The use of immunosuppressive agents in the management of recalcitrant lower limb ulcers.

OBJECTIVE: Lower limb ulcers that are resistant to standard forms of treatment place a significant burden on both patients and health services. There is no widely agreed definition of a recalcitrant ulcer but failure to heal following 6-12 months of focused treatment would identify a small group of patients with highly resistant ulceration. We describe a series of patients with recalcitrant ulceration for which immunosuppressive agents have been used. METHODS: This is a case series of 13 patients who underwent immunomodulation therapy for lower limb ulcers at a tertiary referral university hospital. Regimens of immunomodulation used mainly ciclosporin and/or cyclophosphamide, with concurrent antibiotic therapy. Case notes and computer systems were analysed by two reviewers. A patient was deemed to have a success if their ulcer fully healed while on immunomodulation therapy. RESULTS: Over a period of eight years, from 2004-2012, 13 patients underwent immunomodulation therapy. Among these patients there were 18 ulcerated limbs. Ulcer healing occurred in 10 limbs out of 18 (55.6%) and full healing occurred in six patients (46.2%). Ulcers were present for a median of five years (range 2-40 years), with a median diameter of 7.5 cm (range 4-18 cm) before treatment. CONCLUSION: Treatment of truly recalcitrant ulceration can be very frustrating for both the patient and physician, with poor success from more standard forms of treatment. We report experience with immunomodulation therapy that suggests there may be benefit from using this treatment in a subset of patients with this debilitating disease.

Surgical factors in the prevention of infection following major lower limb amputation.

OBJECTIVES: Infection following major lower limb amputation is common but surgical influences on the rates of infection are not known. We aim to assess the influence of peri-operative surgical factors on outcome. DESIGN AND METHODS: Review of a prospective database included all patients undergoing a major lower limb amputation from March 2008 to July 2010. Infection was classified using Centre for Disease Control criteria and multivariate analysis performed to identify significant risk factors. RESULTS: 127 patients, median age 78 yrs (31-98) were included. 34.6% of patients developed a wound infection following surgery; 47.7% of which were classed as superficial incisional surgical site infections, with 52.3% being deep incisional surgical site infections. There was a higher infection rate in below knee than above knee amputations (p < 0.001). There was no relationship between the grade of the operating surgeon (p = 0.829), peri-operative antibiotics (p = 0.933), length of operation (p = 0.651), use of nerve catheter (0.267) and the post-operative presence of infection. There was a higher rate of infection with the use of suction drains (p < 0.05). The use of skin clips rather than sutures was associated with an increased rate of infection (p < 0.05). There was an increased need for revision surgery with the use of skin clips, although this was not significant (p = 0.07). CONCLUSIONS: Skin clips and surgical drains adversely influence the risk of infection in major limb amputation and their use should be avoided.

Total parathyroidectomy without autotransplantation for renal hyperparathyroidism.

BACKGROUND: Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure. METHODS: A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1-120) months. RESULTS: Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15.7 per cent. Thirty-three patients (28.7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12.2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35.4 (range 5.4-200.0) pmol/l. The reoperation rate was 3.5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands. CONCLUSION: Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate.

Prior exposure to major flooding increases individual preparedness in high-risk populations.

INTRODUCTION: July 2007 brought unprecedented levels of flooding to the United Kingdom. Health and financial implications were vast and still are emerging. Hydrological disasters will increase in frequency. Therefore, individual preparedness is paramount, as it may mitigate some of the devastating impacts of flooding. Literature on individual preparedness for flooding is scarce, so it is key that current levels of awareness, information gathering, and protective behaviors are investigated. It also is not clear whether being in a high-risk area or having recent exposure to flooding are motivational factors for preparedness. OBJECTIVES: The objectives of this study were to: (1) ascertain whether prior experience with flooding is a strong motivational factor for preparedness for future flooding episodes; and (2) assess preparedness in populations at high risk for flooding. METHODS: A prospective questionnaire survey was sent to individuals living in two towns in the United Kingdom, Monmouth and Tewkesbury. Both towns are deemed to be at significant risk for flooding, and Tewkesbury was severely affected by the July 2007 flooding disaster. Data were obtained from these two populations and analyzed. RESULTS: A total of 125 responses (of 200) were returned, and demographic data indicated no major differences between the two populations. The number of protective behaviors was higher from participants from Tewksbury (flood risk and exposure; p=0.004). Participants from Tewkesbury were more likely to be aware of living in a flood-risk area and of the emergency systems present in the area, and feel prepared for future episodes of major flooding (p=0.03, p=0.005). Awareness of living in a flood risk-area increased the likelihood of being knowledgeable about emergency systems and adopting protective behaviors (p=0.0053, p=0.043). However, feeling prepared for future episodes of flooding was not associated with a strong increase in knowledge gained to prepare for flooding or having an increased number of protective behaviors. CONCLUSIONS: Awareness of being at-risk for flooding is vital for self-protective behavior. Both awareness of risk and recent exposure are motivational for flood preparedness. Recent exposure to flooding increases awareness, but it is unknown how long this effect will last. Recent exposure increases the preparedness of individuals for major flooding 18 months after major flooding and, if it continues, will help mitigate the devastating health, financial, and social effects of major flooding.

