Bleomycin electrochemotherapy for the management of locally advanced metastatic melanoma: Two notable clinical cases potentially indicating a greater therapeutic role in the era of targeted and immuno-therapy.

Bleomycin electrochemotherapy (ECT) has emerged as a treatment modality for locally advanced metastatic melanoma over the past decade. The phenomenon of reversible electroporation enhances cell permeability when a pulsed electrical current is applied to tissues. This facilitates enhanced cytotoxicity of bleomycin with minimal systemic side effects. We present two case analyses of patients with advanced metastatic melanoma of lower limb which did not respond to alternative therapies, including immunotherapy and isolated limb perfusion, but had a positive clinical response to bleomycin ECT. Locoregional control of the tumour was gained along with positive functional outcomes for the patients including increased mobility and reduced malodour. Bleomycin ECT is an exciting new therapeutic modality in the armamentarium of the plastic surgeon. Operating parameters have been developed and refined which facilitate its safe use along with incorporation into international melanoma guidelines. Evidence in the literature supports its use in select cases, however, it is vital that we share our experiences in its use so that its role can be better defined. Particularly in the era of rapidly developing systemic treatments which are decreasing mortality and thereby increasing the number of patients requiring locoregional disease managment.

Improving patient discharge process using electronic medication input tool and on-line guide to arranging follow-ups.

Complete, accurate and timely discharge summaries (TTOs) enable effective communication between hospital teams and GPs. It can prevent adverse events and reduce hospital readmission rates (1). If the discharge summary does not contain important information (e.g. follow-up arrangements, accurate discharge medication list), or if follow-up arrangements are not made, then patient care and outcome can be adversely affected (2,3). An electronic Medication Input Wizard was developed to improve the quality and reduce the error rates of TTOs. The Wizard makes entering drug information faster; prompts for reasons medication changes; provides examples for Controlled Drug (CD) prescribing; and prompts to refer patients taking warfarin to anticoagulation clinic. An on-line guide was developed which explains how to arrange investigations and appointments. Retrospective studies of TTOs were carried out before and after these interventions, analysing documentation of medication and completion of intended follow-up arrangements. A baseline audit found 65% of medication changes on TTOs were not clearly documented, and only 8% with changes documented reasons. 40% of prescriptions for CDs were incorrect delaying discharge by 4.9 hours per patient. 80% of intended follow-ups actually happened. After intervention, TTOs written using the Wizard had 100% of medication changes documented, and 75% were documented with reasons. CD errors decreased to 28% (76% of errors were done without using the Wizard). Follow-up arrangements that occurred increased to 86%. A survey showed 78% of Doctors reported the Wizard was faster than typing the details in separate textboxes, and 94% believed it was beneficial. Systems should be optimised to encourage better documentation of medication details and reduce prescribing errors. Guides that explain how to make follow-up arrangements should be accessible to Doctors, to make sure follow-ups are organised correctly.

Improving transmission rates of electronic discharge summaries to GPs.

Discharge summaries are a vital tool to communicate information from Hospital to Primary Care teams; updating GPs about what happened during an admission, and handing over care detailing any follow up care required. Historically, Discharge Summaries have been posted to hospitals, increasing costs for hospitals, creating administrative work for GP practices receiving the letters, and resulting in some letters being lost or delayed in reaching the GP, with implications for patient safety if follow up requests are not received and acted upon. In an effort to improve patient care, the Clinical Commissioning Group in Surrey drew up a contract with Ashford and St Peter's Foundation Trust, aiming to increase the percentage of discharge summaries sent electronically from the rate of 9% sent within 24 hours, to over 75%. This contract set targets of 50% in May, 65% in June, and 80% in July. Financial penalties would be imposed if targets were not achieved, starting in June 2013. The Trust set up a working group comprising of doctors, IT personnel and ward PAs to devise a multi-pronged solution to achieve this target. The electronic discharge summary system was reviewed and improvements were designed and developed to make the process of signing off letters easier, and transmission of signed off letters became automated rather than requiring manual transmission by ward PAs. Presentations and leaflets to explain the importance of prompt completion and transmission of discharge summaries were given to Doctors to improve compliance using the revised IT system. Figures on transmission rates were automatically emailed to key stakeholders every day (Ward PAs, Divisional Leads) showing performance on each ward. This helped identify areas requiring more intervention. Areas (e.g. Day Surgery) that had not used electronic discharge summaries were engaged with, and persuaded to take part. As a result, transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% on May 11th 2013, to 76% by June 29th 2013. This has improved communication with GPs, led to more reliable handover of care, and reduced costs for the Trust (both in processing and postage costs, and by avoiding fines).

Melanoma diagnosed 27 years after a benoxaprofen-induced photosensitivity reaction.

BACKGROUND: The propionic acid derivative Benoxaprofen was introduced for the treatment of rheumatic disorders in 1980. Its product license was then withdrawn 2 years later due to concerns over serious dermatologic, hepatic and renal side effects. Photosensitivity was the most common side effect with reported incidence of up to 50%. MAIN OBSERVATIONS: We present the first case report of a patient who presented with a melanoma diagnosed 27 years after a benoxaprofen-induced photosensitivity reaction. With an estimated 1.5 million patients previously on benoxaprofen, a large number of patients may potentially face increased risk of developing malignant melanoma. This case report can only suggest an association between solar injury secondary to benoxaprofen-related photosensitivity and subsequent melanoma. However the primary factor that improves survival from melanoma is early diagnosis, and so clinicians treating this group of patients should be aware of this risk. CONCLUSION: Although benoxaprofen is no longer in clinical use, the long-term sequelae to its photosensitizing effects may still be clinically important. Clinicians treating this group of patients should be vigilant, and consider a low threshold for diagnostic biopsy of suspicious skin lesions.

A case report and review of soft tissue metastatic squamous cell carcinoma of the upper limb in the absence of a primary tumour.

Soft tissue metastases and distant perineural metastases of an unknown primary are rare presentations of cancer. We present a patient with soft tissue and intraneural metastatic squamous cell carcinoma to the left arm with unknown primary that was treated with wide excision, followed by adjuvant radiotherapy. The patient was followed up for 3 years, and has had no signs of recurrence. We discuss the management of this patient and review available literature to share our experience of managing this rare condition. Soft tissue and perineural metastases are rare, but should form part of the differential diagnosis in patients presenting with soft tissue (or nerve) swellings. To our knowledge, the presence of metastatic soft tissue SCC in the extremity with intraneural spread in the absence of a primary tumour has not been reported in the literature.

Bilateral well leg compartment syndrome associated with lithotomy (Lloyd Davies) position during gastrointestinal surgery: a case report and review of literature.

INTRODUCTION: Well leg compartment syndrome is a rare complication that can occur after prolonged surgery in lithotomy position. We stress the importance to recognize high-risk patients for this complication and finding ways to reduce this risk. We also emphasize high level of suspicion of at risk patients and early recognition of signs and symptoms to enable early diagnosis and treatment. METHODS: Presentation of a case report of bilateral well leg compartment syndrome with review of literature and discussion of the pathophysiology, risk factors and treatment of this condition. RESULT: This is a possible complication of surgery associated with significant morbidity and mortality. Published papers have suggested possible ways to reduce this risk and achieve early diagnosis. CONCLUSION: Clinicians should be aware of the aware of the risk factors for developing well leg compartment syndrome and in patients and have high index of suspicion when assessing them. Further studies looking at the risks, benefits and feasibility of suggestions on ways to reduce this risk is required.