Ecthyma gangrenosum: A case report in a child with acute lymphoblastic leukaemia.

Aim: We present a case of Ecthyma gangrenosum (EG) affecting left thigh in a child with acute lymphoblastic leukaemia (ALL) with an aim to raise awareness about this condition. Case presentation: A 7-year-old female child who presented with lethargy, pallor and lumps to inner lip was diagnosed with B-cell precursor ALL. She was started on treatment as per UKALL 2011 guidelines Regime B. On day 28, she developed neutropenic sepsis along with a new lesion in her left thigh. She was started on intravenous Meropenum, Gentamicin and Caspofungin. The clinical diagnosis of EG was made based on lesion progression, positive blood and wound swab & tissue cultures for Pseudomonas aeruginosa and patient's immunocompromised status. The wound healed with secondary intention following debridement. We present a series of photographs to demonstrate her remarkable improvement. Discussion: EG occurs in 1-30% of cases of Pseudomonas sepsis; other bacteria and fungi can be associated with this condition. It is identified more in oncology patients as seen in our patient. A multidisciplinary team approach should be provided in 3 stages with empirical antibiotics, followed by targeted antibiotics or antifungals & surgical debridement. Our patient was treated in similar fashion and made a good recovery. Conclusion: It is a rare skin condition associated with a high mortality. We suggest all clinicians to be vigilant about this condition to be able to provide accurate diagnosis and prompt treatment to improve the overall prognosis.

Bile vomiting in paediatrics: what do we really know?

Bile vomiting is clinically significant in neonates and children, indicating intestinal obstruction until proven otherwise. The aim of this study was to assess whether nursing staff within a children's hospital were able to accurately identify bilious vomiting and if a deficiency existed, whether educational posters could rectify this problem. A primary audit was conducted in the Royal Aberdeen Children's Hospital evaluating the ability of nursing staff to identify bile vomit and its significance. Educational posters were distributed and a secondary audit was conducted after six months to complete the audit cycle. The second audit also compared the knowledge of different medical professionals. In the primary audit, 41% of nurses selected the colour yellow, compared with 18% of nurses in the second audit with approximately 70% selecting dark-green. Thirty-three percent of nurses in the primary audit confirmed intestinal obstruction as the cause of bile vomiting, compared with 64% of nurses in the secondary audit. In conclusion, this study identified a deficiency in the recognition of bile vomiting among nurses, but demonstrates that the use of educational posters can significantly improve knowledge. This can be beneficial in the early recognition of this potential surgical emergency.

The peripheral portacath provides safe and convenient venous access in pediatric and adolescent patients.

INTRODUCTION: Adolescent patients with chronic conditions rely on permanent venous access for safe treatment and supportive care. Traditionally this is provided by a central venous access device (CVAD) e.g. Hickmann catheter or totally implanted subcutaneous port or also called Port-a-Cath (PaC). We reviewed the patient experience, safety and feasibility of insertion of peripheral inserted implanted subcutaneous port (peripheral PaC). METHODS: Medical records of patients who underwent insertion of peripheral PaC under ultrasound guidance at our institution since between 2012-2017 were reviewed to ascertain specific details including duration of insertion and complication rate. Short structured questionnaires were used to assess nursing and patient satisfaction. RESULTS: Twenty eight peripheral PaC were inserted at our institution. There were 17 female and 11 male patients aged between 12.3 and 18.7 years (median = 16.1). Six were inserted under local anesthetic (LA) in patients who were not fit for general owing to mediastinal mass or lung disease. At the time of analysis 2 PaCs remained in situ with a median duration of 8 months (range 3-48). Removal of 26 PaCs was under LA in 15 cases and under GA in 11. Complications were observed in 9 cases but only necessitated early removal or replacement in 3 cases (displacement and disconnection) and repositioning in 1 case. Thrombosis was seen in 2 patients who required systemic anticoagulation but had complete resolution. CONCLUSION: This study shows that the use of peripheral PaC is safe. The feedback from patients and nursing staff supports the use of the peripheral PaC. We are exploring additional patient groups that might benefit from this device.

Studying mental illness: a student's perspective.

Upon deinstitutionalization, a mentally ill person's awareness of the stigma attached to his or her illness can negatively influence any effort to become a productive member of society. Support systems are vital in that they facilitate such efforts. The family is perhaps the most important support system because it provides emotional support, which is crucial because it promotes a sense of self-esteem and decreases depression, anxiety, sickness, and mortality. An awareness of stigma on the part of the family could undermine its role as a support system for a relative with mental illness.

A new scoring system for the evaluation of clubfoot: the IMAR-Clubfoot scale.

BACKGROUND: Recently much interest has been shown regarding the biomechanical techniques for the assessment of clubfoot but as yet their specific role in such an endeavour is unclear. Several scoring systems have been designed but none have been adopted as a standard. The ideal system should be simple, modular, reliable, repeatable and be able to assess functional deformity objectively. OBJECTIVE: This study was aimed to develop a comprehensive scoring system and to demonstrate the potential of such an assessment tool in evaluating clubfoot. METHODS: A new innovative scoring system, the IMAR-Clubfoot scale, was designed, which incorporated clinical and biomechanical data. Clinical assessment was performed using a questionnaire and standard clinical criteria while the biomechanical evaluation was undertaken using the Podotrack, the optical dynamic pedobarograph and the GAITRite systems. Thirteen children (16 clubfeet) were recruited for assessment using the IMAR-Clubfoot scale. RESULTS: The model can detect abnormalities related to talipes equinovarus and quantify them objectively. The results also emphasise the need for such a comprehensive system, which combines clinical and biomechanical data as there was no statistical correlation between these data. CONCLUSION: The scoring system would be helpful in assessing the deformity, deciding upon appropriate management and objectively defining the success/failure of treatment at patient follow-up.

Foot pressure in clubfoot--the development of an objective assessment tool.

BACKGROUND: There are no universal criteria for the assessment of clubfoot. The ideal method should assess functional deformity reliably and objectively. Biomechanical techniques have also been suggested but their role remains undefined. OBJECTIVE: This study aimed to assess surgically corrected clubfeet by biomechanical means with the intention to develop certain ratios to aid in objective assessment. METHODS: Thirteen children (16 feet) with idiopathic clubfoot, who had previously undergone surgery (lateral-posteromedial release), were reviewed. Various clinical measurements were collected and symptoms assessed using a specially designed questionnaire. Biomechanical (foot pressure) parameters were obtained using two systems: Podotrack and Dynamic Pedobarograph. RESULTS: The results showed that foot pressure data were able to demonstrate abnormalities in foot posture and pressure distribution, which could objectively identify clubfoot deformities. In particular, ratios were calculated, which could be used to determine severity and monitor progression. CONCLUSION: This study suggests that foot pressure analysis should be routinely used in the assessment of clubfoot. The ratios calculated would be of immense help to the clinicians in monitoring the success of treatment and for early prediction of relapse in patients treated for clubfoot.