During the last 30 years, scientific, experimental, and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic throughout the world ( 1 Williams P.B. Haley J.F. Endotoxin as a factor in adverse reactions to latex gloves. Ann Allergy Asthma Immunol. 1997; 79: 303-310 Abstract Full Text PDF PubMed Scopus (51) Google Scholar , 2 Cooke S.A. Hamilton D.G. The significance of starch powder contamination in the etiology of peritoneal adhesions. Br J Surg. 1977; 64: 410-412 Crossref Scopus (38) Google Scholar , 3 Giercksky K.E. Qvist H. Giercksky T.C. Warloe T. Nesland J.M. Multiple glove powder granulomas masquerading as peritoneal carcinomatosis. J Am Coll Surg. 1994; 179: 299-304 PubMed Google Scholar , 4 Swanson M.C. Bubak M.E. Hunt L.W. Yunginger J.W. Warner M.A. Reed C.E. Clinical aspects of allergic disease: quantification of occupational latex aeroallergens in a medical center. J Allergy Clin Immunol. 1994; 94: 445-451 Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar ). Realizing the dangers of cornstarch on examination and surgical gloves, Germany’s regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1977 ( 5 Allmers H. Schmengler J. John S.M. Decreasing incidence of occupational contact urticaria caused by natural rubber latex allergy in German health care workers. J Allergy Clin Immunol. 2004; 114: 347-351 Abstract Full Text Full Text PDF Scopus (138) Google Scholar ). In 2000, the Purchasing and Supply Agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch ( 6 Medical Device Agency (MDA). SAFETY NOTICE: MDA SN 9825 Latex medical gloves (surgeons’ and examination), powdered latex medical gloves (surgeons’ and examination). MDA, London, UKJune 1998http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con2022789.pdf Google Scholar ).

If this educational program heightens the surgeon's, resident's, and student's interest in the biology of vascular wound closure and infection, the long years occupied in our search for improved methods of wound management would more than fulfill our expectations. As with any master surgeon, he/she must understand the tools of his/her profession. This linkage between a surgeon and surgical equipment is a closed kinematic chain in which the surgeon's power is converted into finely coordinated movements that result in vascular wound closure with the least possible scar and without infection. The description of wound repair of blood vessels will be confined to arterial surgery in which the surgeon attempts to establish a new non-wettable intima and to reestablish a strong elastic muscular media. Repair of vessel wall wounds is encountered in arteriotomy for vascular access as well as in artery-to-artery anastomoses. In both circumstances, wound repair is primarily at the suture line. The surgical needles of Syneture™ are produced from stainless steel alloys, which have excellent resistance to corrosion. A new high-nickel stainless steel, SURGALLOY ™, has been used recently by Syneture™ to manufacture surgical needles. We prefer a polybutester monofilament suture whose surface is coated with an absorbable polymer. This absorbable coating of the VASCUFIL™ monofilament sutures markedly reduces its drag forces in vascular tissue. The surgeon can practice using these sutures in femoral arteriotomies in animals.

There are more than 5 million participants in 1 of 6 gymnastic disciplines that are prone to spinal cord injuries. Working with the gifted scholar and attorney, Jeffrey Beaton, the authors have participated in developing an injury prevention program for children and teenagers who participate in gymnastics. This program includes the following components: (1) a gymnastics center that complies with the e-Book design of gymnasticszone.com; (2) all teachers and students in gymnastics should be members of USA Gymnastics (USAG) and purchase a copy of the USA Gymnastics Safety Manual, the official manual of the United States Gymnastics Safety Association; (3) trampolines should be sunk in the ground with the bed level with the floor; and finally, (4) immediate emergency access of the injured gymnast to either a skilled orthopedic or neurosurgeon.

