Case Report and Literature Review of Giant Cutaneous Malignant Melanoma: What's Keeping Patients Away?

Background. Giant cutaneous malignant melanoma (MM) is a term that has previously been used to define lesions that are at least 10 cm in diameter or 48 mm in thickness. Such tumours are rare. There is no substantial body of evidence considering why patients may delay presentation with MM until they reach this size. This case report presents one of the largest cases of giant cutaneous MM to date and the first in the literature to show excellent response to adjuvant immunotherapy. The patient was treated successfully and remains alive and well 12 months following initial surgery. A review of the literature discussing giant MM identified a significant need for education on the importance of seeking medical attention in order to prevent advanced disease, especially for vulnerable individuals.

Does 'Prison Napalm' work? Measuring the cooling temperature of sugar solution burns in a porcine model.

Non-accidental scalds sustained with sugar solution are potentially devastating and often associated with assaults within prisons where they are commonly known as 'Napalm' attacks. However, little is known about the mechanism behind such injuries. Proposed explanations have included a higher initial temperature, increased viscosity compared to water and lower emissivity, although these have yet to be demonstrated in any experimental model. We therefore set out to measure the post-exposure cooling temperature of the dermis after exposure to different concentrations of boiled sugar solution in a dead porcine model. Dead pork belly tissue was pre-heated to human body temperature (36.3-38.4 °C). Five solutions with different concentrations of sugar (0, 250, 500, 1000 and 2000 g/L) were heated to boiling point using standard commercially available kettles and then poured directly onto the tissue. Intradermal temperatures of the dermis were measured at one-minute intervals for a duration of 10 min. At one-minute after exposure, average intradermal porcine temperatures were 46.7 °C, 47.9 °C, 48.9 °C, 50.8 °C and 51.7 °C respectively for increasing concentrations of sugar solution. The rate of cooling was similar in all solutions with an average loss of 1.5 °C per minute. Using a generalised mixed model accounting for concentration and time period, it was identified that increasing sugar concentration resulted in statistically higher temperatures of burn (p = 0.006). Our report finds that higher concentrations of boiled sugar solution caused a higher initial temperature of burn but did not influence cooling rates. This suggests that 'Prison Napalm' attacks will indeed cause more severe burns than those utilising plain water, but not for all the widely believed reasons. We therefore recommend that access to kettles in prison cells should be limited, but where such access is deemed a right, consideration should be given to temperature restricted devices, as is the case in other countries.

Temporary Migration for Training: A Special Case.

BACKGROUND: Against a background of globalization and medical migration, issues have been raised regarding training outside the clinician's own context. OBJECTIVE: There is a dearth of published literature on these issues and we aimed to explore these. METHODS: Taking Chang Gung Memorial Hospital fellowships in microfacial and craniofacial surgery as our case study, we developed an online survey to look at the circumstances leading junior doctors to seek specific, high-level training outside their country of intended practice and how effective this was for their future career, the service they provide, and their institutions. RESULTS: Fellows come to the Chang Gung Memorial Hospital predominantly from Europe, North America, and Asia, rather than specifically from developing countries. The predominant reasons were professional, personal, and to gain training that was not available at home, followed by career development. The fellowship was not commonly used as a career step or a means of migration. Our results showed that most fellows received training that enabled them to provide a service for complex cases on returning to their home country. Implementing newly acquired skills at home did not present any consistent challenges for fellows. CONCLUSIONS: This study addressed a new phenomenon for the literature on medical migration: temporary migration from developed countries for the purposes of training and not permanent migration. The motivation for seeking these fellowships was to make up for training opportunities that were not available in highly planned health economies. To develop their practice in their home institutions, fellows often had to make adjustments to ensure effective transfer of skills and, in doing so, contribute to service development.

Selective Fiber Degeneration in the Peripheral Nerve of a Patient With Severe Complex Regional Pain Syndrome.

Aims: Complex regional pain syndrome (CRPS) is characterized by chronic debilitating pain disproportional to the inciting event and accompanied by motor, sensory, and autonomic disturbances. The pathophysiology of CRPS remains elusive. An exceptional case of severe CRPS leading to forearm amputation provided the opportunity to examine nerve histopathological features of the peripheral nerves. Methods: A 35-year-old female developed CRPS secondary to low voltage electrical injury. The CRPS was refractory to medical therapy and led to functional loss of the forelimb, repeated cutaneous wound infections leading to hospitalization. Specifically, the patient had exhausted a targeted conservative pain management programme prior to forearm amputation. Radial, median, and ulnar nerve specimens were obtained from the amputated limb and analyzed by light and transmission electron microscopy (TEM). Results: All samples showed features of selective myelinated nerve fiber degeneration (47-58% of fibers) on electron microscopy. Degenerating myelinated fibers were significantly larger than healthy fibers (p < 0.05), and corresponded to the larger Aα fibers (motor/proprioception) whilst smaller Aδ (pain/temperature) fibers were spared. Groups of small unmyelinated C fibers (Remak bundles) also showed evidence of degeneration in all samples. Conclusions: We are the first to show large fiber degeneration in CRPS using TEM. Degeneration of Aα fibers may lead to an imbalance in nerve signaling, inappropriately triggering the smaller healthy Aδ fibers, which transmit pain and temperature. These findings suggest peripheral nerve degeneration may play a key role in CRPS. Improved knowledge of pathogenesis will help develop more targeted treatments.

Propionibacterium avidum infection following breast reduction: high morbidity from a low-virulence pathogen.

Propionibacterium avidum is a common inhabitant of sebaceous glands, traditionally considered to be of low virulence and generally found on implanted foreign material. We report a rare case of P. avidum breast abscess, causing severe morbidity following breast reduction surgery. A 36-year-old woman presented with a non-painful wound discharge 3 weeks postoperatively, and was treated conservatively. She was readmitted 7 weeks postoperatively with a red and tender breast. A purulent discharging abscess was drained under ultrasound guidance. A 2-week intravenous course of amoxicillin-clavulanic acid, followed by oral replacement for a month resulted effective. Serial ultrasound imaging was useful in treatment decision-making. The infective potential of P. avidum may be underappreciated. Proximity of sutures to the axilla, tobacco smoking and the potential for resorbable sutures to host bacteria may predispose to infection, and should raise the clinician's awareness.