Marked elevation of urinary zinc levels and pleural-friction rub in metal fume fever

Zinc fume is a well-recognized cause of metal fume fever, characterized by acute or subacute symptoms of respiratory tract inflammation, myalgias and fever (similar to influenza) associated with a variety of metal oxide fumes. A welder of galvanized steel developed metal fume fever, a pleural friction rub and markedly elevated urinary zinc excretion despite work-site surveillance data indicating exposures close to the Occupational Safety and Health Administration, Permissible Exposure Limit. This patient suggests that exposure data may be misleading. This case had the highest urine zinc levels reported in the literature and a previously unreported coexistent pleural friction rub. The symptoms resolved with administrative and engineering controls to decrease exposure.     

Transvenous n-butyl-cyanoacrylate infusion for complex dural carotid cavernous fistulas: technical considerations and clinical outcome

BACKGROUND AND PURPOSE: Endovascular transvenous embolization has been advocated as the treatment technique for dural carotid cavernous fistulas (dCCFs). Most centers use platinum coils primarily. The purpose of this study was to evaluate the technical aspects, efficacy, and safety of transvenous n-butyl cyanoacrylate (n-BCA) infusion in dCCFs as a primary alternative or adjunct to coil embolization. METHODS: We retrospectively evaluated 14 patients with dCCFs who were treated at this institution from 1999 to 2004 by using n-BCA infusion alone or in combination with coils. The efficacy of treatment and safety aspects were studied in dCCFs of Barrow type B (4/14), C (2/14), and D (8/14). Six patients were treated with transvenous n-BCA infusion alone in the cavernous sinus, 7 with a combination of transvenous n-BCA and coil embolization, and one with transvenous n-BCA combined with transarterial polyvinyl alcohol (PVA)-particle embolization of the feeding arteries. RESULTS: An angiographic obliteration and clinical cure was achieved in all patients. Technical complications were nonsymptomatic and included spillage of an n-BCA droplet into a middle cerebral artery branch retrograde through the arteriovenous fistulas in one patient and perforation of the inferior petrosal sinus during microcatheter placement in another. A third patient developed temporary palsy of the sixth cranial nerve a few days after the treatment. CONCLUSION: In this small series, the use of n-BCA either alone or in conjunction with detachable coils was a safe and effective technique for the treatment of symptomatic patients presenting with complex dCCFs.     

Powder emission rates of four air polishing devices

OBJECTIVES: Although highly effective in plaque and stain removal, the use of air polishing devices (APDs) on denuded root surfaces may lead to clinically relevant loss of tooth substance. As the amount of powder emitted by an APD may have a significant impact on the safety and efficacy of the instruments, the purpose of the study was to quantify the amount of powder emitted by APDs depending on their powder filling status and powder setting. METHODS: Four different APDs were filled to maximum level and the cumulative amount of powder emitted, depending on instrument settings and filling status, was quantified during 15 subsequent 120-s periods of use. Differences in powder emission were analyzed using anova repeated measures. RESULTS: Exact powder dosage was possible in one APD only (Dentsply Prophyjet) where emission rates also remained constant over the first five periods assessed. In the three other APDs assessed (EMS Air-Flow, Satellec Air-Max, KaVo Prophyflex II powder emission depended on the amount of powder present in the powder chamber and declined with ongoing use. Changes in powder setting had a significant impact on powder emission in all APDs assessed, apart from the KaVo Prophyflex II unit. CONCLUSIONS: Powder emission of APDs may vary greatly depending on the amount of powder present in the powder bowl. Therefore, instrument powder setting may not be a reliable parameter for safety and efficacy adjustments. This should be considered in clinical applications as well as in future research.     

Fractures and Dislocations of the Forefoot: Operative and Nonoperative Treatment

Effective treatment of common bone injuries of the forefoot is dependent on a clear understanding of both the osseous anatomy of the foot and the biomechanics of gait. Obtaining a thorough history and performing a careful physical examination are especially important because the complex anatomy of the region often makes radiographic diagnosis difficult. The keys to making the correct diagnosis in the injured forefoot are detailed, with emphasis on obtaining the appropriate radiographic studies. Included in the discussion are injuries to Lisfranc's joint and the metatarsophalangeal and sesamoid joints, as well as metatarsal and phalangeal fractures. Guidelines for operative and nonoperative management of these injuries are presented.     

Alcohol-induced sleepwalking or confusional arousal as a defense to criminal behavior: a review of scientific evidence, methods and forensic considerations

An increasing number of criminal cases have claimed the defendant to be in a state of sleepwalking or related disorders induced by high quantities of alcohol. Sleepwalkers who commit violent acts, sexual assaults and other criminal acts are thought to be in a state of automatism, lacking conscious awareness and criminal intent. They may be acquitted in criminal trials. On the other hand, criminal acts performed as the result of voluntary alcohol intoxication alone cannot be used as a complete defense. The alcohol-induced sleepwalking criminal defense is most often based on past clinical or legal reports that ingestion of alcohol directly 'triggers' sleepwalking or increased the risk of sleepwalking by increasing the quantity of slow wave sleep (SWS). A review of the sleep medicine literature found no sleep laboratory studies of the effects of alcohol on the sleep of clinically diagnosed sleepwalkers. However, 19 sleep laboratory studies of the effects of alcohol on the sleep of healthy non-drinkers or social drinkers were identified with none reporting a change in SWS as a percentage of total sleep time. However, in six of 19 studies, a modest but statistically significant increase in SWS was found in the first 2-4 h. Among studies of sleep in alcohol abusers and abstinent abusers, the quantity and percentage of SWS was most often reduced and sometimes absent. Claims that direct alcohol provocation tests can assist in the forensic assessment of these cases found no support of any kind in the medical literature with not a single report of testing in normative or patient groups and no reports of validation testing of any sort. There is no direct experimental evidence that alcohol predisposes or triggers sleepwalking or related disorders. A legal defense of sleepwalking resulting from voluntarily ingested alcohol should be consistent with the current state of art sleep science and meet generally accepted requirements for the diagnosis of sleepwalking and other parasomnias.     

Increasing colorectal cancer testing: translating physician interventions into population-based practice

Colorectal cancer (CRC) screening in the Medicare population remains low despite Medicare coverage. We describe a population-based effort to increase CRC testing of Medicare enrollees in two States through promotion and distribution of office-based tools to primary care physicians and gastroenterologists. Small increases in colonoscopy test use by primary care physicians were observed, but the differences were not statistically significant. Results in one State were stronger than the other, and two components of the intervention appeared more promising than others. Use of CRC tests can be increased, but additional approaches are needed.     

Argument against use of food additives for osteoarthritis of the hip

Food additives and other forms of alternative medicines have been embraced by the general public. Some of these compounds including glucosamine and chondroitin sulfate have shown efficacy in relieving pain associated with osteoarthritis. However, evidence is limited concerning the chondroprotective ability of these agents. More controlled studies and basic research is necessary to evaluate these claims especially because these compounds are not under regulatory control.