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Biomedical subjects

A J Singer

Publications and source records attributed to A J Singer.

At least 55 records · Page 3Linked to original sources
PubMed1998

Aspergillosis of the testis in a renal transplant recipient.

Aspergillus is ubiquitous worldwide. It is found primarily in soil, dust, vegetation, and decaying matter. While disseminated aspergillosis affects the testis only 1% of the time, testicular aspergillosis in the absence of disseminated disease is exceedingly rare, as demonstrated in the present case report.

Aspergillosis↗
PubMed1998

Irrigation in facial and scalp lacerations: does it alter outcome?

STUDY OBJECTIVE: Animal and human studies suggest that irrigation lowers the infection rate in contaminated wounds, but there is no evidence that this common practice is beneficial for "clean" lacerations. We tested the null hypothesis that there is no difference in the infection rate for noncontaminated lacerations to the face and scalp that are irrigated before primary closure compared with similar wounds that are closed primarily without irrigation. METHODS: We performed a cross-sectional study of consecutive patients presenting to a suburban, academic emergency department between October 1992 and August 1996. Patients with nonbite, noncontaminated facial skin or scalp lacerations who presented less than 6 hours after injury were included. Structured, closed-question data collection instruments were completed at the time of laceration repair and at suture removal. The primary outcome parameters were the incidence of wound infection and the short-term cosmetic appearance of lacerations in patients who did or did not receive irrigation. RESULTS: A total of 1,923 patients were included in the study group; 1,090 patients received saline irrigation, and 833 patients did not. The irrigation and nonirrigation groups were similar with regard to time from injury to presentation (1.56 versus 1.42 hours, respectively), frequency of linear wound morphology (82% versus 88%), frequency of smooth wound margins (72% versus 82%), number of layers of closure (1.14 versus 1.26), number of skin sutures applied (4.98 versus 4.65), number of deep sutures applied (.70 versus 1.05), and use of oral antibiotic prophylaxis (2.8% versus 4.0%). With respect to outcomes, the incidence of wound infection was not significantly different between the two treatment groups (.9% versus 1.4%, respectively; P = .28). Likewise, the percentage of patients who had an "optimal" cosmetic appearance was similar in the two groups (75.9% versus 81.7%, respectively; P = .07). CONCLUSION: Irrigation before primary closure did not significantly alter the rate of infection or the cosmetic appearance in our study population with clean, noncontaminated facial and scalp lacerations.

Adolescent↗
PubMed1998

Comparison of wound care practices in pediatric and adult lacerations repaired in the emergency department.

OBJECTIVE: We compared emergency physician's wound care practices in young children (< or = 5 years) and adults (> or = 18 years) and the effect of these different practices on infection rate and cosmetic appearance. DESIGN: Cross sectional study. SETTING: University hospital emergency department that rarely uses conscious sedation. PARTICIPANTS: Consecutive patients who presented with lacerations over a four-year period. METHODS: Structured closed question data sheets that assessed 26 separate wound characteristics were prospectively completed at initial presentation and at suture removal. Infection and cosmetic appearance were assessed with previously validated scales. chi(2) tests were used for categorical variables, t tests for continuous variables. RESULTS: We evaluated 3624 patients: 853 children and 2771 adults. Wounds in children were more likely to be on the head (86 vs 38%, P < 0.01); linear (88 vs 77%, P < 0.01); shorter (1.9 vs 3.0 cm, P < 0.01); less often contaminated (4 vs 11%, P < 0.01); and more commonly caused by blunt injury (69 vs 37%, P < 0.01). With respect to treatment, lacerations in children were less likely to receive irrigation (53 vs 77%; P < 0.001) but slightly more likely to be scrubbed (50 vs 45%, P = 0.01). The two groups received similar numbers of sutures per centimeter (2.6 vs 2.3). Using logistic regression, the differences in irrigation were not explained by the differences in laceration characteristics. Despite less frequent irrigation, children had lower wound infection rates (2.1 vs 4.1%; P = 0.004) and better cosmetic appearances (optimal score, 75 vs 64%, P = 0.0003). CONCLUSIONS: Emergency physicians at our institution are less likely to irrigate lacerations in children than adults; however, children had a lower infection rate and more favorable cosmetic outcome.

Adult↗
PubMed1998

Low-frequency sonophoresis: pathologic and thermal effects in dogs.

