Ensuring universal assessment and management of vitamin D status in melanoma patients at secondary care level: a service improvement project.

BACKGROUND/AIMS: Melanoma is the most aggressive skin malignancy with an ever-increasing caseload, especially in the western world. Recently developed immunotherapeutic modalities have substantially improved the prognosis of advanced melanoma. The association between serum levels of vitamin D and prognosis of melanoma has been a focus of ongoing research, with some evidence of vitamin D's potential as an adjunctive modality to immunotherapy. The National Institute for Health and Care Excellence guidelines clearly recommend that assessment of vitamin D levels and relevant advice should be an inherent aspect of the management of patients with melanoma at the secondary care level. METHOD: A service improvement project was conducted to ensure full compliance of practice in the authors' skin unit with the current National Institute for Health and Care Excellence guidelines on the management of vitamin D status in patients with melanoma. RESULTS: After two reaudits the unit's practice complied with National Institute for Health and Care Excellence guidelines by using a multidisciplinary team approach. CONCLUSIONS: The authors propose that the simple and reliable pathway used to achieve and sustain the results could be easily adopted to ensure universal adherence to these guidelines.

Study on Surgical Management of Post Burn Hand Deformities.

CONTEXT: Functionality of the hands is the major determinants of the quality of life in burns survivors. If contractures or scarring affect the dominant hand, as they do on most occasions, the vocation and there by the economic status of the patient suffer. AIM: The aim of this study is to evaluate the different surgical procedures for resurfacing after release of post-burn hand contractures in terms of functional recovery and aesthetic outcome. SETTINGS AND DESIGN: It's a prospective, non-randomised study of 50 patients admitted and undergoing surgical reconstructive procedures for post burn hand contractures in our plastic surgery department. MATERIALS AND METHODS: Resurfacing procedures were done according to type of contracture with individualisation for each case. All cases were followed up with physiotherapy and splinting advices. Functional and aesthetic outcome and recurrence of contracture for each procedure was noted at 6 months. RESULTS: Forty seven percent of the cases were reconstructed with skin grafting, 30% cases with Z plasties and 23% with flap coverage. Split thickness skin grafts (STSG) and full thickness graft (FTSG) reconstructed cases had good recovery of joint mobility in 43% and 75% of cases respectively. Reconstructive procedures were aesthetically acceptable to the patients in 63%, 75% and 94% of STSG, FTSG and Z plasty cases respectively. Recurrence was seen in 17% of STSG done cases. CONCLUSION: Most of the cases can be resurfaced with skin grafting and few cases have clear indication for flap coverage which needs to be planned and executed cautiously. Z plasties with proper planning gives maximum length gain with no donor morbidity as other procedures. Postoperative physiotherapy and splinting is must for better outcome in all cases.

Isolated splenic hydatidosis.

A 27-year-old female presented with pain in the left hypochondrium for the past six months. An abdominal examination revealed mild splenomegaly. An abdominal ultrasonography showed two cystic lesions at the superior pole of the spleen. Contrast enhanced CT scan abdomen confirmed the USG findings, demonstrating splenomegaly with nonenhancing cystic lesions having internal septations and suspicious daughter cysts within it, strongly suggestive of hydatid cysts. On serological testing, the patient was positive for IgG Antibodies against Eccinococcus. Following Pneumococcal vaccination, splenectomy was performed taking precautions to prevent accidental rupture or spillage of contents into the peritoneum. The postoperative period was uneventful with the patient making a swift recovery. Histopathological examination revealed extensive necrosis within the cysts. In the midst of the necrotic material, hooklets were seen. These features were consistent with a diagnosis of an infected Hydatid cyst. It is of utmost importance that a correct preop diagnosis is made since all precautions must be taken to prevent dissemination or seeding of the surgical field. Death has been reported due to anaphylactic shock resulting from spillage during excision or biopsy. The most important factor in diagnosing splenic hydatid cyst is the awareness of its possibility.

