Exploring the Perceptions Surrounding Hospital Chaplains in Patient Care and Healing.

The authors distributed a questionnaire to various hospital staff to explore perceptions surrounding the role of chaplains in patient care and healing through assessing opinions, beliefs, and knowledge. Results revealed a poor understanding of the role of the hospital chaplain in the UK. The authors therefore advocate education programs to increase awareness of the varied role of the hospital chaplain in fulfilling patient spiritual needs to increase referral practices, leading to improved patient outcomes.

IV3000 semi-occlusive dressing use in simple and complex fingertip injuries: efficacy and affordability.

OBJECTIVE: This study aimed to explore the efficacy of the IV3000 semi-occlusive, transparent adhesive film dressing in the non-surgical management of simple as well as more complex fingertip injuries. METHOD: In this qualitative study, patients with fingertip injuries were prospectively recruited and treated conservatively with the dressing between 2015 and 2017. Inclusion criteria included any fingertip injury with tissue loss and patient consent for non-surgical treatment consistent with the study protocol. Exclusion criteria included injuries needing surgical intervention for tendon injury or exposure, joint dislocations, distal phalangeal fractures requiring fixation, bone exposure, isolated nail bed lacerations and any patients eligible for surgical repair who did not wish to be managed conservatively. RESULTS: A total of 64 patients took part in the study. The patients treated with the dressing were asked to rate functional outcome, of whom 40 (62.5%) patients reported the outcome as 'excellent', 19 (29.7%) as 'satisfactory', five (7.8%) as 'indifferent' and none (0%) as 'unsatisfactory'. A reduced pulp volume at completion of healing was felt by 21 (32.8%) patients, but all patients were 'satisfied' with the aesthetic appearance of their fingertips at final clinical review. Average healing time was 4.5 weeks across the group, with the average time for return to work being just under one week. We estimate a 60% reduction in cost with the conservative versus the surgical management option. CONCLUSION: This study showed that, for participants, the IV3000 dressing was an affordable and effective option for the conservative treatment of simple fingertip injuries and in the management of more complex fingertip injuries.

Paediatric Burns From Deployment of a Concealed Aviation Seatbelt Airbag.

The advantages of airbags in reducing the rate of severe injuries and fatalities in motor vehicle crashes are well known but the physical act of airbag deployment can lead to injury to the passenger and the spectrum of airbag trauma resulting from deployment of vehicle airbags has been extensively reported. We present the first reported case of a pediatric burn injury resulting from the accidental deployment of an airbag in an aircraft. A four-year-old female child sustained injuries to the left side of her face and body while she was aboard a stationary airplane and the airbag concealed within the seat belt of her airplane seat unexpectedly and inexplicably deployed just before departure. We are presenting the case to increase awareness of the possibility of this injury in aircraft and to enable minimization of such accidents as well as help establish protocols for dealing with such mishaps if there were to happen.

Subcutaneous fat necrosis requiring plastic surgical intervention in an infant treated with whole-body cooling.

We report an infant who developed subcutaneous fat necrosis of the newborn (SCFN) secondary to cooling treatment for hypoxic ischaemic encephalopathy (HIE). While SCFN is usually self-limiting, this patient went on to develop a large haematoma on his back with overlying skin necrosis necessitating debridement and split thickness skin grafting. Initially, the area affected on his back showed a number of small fluctuant swellings. By day 16 after birth, theses swellings coalesced to form a large 15 cm × 19 cm haematoma with a tense, shiny skin overlying it. On day 17, the large swelling was drained in theatre and a drain was left in situ. Total calcium blood level was raised at 4 mmol/l and he was managed with Pamidronate infusion. Postoperatively, examination of the back showed a 5 cm necrotic area in the centre of the back, and affected area was debrided along with a split skin graft applied to the exposed area.

Pediatric Traumatic Limb Amputation: The Principles of Management and Optimal Residual Limb Lengths.

