Nada Al-Hadithy

Smartphones and the plastic surgeon.

Surgical trainees are facing limited training opportunities since the introduction of the European Working Time Directive. Smartphone sales are increasing and have usurped computer sales for the first time. In this context, smartphones are an important portable reference and educational tool, already in the possession of the majority of surgeons in training. Technology in the palm of our hands has led to a revolution of accessible information for the plastic surgery trainee and surgeon. This article reviews the uses of smartphones and applications for plastic surgeons in education, telemedicine and global health. A comprehensive guide to existing and upcoming learning materials and clinical tools for the plastic surgeon is included. E-books, podcasts, educational videos, guidelines, work-based assessment tools and online logbooks are presented. In the limited resource setting of modern clinical practice, savvy plastic surgeons can select technological tools to democratise access to education and best clinical care.

Outcomes of 52 patients with congenital melanocytic naevi treated with UltraPulse Carbon Dioxide and Frequency Doubled Q-Switched Nd-Yag laser

BACKGROUND A variety of treatment options exist for the management of congenital melanocytic naevi (CMN). Surgical treatment has been the traditional approach. Recently, lasers have been introduced to treat CMN. This study assesses the effectiveness of UltraPulse Carbon Dioxide (UCO2) and Frequency Doubled Q-Switched (FDQS) Nd-Yag laser up to a 15 year period which is the longest follow-up period of any study, as far as we are aware. MATERIALS & METHODS We performed a retrospective review of 52 patients with 314 CMN, treated with UCO2 laser and FDQS Nd-Yag laser. The reduction in visible pigmentation, signs of recurrence and any adverse skin changes were evaluated clinically by two clinicians independent to the laser operator. RESULTS There was minimal visible pigmentation after completion of treatment in 40 patients. Treatment failure occurred in 5 patients, recurrence in 5 and partial success in 2. 5 patients developed hypertrophic scarring, 1 developed hyperpigmentation and 1 patient developed an intracranial melanoma. 87% of patients were satisfied with their treatment and in hindsight would not have chosen surgery. Mean follow-up period was 8 years (interquartile range 3-11 years). CONCLUSION UCO2 and FDQS Nd-Yag lasers are clinically useful treatment options for patients with CMN and have minimal complications. This combined laser regime is particularly effective for the treatment of CMN in cosmetically sensitive and anatomically critical areas, especially when surgical excision may not be straight forward and/or leave unacceptable scars.

National Commissioning Guidelines: Body contouring surgery after massive weight loss

The guidelines for body contouring reconstructive surgery present an evidence-based guide for management of redundant tissue after massive weight loss. A standardised referral pathway to ensure safe and equitable patient care on the National Health Service (NHS) throughout England is recommended. A database of all patients for research purposes is suggested.

Does the degree of ptosis predict the degree of psychological morbidity in bariatric patients undergoing reconstruction

Background: There is proven therapeutic benefit in bariatric surgery for obese patients. Successful bariatric surgery will result in massive weight loss and ptotic skin, which can cause significant functional and psychological problems. As the incidence of bariatric surgery increases, so will the demand for plastic surgery. Currently, there is no evidence-based indication for massive weight loss body contouring, and therefore there is no standardized provision. Methods: A prospective, multicenter, observational study of outcomes in 75 patients undergoing bariatric and plastic surgery procedures at two clinical sites was performed to determine whether the degree of ptosis can be determined by the type (malabsorptive or restrictive) of bariatric surgery and if the extent of disfigurement has an impact on psychological morbidity. Results: Massive weight loss body contouring is not purely aesthetic surgery, but it leads to functional and psychosocial benefits. This study has given preliminary data on which anthropometric measurements and their thresholds lead to the greatest benefit from massive weight loss body contouring. From this study, the fourth quartiles of the anthropometric measurements xiphisternum to pubic symphysis (≥91 cm), umbilicus to pubic symphysis (≥38 cm), and hip circumference (≥143 cm) were statistically significant in crossing the psychometric tolerances from within the normal range to pathological psychology. Conclusions: This study demonstrates that there is a statistically significant, quantifiable correlation among type of bariatric surgery, degree of ptosis, and psychological morbidity in patients who have undergone bariatric surgery. This pilot study could provide the basis for evidence-based guidelines for plastic surgery referral.

Panton-Valentine leukocidin pneumonia: an emerging threat.

