Diabetes mellitus and burns. Part II-outcomes from burn injuries and future directions.

Diabetes mellitus is an increasingly prevalent comorbidity in patients presenting to burn facilities. Diabetic patients tend to be older and present in a delayed manner with deeper injuries predominantly affecting the lower limb. Morbidity from burns is higher in this cohort including a longer length of hospital stay, greater need for surgical interventions and increased rate of infective complications. Nevertheless, there seems to be little effect of diabetes on associated mortality. The second part of this review article concentrates on the epidemiological profile of diabetic burn patients and the effect of the disease on morbidity and mortality. In addition, we present a review of therapeutic adjuncts, which may hold promise for the future management of this cohort of burn patients.

Diabetes mellitus and burns. Part I-basic science and implications for management.

The number of diabetic patients presenting to burn services is predicted to increase significantly over the next decades. Diabetes mellitus represents an independent risk factor for sustaining burn injuries and mediates alterations to key physiological systems including the vascular, renal, nervous, gastrointestinal and immune system. The effects of the pathophysiological permutations need to be carefully considered during both the acute as well as the long-term rehabilitation phase of injury. The purpose of the first part of this review is to outline the metabolic permutations observed in diabetes mellitus pertinent to the clinical presentation and management of burn patients.

Resection of a large carotid paraganglioma in Carney-Stratakis syndrome: a multidisciplinary feat.

A 39-year-old man was referred to the vascular surgeons with a right-sided cervical mass, palpitations, headaches and sweating. He had presented with abdominal discomfort 12 months earlier. Investigations had revealed a gastrointestinal stromal tumour (GIST) and left adrenalectomy. CT of the neck with contrast demonstrated a large right carotid paraganglioma, extending superiorly from below the carotid bifurcation to encase the internal carotid artery. Genetic screening confirmed the diagnosis of Carney-Stratakis syndrome, an SDH-D germline mutation leading to GIST and multifocal paragangliomas. Successful surgical excision required considerable multidisciplinary teamwork between neuroendocrinologists, anaesthetists and surgeons. The tumour was highly vascular and involved the right carotid body, hypoglossal and vagus nerves. Access was challenging and maxillofacial surgical expertise were required for division of the mandible. The patient made a good recovery following speech and swallowing rehabilitation.

Research priorities in light of current trends in microsurgical training: revalidation, simulation, cross-training, and standardisation.

Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training.