Nodular melanoma presenting as an exophytic subungual mass.

Despite being recognised and reported in the literature for decades, subungual melanoma of the foot remains a diagnostic pitfall, with it commonly being mistaken for benign conditions. We present an interesting case of delayed diagnosis of subungual melanoma of the hallux that was misdiagnosed in the community for over one year. With melanoma being the fourth most commonly diagnosed cancer in Australia in 2013, this case serves as a reminder to all clinicians about the importance of maintaining a high index of suspicion for melanoma of the foot.

Understanding administrative abdominal aortic aneurysm mortality data.

OBJECTIVE: Administrative data in the form of Hospital Episode Statistics (HES) and the Scottish Morbidity Record (SMR) have been used to describe surgical activity. These data have also been used to compare outcomes from different hospitals and regions, and to corroborate data submitted to national audits and registries. The aim of this observational study was to examine the completeness and accuracy of administrative data relating to abdominal aortic aneurysm (AAA) repair. METHODS: Administrative data (SMR-01 returns) from a single health board relating to AAA repair were requested (September 2007 to August 2012). A complete list of validated procedures; termed the reference data set was compiled from all available sources (clinical and administrative). For each patient episode electronic health records were scrutinised to confirm urgency of admission, diagnosis, and operative repair. The 30-day mortality was recorded. The reference data set was used to systematically validate the SMR-01 returns. RESULTS: The reference data set contained 608 verified procedures. SMR-01 returns identified 2433 episodes of care (1724 patients) in which a discharge diagnosis included AAA. This included 574 operative repairs. There were 34 missing cases (5.6%) from SMR-01 returns; nine of these patients died within 30 days of the index procedure. Omission of these cases made a statistically significant improvement to perceived 30-day mortality (p < .05, chi-square test). If inconsistent SMR-01 data (in terms of ICD-10 and OPCS-4 codes) were excluded only 81.9% of operative repairs were correctly identified and only 30.9% of deaths were captured. DISCUSSION: The SMR-01 returns contain multiple errors. There also appears to be a systematic bias that reduces apparent 30-day mortality. Using these data alone to describe or compare activity or outcomes must be done with caution.

Vascular training in Scotland and Northern Ireland: The trainee perspective prior to introduction of the new vascular curriculum.

BACKGROUND: The last decade has seen the evolution of vascular surgery from a sub-specialty of general surgery to that of an independent, stand-alone specialty. The introduction of a vascular-only curriculum is anticipated to require significant change from the current provision for vascular surgical training to allow vascular trainees to acquire the specialist skills in elective, emergency, and endovascular surgery to provide endovascular services in the future. AIM: To provide an insight into current vascular training in Scotland and Northern Ireland. METHOD: Specialty trainees in general surgery, with a sub-specialty interest in vascular in Scotland and Northern Ireland were asked to carry out a voluntary online survey between May 2012 and July 2012. RESULTS: 22 specialty trainees/specialist registrars who have declared a sub-specialty interest in vascular surgery were identified and polled. 20 trainees completed the survey. 13 trainees still participated in general surgical on-call rotas. Formal teaching opportunities were readily available but only 10 trainees could attend regularly. All trainees worked in units offering endovascular treatment for aneurysm and occlusive disease, but few had dedicated training sessions in endovascular skills. All endovascular simulation-based training was industry sponsored. The majority of trainees report a good overall training experience and are keen to see the implementation of a vascular-specific curriculum. 15 trainees had undertaken a dedicated period of research towards a higher degree, with only 50% based on a vascular topic. CONCLUSION: The majority of trainees reported a positive training experience with Scotland and Northern Ireland having great potential as vascular training deaneries. The survey identifies specific areas that could be improved by the development of the new curriculum in vascular surgery to provide excellent vascular training in Scotland and Northern Ireland.

Temporal artery biopsy--how can we improve performance?

INTRODUCTION: Temporal arteritis is a rare systemic disease of undefined aetiology. The British Society for Rheumatology has issued evidence-based guidance in the form of an investigative algorithm, central to which is biopsy of the superficial temporal artery (TA). Currently in Glasgow these patients are being referred to the regional vascular unit. We sought to identify areas where local practice could be improved. METHODS: This was a retrospective review of TA biopsy performed since the amalgamation of vascular services in Glasgow. RESULTS: There were 32 cases with a complete dataset. The majority of patients referred were women (66%), with a mean age of 68 years (range 43-86 years). A variety of different clinical symptoms were reported. The mean ESR was 53 (range 2-122). The median waiting time from referral to surgical biopsy was 6 days (inter-quartile range 2-8 days). Seven patients waited for more than 14 days for the procedure to be performed. There were four positive biopsies in this case series. TA biopsy influenced the duration of glucocorticosteroid therapy. CONCLUSION: From this study we believe that the following changes to local practice would be simple, cost effective and could improve the quality of patient care delivered.

