Travelling abroad for aesthetic surgery: Informing healthcare practitioners and providers while improving patient safety.

Travelling abroad for surgery is a phenomenon reported internationally. It is particularly likely for aesthetic procedures not undertaken routinely by national health services. We assessed the impact of these patients presenting to the UK National Health Service (NHS) with concerns or complications on their return. All 326 UK consultant members of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) were asked to complete a short questionnaire about patients that had presented to the NHS with complications or concerns following surgery abroad. The results were subsequently presented to the Department of Health (DH). 203 (62%) UK consultant plastic surgeons responded. 76 (37%) of the 203 respondents had seen such patients in their NHS practice, most commonly following breast or abdominal procedures. A quarter underwent emergency surgery, a third out-patient treatment and a third elective surgical revision. In response to these findings, the DH clarified that NHS teams should provide emergency care to such patients but should not undertake any elective revision procedures. Travelling abroad for aesthetic surgery may reduce its cost. However, aesthetic procedures have high minor complication rates, and peri-operative travel is associated with increased risks. Fully informed consent is unlikely when patients do not meet their surgeon prior to paying and travelling for surgery, and national health services are used to provide a free safety net on their return. To help minimise the potential risks, BAPRAS has clarified the responsibilities of the NHS and is acting to better inform UK patients considering travelling abroad.

Seating and pressure support needs of people with cancer in the cervix or rectum: a case series on the clinical usefulness of pressure mapping assessment.

Pressure sores present a challenge to people with rectal and cervical cancers due to weight loss, compromised nutrition, chemotherapy and radiotherapy. Affected individuals often experience intense pain on sitting, and prefer to spend the majority of their time lying down. This pilot study, employing a case study design, investigated the pressure care needs of such persons using pressure mapping, a technology designed to measure pressures at the seating interface. Four participants were mapped on a selection of five cushions, three of which were developed to specifically reduce midline posterior pressure/pain relief. Participants rated the cushions for comfort. Findings demonstrated an inconsistent relationship between interface pressures and perceived cushion comfort, suggesting that patient-rated comfort is a poor indicator of high interface pressures. The specialized cushions did not always meet the needs of this target population and no one cushion suited all. This study demonstrated the precarious clinical balance needed between comfort and achieving optimal pressure reduction in cushion prescription for this client group, and suggested that comfort was more important than pressure reduction in terms of their seating needs.

Interface pressure measurements: visual interpretation of pressure maps with MS clients.

PURPOSE: Pressure mapping systems provide useful information for pressure care assessment. Healthcare professionals tend to rely upon their colour-coded pressure maps to assist clinical decision-making, based on ranking these from best to worst pressure distribution. The current study investigated whether such ranking is an appropriate method of assessment when compared to use of the numerical output of average and maximum pressure values (mmHg), yielded by the system. METHOD: This community-based correlational study involved 27 multiple sclerosis clients (15 wheelchair users; 12 non-wheelchair users). Pressure maps were recorded on each participant's current seating surface and on six pressure reducing cushions, using the Force Sensing Array pressure mapping system. Outcome measures included (1) rank order of pressure maps based on visual interpretation by two occupational therapists, (2) average pressure (mmHg) and (3) maximum pressure (mmHg). Visual ranking of the colour-coded pressure maps was correlated with average and maximum pressure values for each map. RESULTS: Correlations between visual ranking of maps and maximum pressures were high for six out of seven surfaces (p < 0.05) for non-wheelchair users; however, they were much less between average pressures and visual interpretation for the same cohort. Similarly, correlations between visual ranking of maps and average pressures for wheelchair users was minimal and was only noted as being high (p < 0.05) on two surfaces when considering maximum pressures and visual interpretation. CONCLUSIONS: This study contests the usefulness of the visual ranking of pressure maps in interpreting interface pressures with MS clients, especially with wheelchair users. Visual interpretation of pressure maps by clinicians may be useful in eliminating inappropriate support surfaces from a selection, or those that display easily identifiable 'extremes' of pressure values. Clinicians need to incorporate and interpret the numerical data as well as pressure maps when conducting their assessment and making provision.

Hammocking: the effect of cushion covers on interface pressure measurements.