Pharyngeal perforation secondary to electrical shock from a Taser gun.

The case history is presented of a patient who developed pharyngeal perforation following the use of a Taser electroshock gun. This complication has not previously been reported.

Core trainee boot camp, a method for improving technical and non-technical skills of novice surgical trainees. A before and after study.

INTRODUCTION: The transition to surgical training can be a stressful time for trainees and is most evident during national handover periods where new graduates start and senior trainees rotate to new programmes. During this time, patient mortality can increase and Hospital efficiency reduces. This influence is compounded by the impact of working time directives. Intensive, simulation rich training programmes or "Boot Camps" have been postulated as a solution. This article highlights the development of a surgical boot camp for novice surgical trainees and the impact this can have on training. METHOD: A novel surgical boot camp was developed for all trainees within a surgical training region including nine acute NHS trusts. Participating cohort of trainees completed pre and post course questionnaires to assess technical and non-technical skills. RESULTS: 25 trainees attended and completed the pre and post boot camp questionnaire. Significant improvements were seen with technical skills (p = 0.0429), overall non-technical skills (p < 0.001) including leadership (p = 0.022), communication (p = 0.010), situational awareness (p = 0.022), patient handover (p = 0.003), ward round skills (p = 0.005) and outpatient skill (p = 0.002). Trainees reported significantly increased ability to assess and manage a critically unwell patient (p = 0.001) and a trauma patient (p = 0.001). 96% of trainees have utilised the skills they learnt on Boot Camp and all trainees would recommend it as an induction programme. CONCLUSION: Surgical Boot Camps offer a timely chance to develop technical and non-technical skills whilst enhancing a trainee's confidence and knowledge and reduce the patient safety impact of the handover period.

Prosthetic repair of prevascular femoral herniation.

INTRODUCTION: In prevascular femoral hernias the sac is situated anterior to the femoral vessels in the groin. These hernias are rare and a preoperative diagnosis is seldom considered. Traditionally the surgeon had to do the best with the situation that confronted him/her. The aim of this study was to evaluate the use of a prosthetic mesh-plug via a low anterior groin approach. METHODS AND RESULTS: Over a nine-year period, six patients (all men, aged 46-82 year) were treated for prevascular herniation using a mesh-plug. Five patients had previous groin surgery. Follow-up ranged from 15 months to nine years, during which no recurrence, infection or vascular compromise was detected. DISCUSSION: Prevascular herniation is rare and the diagnosis may be difficult. Our results suggest that mesh-plug repair via a low approach is feasible and safe and may provide another option for a surgeon encountering a prevascular hernia.

Effective e-learning in surgical education: the core values underpinning effective e-learning environments and how these may be enhanced for future surgical education.

e-learning is a valuable tool that has a number of advantages for Surgical Oncology training and education. The rapidly evolving nature of, and limited clinical exposure to oncological practice creates challenges for surgical trainees to stay up to date and engaged. Online learning can be accessed anywhere at any time and allows trainees to develop, apply and be assessed on their learning. To be effective, it must be educationally sound and embrace technology to enhance learners' experience.

Bezoar: an unusual palpable mass in the right iliac fossa.

A 64-year-old gentleman presented with a 12-h history of right iliac fossa pain. On examination, the patient had a tender 8 × 6 cm mass in the right iliac fossa with localised peritonitis. The working diagnosis at this time was an appendix mass or caecal cancer. A computed tomography scan revealed the characteristic 'bird's nest' appearance of a bezoar. On further questioning, the patient confessed to regularly 'binging' on grapes. The patient described passing the mass and his symptoms completely resolved. This appears to be the only documented case of a bezoar affecting the ascending colon.