The purpose of this report is to discuss management of operating room personnel who have had occupational exposure to blood and other body fluids that might contain hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and human T-cell lymphotropic virus type I (HTLV-I). HBV postexposure prophylaxis includes starting hepatitis B vaccine series in any susceptible unvaccinated operating room personnel who sustain an exposure to blood or body fluid during surgery. Postexposure prophylaxis with hepatitis B immune globulin (HBIG) is an important consideration after determining the hepatitis B antigen status of the patient. Ideally, all operating room personnel should be vaccinated with hepatitis B vaccine before they pursue their career in surgery. Immune globulin and antiviral agents (eg, interferon with or without ribavirin) should not be used for postexposure prophylaxis of operating room personnel exposed to patients with HCV; rather, follow-up HCV testing should be initiated to determine if infection develops. Postexposure prophylaxis for HIV involves a basic four-week regimen of two drugs (zidovudine and lamivudine; lamivudine and stavudine; or didanosine and stavudine) for most exposures. An expanded regimen that includes a third drug must be considered for HIV exposures that pose an increased risk for transmission. When developing a postexposure prophylaxis regimen, it is helpful to contact the National Clinicians’ Postexposure Prophylaxis Hotline, (888) 448-4911. Prevention should be a major consideration in postexposure prophylaxis with the use of the double-glove hole indication system by all operating room personnel.

This scientific article was designed to teach the individual reader the scientific basis for suture and needle selection as well as to illustrate the appropriate surgical techniques involved in wound repair of skin incisions. Because the US Food and Drug Administration permits 1.5% of the sterile surgical gloves to have holes, the operating room personnel should wear sterile surgical double-glove hole indication systems that detect holes in the outer glove. From the surgeon's point of view, the rate of gain of strength of the skin wound is a key determinant of many decisions including when the suture can be removed, the level of patient activity, and the selection of the incision. Important considerations in wound closure are type of suture and mechanical performance, in vivo and in vitro. Measurements of the in vivo degradation of sutures separate them into two general classes, absorbable and nonabsorbable. Sutures that undergo rapid degradation in tissues, losing their tensile strength within 60 days, are considered absorbable. Those that maintain their tensile strength for longer than 60 days are considered nonabsorbable. For skin closure with nonabsorbable suture, we favor the use of the polybutester suture that is coated with an absorbable polymer, VASCUFIL™. When absorbable sutures are used for a dermal skin closure, the synthetic monofilament MAXON™ is recommended. Absorption of the suture is complete between 90 and 110 days. In either case, we would recommend that the suture be attached by a sewage attachment to a SURGALLOY™ reverse cutting stainless steel suture. Continuous percutaneous suture closure has definite, distinct advantages over interrupted suture closure. Although continuous dermal wound closure is technically more challenging for the surgeon than interrupted dermal suture closure, it has become an important wound closure technique. A monofilament absorbable synthetic MAXON™ attached to a reverse cutting edge SURGALLOY™ stainless steel needle is ideally suited for continuous dermal skin suture closure.

Hip fracture occurrences in nursing homes are associated with high morbidity, mortality, and high health care costs in elderly people. In the United States, approximately 340,000 hip fractures occur each year, while more then 90% are associated with falls. Osteoporosis is a skeletal disorder causing impaired bone strength that increases the risk of fracture. In the United States alone, osteoporosis affects < 10 million individuals aged > or =50. The American Association of Clinical Endocrinologists (AACE), North American Menopause Society (NAMS), and National Osteoporosis Foundation (NOF) have developed recommendations for the identification of patients with osteoporosis who need therapy. Good nutrition with adequate supplements of calcium and vitamin D3 is considered one of the most important lifestyle factors for maintaining adequate bone mineral density. Only a combination of calcium and vitamin D therapy has been shown to increase the bone mineral density as well as a reduction in the nonvertebral fractures.

