Self-harm, suicide and brain death: the role of the radiologist.

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

Balloon Cell Urethral Melanoma: Differential Diagnosis and Management.

Introduction. Primary malignant melanoma of the urethra is a rare tumour (0.2% of all melanomas) that most commonly affects the meatus and distal urethra and is three times more common in women than men. Case. A 76-year-old lady presented with vaginal pain and discharge. On examination, a 4 cm mass was noted in the vagina and biopsy confirmed melanoma of a balloon type. Preoperative CT showed no distant metastases and an MRI scan of the pelvis demonstrated no associated lymphadenopathy. She underwent anterior exenterative surgery and vaginectomy also. Histology confirmed a urethral nodular malignant melanoma. Discussion. First-line treatment of melanoma is often surgical. Adjuvant treatment including chemotherapy, radiotherapy, or immunotherapy has also been reported. Even with aggressive management, malignant melanoma of the urogenital tract generally has a poor prognosis. Recurrence rates are high and the mean period between diagnosis and recurrence is 12.5 months. A 5-year survival rate of less than 20% has been reported in balloon cell melanomas along with nearly 20% developing local recurrence. Conclusion. To the best of our knowledge, this case is the first report of balloon cell melanoma arising in the urethra. The presentation and surgical management has been described and a literature review provided.

Gluteal fold flaps for perineal reconstruction.

Defects of the perineum are created during ablative procedures for gynaecological, urological and colorectal malignancies. The gluteal fold flap is a reliable means of reconstructing these defects. We retrospectively reviewed case notes of gluteal fold flaps performed for perineal reconstruction over four years (2007-2010) in our institution. 77 perineal defects were reconstructed using unilateral or bilateral gluteal fold flaps (127 flaps in total). 50% of all patients are discharged before 11 days, and 90% were discharged within one month. Mean time to discharge was 13.2 days. 70% of all patients were completely healed at 2 months, and 85% completely healed at three months. Pre-operative radiotherapy was found to have a prolonging effect on the time to discharge (P<0.05) but did not reach statistical significance when considering the eventual time to healing. The number of co-morbidities that each patient had at the time of surgery had a prolonging effect on both time to discharge and time to healing (P<0.03). The type of resected areas that required reconstruction did not have a statistically significant effect on the time to discharge, but defects where the anus had been resected did eventually take longer to heal than those were the anus was not resected (P<0.01). 124 flaps were successful (97.6%) with total or partial flap loss occurring in three. Complications were seen in 34 of the 77 patients (44%), with simple wound breakdown resulting in delayed healing seen most frequently (30%). The gluteal fold fasciocutaneous flap is a versatile option for reconstructing a wide range of pelvic and perineal defects. Patients with multiple co-morbidities, cases with radiotherapy and instances where the anus has been resected are more likely to experience longer healing times. We present our algorithm for management for perineal defects after tumour resection.

Home haemodialysis in Ireland.

BACKGROUND: A home haemodialysis programme (HHD) was established in Ireland in 2009 following studies suggesting better outcomes and a survival advantage when compared to conventional in-centre dialysis. AIM: The aim of this study was to assess the outcomes in patients commenced on the HHD programme. METHODS: Baseline characteristics, standard dialysis parameters, blood pressure control, antihypertensive usage, vascular access problems, hospitalisation rates and technical issues related to dialysis were analysed. RESULTS: Seventeen patients were followed over a 2-year period. Time spent travelling for dialysis-related treatments was reduced with time on dialysis per week increased. There was a trend towards lower blood pressure with nine patients, either discontinuing or having a reduction in antihypertensive medications. There were eight episodes of hospitalisation with the majority of complications related to vascular access. CONCLUSION: Home haemodialysis is a community-based therapy, offering an alternative to conventional in-centre haemodialysis in a select patient population.

Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap.

BACKGROUND: Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap. METHODS: The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3-23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204-792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10-174) weeks. RESULTS: Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy. CONCLUSION: Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.