Monitoring Network Confirms Land Use Change is a Substantial Component of the Forest Carbon Sink in the eastern United States.

Quantifying forest carbon (C) stocks and stock change within a matrix of land use (LU) and LU change is a central component of large-scale forest C monitoring and reporting practices prescribed by the Intergovernmental Panel on Climate Change (IPCC). Using a region-wide, repeated forest inventory, forest C stocks and stock change by pool were examined by LU categories. In eastern US forests, LU change is a substantial component of C sink strength (~37% of forest sink strength) only secondary to that of C accumulation in forests remaining forest where their comingling with other LUs does not substantially reduce sink strength. The strongest sinks of forest C were study areas not completely dominated by forests, even when there was some loss of forest to agriculture/settlement/other LUs. Long-term LU planning exercises and policy development that seeks to maintain and/or enhance regional C sinks should explicitly recognize the importance of maximizing non-forest to forest LU changes and not overlook management and conservation of forests located in landscapes not currently dominated by forests.

Integration of bovine leukaemia virus in the ovine genome.

Circulating lymphocytes and tumour cells from 12 sheep experimentally infected with bovine leukaemia virus (BLV), for periods of time varying from 9 to 48 weeks, were analysed for evidence of integrated and unintegrated provirus. Hybridization analysis demonstrated that the provirus was integrated at one or two sites in all cases. Integration was observed at different sites in the animals studied and there was no evidence of unintegrated virus molecules in infected sheep lymphocytes or tumour cells. The data obtained support a monoclonal origin of different tumours in the same sheep.

Differential distribution of ATPase- and T6-positive cells (Langerhans cells) in the limbus and cornea of Hereford and non-Hereford cattle.

Epithelial sheets from the limbus, cornea, and third eyelid of Hereford and non-Hereford cattle were examined for the presence of Langerhans cells (LC) using the membrane enzyme ATPase as a marker for LC. The aim of the study was to test the hypothesis that differences in LC density exist between the various ocular epithelia of these animals producing depressed immune surveillance in the case of Hereford cattle. The presence of LC in ocular tissues was confirmed by parallel studies which detected epithelial cells bearing T6, an antigen expressed by human LC. Studies using serial sections demonstrated that T6+ cells also reacted with an anti-human HLA-DR monoclonal antibody. The detection of T6+, DR+ and ATPase+ cells in ocular epithelium in the absence of infiltrating macrophages suggested that LC are present in these tissues. While there were no significant differences in the density of T6+ cells between non-Hereford and Hereford cattle, in the latter ATPase+ cells were significantly fewer in the lateral, medial, and upper limbus.

Atypical incisional hernia following Pfannenstiel incision.

INTRODUCTION: Herniation following Pfannenstiel incision is rare. Closure of the incision in four layers including the rectii abdominis, is done uncommonly. The authors report five cases of interstitial herniae between the rectus muscles and the anterior rectus sheath, incarcerating omentum and bowel. Four patients underwent repair, two as an emergency. One patient was managed conservatively. METHOD: Subsequently all consultant and specialist registrars in obstetrics and gynaecology in the Wessex region were sent questionnaires on their methods of closure of Pfannenstiel incisions and rates of associated herniae. Fifty-three of 74 surgeons responded and only three (5.6 %) routinely closed the abdominal recti. The surveyed surgeons felt post-Pfannenstiel incisional hernia rates were low (0-1 %) though the rate was unknown to 33 % of surgeons. CONCLUSION: Complex incisional interstitial herniae of this type have not previously been described. Closure of the rectii abdominis (as originally described by Pfannenstiel in 1900) could minimise the incidence of incisional herniae.

Audit of referral patterns for hernia repair - are general practitioners aware of the changing face of herniorrhaphy?

INTRODUCTION: The objective of this study was to examine referral patterns from general practitioners for groin hernia surgery and to assess their knowledge of services available to their patients. PATIENTS AND METHODS: An anonymous postal questionnaire was sent to 120 general practitioners (GPs) in the South East Wales region who routinely refer patients for inguinal hernia surgery to the Royal Gwent Healthcare NHS Trust. RESULTS: A total of 86 questionnaire replies were returned. There was variation in referral patterns between the GPs with the majority (84%) referring their patients for groin hernia repair to either a general surgeon or as an open referral. Only 14% referred directly to a hernia specialist and none regularly referred to a laparoscopic surgeon. CONCLUSIONS: Referral patterns for inguinal hernia surgery do not reflect services provided in secondary care. Further education is required so that a patient's care can be optimised.

