The importance of bicarbonate in large volume anesthetic preparations. Revisiting the tumescent formula.

BACKGROUND: The tumescent local anesthetic approach is now being used more widely in dermatologic surgery. Although the original formula contains 12.5 mEq sodium bicarbonate per 50 mL of lidocaine, traditionally buffered solutions contain 1 mEq per 10 mL. OBJECTIVE: This study examines the effects of changing the concentrations of sodium bicarbonate in the tumescent formula. METHODS: Various concentrations of sodium bicarbonate in tumescent anesthetic preparations were measured for pH. RESULTS: Tumescent anesthetic preparations containing 5 mEq/L have a more physiologic pH (7.41) than the classic formula of 12.5 mEq/L (7.73). Clinical use of this reduced sodium bicarbonate solution showed no difference from the original formula. CONCLUSIONS: Sodium bicarbonate can be used in a 1 mEq per 10 mL of lidocaine ratio similar to other buffered anesthetic solutions. This solution is physiologic in pH. However, some thought should also be given to the pKa of lidocaine, which is at pH 7.9. To achieve this even higher concentration (20 mEq/L) bicarbonate must be added to the tumescent solution. Thought must be given to these concepts when tumescent solutions are used in large volumes.

Erythema elevatum diutinum in a patient with Crohn's disease.

A possible association between erythema elevatum diutinum and Crohn's disease is described. To our knowledge, erythema elevation diutinum has never been reported in a patient with Crohn's disease, nor has the disorder been considered one of the cutaneous manifestations of inflammatory bowel disease. Erythema elevatum diutinum is believed to be mediated by the deposition of circulating immune complexes in the dermal perivascular spaces. Our patient showed clinical and histopathologic findings typical of both erythema elevatum diutinum and Crohn's disease. The patient also had a positive Raji cell assay, which demonstrates the presence of a circulating immune complex. Increased levels of circulating immune complexes have been found in patients with inflammatory bowel disease, and the gastrointestinal inflammation in Crohn's disease could lead to enhanced antigenic exposure and increased formation of immune complexes. We contend that inflammatory bowel disease may have contributed to the development of erythema elevatum diutinum in our patient.

Progeria.

Progeria, also known as the Hutchinson-Gilford syndrome, is an extremely rare condition that was initially reported by Johnathan Hutchinson in 1886 and further described by Hastings Gilford in 1904. Transmission is most likely from a sporadic autosomal dominant mutation. Clinical manifestations are evident by the first or second year of life and include the physical characteristics usually associated with the elderly. Mentally, patients are alert and attentive with normal intelligence and emotions. Histopathologic changes occur primarily in the skin, bone, and cardiovascular tissues, while other organs appear to be unaffected. Laboratory findings are unremarkable, with the exception of an increased urinary excretion of hyaluronic acid. The diagnosis rests on the clinical presentation; at present, no treatment has been proved to be effective. Death results from cardiovascular abnormalities in the majority of cases and usually occurs between the ages of 10 and 15 years. Current research suggests an underlying defect of hyaluronic acid that may possibly account for the entire process.

Incidence of skin disease in rural Jamaica.

The incidence of skin disease in people seeking health care in rural Jamaica during the period January to December 1985 has been studied. Results indicate that of 14,179 clinic visits reviewed, 6% involved a primary dermatologic diagnosis. Infectious and parasitic diseases predominated, with scabies, impetigo, and tinea being the most common diagnoses. Of these, scabies accounted for nearly one third of all dermatologic visits. Noninfectious skin disease accounted for less than 10% of dermatologic diagnoses, with unclassified eczema making up the majority. Undiagnosed skin conditions contributed one third of dermatologic visits, with an incidence inversely related to the incidence of scabies visits. This relationship suggests that many evaluations of skin conditions were based on the exclusion of scabies with no alternative diagnosis.

Meat tenderizer in the acute treatment of imported fire ant stings.

Meat tenderizer containing the proteolytic enzyme papain was tested for therapeutic efficacy in the sting of the imported fire ant. The parameters of pain and itching were used to evaluate qualitatively the sting response in 22 healthy medical students, and the laser Doppler velocimeter was used to assess quantitatively the change in cutaneous blood flow. The results indicated that, during the acute-phase reaction, no clinically or statistically significant difference was found between stings treated with meat tenderizer and stings treated without tenderizer. Therefore we conclude that meat tenderizer is of no therapeutic value in the acute treatment of the imported fire ant sting.