Pediatric traumatic limb amputations are rare and their acute and long term management can be challenging in this subgroup of patients. The lengthy and costly hospital stays, and resulting physical and psychological implications leads to significant morbidity. We present a summary of treatment principles and the evidence base supporting the management options for this entity. The initial management focuses on resuscitating and stabilization of the patients, administration of appropriate and adequate analgesics, and broad spectrum antibiotics. The patient should ideally be managed by an orthopedic or a plastic surgeon and when an amputation is warranted, the surgical team should aim to conserve as much of the viable physis as possible aimed at allowing bone development in a growing child. A subsequent wound inspection should be performed to assess for signs of ischemia or non-viability of tissue. Depending on the child's age, approximations of the ideal residual limb length can be calculated using our guidelines, allowing an ideal stump length at skeletal maturity for a well-fitting and appropriate prosthesis. Myodesis and myoplasties can be performed according to the nature of the amputation. Removable rigid dressings are safe and cost effective offering better protection of the stump. Complications such as necrosis and exostosis, on subsequent examination, warrant further revisions. Other complications such as neuromas can be prevented by proximal division of the nerves. Successful rehabilitation can be accomplished with a multidisciplinary approach, involving physiotherapist, play therapist and a child psychiatrist, in addition to the surgeon and primary care providers.

Control of hair growth using long-pulsed alexandrite laser is an efficient and cost effective therapy for patients suffering from recurrent pilonidal disease.

Pilonidal sinus (PNS) and its surgical management have a profound impact on hospital resources in terms of finances and productive man-hours. Surgical treatment has been the mainstay of treatment of both acute and chronic pilonidal sinus but recurrence is common. The control of hair growth in the sinus region plays an important role in preventing recurrence. Here, we discuss our experience of treating 19 patients suffering from recurrent pilonidal sinus with laser depilation and its long-term cost effectiveness. This is a retrospective study on patients who had recurrence of pilonidal sinus following multiple surgical treatments. They were treated using long-pulsed alexandrite laser for depilation in the sinus area, an outpatient procedure. Their clinical characteristics and outcomes were then evaluated. There was a significant reduction in hair density after laser treatment (p < 0.001). The disease-free period after laser treatment was significantly longer than that one after surgical treatment (p < 0.001). The average cost of repeated surgical treatment per disease-free month was significantly higher than that of laser treatment (p < 0.001). Evidence suggests the role of natal cleft hair growth in the evolution of the pilonidal disease; therefore, control of hair growth should be considered as an adjunct to the initial treatment via surgery. Compared to surgical treatment of recurrences, laser depilation is an efficient and cost-effective method of preventing recurrence and reducing morbidity and loss of man-hours. We suggest that laser depilation of the pilonidal sinus should be funded by clinical commissioning groups.

Surgical treatment of primary hyperparathyroidism: description of techniques and advances in the field.

Primary hyperparathyroidism is a disease commonly seen in patients above 60 years of age. It is the most common cause of asymptomatic or symptomatic hypercalcemia, usually found incidentally on routine check-ups. Surgical treatment is the only definitive treatment of choice in the symptomatic patient; however, it can also be employed in asymptomatic patients. First described in 1925, bilateral neck exploration is the gold standard of treatment for primary hyperparathyroidism. The recent interest in minimally invasive surgeries has led to better and improved techniques of neck exploration with improved cosmetic results and lesser chances of transient or permanent hypoparathyroidism due to inadvertent removal of normally functioning parathyroid tissue. These include unilateral neck explorations, minimally invasive parathyroidectomies and minimally invasive radio-guided parathyroidectomy. The intact parathyroid hormone assays have greatly added to the detection of normal and abnormal functioning glands, hence better surgical outcomes.

Gynaecomastia correction: A review of our experience.

