, 1171, and 2118 gm for the no complications, minor complications, and tissue necrosis groups, respectively. The results from this study suggest that a laser Doppler perfusion monitor could prove useful for monitoring areolar perfusion following reduction mammaplasty, especially in patients with extremely large breasts and/or dark skin. Our studies have shown that laser Doppler perfusion values that consistently are in the range of 1.0 to 2.0 ml/min/100 gm indicate marginal perfusion, and the recovery of these patients should be followed closely. Furthermore, patients with consistent perfusion values equal to or less than 1.0 coupled with other clinical signs of low perfusion should be considered for suture removal and/or free nipple graft.

Analysis of hypospadias and fistula repair.

A total of 83 children underwent hypospadias repair from 1977 to 1991. The method of repair was based on individual patient pathology. Meatal advancement and glanuloplasty repair (MAGPI) was the most common operation performed (n = 37) followed by flip flap (n = 19), free tube graft (n = 11), and vascularized tube graft (n = 16). Fistula formation was the most common complication, with an overall incidence of 16 per cent. Fifty-four per cent of fistulas occurred following free tube graft urethroplasties, and 25 per cent of fistulas were noted following vascularized tube graft procedures. After 1986 the fistula rate decreased to 11 per cent in vascularized tube grafts, indicating a learning curve for this procedure. Seventy per cent of all fistulas required uncomplicated surgical repair, and 30 per cent closed spontaneously. We present our experience involving hypospadias repair, fistula formation, and management with an emphasis on penile hypospadias.

WomanKind: an innovative model of health care response to domestic abuse.

PIP: This article focuses on the role of the WomanKind program in creating opportunities for discussing domestic violence and training health professionals. The WomanKind program is based on the belief that without such discussion, health care providers will continue to treat the medical and mental health problems that bring women to their doors without addressing the underlying pattern of abuse that is the root cause. WomanKind has evolved to integrate case management/advocacy services for victims of domestic abuse, in addition to education and consultation for health professionals. It also provides case management and advocacy services, including crisis intervention, assessment and evaluation, and ongoing assistance to battered women who suffer from physical, emotional, or sexual abuse by a current or former partner. The WomanKind staff consists of a director who oversees the program, including marketing and public relations, education and training, as well as assisting the full-time program coordinators at each of the three hospital sites. An intensive 40-hour training program provides the new WomanKind volunteers with an understanding of the issues of domestic abuse and violence, as well as knowledge of community resources. The program goals are elaborated in this article as well as the program marketing techniques.^ieng

Plastic surgery.

Animal studies and early clinical trials have shown that growth factors can be powerful agents in manipulating wound repair. Hyperbaric oxygen therapy does not contribute to reperfusion injury and appears to protect the microcirculation.

Management of lawn mower injuries to the foot and ankle.

Seventy consecutive patients treated for lawn mower injuries to the foot and ankle were reviewed to determine optimal treatment, functional results, and complications. Injuries were classified into 1 or more functional-anatomical zones (I, digits; II, dorsum; III, plantar nonweight-bearing surface; IV, heel; and V, ankle) for a total of 96 injuries. Thirty-one patients were available for follow-up. Mean age was 36.7 years and 84% were males. Most injuries (67%) involved patients > 16 years old using a push mower; however, 18% involved children < 5 years old, usually caused by riding mowers (70%). Primary closure after adequate irrigation and debridement was the preferred method of treatment except in patients with Zone IV injuries. Antibiotic prophylaxis was used in almost all injuries (93%). A 100% ambulation rate was achieved with 10% of patients requiring a prosthesis. Zone IV (heel) injuries had a 50% complication rate from chronic soft tissue breakdown. The wound infection rate per injury was 12.5% and did not vary significantly between closed (11.4%) and open (17.6%) treatment. Lawn mower injuries to the foot and ankle can be closed primarily after adequate irrigation and debridement without compromise of infection rate or function. Antibiotic prophylaxis is recommended. One-sixth of these injuries involve children < 5 years of age and can be prevented.