The risk of eye splash in burn surgery.

Although the incidence of eye splash injury has been assessed for a number of surgical specialities, such risks posed to the burn surgeon have not been previously quantified. During 100 consecutive procedures the operating burns team wore a clean set of goggles, counting the number of blood splashes on the goggles after each procedure. During this study there were 47 cases of potential eye splash injury, although the individual was only aware of 2 of these intra-operatively. Seven of the splashes involved more than 6 blood droplets on the goggles. The consultant burn surgeon was the most likely to be splashed, sustaining a potential injury in over half cases operated upon. Procedures greater than 45 min in length were more likely to result in a splash than those shorter than 45 min. We recommend that eye protection should be used either in the form of goggles or a visor and should encompass all burn theatre cases as a matter of policy.

MRI 'magic angle' imaging of finger tendons.

The value of using the technique of magic angle MR imaging to demonstrate finger tendons is explored. Images of fresh frozen cadaveric specimens are presented and the structures that can be visualized in the finger are described. The results suggest that magic angle MR imaging may be a useful non-invasive technique of visualizing the details of the tendons and their surrounds in the hand.

Two-stage hypospadias repair: audit in a district general hospital.

The number of techniques for hypospadias repair is testament to the challenges associated with this condition. In 1994, the senior author undertook an audit of his repairs using the van der Meulen [Plast. Reconstr. Surg. 59 (1977) 20615] technique and determined that the revision rate of 11% was unsatisfactory and the cosmetic result sub-optimal. He, therefore, retrained and began in 1995, using the two-stage technique popularised by Bracka [Br. J. Plast. Surg. 48 (1995) 345]. We undertook an audit of all corrections performed in the period from September 1995 to March 2002. The computer database in the main theatre suite was used to identify all patients on whom such a repair had been undertaken and those notes retrieved. Data was collected on a number of variables including age at operations, complications such as urinary tract infection and fistulae, and total number of corrective operations. One hundred and nineteen patients were identified, of which seven had no records available. Of the remaining 112, 81 were primary repairs, in whom the complication rate was 2.5% for stage I (graft loss) and 9.8% for stage II (fistula rate 7.4%, stenosis 1.2%, baggy urethra requiring reconstruction 1.2%). The remaining 31 patients were those with unsatisfactory single-stage repairs and in this group, graft loss was seen in three cases (10%). The fistula rate was 4/31 (12.9%) and the stenosis rate 2/31 (6.5%). These results compare favourably with a number of published series from surgeons who have super-specialised in this field. We conclude that the two-stage repair is a useful and reliable technique in the hands of a Plastic Surgeon who has a broader interest.

Fissurectomy as a treatment for anal fissures in children.

INTRODUCTION: Anal fissures, characterised by painful defecation and rectal bleeding, are common in both children and infants. A significant proportion are resistant to simple laxative therapy, and no simple surgical treatment has been described which does not risk compromising sphincteric function. This study reports the initial experience of fissurectomy as a treatment of this condition. PATIENTS AND METHODS: Over a 36 month period, 37 children with an anal fissure were treated by fissurectomy. There were 14 boys and 23 girls, with an age range of 17 weeks to 12 years. Fissurectomy was performed under general anaesthetic, with additional caudal anaesthesia. Stay sutures were used to avoid the need for an anal retractor, thereby preventing stretching of the internal anal sphincter. Of the 37 operations, 36 (97%) were performed as day cases and all children were discharged on laxative therapy. RESULTS: At review, 6 weeks postoperatively, 30 (81%) were asymptomatic. Six (16%) patients were symptomatic; however, 4 of these had failed to comply with the postoperative laxative regimen. One patient failed follow-up. CONCLUSIONS: Fissurectomy is a successful treatment for anal fissures, when combined with postoperative laxative therapy. As dilatation of the internal anal sphincter is not involved, the risk of iatrogenic faecal incontinence is obviated.