Some Knowledge Bonding With Dermabond

http://jucm.com/magazine/issues/2013/1013/files/11.html

     Hands down, this linked article the the Journal of Urgent Care Medicine is one of the best clinical summaries of Dermabond I have ever read. Note the author does a solid melding of academics and "real world" experience. A few highlighted pearls

• The majority Dermabond failures are not due to the "glue breaking" or cohesive failure. Most of the time it is substrate failure, or the glue not bonding to the skin. Remedies include alcohol swabs around the wound to remove oil and other skin contaminants, and keeping the area as dry as possible. One superb tip was to be sure to include a boundary of 1-2 CENTIMETERS of normal skin around the laceration to allow an increased bonding area and lessen the chance of wound dehiscence. I will admit I have been using usually an area of about 5mm at most to anchor the glue. (Hint-get out a ruler and see these exact sizes- you too will be surprised!)
• Many patients bark out to the medical provider, "Well geez Doc, I could have just used the super glue I use on my exhaust pipe to pass my license tag inspection!" The article actually cites that over the counter "Super glue" polymerizes much faster than medical glue and as such, releases enough heat to cause first degree burns. So, now you get the last laugh!
• The article highlights a use I may explore, which is Dermabond on large elderly skin tears that are too frail to suture. Key here is avoiding tears that look as if they may form a large hematoma.
• Confession- I have done this too. Air movement (waving your hand) does not speed glue polymerization. The package insert for Dermabond is a 2 minute period. The article states 2.5 minutes.
• Lastly, don'f forget the #1 credo of all wound healing: The key to lessen scarring is to properly approximate the skin layers. So, you must be able to pull the wound "tight" enough to align the dermis, epidermis, and thereby prevent the glue from improperly seeping deep into the wound and slowing healing. Consider a small steristrip to approximate the area if routine skin tension does not approximate layers well. Obviously you want a small steristrip, since as mentioned above you need the skin surface area to allow full bonding. 

The article is well worth your time. I guarantee you will find an item to help your practice and improve outcome.

"Urine" Trouble if You Forget This New Pathogen

http://www.familypracticenews.com/index.php?id=2633&tx_ttnews%5Btt_news%5D=216531&cHash=ff838b0caa41c6e4bbcb00b5ac003482

I consider this one of the most influential articles ever for this blog because it will change your urgent care practice. The link mentions a semi-new and virulent urethritis pathogen- Mycoplasma genitalium.  Long lumped under the amorphous microbiological class of "atypical pathogens for urethritis", this mycoplasma strain in recent studies has been implicated for 15-20 % of clinically significant urethritis issues. Moreover, this mycoplasma displays considerable resistance to the usual urethritis empiric meds of doxycycline, cipro, and zithromax. In fact, it currently (unless resistance patterns morph over time) is mainly susceptible to Avelox. 

Just think, how many times has a male (or female) come in with urethritis, you see some WBC on the UA, you empirically start zithromax or doxycycline, and then they still have significant symptoms 5 days later when he or she returns to the clinic and you say, "Well, good news is your gonorrhea and chlamydia are negative. I am unsure why you still have urinary issues (you internally think non compliance)." Perhaps you send them to a urology consult, expecting interstitial cystitis. Regardless, this article outlines that persistent urethritis (or even cervicitis) issues unresponsive to the usual antibiotics with a negative gc/chlamydia need a course of Avelox (to eradicate M. genitalium), and also a course of concomitant  Flagyl, to eradicate the less common Ureaplasma urealyticum. 

SUMMARY: Don't shrug your arms with urethritis when the patient returns with issues despite treatment. Instead, try a 7-10 day course of Avelox and Flagyl, The article estimates 15-20% of urethritis is due to these non culturable organisms. Hence, this means the urine culture also will show up negative. Note also with M. genitalium that there seems to be resistance to traditional fluoroquinolones like Cipro or Levaquin. While Avelox and Flagyl should NOT be first line treatments, they certainly should be second line urethritis interventions. I can say this will give me new options for many of my frustrated patients, and I am sure you too have patients like this....if you just keep your eyes open.....