Irreversible sensorineural hearing loss due to clarithromycin.

Clarithromycin is a commonly used advanced generation macrolide. This case study reviews a case of an 81 year old woman who developed sensorineural deafness in the right ear after the start of low dose oral clarithromycin for an infective exacerbation of chronic obstructive pulmonary disease. Despite cessation of this drug after only three days, the sensorineural deafness was found to be irreversible. Reversible sensorineural deafness secondary to macrolides has previously been described and evidence in the literature shows that a dose related phenomenon occurs. Research has indicated that transient dysfunction of the outer hair cells could be the possible mechanism. In this case, however, the patient experienced an irreversible sensorineural deafness associated with the start of low dose oral clarithromycin. This is a side effect profile that has not previously been reported.

Integration of bovine leukaemia virus at all stages of enzootic bovine leukosis.

Integration of bovine leukaemia virus DNA was investigated at all stages of infection in cattle. We report here the detection of integrated proviral DNA in the majority of antibody positive animals without lymphocytosis. In all but one case virus was integrated at a number of different sites. Hybridization analysis failed to detect proviral sequences in animals shown to be BLV antibody-negative by the Agar Gel Immunodiffusion assay. The pattern of integration in leukocytes from animals with persistent lymphocytosis was similar to that in sero-positive animals without lymphocytosis in that multiple sites of integration were evident. As reported by others only one or a few sites of integration were detected in tumours from enzootic bovine leukosis animals. Tumours from different sites in individual animals were either monoclonal or oligoclonal.

Molecular cloning and sequencing of an Australian isolate of proviral bovine leukaemia virus DNA: comparison with other isolates.

The molecular cloning and characterization of an EcoRI fragment, 8.26 kb in size, of an Australian isolate of bovine leukaemia virus (pBLV-A1) is described. This fragment includes most of the proviral genome as well as 340 bp of flanking bovine DNA sequence at the 5' end. Approximately 790 bp, including the 3' long terminal repeat, was missing from this clone. At the level of restriction enzyme mapping, this isolate could be distinguished from American, Belgian and Japanese isolates. DNA sequencing of the entire clone demonstrated some variation at the amino acid level between pBLV-A1 and the Japanese and Belgian isolates, particularly in the gag gene. In that gene there were 59 amino acid changes compared to the Japanese isolate and 24 compared to the Belgian isolate. The greater number in the case of the Japanese isolate was due to both single nucleotide changes and frameshift in a single region of the gene. This study also demonstrates that there are large tracts of amino acid sequence, particularly within the env and pol genes, that are highly conserved in different isolates. Some of these conserved sequences exist in regions containing epitopes important in virus infectivity.

Interferon-alpha-2b and oral cytarabine ocfosfate for newly diagnosed chronic myeloid leukaemia.

BACKGROUND: Treatment with interferon and subcutaneous cytarabine produces superior cytogenetic responses in chronic myeloid leukaemia (CML) than treatment with interferon alone, but at the expense of greater toxicity. Cytarabine ocfosfate (YNK01) is an oral precursor of cytarabine that may overcome some of the inconvenience and toxicities associated with subcutaneous cytarabine administration. PATIENTS AND METHODS: We studied the efficacy and tolerability of combination therapy with interferon-alpha-2b and YNK01 in patients with newly diagnosed, untreated CML. Forty patients were treated with interferon-alpha-2b (5 MU/m2/day) plus monthly courses of YNK01 (600 mg/day for 10 days) for 1 year. RESULTS: The 6-month complete haematological response rate was 63% and the 1-year major cytogenetic response rate was 30%, with 10% of cytogenetic responses being complete. With a median follow-up of 57 months, the estimated 5-year overall survival was 86% (95% confidence interval 70% to 94%). Treatment tolerability was poor, with toxicity leading to discontinuation of one or both drugs in 60% of cases. The median daily dose of interferon alpha-2b was 7.75 MU and the median dose of YNK01 was 600 mg/day for each 10-day treatment cycle. CONCLUSIONS: Interferon-alpha-2b and YNK01 produce cytogenetic responses comparable to those achieved with interferon-alpha-2b and parenteral cytarabine, although toxicity was excessive. Alternate dosing strategies may enhance the tolerability of YNK01.