1. Felix CW,Raw oyster eaters believe they have hazard under control. Food Prot Rep 1995;11:1 - 2.
2. Centers for Disease Control Web Site. CDC health advisory: cases of Vibrio vulnificus identified among Hurricane Katrina evacuees. September 7, 2005. Available at http://www.phppo.cdc.gov/HAN/ ArchiveSys/ViewMsgV.asp?AlertNum=00233.
3. Vibrio illnesses after Hurricane Katrina-multiple states, August- September 2005. MMWR Morb Mortal Wkly Rep 2005;54(37): 928 - 31.

Adult bicycle handlebar injury

Bicycle handlebar trauma has been well documented in children. Winston et al [1] described spleen, liver, and pancreatic lacerations and Renal injuries as the most commonly traumatized sites. Other reported injuries include traumatic abdominal wall hernias and ruptures, aortic rupture, transection of the common bile duct, traumatic Arterial occlusion, and groin injuries [2-6]. Presumably, the handlebar of a typical child’s bicycle acts as a spear, concentrating what may be a relatively small amount of energy into a focal point of injury.

Interestingly, little has been documented about bicycle handlebar trauma in adults. This is probably true for many reasons, including the adult’s more developed abdominal musculature. Adults may also be less likely to ride bicycles that could cause this type of injury and may be less inclined to ride a bicycle as recklessly as children and adolescents. This is a case presentation of blunt trauma from a bicycle handlebar causing a significant and unusual Abdominal injury in an adult.

A 49-year-old woman was brought to triage via private vehicle after developing gradually worsening abdominal pain 1 hour after a fall from her bicycle. She sustained a direct impact to her abdomen from her bicycle’s handlebar. The patient denied any head, neck, chest, back, or extremity injury.

Physical examination revealed an alert, diaphoretic, and somewhat obese woman in moderate distress (vital signs: heart rate, 92; respiratory rate, 22; blood pressure, 130/100 mm Hg). The primary survey was unremarkable. The secondary survey was notable only for diffuse involuntary guarding on Abdominal examination with diminished bowel sounds.

The patient’s work-up included an immediate trauma surgery consult and computed tomography scan of her abdomen and pelvis. Laboratory data were unremarkable. Management of this patient consisted of establishing 2 large-bore intravenous lines with normal saline infused at a to keep open (TKO) rate and providing Intravenous morphine sulfate for pain. She remained hemodynamically stable.

The computed tomography scan revealed a moderate to large hemoperitoneum and a possible small bowel rupture (Fig. 1). Emergent Exploratory laparotomy was performed. The chief finding noted 1 L of hemoperitoneum secondary to multiple small bowel mesenteric defects and an actively

Fig. 1 Computed tomography scan of abdomen demonstrating moderate to large hemoperitoneum.

bleeding mid small bowel vessel, which was repaired. A partial small bowel resection was performed because of the presumed compromised Blood supply. The patient had an unremarkable postoperative course and was discharged home on the seventh postoperative day.

The reason this case is unusual is twofold: Not only is it extremely unlikely for an adult to sustain significant trauma from a bicycle handlebar, the injury described in this case is also very atypical as mesenteric injury from blunt trauma is quite rare in its own right [7]. The medical literature regarding pediatric handlebar injuries is extensive. Interest- ingly, this type of injury is not well described.

Children are certainly much more prone to bicycle handlebar injuries. According to Winston et al [1], an estimated incidence of such injuries is 1.15 per 100000 in patients 19 years and younger with an estimated cost of

$9.6 million annually, $10 million in lifetime Medical costs, and $11.5 million in lifetime productivity losses. Bicycle handlebar injuries can be quite devastating and deliver a significant physical and Financial burden.

The handlebar essentially acts as a spear, usually causing

little external or soft tissue injury of significance; although those who are directly injured by the handlebar are more prone to have significant intra-abdominal or soft tissue injury. Children’s bicycles often have small diameter handlebars, making them more spearlike. Because there are often little or no external signs of trauma, treatment delay is commonplace.

Bicycling has become a very popular sport in the United States, especially in the adult population. According to BikeThisWay.com, there are 42.5 million cyclists in the United States, 87% of which are between the ages of 18 and 44 years. Although adults are not nearly as high a risk for handlebar abdominal injuries, it is certainly plausible that an adult cyclist can sustain one as this case demonstrates. With so many adult bicyclists, perhaps clinicians should have a

higher index of suspicion when evaluating an injured adult cyclist for these injuries.

Preventing handlebar injuries is quite difficult. Retract- able handlebars that would absorb energy on collision are under investigation [8]. Prevention is probably best empha- sized by promotion of safe bicycling habits. Fitting a person for a bicycle appropriately is extremely important, specif- ically sizing appropriately for the person’s weight, age, and skill level. Good bicycle maintenance is also an important factor in prevention of all types of bicycle-related injuries.