INTRODUCTION: Gynaecomastia is a common problem in the male population with a reported prevalence of up to 36%. Various treatment techniques have been described but none have gained universal acceptance. We reviewed all gynaecomastia patients operated on by one consultant over a 7-year period to assess the morbidity and complication rates associated with the procedure. MATERIALS AND METHODS: Clinical notes and outpatient records of all patients who underwent gynaecomastia correction at University Hospital North Staffordshire between 01/10/2001 to 01/10/2009 were retrospectively reviewed. A modified version of the Breast Evaluation Questionnaire was used to assess patients satisfaction with the procedure. RESULTS: Twenty-nine patients and a total of 53 breasts were operated on during the study period. Patients underwent either liposuction alone (6 breasts - 11.3%), excision alone (37 breasts - 69.8%) or both excision and liposuction (10 breasts - 18.9%). Twelve operated breasts (22.6%) experienced some form of complication. Minor complications included seroma (2 patients), superficial wound dehiscence (2 patients) and minor bleeding not requiring theatre (3 patients). Two patients developed haematomas requiring evacuation in theatre. No cases of wound infection, major wound dehiscence or revision surgery were encountered. Twenty-six patients (89.7%) returned the patient satisfaction questionnaire. Patients scored an average 4.12 with regards comfort of their chest in different settings, 3.98 with regards chest appearance in different settings, and 4.22 with regards satisfaction levels for themselves and their partner/family. Overall complication rate was 22.6%. Grade III patients experienced the highest complication rate (35.7%), followed by grade II (22.7%) and grade I (17.6%). Overall complication rates among the excision only group was the highest (29.8%) followed by the liposuction only group (16.7%) and the liposuction and excision group (10.0%). There were high satisfaction rates amongst both patients and surgeon. Eleven patients (37.9%) had their outcome classified as 'excellent' by the operating surgeon, 16 patients (55.2%) as 'good', 1 (3.4%) as 'satisfactory' and 1(3.4%) as 'poor'. CONCLUSION: Gynaecomastia is a complex condition which poses a significant challenge to the plastic surgeon. Despite the possible complications our case series demonstrates that outcomes of operative correction can be favourable and yield high levels of satisfaction from both patient and surgeon.

A new continuous suture technique in ear reconstruction with full-thickness skin grafts.

Ear reconstruction with full-thickness skin grafts can be a challenging task for plastic surgeons. It is often necessary to remove the underlying cartilage with the skin lesion and the resultant defect may be deeply concave. We present a short clinical report to describe an improved technique that we find useful in reducing the diameter and depth of anterior pinna contour defects, in improving graft take, and in reducing the size of the donor-site scar.

Aesthetic sculpting for the natal cleft and buttock lift using an innovative periosteal-dermal suture suspension technique.

Natal cleft contouring poses a reconstructive challenge. Buttock aesthetics and the need for careful scar placement are part of the challenge faced by plastic surgeons. Various steps of the reconstructive ladder can be used with varying outcomes. We report a patient who underwent natal cleft reconstruction using a new suture technique and had a cosmetically pleasing outcome.

Free radial forearm fasciocutaneous flap in the treatment of distal third tibial osteomyelitis.

BACKGROUND: Osteomyelitis of the lower limb, associated with soft-tissue defects, is a reconstructive challenge. Microvascular free-tissue reconstruction is an important surgical option with the superiority of free muscle and myocutaneous flaps being explored by various publications. Muscle flaps provide good quality vascularized tissue which can be contoured into defects, but their bulk can often lead to the reconstruction having a suboptimal aesthetic outcome. This result is usually most evident in the lower third of the tibia. We present our series of free radial forearm fasciocutaneous flaps for reconstruction of distal third tibial soft-tissue defects following debridement of osteomyelitic foci and bony stabilization. METHODS: A retrospective case-note review of 20 patients treated with free radial forearm fasciocutaneous flap reconstruction of distal third tibial soft-tissue defects following excision of osteomyelitis and adjacent scar tissue, and bony stabilization between January 1999 and December 2006 was conducted. RESULTS: There were 20 patients who had established osteomyelitis of the distal third of tibia following previous open fractures. The mean size of the soft-tissue defect at the time of the free fasciocutaneous flap procedure was 72.3 cm(2) and the mean bony defect was 3.4 cm. The mean duration of the procedure was 417 minutes and flap ischemia time did not extend beyond 60 minutes in any of the cases. Overall flap survival was 100% and all patients had radiologic bony union at a mean of 5.73 months. The average period of follow-up was 22.5 (range, 19-36) months, and none of the patients had a recurrence of the disease during the follow-up period. CONCLUSION: Free fasciocutaneous flap reconstruction for soft-tissue defects of the lower limb in our series was seen to be safe, reliable, and provided an aesthetic outcome with high patient satisfaction rates. We advocate the use of free fasciocutaneous flaps for small-to-moderate sized defects of the distal third of the tibia after debridement for chronic osteomyelitis. Although we have used radial forearm flaps in our series, more modern free fasciocutaneous flaps with less donor-site morbidity may be preferred.