PURPOSE: To investigate the effects of the cushion covers on interface pressure measurements using pressure mapping technology. METHODS: Sixty-one healthy participants were recruited for a laboratory-based study using a single group design. Participants were pressure mapped on a visco-elastic foam cushion and a foam and fluid pack cushion with their covers on and with their covers removed. An air-filled cushion was tested with two different types of covers, an incontinence cover and a 'Comfair' cover. Average and maximum pressures recorded at 6 mins by the Force Sensing Array pressure mapping system were used for statistical analysis. RESULTS: There were no significant differences in maximum pressures for the three cushions tested with their covers on or with their covers removed. The cushion with the foam base and fluid pack did not demonstrate any significant differences in average pressure with the cover on or with the cover removed. However, the visco-elastic foam cushion showed significantly lower average pressures with the cover on (p=0.019). The air-filled cushion showed lower average pressures with the incontinence cover on, when compared to the Comfair cover (p=0.029). CONCLUSION: Contrary to the belief that the process of hammocking may create surface tension within the cushion covers, which in turn may adversely affect the cushions ability to reduce interface pressure, the cushions tested in the current study did not show significantly lower interface pressure measurements with the covers removed. Therefore the covers did not adversely affect the cushion's ability to reduce interface pressure. The findings of this study require verification with disabled clients.

An investigation of the impact of the Force Sensing Array pressure mapping system on the clinical judgement of occupational therapists.

OBJECTIVES: To examine the impact of pressure mapping technology on the clinical decisions of occupational therapists and to examine the role of the Braden Scale in assisting with the selection of pressure-reducing cushions. DESIGN: Case studies. SETTING: Community. SUBJECTS: Forty clients. INTERVENTIONS: Clients were pressure mapped on their current seating surface and on four pre-selected cushions by the principal researcher. An occupational therapist completed the Braden Scale and a decision tree to assist in recommending a suitable pressure-reducing cushion. MAIN OUTCOME MEASURES: Interface pressure maps, Braden Scale, and the cushion recommended, using a decision tree to guide clinical judgement. RESULTS: Thirty per cent (12) of the 40 cushions recommended were changed when the pressure maps from the Force Sensing Array (FSA) system were viewed. In 70% (26) of cases, the maps supported the cushion recommended. In 25% (10) of the cases, the maps showed that the client's current seating surface was unsuitable. After viewing the pressure maps, a surface other than the client's current surface was recommended in 47% (19) of the cases. There was a lack of agreement between the risk level of the clients as identified by the Braden Scale score, and the risk level of the clients as identified by the occupational therapist using a decision tree and the FSA maps. CONCLUSION: Pressure mapping technology has a positive impact on clinical decisions regarding the provision of pressure-reducing cushions. Future research should examine the predictive validity of this technology. The Braden Scale may underpredict the risk level of the clients.

Caregivers of people with multiple sclerosis: experiences of support.

The aim of this phenomenological study was to gain an understanding of the experiences of a group of caregivers of people with multiple sclerosis (MS). Sixteen caregivers from Northern Ireland and the Republic of Ireland participated in focus group interviews. The theme of support, either sought or received, emerged as a major aspect of the experiences described. Caregivers' feelings about, and experiences of, support appeared to change over time. Four common phases that caregivers experienced in relation to support were identified as: 'rejecting', 'resisting, 'seeking' and 'accepting' support. This paper will present and discuss these four phases. The study findings highlight the complexity of issues surrounding a caregiver's decision to seek and accept support. It is hoped that the phases identified within this study are useful in depicting how caregivers of people with MS may progress through stages in their desire for, and acceptance of support. Findings from this study are useful to healthcare professionals who work with people with MS and their caregivers by increasing awareness that a caregiver's attitude toward and acceptance of support changes over time.

Pressure mapping systems: reliability of pressure map interpretation.

