Fatal septicaemia in a previously healthy man following a dog bite.

A rare case of fatal septicaemia after a dog bite in a previously healthy individual is presented and discussed. Capnocytophaga canimorsus (DF-2 bacterium) was isolated from blood cultures. Our case shows the importance of immediate antibiotic treatment for all dog and cat bites, regardless of severity.

Hepatitis B vaccination: uptake by medical staff in accident and emergency departments.

To assess the current uptake of hepatitis B vaccine and attitudes towards immunization among accident and emergency practitioners in the UK, a postal survey was carried out. Questionnaires were sent to 742 members of the British Association for Accident and Emergency Medicine (BAEM). Four hundred and six (55%) replies were received. Of 351 respondents in career-grade posts 309 (88%) had received a full course of immunizations. Five respondents were not immunized and not intending to be so, reporting 13 different factors influencing their decisions. The risks of hepatitis B in nonimmune subjects are discussed, as are new government guidelines on the protection of health care workers from hepatitis B infection.

Radiographic features in 1016 adults admitted to hospital with acute asthma.

A retrospective review was carried out of the radiographic features of 1016 adults admitted to hospital with acute asthma over a 4-year time period. The radiographic features were classified into five groups: (I) normal, 536 patients (52.9%); (II) features compatible with obstructive lung disease, 323 patients (31.8%); (III) complications of asthma including infection, segmental or greater atelectasis, one case of pneumomediastinum and one case of pneumothorax, 83 patients (8.2%); (IV) unimportant incidental findings, six cases (0.6%); and (V) important incidental findings including tuberulosis, heart failure, and bronchial neoplasm, 68 cases (6.7%). We conclude that in this large series of patients presenting with asthma symptoms severe enough to merit admission there is an incidence of clinically significant radiographic abnormalities of approximately 15%. Admission chest radiography is therefore indicated in adults who are hospitalized with acute asthma.

Corneal endothelial response to polymethylmethacrylate versus hydrogel lenses after phacoemulsification.

We performed a study to evaluate the corneal endothelial cell response in 26 patients who received a polymethylmethacrylate (PMMA) intraocular lens and 26 patients who received a soft, nonfolded poly-hydroxy-ethylmethacrylate (poly-HEMA) intraocular lens after posterior chamber phacoemulsification. Specular microscopy and pachymetry were done before surgery and a mean of 8 or more weeks after surgery. The mean percent cell loss was 8.2% in the PMMA group and 10.7% in the poly-HEMA group. There was no significant difference in the pachymetry values before or after surgery between the two groups; however, in the poly-HEMA group the postoperative value was significantly higher than the preoperative value (p = 0.027). The results suggest that the amount of perioperative corneal endothelial cell loss with poly-HEMA lenses is similar to that with PMMA lenses. Further study is needed to fully evaluate the long-term corneal effects of poly-HEMA lenses.

Medical antishock trousers (MAST): a review.

A review of the literature on medical antishock trousers (MAST) is presented together with a report on their use at Hope Hospital, Salford. Their relevance in British emergency management and future uses are considered.

The Scarborough express train crash: four case reports.

Four cases are presented of patients who sustained blunt trauma to the epigastrium in a train crash. Two patients sustained a transected pancreas. The mechanism of injury is discussed.

Plasma catecholamines in the acute phase of the response to myocardial infarction.

Plasma catecholamine (adrenaline, noradrenaline and dopamine) concentrations have been measured in 48 patients within 6 hours of the onset of symptoms of an acute myocardial infarction. The concentrations of all three catecholamines were elevated, and there were positive correlations between plasma noradrenaline concentrations and the severity of infarct as assessed by the coronary prognostic index and serum LDH levels. Plasma glucose, free fatty acid, lactate and cortisol levels were elevated while insulin levels were reduced. The site of infarction did not influence the pattern of hormonal and metabolic responses although heart rate was significantly lower in the inferior than in the anterior infarct group. Seven patients went into ventricular fibrillation shortly (less than 1.8 h) after blood sampling. Plasma catecholamine concentrations were markedly elevated in these patients with levels similar to those previously reported after cardiac arrest.

Prevention of wound infection following vasectomy.

A prospective study on 90 patients undergoing vasectomy as day cases is reported. The use of a chlorhexidine gluconate bath or shower on day 1 and day 2 post-operatively reduced the wound infection rate from 37.8 to 6.7%. It is suggested, therefore, that this technique is an economical and successful way of reducing the incidence of infection in these patients.

PIP: The value of postoperative showering with chlorhexidene gluconate in reducing wound infection after vasectomy was evaluated in a series of 90 men who underwent sterilization as day cases. All patients received a preoperative shower with chlorhexidene gluconate. However, only 45 cases received chlorhexidene gluconate postoperatively (on days 1 and 2 after the procedure). The remaining 45 patients followed the standard regimen of taking salt baths 24 hours after discharge. At follow up 7 days after the procedure, wound infection was noted in 17 controls (37.8%) but only 3 (6.7%) of the patients who used chlorhexidene gluconate postoperatively. Wound infection was defined by the presence of purulent or serous discharge. These results suggest that postoperative use of chlorhexidene gluconate can significantly reduce wound infection after vasectomy.