Ideally, the choice of the suture material should be based on the biological interaction of the materials employed, the tissue configuration, and the biomechanical properties of the wound. Measurements of the in vivo degradation of sutures separate them into two general classes: absorbable and nonabsorbable sutures. The nonabsorbable sutures and absorbable sutures are classified according to their origin. When considering an absorbable suture's tensile strength in vivo, we recommend that the manufacturer provides specific recommendations of its holding strength, rather than the percentage retained of its initial tensile strength. The newest advance in nonabsorbable sutures is polybutester suture, which is a block copolymer that contains butylene terephthalate (84%) and polytetramethylene ether glycol terephthalate (16%). The expanded polytetrafluoroethylene (ePTFE) suture has been expanded to produce a porous microstructure that is approximately 50% air by volume. The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer. A search for a synthetic substitute for absorbable collagen sutures led to the development of the POLYSORB™ sutures that can reliably approximate tissues with a low risk for infection. The latest innovation in the development of monofilament absorbable sutures has been in the rapidly absorbing CAPROSYN™ suture. A new high-nickel stainless steel, SURGALLOY™, has been used recently to manufacture surgical needles. Biomechanical performance studies of cutting edge needles made of S45500 stainless steel alloy and SURGALLOY™ stainless steel demonstrated that needles made of SURGALLOY™ had superior performance characteristics over those made of S45500.

All surgical healthcare professionals and their patients should be aware of exposure to blood from individuals infected with potentially transmissible disease. The site that was most susceptible to sharp injuries was the index finger of the surgeon's hand. It is also important to note that needles cause the vast majority of sharp injuries. During the last two decades, there have been two revolutionary advances in preventing accidental needlestick injuries during surgery that include the development of blunt tapering point needles as well as the double-glove hole indication systems. During the innovative development of blunt taper point needles, a glove manufacturer, Molnlycke, Inc., devised non-latex and latex double-glove hole puncture indication systems that are being used throughout the world. The reliability of these double-glove hole indication systems in detecting holes in the outer glove has been reliably documented by scientific studies that are published in peer-reviewed journals. On the basis of these extensive quantitative studies, the authors recommended that the double-glove hole indication system be used in all operative procedures to prevent the transmission of deadly bloodborne viral infections.

Background: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. Objectives: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. Discussion: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. Conclusion: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.

During the last four decades, there have been revolutionary advances in the development of skin staples as well as tissue adhesives. One of the purposes of this collective review is to provide an overview of recent advances in the development of metal and absorbable skin staples and tissue adhesives. In addition, we will provide technical considerations in the use of metal and absorbable skin staples and tissue adhesives during surgery. On the basis of extensive experimental studies, we would recommend the Autosuture (TM) Multifire Premium (TM) metal skin stapler. During a surgical operation, the rotating head of this skin stapler can have its skin stapling cartridge removed once for additional stapling. The revolutionary Insorb (TM) subcuticular skin stapler is designed to combine the cosmetic result of absorbable sutures with the rapid closure times associated with metal skin staplers, while eliminating the need for metal staple removal postoperatively. The Insorb (TM) absorbable staple is composed of a copolymer that is predominantly polylactide, which is absorbed over a period of a few months. The superior performance of the Insorb (TM) absorbable staple has been confirmed by experimental and clinical studies. In the last 20 years, surgeons have become increasingly interested in replacing sutures by means of adhesive bonds in the closure of surgical wounds. A recent collective review of clinical studies done with tissue adhesive has recommended that there is a need for well-designed randomized, controlled trials comparing tissue adhesives and alternate methods of closure, especially in patients whose health may interfere with wound healing.

Edlich, Richard F. MD, PhD, FACEP, FACS, FASPS; Rodeheaver, George T. PhD; Thacker, John G. PhD; Borel, Lise DMD; Stevens, Holly S.; Dahlstrom, Jill J.; Clark, Jamie J.; Wallis, Anne G.; Rhoads, Samantha K.; Lin, Kant Y. MD, FASPS; Cox, Mary J. MD, FAO; Zura, Robert B. MD, FAAOS Author Information

Multiple Sclerosis (MS) is an inflammatory disease that demyelinates the central nervous system causing progressive disability. The urodynamics of MS patients is an important consideration because these patients are susceptible to acute urinary bladder retention associated with a high fever. Treatment should include irrigation using a Foley catheter and an irrigation syringe to remove residual urine and sediment from the neurogenic bladder, intravenous fluid resuscitation, bacteriological analysis of the residual urine, and admission to an Intensive Care Unit for further evaluation by a urologist. After discharge, suprapubic cystostomy should be a consideration for patients who have chronic urinary tract infections associated with acute urinary bladder retention, as well as limited mobility to perform self catheterization, or limited personal care assistants trained to perform a urethral clean intermittent catheterization.