Fibrin glue with gentamicin as an alternative to conventional surgery in experimental treatment of duodenal fistula in rats.

Duodenal fistula is a significant ongoing surgical problem. Minimal invasive treatment might be an alternative to conventional open surgery. This study aimed to investigate whether addition of gentamicin to fibrin adhesive can augment current surgical methods. Having established a fistula, the defect was closed using the following: simple suturing, suturing covered with fibrin sealant only, or suturing with fibrin sealant mixed with gentamicin. Bursting pressure and macroscopic and microscopic examination were evaluated on the second and sixth day after surgery. The study demonstrated there was no significant difference in overall outcome between the 3 groups. However, on macroscopic examination, the mixture of antibiotic and fibrin adhesive decreased formation of adhesions and abscesses. Microscopically, there was decreased inflammation, improved granulation, and earlier onset of fibrin filament deposition, possibly leading to enhanced wound healing. The addition of gentamicin to fibrin sealant can be a useful adjunct to standard surgical closure in duodenal fistula management.

Incorporating multi-source feedback into a new clinically based revision course for the FRCS(Plast) exam.

BACKGROUND: Exit exams for completion of surgical training are demanding and have relatively low pass rates with many candidates requiring multiple attempts. AIM: To establish a new, clinically based exam preparation course, utilising multi-source feedback, to identify candidates at risk of failure and improve pass rates. METHODS: We describe the process of establishing a new, unique, clinically based exam preparation course incorporating multi-source feedback from examiners, patients, nurses and other trainees. We present the course results as well as the exam results for each candidate and analyse the results of the multi-source feedback. RESULTS: Nine candidates have so far successfully completed both the preparation course and the FRCS(Plast) exam. Success in the exam preparation course accurately predicts success in the FRCS(Plast) exam. Nursing staff and patients tend to give higher scores than examiners and trainees. The majority of marginal failures from the course went on to pass the exam, indicating that the course allows candidates to successfully address weaknesses identified on the course. CONCLUSION: A clinically based exam preparation course utilising multi-source feedback allows identification of candidates at risk of failing a surgical training exit exam and allows targeted training in order to maximise pass rates.

Correction of Stahl ear deformity using a suture technique.

Correction of partial ear deformities can be a challenging task for the plastic surgeon. There are no standard techniques for correcting many of these deformities, and several different techniques are described in literature. Stahl ear is one such anomaly, characterized by an accessory third crus in the ear cartilage, giving rise to an irregular helical rim. The conventional techniques of correcting this deformity include either excision of the cartilage, repositioning of the cartilage, or scoring techniques. We recently encountered a case of Stahl ear deformity and undertook correction using internal sutures with very good results. The technical details of the surgery are described along with a review of literature on correcting similar anomalies.

Nursing monitoring and management of free and pedicled flaps--outcomes of teaching sessions on flap care.

BACKGROUND: Close monitoring is crucial following successful flap surgery because early detection of signs of deterioration can result in a successful intervention and salvage of the flap. An observational audit of practice highlighted short comings in flap monitoring in our Plastic Surgery unit. We created and delivered a teaching session to junior nursing staff with regard the basic principles of flaps and their postoperative care and generated a universal postoperative flap monitoring protocol to help improve and standardize care provision. METHODS: Following a group teaching session, all healthcare providers provided input to create a flap monitoring chart. A cartoon was drawn and placed around the ward to consolidate the ideas generated. RESULTS: The working relationship between doctors and nurses on the ward improved dramatically. Nursing staff felt more confident in their ability to deal with flaps postoperatively and felt more able to contact the surgeons about any concerns or clarifications needed. A re-audit of procedures following these interventions showed improvement in detection of flap ischemia. DISCUSSION: Good patient care within any healthcare system is entirely dependent on the effective function of the multidisciplinary team while maintaining the patient as the focus of care. With both subjective and objective evidences of improvement in the care of flaps in our Plastic Surgery Unit, we can confidently conclude that our teaching program and postoperative flap protocol has been a successful intervention.