OBJECTIVE: Low-frequency sonophoresis has recently been shown to significantly facilitate transdermal permeability of various substances (e.g., insulin) in animal models, thus eliminating the need to inject such agents. Prior to human trials, the authors studied the safety profile of low-frequency sonophoresis in dogs by evaluating microscopic and temperature changes in the skin after sonophoresis. METHODS: An evaluator-blinded canine study of sonophoresis using different energy intensities and probe diameters was performed. Low-frequency ultrasound was applied for 60 seconds to the clipped abdominal skin of 3 anesthetized adult mongrel dogs using a sonicator operating at a frequency of 20 KHz with a maximal energy output of 400 W. The sonicator was immersed in normal saline, and intensities of 4%, 10%, 20%, 30%, and 50% were applied during 600 msec of every second (pulsed mode). Three probes, 1-cm cylindrical, 5-cm cylindrical, and 10-cm disc-shaped, were evaluated. Each experimental condition was performed twice. Subcutaneous temperatures were measured by temperature probe before and after sonophoresis. At 30 minutes post-sonophoresis, full-thickness skin biopsies were taken for blinded histopathologic evaluation. RESULTS: Minimal urticarial reactions were noted with the 1-cm probe at intensities of < or = 20% and with the 5-cm probe at 4% intensity. With higher intensity, thermal injuries were observed grossly with erythema and vesicles. The microscopic correlates were papillary and dermal edema with neutrophils and telangiectasia. The conditions producing vesicles grossly had foci of epidermal necrosis, subepidermal vesicles, and degeneration of papillary dermal collagen. With still higher intensities, confluent epidermal necrosis became apparent. Use of the 10-cm probe did not result in any injury. CONCLUSIONS: Low-frequency ultrasound at low intensities appears safe for use to enhance the topical delivery of medications, producing only minimal urticarial reactions. Higher-intensity conditions resulted in second-degree burns, most likely attributable to localized heating.

Administration, Cutaneous↗
PubMed1998

Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Stony Brook Octylcyanoacrylate Study Group.

OBJECTIVE: To compare a new tissue adhesive, 2-octylcyanoacrylate, with standard wound closure techniques for the repair of traumatic lacerations. METHODS: A prospective, randomized, controlled clinical trial enrolled consecutive patients > 1 year of age with non-bite, non-crush-induced lacerations who presented < 6 hours after injury. Structured closed-question data sheets were completed at the time of laceration repair and suture removal. Patients were randomly assigned to treatment with either 2-octylcyanoacrylate or standard wound closure. Infection was determined at the time of suture removal. Long-term cosmetic appearance (> 3 months) was assessed by physicians using a previously validated categorical cosmetic scale and by patients using a 100-mm visual analog scale. RESULTS: There were 63 patients randomized to the octylcyanoacrylate group and 61 patients treated with standard wound closure techniques. The 2 treatment groups were similar with respect to age, gender, race, medical history, and wound characteristics. At the 5-to-10-day follow-up, only 1 wound was infected and only 2 wounds required reclosure due to dehiscence. These 3 patients received treatment with octylcyanoacrylate. At long-term follow-up, the cosmetic appearances were similar according to the patients (octylcyanoacrylate, 83.8 +/- 19.4 mm vs standard techniques, 82.5 +/- 17.6 mm; p = 0.72) and the physicians (optimal cosmetic appearance, 77% vs 80%; p = 0.67). CONCLUSIONS: Wounds treated with octylcyanoacrylate and standard wound closure techniques have similar cosmetic appearances 3 months later.

Adolescent↗
PubMed1998

Cutaneous tape stripping to accelerate the anesthetic effects of EMLA cream: a randomized, controlled trial.

UNLABELLED: Most medications are not absorbed topically due to the stratum corneum barrier. While effective as a topical anesthetic, EMLA cream is absorbed slowly, delaying its effects for up to one hour, thereby limiting its usefulness. OBJECTIVE: To determine whether removal of the cornified layer of the skin by tape stripping (TS) would allow more rapid onset of anesthesia after topical application of EMLA cream prior to IV catheterization (IVC). METHODS: This was a prospective, randomized, controlled trial comparing the levels of pain of IVC 15 minutes after topical application of EMLA cream in patients who had TS vs patients who did not. The setting was a suburban university-affiliated ED. A convenience sample of 68 alert adult patients requiring IVC were enrolled. The primary outcomes measured were pain of IVC and pain of TS using a previously validated 100-mm visual analog scale as well as the IVC success rate. RESULTS: The pain of IVC was less for TS vs control patients [29.7 mm (95% CI=20.4 to 39.0 mm) vs 15.9 mm (95% CI=9.1 to 22.6 mm), p=0.017]. The mean pain of TS was 4.8+/-7.4 mm. The IVC success rate for TS vs control patients was 91% vs 74% (p=0.056). There were no adverse events after TS. CONCLUSIONS: Removal of the cornified layer of the skin resulted in a more rapid anesthetic effect of EMLA cream as evidenced by lower IVC pain scores after TS. The effectiveness of TS for enhanced absorption of other medications should be investigated.