Jeffrey H. Bohmer MD Arthur F. Proust MD

Department of Emergency Medicine Delnor Community Hospital Geneva, IL 60134, USA

doi:10.1016/j.ajem.2005.12.022

References

1. Winston FK, Weiss HB, Nance ML, et al. Estimates of the incidence and costs associated with handlebar-related injuries in children. Arch Pediatr Adolesc Med 2002;156:922 - 8.
2. Winston FK, Shaw KN, Kreshak AA, et al. Hidden spears: handlebars as injury hazards to children. Pediatrics 1998;102:596 - 601.
3. Guerro MA, Lin PH, Bush RL, et al. Splenic and pancreatic infarction due to motorcycle handlebar injury. J Trauma 2005;58:1304.
4. Tracy TF, Silen ML, Graham MA. Delayed rupture of the abdominal aorta in a child after a suspected handlebar injury. J Trauma 1998;40:119 - 20.
5. Munshi IA, Khachi GK. Bicycle handlebar injury. J Emerg Med 2003;24:215 - 6.
6. Erez I, Lazar L, Gutermacher M, et al. Abdominal injuries caused by bicycle handlebars. Eur J Surg 2001;167:331 - 3.
7. Nolan BW, Gabram SGA, Schwartz RJ, et al. Mesenteric injury from blunt abdominal trauma. Am Surg 1995;61:501 - 6.
8. Arbogast KB, Choen J, Otoya L, et al. Protecting the child’s abdomen: a retractable bicycle handlebar. Accid Anal Prev 2001;33:753 - 7.

An unusual form of self-mutilation: tongue amputation with local anesthesia

Self-mutilation is generally defined as the behaviors damaging body tissues seriously without aiming death consciously [1-4]. Self-mutilation is expressed as self-aid action that is fast, providing a temporary solution to be rid of depersonalization, guilt, the sensation of being refused, hallucination, being busy with sexual subjects, and complex feelings [5]. However, in some cases, self-mutilation, especially the behavior of bcutting,Q provides one to return to reality or to be saved from anxiety [6,7]. Besides being able to be seen together with various psychiatric disorders (schizophrenia, depression, personality disorders, and men- tal retardation, etc), it can also be seen in growth disorders and other syndromes [8].

The self-mutilating patient is an unusual psychiatric presentation in the ED. The three most commonly reported

types of self-injurious behavior are self-cutting of the skin, ocular self-mutilation, and genital self-mutilation [1]. Among these cases, repeating self-mutilation cases of various organs are encountered, but we could not find a case about tongue amputation accompanied with local anesthesia related with repeating schizophrenic auto-castration and self-mutilation, and we discussed the case.

The patient, who is 27, single, unemployed, and living in a district, was brought to the Medical Faculty of Pamukkale University by his family. The rise of sounds he heard; being in doubt about his near environment, this patient who has been observed with the diagnosis of schizophrenia for seven years has begun to experience nervous attitudes. The voice he has been hearing has been telling him that he must cut his tongue. Then, the patient cut his tongue and was brought to the emergency service by his relatives. He had also cut his testicles and penis complying with the voice he had heard beforehand. The first vital diagnosis of the patient was evaluated as normal. According to the patient, he expressed that he cut one-third part of his tongue’s tip about 2 hours ago. Before cutting, so as not to feel the pain, he said that he bought the medicine named Jetokain (Lidocaine HCI 20 mg, Epinephrine 0, 125 mg/mL) ampule from a chemist and then he injected a part of the 18-ampule Jetokain to the bottom and on the top of his tongue. He poured some of the medicine and cut his tongue. The patient, living in the country without any health official, said that he had learned of the local anesthesia he made by observing a dentist from whom he received tooth treatment. To prevent the piece of his tongue that he cut from being sewn on again, the patient said that he cut that piece into smaller pieces with a pair of scissors. In the first physical examination of the patient who was taken to the nearest second-step health clinic and sent to our emergency service after the first interference, a straight cut on the front part of the tongue with amputation of one- third distal part of the tongue (amputated part was separated into very small parts) without active bleeding of the cut was determined (Fig. 1A). A tetanus toxoid was applied to the patient, analgesia was provided, and antibiotherapy was started. After otolaryngology and head and neck surgery consultation, urgent reconstructive surgery interference was not considered because the amputated piece was separated into too little pieces, making reconstruction inapplicable. The patient, whose other system examinations were determined as normal, was learned to take medical treatment with the diagnosis of chronic schizophrenia for approximately 7 years, and he was taking Fluphenazine decanoate retard 25 mg every 15 days intramuscular, Biperidene HCI 6 mg/day, and Risperidone 3 mg/day.

The patient was consulted and evaluated by psychiatry in the emergency service. In the psychological examination of the patient, his conscious was open; he was orientative, cooperative, quiet, calm, and introverted; and person, time, and place orientation was good. He looked his age, seemed plump, self-care was bad. He had a difficulty because of the tongue cut. According to the information obtained from his