Barrier precautions in trauma: is knowledge enough?

OBJECTIVES: The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. METHODS: A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. RESULTS: Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). CONCLUSION: The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.     

A prospective,randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia

HYPOTHESIS: Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias. DESIGN: Prospective, randomized controlled trial. SETTING: University-affiliated private hospital. PATIENTS: Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter. INTERVENTION: Nissen fundoplication with posterior cruroplasty (n = 36) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene (PTFE) mesh (n = 36). MAIN OUTCOME MEASURES: Recurrences, complications, hospital stay, operative time, and cost. RESULTS: Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was $960 +/- $70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006). CONCLUSION: The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.     

Midshaft hypospadias

The key to successful hypospadias surgery is minimal tissue handling, tension-free reconstruction, the use of well-vascularized tissue, and knowledge of which repairs are indicated. Preservation of the urethral plate along with an onlay graft has a low complication rate and should be attempted for midshaft hypospadias repair. Although tubularized pedicle flaps increase the risk of complications such as urethral strictures, urethral diverticula, and fistulas, they provide a good alternative in the presence of a poorly developed urethral plate. For correction of the penile curvature, we recommend ventral lengthening procedures in cases where simple dorsal plication will result in shortening of an already compromised penile length. Using these principles, excellent cosmetic and functional results can be expected for treatment of midshaft hypospadias.     

Adjuvant activity of emulsan,a secreted lipopolysaccharide from acinetobacter calcoaceticus

Several promising adjuvant candidates have been studied over the past 75 years; however, only alum is currently approved for human use. The complex acylated polysaccharide emulsan, secreted from Acinetobacter calcoaceticus, represents a new candidate. Unique features of this family of polymers are their amenability to structural tailoring and their emulsification behavior. We demonstrate that emulsan activates macrophages in a dose-dependent manner. This activation is dependent on the presence of the fatty acid side chains that decorate the polysaccharide backbone, and, furthermore, the level of activation can be affected by changes in the chemical characteristics of emulsan structural variants. One emulsan variant was examined in a classical hapten carrier immunization protocol and demonstrated significant adjuvant activity as determined by hapten-specific antibody titers. This immune response was characterized by a high immunoglobulin G2a titer, consistent with a Th1 response. The significant immunopotentiation demonstrated by this complex polymer establishes emulsan as an exciting new candidate adjuvant. Furthermore, by manipulating the chemical structure of this compound, we can explore the physical basis of pattern recognition receptors and macrophage activation.     

Angle closure glaucoma following pupillary block in an aphakic perfluoropropane gas-filled eye

We report the case of a 35-year-old aphakic patient who developed an intractable secondary glaucoma due to angle closure after pupillary block following the use of perfluoropropane (C3F8) gas at a nonexpansile concentration of 14%.