BACKGROUND: Pressure mapping systems offer a new technology to assist with pressure care assessment. Data output from such systems can be presented in three forms: numerical data, a three-dimensional grid and a colour-coded pressure map. OBJECTIVES: To (1) investigate whether sole use of the pressure map was a reliable method of interpreting interface pressures when compared with use of the numerical data; (2) establish the inter- and intra-rater reliability of using pressure maps to assess pressure and determine whether reliability depended upon system operator experience; and (3) examine whether reliability extended to the range of seating surfaces being tested. DESIGN: A reliability study assessing the ranking of pressure maps recorded by the Force Sensing Array pressure mapping system. SETTING: A university occupational therapy department and a community NHS trust. SUBJECTS: Fifteen occupational therapists with experience in pressure mapping and 50 occupational therapy students with no practical experience of pressure mapping. INTERVENTIONS: Two sets of pressure maps were pre-recorded with an able-bodied adult seated on a variety of surfaces, with maps on each individual surface recorded over a 20-minute period at 2-minute intervals. Subjects ranked both sets of maps in terms of 'best to poorest' distribution of pressure. MAIN OUTCOME MEASURES: Rank orders of (1) pressure maps; (2) average interface pressures (mmHg); (3) maximum interface pressures (mmHg). RESULTS: The use of pressure maps to interpret interface pressures was a reliable method. Significant agreement existed within (p < 0.001) and between groups of operators and reliability extended over the range of seating surfaces tested. CONCLUSIONS: The practice of using pressure maps to interpret interface pressures in seating as opposed to using the associated numerical data can be supported. This was shown to be a reliable method of assessment by both experienced and less experienced operators across a range of seating surfaces.

The needs and experiences of caregivers of individuals with multiple sclerosis: a systematic review.

PRIMARY OBJECTIVE: To appraise recent studies regarding the needs and experiences of caregivers of individuals with multiple sclerosis (MS). DESIGN: The following computerized databases were searched: CINAHL, BIDS IBSS, ASSIA, MEDLINE, PSYCHINFO, British Nursing Index, ISI Web of Science, Zetoc, AMED (1990-April 2002). The computer-based search was supplemented by manual searches of the reference lists of all retrieved studies and review articles. Inclusion and exclusion criteria were formulated. RESULTS: Twenty-four studies from across the world that met the inclusion criteria were reviewed. The majority of studies were descriptive in nature. The studies covered a variety of topics, including how carers assist people with MS, the effect of providing care on a carer's physical and psychological well-being, social life, financial situation and overall quality of life, and how carers cope with the stresses of providing care. CONCLUSIONS: Providing care for a person with MS has a major impact on all areas of the caregiver's life. Perceived social support has been shown to have a beneficial impact on the caregiver. Limitations in design and variation in methodology of studies limits the generalizability of findings. There is a need for further research, in particular the development of reliable and valid disease-specific caregiver assessment instruments.

Patient satisfaction with Trilucent breast implants.

We report our findings in a retrospective study of patient satisfaction with soybean oil-filled mammary implants. Sixty-two women who had breast augmentation with Trilucent breast implants were sent a questionnaire to assess their satisfaction with implant placement; 19 of the 62 attended for clinical examination. Overall satisfaction with triglyceride implant placement was high: very pleased 45% (18/40), pleased 32.5% (13/40), content 12.5% (5/40). The majority of women felt that it had enhanced their body image and lifestyle (82.5%).

Mechanism-based inactivation of rat liver cytochrome P-450 2B1 by 2-methoxy-5-nitrobenzyl bromide.

Mechanism-based inactivators serve as probes of enzyme mechanism, function, and structure. Koshland's Reagent II (2-methoxy-5-nitrobenzyl bromide, KR-II) is a potential mechanism-based inactivator of enzymes that perform O-dealkylations. The major phenobarbital-inducible form of cytochrome P-450 in male rat liver microsomes, CYP2B1, is capable of catalyzing O-dealkylations. The interactions of KR-II with purified CYP2B1 in the reconstituted system containing P-450, NADPH:P-450 oxidoreductase, and sonicated dilaurylphosphatidyl choline were studied. The benzphetamine N-demethylase activity of CYP2B1 was inactivated by KR-II in a time- and NADPH-dependent manner, and the loss of activity followed pseudo-first-order kinetics. The inactivation also required KR-II, and the rate of activity loss was dependent on the concentration of KR-II in a saturable fashion. The inactivator concentration required for the half-maximal rate of inactivation (KI) was approximately 0.1 mM. The inactivation was not prevented by the addition of the nucleophiles dithiothreitol and glutathione, nor was it reversed by gel filtration. The present results demonstrate that KR-II is a mechanism-based inactivator of rat CYP2B1.