Perforator plus fasciocutaneous flaps in the reconstruction of post-burn flexion contractures of the knee joint.

BACKGROUND: A post-burn flexion contracture of the knee joint is a disabling condition which interferes with an upright posture and a bipedal locomotion. Islanded perforator flaps have been used to resurface the tissue defect which is produced as a result of the contracture release. Despite their various advantages, they are limited by an increased tendency to undergo venous congestion. Perforator-plus flaps can be used to overcome this limitation, while retaining the merits of the islanded perforator flaps. METHODS: Ninteen patients with post flame burn flexion contractures of the knee joints underwent surgical releases and coverages by various local fasciocutaneous perforator-plus flaps. The patients were followed up for 6 months and the various aspects of the functional and the aesthetic rehabilitations were assessed. RESULTS: All the local fasciocutaneous perforator-plus flaps resurfaced the tissue defect over popliteal fossa with good colour and texture match and maintenance of the contour. None of the flaps had any significant early or delayed complications (which included venous congestions) which necessitated reoperations. All the patients were satisfied with the functional and aesthetic outcomes. CONCLUSION: Local fasciocutaneous perforator-plus flaps can be considered as one of the primary treatment modalities for the surgical release and reconstruction of post burn flexion contractures of the knee.

Anterior plagiocephaly in an atypical case of apert syndrome.

Apert syndrome is a congenital craniosynostosis syndrome comprising of bilateral coronal synostosis , symmetric syndactyly of hands and feet and midface hypoplasia. We present an atypical phenotype of this syndrome with right sided unilateral coronal synostosis. However, type I apert hand and other clinical and radiological features suggestthe diagnosis. Genetic analysis revealed an absence of the specific missense mutations in the FGFR 2 gene that is found in patients with this syndrome. We conclude that this patient represented a rare atypical variant of Apert syndrome. Further analysis is required to map the associated genotype.

Reinforced tension line suture closure after midline laparotomy in emergency surgery.

Midline laparotomy is an emergency surgical operation frequently performed in cases of intra-abdominal pathology. Closure of the incision is usually done by continuous suturing by mass closure. In an emergency operation the intra-abdominal milieu is usually contaminated leading to gut oedema and, hence, an increase in postoperative intra-abdominal pressure. It is complicated by wound dehiscence, burst abdomen, etc. The cause of this complication is an increase in horizontal tensile forces on the site of the insertion of sutures which cuts the sheath. In this technique of reinforced tension line suture peak tensile forces are distributed from the suture base to the surrounding tissue through a horizontal suture, thereby preventing the suture from cutting through the tissue. From July 2007 to June 2009 patients requiring laparotomy were randomly divided into test and control groups by a 'closed envelope' technique. Their postoperative intra-abdominal pressure was recorded by urinary bladder catheter manometry. The result of this technique was compared with the incidence of burst abdomen in cases where it was closed by continuous suture. A total of 190 patients underwent laparotomy. In 90 the abdomen was closed by reinforced tension line (RTL) and in 100 patients by continuous suturing. None of the RTL group had a burst abdomen. Thirteen who had closure by continuous suture had a burst abdomen. The analysis of the results was done using the chi-square test. On comparing the incidence of burst abdomen in cases operated by continuous suture technique and by RTL, the P value was found to be 0.0026 which is highly significant. On analysis of the incidence of burst abdomen in cases having a grade II intra-abdominal pressure the P value was found to be 0.0009 which is highly significant. Closure of midline incision by RTL reduces the incidence of burst abdomen. Registration No. PROVCTRI/2008/091/000269 (http://www.ctri.in).

Congenital intra-mesosigmoid hernia- a case report of a rare sigmoid mesocolon hernia.

Internal hernia is the protrusion of the viscera through normal or abnormal peritoneal or mesenteric apertures within the confines of peritoneal cavities.