British dental surgery and the First World War: the treatment of facial and jaw injuries from the battlefield to the home front.

When Britain went to war in 1914, the British Expeditionary Force was deployed without a single dentist. Initially considered combatants, the only dental professionals who could serve at the Front were medically qualified dental surgeons in the Royal Army Medical Corps. In treating the traumatic facial and jaw injuries caused by trench warfare, the dental surgeons of this era earned their place on specialist surgical teams and established the principles of oral and maxillofacial surgery. This article will examine the contribution of specialist dental surgeons to the management of facial and jaw wounds in the First World War along the chain of evacuation from the battlefield to the home front, using illustrative examples from the Hunterian Museum at the Royal College of Surgeons of England.

The role of subintimal angioplasty in the management of arterial disease of the lower limb: the North-East of Scotland experience.

INTRODUCTION: The management of occlusive femoropopliteal disease continues to evolve and a definitive strategy remains to be defined. We examine the utility ofsubintimal angioplasty (SIA) in our institution. METHODS: A retrospective study with predefined end-points, including technical success and primary patency. RESULTS: 61 consecutive cases were identified (claudicants n=29 and critical ischaemia n=32). Sixty-four percent of occlusions were greater than 10 cm with poor run-off (60% with two vessels or less). Technical and physiological success was 95% and 79% respectively, with clinical improvement reported by 72%. At a mean follow-up of 20 months twelve-month primary patency (assessed clinically, with ABPI and selective duplex scanning) was 67% (subgroup analysis: claudicants 83%, criticals 53%, p=0.02) and morbidity 8% with no limb loss or procedure related mortality. CONCLUSION: SIA is an effective procedure for chronic lower limb ischaemia with acceptable outcome. Our experience correlates well with evidence in the current literature.

Tumoral calcinosis of the filum terminale.

OBJECTIVE AND IMPORTANCE: Tumoral calcinosis is a rare disorder presenting with tumor-like masses of calcification, usually in soft tissues around large joints. Although this condition has been reported in the spine, this is the first reported instance of this uncommon lesion occurring in the intradural compartment, involving the filum terminale. CLINICAL PRESENTATION: A 55-year-old man presented with back and right leg pain. Initial investigations revealed no cause. A review of his original magnetic resonance imaging scans revealed an intradural calcified mass at L3 level. Surgical exploration was undertaken. INTERVENTION: A L3 laminectomy revealed a calcified mass adherent to the filum terminale. Frozen section from this mass revealed tumoral calcinosis involving the filum terminale. CONCLUSION: This is the first known case of intradural involvement by tumoral calcinosis. This is an uncommon disorder, and a high index of suspicion is required to diagnose the condition, which can recur if incompletely removed.

Vasopressin therapy for upper gastrointestinal tract hemorrhage. Has its efficacy been proven?

Of four reported studies of vasopressin therapy in acute upper gastrointestinal tract hemorrhage, three found vasopressin to be effective and one did not. The studies differed with regard to population, design, and methods. The one study that found vasopressin to be ineffective in controlling gastrointestinal tract hemorrhage may have been better controlled with regard to duration of therapy and evaluation of patients. However, the population studied appeared to be different and the authors may have failed to demonstrate a beneficial effect of vasopressin in a select subgroup of patients. Vasopressin dosing has also been a point of controversy. Hemodynamic data thus far support the use of low-dose infusions. The use of terlipressin (Glypressin), a new analogue of vasopressin, also appears promising.

Observations on Ichthyosporidium giganteum (Microsporida) with particular reference to the host-parasite relations during merogony.

Connective tissue cells, particularly fibroblasts, of the fish Leiostomus xanthurus Lacépède respond to the invading microsporidian parasite Ichthyosporidium sp. [assumed to be identical with Ichthyosporidium giganteum (Thélohan)] by proliferating themselves, coalescing into a syncytium, synthesizing copious amounts of cytoplasm around the parasites, and walling off the parasitized islands of cytoplasm with fibrous capsules. The resulting cysts are xenoparasitic complexes of the syncytial xenoma type, clearly different from the cell hypertrophy tumor (xenoma sensu Weissenberg) exemplified by the Glugea cyst. These findings involve a new concept of the structure and host-parasite relations of Ichthyosporidium. Formerly, the parasitized masses of cytoplasm were interpreted as extracellular plasmodial stages of the parasite (stages uncharacteristic of the microsporidia), while the parasites themselves were interpreted as nuclei of the "plasmodia." Actually, the parasite undergoes merogony in parasitophorous vacuoles which coalesce before sporogony begins. The nuclei of the mermonts are very small chromatin granules, becoming transformed into large basophilic diplokarya of the sporonts. Sporulation is diplokaryotic throughout, the diplokarya becoming reduced in size through 2 steps during sporogony.