It has been well documented in the medical literature that powdered medical gloves can have serious consequences to patients and health-care workers. Adverse reactions to natural latex gloves, such as contact dermatitis and urticaria, occupational asthma, and anaphylaxis, have been documented as a significant cause of Workers' Compensation claims among health-care workers. While the cost of examination and surgical gloves is significant, this factor must be considered with the total cost of Workers' Compensation claims and possible litigation bestowed upon hospitals and glove manufacturing companies. In the United States, Canada, Belgium, and Germany, medical leaders have documented the dangers of powdered latex gloves and have implemented transition programs that are reducing Workers' Compensation claims filed by health-care workers. While attorneys view litigation against powdered glove manufacturers as the "next big tort", the authors of this article were not able to document all compensation costs to disabled workers because many settlements do not allow the claimant to disclose this information.

In March and early April 2009, Mexico experienced outbreaks of influenza caused by the H1N1 virus, which has spread throughout the world. With the pandemic of H1N1 infections, we have discussed in this scientific article strategies that should limit the spread of the influenza A (H1N1) virus in our country. Specific vaccines against the influenza H1N1 virus are being manufactured, and a licensed vaccine is expected to be available in the United States by mid-October 2009. However, some health-care workers may be hesitant to take a vaccine because it contains a mercury preservative-thimerosal-which can be harmful to their health. When caring for patients with respiratory infections, the health-care worker should be wearing a facial respirator. In a report from the Centers for Disease Control and Prevention (CDC), it was indicated that each health-care professional should be required to do a respiratory fit testing to identify the ideal model. Because it has been well documented that a vitamin D deficiency can precipitate the influenza virus, we strongly recommend that all health-care workers and patients be tested and treated for vitamin D deficiency to prevent exacerbation of a respiratory infection.

Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin that is rapidly progressive and accompanied by vascular collapse and disseminated intravascular coagulation. It usually occurs in children, but this syndrome has also been noted in adults. The purpose of this collective review is to provide modern concepts on the diagnosis and treatment of neonatal purpura fulminans, idiopathic purpura fulminans, and acute infectious purpura fulminans. There are three forms of this disease that are classified by the triggering mechanisms. First, neonatal purpura fulminans is associated with a hereditary deficiency of the natural anticoagulants Protein C and Protein S as well as Antithrombin III. Idiopathic purpura fulminans usually follows an initiating febrile illness that manifests with rapidly progressive purpura. Deficiency of Protein S is considered to be central to the pathogenesis of this form of the disease. The third and most common type of purpura fulminans is acute infectious purpura fulminans. The mortality rate has decreased with better treatment of secondary infections, supportive care, and new treatments, but it remains a disabling condition often requiring major amputations.

Mercury is one of the most dangerous environmental toxins. Realizing the environmental dangers of mercury, the Norwegian Minister of the Environment and International Development, Erik Solheim, has therefore prohibited the use of mercury in products in Norway. This ban will include dental filling materials (amalgam) and measuring instruments, as well as other products. This ban is valid from January 1, 2008. Sweden announced a similar ban, and dentists in Denmark will no longer be able to use mercury in fillings after April 1, 2008. It is indeed unfortunate that the United States has not taken a leadership role in enacting Informed Consent Legislations for patients receiving dental amalgam restorations. Informed Consent Legislations have been enacted by Maine, California, Connecticut, and Vermont.