This paper describes 44 percutaneous epidondylar releases performed on 34 patients with humeral epicondylitis. There were 35 instances of lateral epicondylitis and 6 of medical epidondylitis. Thirty-two of the lateral releases had an excellent result and 3 were unsatisfactory. Five of the medial procedures were rated as excellent and one unsatisfactory. Two of the three unsatisfactory lateral procedures were reoperated upon with an excellent result. The one unsatisfactory medial epicondylitis underwent reoperation and had excellent results. In our experience, percutaneous release has a high rate of success, is simple to perform, does not require hospitalization, and has been without complication.

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A rapidly fatal case of pulmonary tularemia in a 43-year-old man who was transferred to a tertiary care facility is presented. The microbiology laboratory and autopsy services were not notified of the clinical suspicion of tularemia by the service caring for the patient. Despite having a laboratory bioterrorism procedure in place and adhering to established laboratory protocol, 12 microbiology laboratory employees were exposed to Francisella tularensis and the identification of the organism was delayed due to lack of notification of the laboratory of the clinical suspicion of tularemia. A total of 11 microbiology employees and two persons involved in performing the patient's autopsy received prophylactic doxycycline due to concerns of transmission. None of them developed signs or symptoms of tularemia. One microbiology laboratory employee was pregnant and declined prophylactic antibiotics. As a result of this event, the microbiology laboratory has incorporated flow charts directly into the bench procedures for several highly infectious agents that may be agents of bioterrorism. This should permit more rapid recognition of an isolate for referral to a Level B laboratory for definitive identification and should improve laboratory safety.Francisella tularensis, a fastidious gram-negative coccobacillus, is an uncommonly encountered organism in most clinical microbiology laboratories. Nevertheless, the need for diagnostic laboratories to be familiar with this organism has taken on increased importance due to its possible use as a bioterrorism agent (4,7,8,10,13). F. tularensis has been classified as a Category A critical biological agent because it can be disseminated easily, causes high mortality with the potential for major public health impact, might cause public panic and social disruption, and requires special action for public health preparedness (3). It was reportedly developed as a weapon by both the United States (10) and the Soviet Union (1).Despite the presence in the clinical microbiology laboratory of a written procedure for working with agents of bioterrorism, including F. tularensis, the identification of F. tularensis isolated from a fatal case of pulmonary tularemia was delayed, resulting in the manipulation of the organism at the bench by laboratory workers, many of whom subsequently began taking prophylactic antibiotics. Although tularemia is rare, with approximately 200 cases annually in the United States, in Pike's study of 3,921 cases of laboratory-associated infections, it ranked second in the United States as a cause of laboratory-associated infections, behind only brucellosis, and third worldwide, behind brucellosis and typhoid (15).We report a fatal case of culture-proven tularemia and the associated laboratory investigation prompted upon learning of the cause of the patient's demise. We provide guidelines that will assist other laboratories in suspecting and more safely dealing with infections caused by this organism. Case report.A 43-year-old man with no significant past medical history pr...

Fluorescence in situ hybridization (FISH) using peptide nucleic acid (PNA) probes targetingIdentification of Staphylococcus aureus in blood cultures begins with presumptive identification of gram-positive cocci in clusters (GPCC) in the Gram-stained smear of blood culture bottles that signal a positive result, whereas final identification must await subculture and overnight incubation (1,8). This delayed identification often results in empirical antibiotic therapy administered to patients with GPCC-positive blood cultures, although the majority of GPCC-positive blood cultures are later identified as coagulase-negative staphylococci (CoNS), such as Staphylococcus epidermidis, a common blood culture contaminant. Direct identification of S. aureus in GPCC-positive blood culture bottles may provide important diagnostic information, which would allow the selection of an appropriate course of treatment in a timely manner.Immunological, tube coagulase, and stable-endonuclease methods routinely used for identification of S. aureus following subculture have been applied directly to GPCC-positive blood culture bottles, but with variable sensitivities and specificities (6, 9, 10). In addition, molecular techniques, such as hybridization protection (3), fluorescence in situ hybridization (FISH) (5), and PCR (2) have been described for identification of S. aureus directly from positive blood cultures. In general, all studies have been performed on just a single blood culture medium and, therefore, do not address the potential for interference from different blood culture media, which in fact might explain the variable results. Furthermore, none of the studies involve blood culture media supplemented with charcoal, such as that used in the FAN BacT/Alert medium (bioMerieux, Hazelwood, Mo.), or resins, such as that in the BACTEC Plus medium (Becton Dickinson, Sparks, Md.). Those supplements may interfere with assays for direct identification of positive blood culture organisms.FISH with a peptide nucleic acid (PNA) probe to target 16S rRNA of S. aureus is a novel method for the rapid and specific identification of S. aureus directly from GPCC-positive blood cultures. S. aureus PNA FISH had a 97% sensitivity and 100% specificity compared to conventional methods when tested with the BacT/Alert blood culture system and FAN medium (7). The aim of the present study was to perform a blinded comparison of S. aureus PNA FISH with conventional methodology on blood cultures representing the ESP medium (Trek Diagnostic Systems, Inc., Westlake, Ohio), BACTEC medium (Becton Dickinson), and BacT/Alert medium (bioMerieux). Routine positive blood culture bottles in which gram-positive cocci in clusters were observed in Gram-stained smears were randomly collected at each of eight clinical microbiology laboratories. For the study, one smear for future testing was prepared from each blood culture shortly after the Gramstaining results were known. The smears are stable at room temperature for several weeks and were collected over a 1-to 2-week pe...