Two cases of meningococcal purpura fulminans: the 'less is more' approach.

This study presents a case series of patients with meningococcal purpura fulminans who were treated at a tertiary referral centre within a few days of each other. Presenting with signs and symptoms of florid meningococcal sepsis, they were managed initially by physicians and intensivists, whereas the development of large purpuric areas and tissue necrosis was managed expectantly by plastic surgeons. When the patients were deemed to have recovered clinically and the necrosis delineated, surgical management was implemented with subsequent involvement of various rehabilitation services. This article highlights the cases of two patients, and their clinical presentation, management and rehabilitation together with a current literature review on this area.

Treacher Collins syndrome: an undescribed characteristic of the condition and its management with botulinum toxin and surgery.

Mandibulofacial dysostosis (Treacher Collins syndrome) is associated with clinical abnormalities of structures derived from the first and second branchial arches, including antimongoloid slant of palpebral fissures, colobomas of the lower eyelid, eyelash malformations, and malar and mandibular defects. We describe an unusual clinical feature associated with colobomas of the lower eyelids, in a patient with mandibulofacial dysostosis, successfully treated with botulinum toxin and subsequent surgery.

Use of an integrated care pathway: a third round audit of the management of shoulder pain in neurological conditions.

OBJECTIVES: To complete a third round audit of management of shoulder pain using an integrated care pathway, to evaluate pro forma documentation and to determine outcome. SUBJECTS AND SETTING: Thirty-four patients with upper limb paresis admitted to a rehabilitation unit during a 22-month period had shoulder pain and were included in the integrated care pathway. METHODS: Retrospective review of pro forma documentation against pre-determined standards. RESULTS: Compared with the second round audit, performance against 5 out of 9 standards for initial assessment and documentation had improved, and ranged from 56% to 94%. Achievement of 9 further standards relating to continued management ranged from 44% to 97%. Variance was not always well recorded. Shoulder pain resolved or improved in 18/34 (53%) of patients. CONCLUSION: Introducing the pro forma improved standards of documentation and demonstrated a positive outcome in over half the patients. Some problems with developing and maintaining integrated care pathways in the context of rehabilitation are discussed.

PICO: a revelation in topical negative pressure therapy?

The authors present the case of a 23-year-old paratrooper who was admitted to intensive therapy unit with florid meningococcal septicemia. Being young, fit, and well, he survived this acute episode with supportive therapy, antibiotics, and inotropes. He made a good recovery and was left with multiple wounds all over his body predominantly on the extensor aspects of his upper and lower limbs and torso.

Anterolateral thigh perforator flap from previously burned skin for secondary reconstruction of neck with post burn sequelae, new limits explored.

We report the use of anterolateral thigh perforator flap (ALTF) from previously burned skin for reconstruction of burn cervical contracture. At the time of treatment, there are no reports of the use of perforator flaps from previously burned skin. We have used this technique and feel that it might be an option to consider in view of the fact that massively burned patients often have limited donor site availability, despite requiring flap tissue to resurface difficult anatomical regions.

The deep inferior epigastric perforator flap for breast reconstruction, the learning curve explored.

The deep inferior epigastric perforator (DIEP) flap has been used as the principle tool for secondary breast reconstruction in our department. This article details our experience in learning and improving the technique with the help of an external team of experienced surgeons. In our initial 65 DIEP flap breast reconstructions our total flap loss rate was reduced from 9.5 to 0%, partial flap loss rate from 31 to 0%, and fat necrosis rate from 17 to 4.3%. We illustrate how a surgical team, which might initially have considered the complication rate from DIEP flap breast reconstruction too high, can benefit from a staged approach to this complex, but useful, reconstruction technique.