Informed consent: are we doing enough?

We report our findings in a prospective, randomised study of patient recall of verbal versus written preoperative warnings. There were 132 patients in the verbal group and 137 in the written group, with a similar age and sex distribution in both groups. Four of the seven preoperative warnings were remembered significantly better by the group receiving the written warnings (P < 0.001-0.05). However, the mean number of warnings recalled was fewer than 3 in the verbal group, and fewer than 4 (P = 0.0057) in the written group (Mann-Whitney U-test). Patients given verbal warnings were less able to recall them than those receiving written warnings. The inference is that they entered into surgery less well informed.

Intrauterine vascular deficiency of the upper limb.

We report six cases of intrauterine vascular deficiency of the upper limb, presenting over a 12-year period, with established areas of necrosis at the time of birth. Three of the six mothers were diabetic. An urgent examination of the neonate should be done to exclude occult systemic thomboses, as early anticoagulation or thrombolytic therapy may be indicated. The majority of cases were managed conservatively with dressings and splintage of the limb; exceptionally surgical intervention was required. Long-term sequelae included flexion contractures and shortening of the forearm bones.

Tessier 30 median mandibular cleft: case report and literature review.

A median mandibular facial cleft (Tessier 30) is a rare congenital abnormality. We report on the two-stage repair of a median cleft of the lower lip and mandible and the seven-year follow-up of such a cleft.

Pathological findings in breast reduction surgery.

A retrospective analysis of pathological findings in 157 female patients undergoing breast reduction is presented. In 33 months 295 breasts were reduced. 25.6% of these patients had an abnormal pathology report, but no cases of premalignant disease or breast cancer were found. A postal questionnaire sent to consultant members of the British Association of Plastic Surgeons in 1994 found 89% routinely sent breast reduction tissue for pathological study. 42% had seen at least one case of breast cancer reported from this tissue. Recommendations for the use of pathology in breast reduction surgery are proposed.

Mad proteins contain a dominant transcription repression domain.

Transcription repression by the basic region-helix-loop-helix-zipper (bHLHZip) protein Mad1 requires DNA binding as a ternary complex with Max and mSin3A or mSin3B, the mammalian orthologs of the Saccharomyces cerevisiae transcriptional corepressor SIN3. The interaction between Mad1 and mSin3 is mediated by three potential amphipathic alpha-helices: one in the N terminus of Mad (mSin interaction domain, or SID) and two within the second paired amphipathic helix domain (PAH2) of mSin3A. Mutations that alter the structure of the SID inhibit in vitro interaction between Mad and mSin3 and inactivate Mad's transcriptional repression activity. Here we show that a 35-residue region containing the SID represents a dominant repression domain whose activity can be transferred to a heterologous DNA binding region. A fusion protein comprising the Mad1 SID linked to a Ga14 DNA binding domain mediates repression of minimal as well as complex promoters dependent on Ga14 DNA binding sites. In addition, the SID represses the transcriptional activity of linked VP16 and c-Myc transactivation domains. When fused to a full-length c-Myc protein, the Mad1 SID specifically represses both c-Myc's transcriptional and transforming activities. Fusions between the GAL DNA binding domain and full-length mSin3 were also capable of repression. We show that the association between Mad1 and mSin3 is not only dependent on the helical SID but is also dependent on both putative helices of the mSin3 PAH2 region, suggesting that stable interaction requires all three helices. Our results indicate that the SID is necessary and sufficient for transcriptional repression mediated by the Mad protein family and that SID repression is dominant over several distinct transcriptional activators.

Apocrine hidrocystoma: report of a case.

A case of apocrine hidrocystoma, mimicking a naso-labial cyst of the maxilla is reported. The histopathological features and treatment of these rare lesions is discussed.

Nail gun injury: a barbed problem.

A case of nail gun injury is reported. Preoperative radiographs are essential to determine whether copper barbs project from the nail shaft before any attempt is made to remove the nail. Thorough exploration is required.