Adult↗
PubMed1998

Thermal characteristics of neutralization therapy and water dilution for strong acid ingestion: an in-vivo canine model.

OBJECTIVE: To determine whether in-vivo neutralization therapy for acid ingestions will superimpose a thermal injury upon tissue already damaged by acid. METHODS: An in-vivo canine model was used with repeated measures of tissue and luminal temperatures. All dogs were placed under halothane general anesthesia. The stomach was exteriorized and temperature probes were placed in the lumen and mucosa. 25 mL of 0.5 N HCl (25 degrees C) was placed in the gastric lumen followed 5 minutes later by 75 mL of either 8% NaHCO3 neutralization (25 degrees C, n = 10) or water dilution (25 degrees C, n = 10). Temperature measurements were recorded at specified intervals for 5 minutes post HCl acid exposure and for 30 minutes post treatment. Temperature profiles were analyzed by repeated-measures ANOVA. Post-treatment changes were evaluated using signed-rank tests. RESULTS: In both treatment groups, treatment resulted in significant decreases in initial mucosa and intraluminal temperatures. Both the mucosa and intraluminal temperatures decreased immediately after treatment with HCO3 by an average of 1.6 degrees C (p = 0.05). In the water dilution treatment group, both temperatures decreased by 1.1 degrees C (p = 0.05). Ensuing post-treatment temperatures increased but did not reach baseline temperatures at any time up to 30 minutes post treatment. CONCLUSIONS: In the in-vivo setting, there is no evidence of hazardous temperature elevation when a weak alkali or dilution therapy is used to neutralize strong acid-induced injury. Contraindication of this form of emergency treatment should not be based on the preconceived idea that a resultant exothermic reaction will cause a superimposed thermal injury. Further clinical study is needed to determine the clinical utility of this emergency therapeutic modality.

Analysis of Variance↗
PubMed1998

Determination of the minimal clinically significant difference on a patient visual analog satisfaction scale.

OBJECTIVE: To determine the minimal clinically significant difference (MCSD) on a visual analog patient satisfaction scale. METHODS: The authors prospectively collected patient satisfaction evaluations during a clinical trial assessing the effect of introducing personal television sets on overall patient satisfaction from their ED encounters. Patient satisfaction was assessed with 2 scales: a 100-mm visual analog scale (VAS) (0 = least satisfied, 100 = most satisfied) and a 7-point categorical scale ("terrible," "mostly dissatisfied," "mixed," "partially satisfied," "mostly satisfied," "pleased," and "delighted"). The differences between the mean VAS scores of "delighted" and "pleased" patients, and between "pleased" and "mostly satisfied" patients were used to determine the MCSD on the VAS. Reliability of each of the scales was determined. RESULTS: 181 patients were evaluated. Mean age was 41 years; 59% were female. On a subset of 19 patients, the VAS yielded an interobserver correlation of 0.93. The kappa measurement of agreement on the categorical scale was 0.77. The mean difference between "delighted" and "pleased" patient VAS satisfaction scores was 6.8 mm (95% CI, 1.3-12.3 mm). The mean difference between "pleased" and "mostly satisfied" patient VAS satisfaction scores was 10.7 mm (95% CI, 5.5-15.8 mm). CONCLUSION: The MCSD in patient satisfaction scores measured with a 100-mm VAS was approximately 7-11 mm. Future studies evaluating differences in patient satisfaction should be designed to detect this difference.

Adult↗
PubMed1998

Application of tissue adhesives: rapid attainment of proficiency. Stony Brook Octylcyanoacrylate Study Group.

OBJECTIVE: To evaluate the 3-month cosmetic outcome following laceration repair with a new tissue adhesive, 2-octylcyanoacrylate, as a function of physician experience with this tissue adhesive. METHODS: The authors prospectively enrolled consecutive patients >1 year of age with non-bite, non-crush-induced lacerations who presented <6 hours after injury and were treated with 2-octylcyanoacrylate. Structured closed-question data sheets were completed at the time of laceration repair and at 3-month follow-up. Long-term cosmetic appearance (>3 months) was assessed by patients using a 100-mm visual analog scale. The cosmetic outcomes were evaluated as a function of the physician application using ANOVA or chi2 tests, as appropriate. This study had 80% power to detect a 10-mm difference between the 2-octylcyanoacrylate and suture groups (alpha, 0.05). RESULTS: Seven physicians applied 2-octylcyanoacrylate to 63 patients; 61 patients received sutures. Patients were similar in the 2 groups (age, gender, race, history, and wound characteristics; p > 0.05 for all). At long-term follow-up, the cosmetic outcomes were similar in the 2-octylcyanoacrylate and suture groups according to patients (VAS 83.8 +/- 19.4 mm vs 82.5 +/- 17.6 mm; p = 0.72) and physicians (optimal score, 77% vs 80%; p = 0.67), and independent of physician experience with the 2-octylcyanoacrylate. One wound developed an infection and one wound necessitated reclosure due to dehiscence. Neither occurred with the first application. CONCLUSIONS: The 3-month cosmetic appearance of wounds treated with 2-octylcyanoacrylate is equivalent to that with sutures and does not improve as physicians become more experienced with use of this tissue adhesive. These data suggest that physicians can develop competence in application of tissue adhesives with a brief training period.