Plasma catecholamines in patients with acute myocardial infarction and in cardiac arrest.

Plasma catecholamine concentrations in cardiac arrest (ventricular fibrillation and asystole) are significantly higher than after myocardial infarction. The levels reached are well above those normally required to stimulate cardiac activity. Possible reasons for the failure of the myocardium to respond to the catecholamines are discussed and the rationale for giving more catecholamines is questioned.

Absence from work following vasectomy.

PIP: This study investigated absence from work after vasectomy in 90 men who underwent the procedure on an outpatient basis. At the follow up visit 7 days later, 37 of the 80 employed patients (46.2%) revealed that they took time off from work following vasectomy. The mean number of days missed was 5.12 days (range 1-10 days). When expressed in terms of all patients in the series, the mean number of days lost was 2.37 days. The main reason given for absence from work was pain or discomfort (27 patients). The majority of men taking time off were from social class 3. Patients were more likely to take time off work when the procedure was performed at the beginning of a week. 29 patients had surgery under local anesthesia and 61 received general anesthesia; there was no significant difference between these 2 groups in absence from work. These results suggest that the assumption of an immediate return to work after vasectomy may be inappropriate for a substantial number of patients. If patients were advised to take 1 day off work following surgery, they might be less inclined to take more time.^ieng

Components of injury (haemorrhage and tissue ischaemia) affecting cardiovascular reflexes in man and rat.

The effects of two components of tissue injury, namely fluid loss from the circulation and tissue ischaemia, on cardiovascular reflex activity have been studied. Moderate blood loss (10-20% blood volume) in the unanaesthetized rat increased the slope of the regression line relating heart period to mean arterial blood pressure and usually displaced it to the left (i.e. towards a relative bradycardia). A blood donation of 500 ml (approximately 10% blood volume) increased the Valsalva ratio in conscious man without a change in resting pulse rate. However, a 15 min period of unilateral limb ischaemia in man reduced the Valsalva ratio. The pattern of change in the pulse rat response to the Valsalva manoeuvre produced by limb ischaemia closely resembles that found previously after limb injury in man. There was no evidence that the endogenous opioids were involved in the interaction between limb ischaemia and cardiovascular reflex activity in man.

Wound infection following vasectomy.

Ninety-four patients undergoing vasectomy as day cases were studied prospectively. An overall infection rate of 32.9% was recorded and, apart from haematoma formation and the nasal carriage of organisms, no factors were found that increased the risk of infection. A preoperative hibiscrub shower did not affect the infection rate, even though it was responsible for a significant reduction in skin flora. This raises the possibility of infection following vasectomy being secondary, not occurring at the time of surgery.

PIP: 94 patients undergoing vasectomy as day cases were studied prospectively to assess the true wound infection rate for vasectomy in the Hope Hospital in Salford Manchester, England, to assess the subsequent morbidity, and to elucidate any factors that may be responsible for infection. The pilot study had already indicated an unacceptably high infection rate and so it was decided to investigate the value of a preoperative hibiscrub shower in reducing the size of the problem. All patients had nasal, scrotal, and perineal swabs taken, the swabs being taken by rolling the swab several times against the area to be sampled. The patients were then randomly assigned to 3 groups. Group 1 consisted of 32 patients undergoing vasectomy alone with no preoperative shower; Group 2, 32 patients undergoing a single preoperative hibiscrub shower; and group 3, 30 patients undergoing a single preoperative shower with ordinary soap. All patients were assessed 7 days postoperatively for wound infection and hematoma formation. The patients also were questioned as to time off work. An infected wound was considered to be any wound that was open and discharging either purulent or serous fluid. In the context of vasectomy an erythematous wound was not considered to be infected, this being part of the inflammatory reaction caused by the catgut skin closure. If the wound was infected a swab was taken. Of the 94 patients, 83 returned postoperatively. The 10 who were contacted at home reported no problems and only 1 patient was lost to follow-up. There were 31 infections among the 94 patients, an overall infection rate of 32.9%. 4 infections were severe and 3 of these had an associated epididymoorchitis. 21 patients (22%) developed hematomas under the wound. None of these was more than 1.5 cm in diameter. 9 of the infected patients had time off work because of the infection. 3 of these were severe infections but 6 were mild. 9 of the noninfected patients also had time off work, the reasons being given being swelling (4) and pain (5). Staphylococcus aureus accounted for 60% of the infections and in only 1 case was it part of a mixed growth. All of the other infections were mixed. No perineal carriers of Staph. aureus were encountered but 15 patients (16%) were found to be nasal carriers of this organism. Phage typing revealed that only 3 of the staphylococcal wound infections were due to the same organisms as found on the nasal swab. Of the Staph. aureus wound infections, 1 group of 3 cases and a separate group of 4 cases revealed the same phage types. The most common organisms found on the scrotum and perineum preoperatively were Staphylococcus epidermidis and diptheroids. A soap shower exerted no significant effect on the number of organisms.