Panton–Valentine Leukocidin (PVL)-positive staphylococcal infection typically presents as soft tissue and bone infection (1, 2). PVL-positive staphylococcal infection may also lead to necrotising pneumonia, a condition that can even be observed before the onset of soft tissue or bone infection (3, 4). Lina et al. reported the first case of PVL-positive leukocidin-producing staphylococcus in pneumonia in 1999 (4). Recent worldwide reports of community-onset skin abscesses, outbreaks of furunculosis and severe pneumonia associated with methicillin-resistant Staphylococcus aureus (MRSA) carrying PVL genes and the staphylococcal cassette chromosome mec (SCCmec) type IV indicate that MRSA infections are evolving into a communityrelated problem. Clonal spread of PVL-positive strains and horizontal bacteriophage-dependent PVL-gene transfer thus contribute to an emerging health care problem (5, 6). We report the case of a 57-year-old previously fit Caucasian, female mathematics and physical education teacher. The patient presented to our hospital with shortness of breath, fever, cough productive of sputum and confusion. She had been well until 7 days prior to the admission when she had been sent home from work with a sore throat and symptoms of a nonspecific viral illness. Her past medical history was unremarkable except for hypothyroidism. She was on no regular medication. There were no drug allergies and risk factors for endocarditis. Upon initial examination, the patient presented with type I respiratory failure and severe sepsis including renal failure. Staphylococcal necrotising pneumonia was diagnosed based on culture results (blood and broncho-alveolar lavage specimens), clinical criteria, and a high-resolution computed tomography (CT) scan demonstrating signs of severe pulmonary infiltration. Chest radiograph (Fig. 1) showed multifocal segmental consolidation bilaterally with suggestion of cavitation in the right upper lobe. CT (Figs. 2–5) of the thorax demonstrated severe bilateral cavitating nodules with surrounding consolidation and air bronchograms worse in the right lung.

The management of open tibial shaft fractures

A 28 year old cyclist was hit by a car in a road traffic incident. It was a side on collision, and his left leg was caught between a bollard and the bumper of the car. The saloon car had been travelling at 30 miles per hour (48 km/h). The cyclist’s left leg had been trapped for 10 minutes before being freed. He had no medical history, was taking no drugs, and had no allergies. On arrival at the emergency department, he was managed according to the advanced trauma life support protocol with a primary survey. His cervical spine was immobilised, his airway was clear, breathing was normal with saturations of 100%, and he was haemodynamically stable, with a Glasgow coma scale of 15 out of 15. He had an 11 cm wound over the anterior part of the left lower leg with an open tibia fracture (fig 1⇓). He was neurovascularly intact with a capillary refill of less than 2 seconds. A trauma series was ordered with additional radiographs for the affected limb. Fig 1 Left leg with open tibial shaft fracture held in a gutter splint ### 1 How would you classify this injury? #### Short answer Open fracture of the tibia, Gustilo-Anderson type 3b. #### Long answer Tibial shaft fractures are the most common long bone fracture and usually affect the fibula too. The highest incidence is in young men—8 per 100 000 persons.1 These fractures usually occur as a result of a high energy impact, and the most common causes are sports injuries and road traffic injuries.2 The Gustilo-Anderson classification describes the contamination, neurovascular status, and soft …

Primary intracranial melanoma in a child with a giant congenital melanocytic naevus and normal MRI

We present a case of a 10-year-old girl with a giant congenital melanocytic naevus, and malignant cerebral melanoma.

A painful swollen finger

A 44 year old right hand dominant gardener presented to the emergency department with a two day history of a painful right ring finger. On closer questioning he had been weeding and pruning three days before presentation. He had not been wearing gloves but could not recall any unusual event. He had no relevant medical history. On examination, the ring finger was swollen and tender along its length, with a blister on the radial aspect. The finger was warm compared with his other fingers, and capillary refill was less than 2 seconds. The finger was kept in flexion at the proximal interphalangeal and metacarpophalangeal joints and passive stretch caused intense pain. ### 1 What is the diagnosis? #### Short answer Flexor sheath infection, also known as infectious flexor tenosynovitis or pyogenic tenosynovitis #### Long answer Infectious flexor tenosynovitis is the inoculation of an infectious agent within the enclosed space of the flexor sheath and multiplication of the organism in the culture rich synovial medium.1 Diagnosis is made by history and clinical examination to elicit Kanavel’s signs (fig 1⇓). Fig 1 Clinical image of swollen painful right ring finger Kanavel’s signs include2: Intense pain on passive stretch is the most clinically reproducible of these four signs,3 4 with tenderness along the tendon sheath being the second most reproducible.5 The presence of all four signs is pathognomonic of pyogenic flexor tenosynovitis. However, a recent study showed that all …

Two different management modalities in a two sibling case report of Adams Oliver syndrome

The authors report two-sibling case of Adams Oliver syndrome. One was managed with early surgical intervention after a period of failed conservative management and the other conservatively managed until reconstruction and surgical correction of alopecia. The goal of treatment is to achieve a complete closure of the defect without encountering any fatal complications such as haemorrhage and infection or causing any long-term neurological morbidity. Various papers have been published related to ACC, yet there is no consensus on the therapeutic approach. The management decision hinges upon balancing the risks of complications including spontaneous sagittal sinus haemorrhage and the risk of surgical intervention. Both treatment modalities proved successful in these cases.