Clinical Competence↗
PubMed1998

Long-term evaluation of cosmetic appearance of repaired lacerations: validation of telephone assessment. The Stony Brook Wound Registry Study Group.

OBJECTIVE: Patients with lacerations are most concerned about the ultimate cosmetic appearance of their wound. We evaluated methods to assess the long-term cosmetic appearance by telephone survey. METHODS: Patients with lacerations repaired in the ED were contacted by telephone and had direct examination a mean of 112 days after injury. At the time of telephone contact to schedule the ED follow-up visit, patients completed a structured survey instrument. Patients rated their laceration appearance from 0 to 100, and completed a 6-item categorical assessment of cosmetic appearance. During ED follow-up, patients assessed satisfaction with a 100-mm visual analog scale (VAS), a 0 to 100 numerical scale, and the same 6-item categorical scale. The criterion standard was the validated 6-item categorical scale used by physicians. A score of 6 is optimal; less than 6 is suboptimal. RESULTS: A total of 103 patients participated (mean age 17 years; 55% male subjects). Wounds were mostly located on the head (72%) and upper extremity (24%). Mean wound length was 1.9 cm. On all numerical scales (numerical assessment by telephone, assessment in the ED by VAS, and by 0 to 100 scale in the ED) the patients considered the wound better when the physicians considered the cosmetic appearance to be optimal (87 mm versus 71 mm; 90 mm versus 73 mm; 90 mm versus 73 mm, respectively; P < .01 for all comparisons). The relationship between the 0 to 100 numerical rating scale used in the ED and that used during the telephone survey revealed a strong relationship. The scales had a mean difference of 2.1 mm (95% confidence interval -26 to 30 mm). However, patient categorical scale assessment from the phone interview was not concordant with physician assessment in the ED (kappa = .12). CONCLUSION: The long-term cosmetic appearance of lacerations repaired in the ED can be assessed by asking patients to grade their lacerations from 0 to 100 over the telephone. By contrast, categorical assessment over the telephone is not concordant with physician assessment in the ED. This information may allow easier assessment of injuries and their long-term consequences.

Adolescent↗
PubMed1997

Effect of duration from symptom onset on the negative predictive value of a normal ECG for exclusion of acute myocardial infarction.

STUDY OBJECTIVE: We hypothesized that the negative predictive value of the ECG would improve with time and assessed the effect of time elapsed from symptom onset to ED presentation on the negative predictive value, sensitivity, specificity, and positive predictive value of the initial ECG in patients presenting with symptoms suggestive of acute myocardial infarction (AMI). METHODS: We conducted a cross-sectional study in a university teaching hospital. Our structured data instrument, completed at the time of presentation included demographics, time of onset of symptoms, history, laboratory, and ECG findings. AMI was diagnosed with the use of international diagnostic criteria. Patients were stratified according to duration of time from symptom onset at 3-hour intervals. RESULTS: We enrolled 526 patients in the study group. The mean age was 59 years; 40% were female. The mean time elapsed from symptom onset to presentation was 185 minutes. A diagnosis of AMI was made in 104 patients (20%). The negative predictive values of a normal ECG for exclusion of AMI, stratified by duration of time from symptom onset, were: 0 to 3 hours, 93.2% (95% confidence interval [CI], 87.4% to 96.1%); 3 to 6 hours, 93.0% (95% CI, 83.0% to 98.1%); 6 to 9 hours, 92.6% (95% CI, 75.8% to 99.1%); and 9 to 12 hours, 94.1% (95% CI, 71.3% to 99.9%) (P = 1.0). The sensitivity, specificity, and positive predictive value of the ECG were similar in all groups. CONCLUSION: The negative predictive value of a normal ECG for exclusion of AMI does not improve as the duration of time from symptom onset to presentation increases. Normal ECG findings cannot be used to rule out an AMI, even those obtained up to 12 hours after symptom onset.

Cross-Sectional Studies↗