Necrotising fasciitis of the upper limb: a review of the literature.

Necrotising fasciitis is an uncommon life-threatening surgical emergency. While most commonly seen in the lower limb it can also affect the upper limb. This article reviews and summarises the current literature on necrotising fasciitis in the upper limb, covering common predisposing factors, clinical presentations, scoring systems, common organism types and the timing of surgical treatment. The key to managing this condition continues to be early clinical diagnosis and aggressive surgical debridement to attempt to reduce the morbidity and mortality of this condition.

Teaching the management of trauma patients through virtual reality.

INTRODUCTION: Virtual reality (VR) fully immersive interactive video teaching (VR FIIT) allows learners to develop through observing and interacting with complex realistic environments, developing technical and nontechnical skills. One such complex clinical environment is managing a trauma patient. Despite the significant developments in managing these patients, foundation doctors are frequently highly anxious due to their limited knowledge and experience. The aim of this project was twofold; to improve foundation doctor performance of managing trauma patients and to reduce their associated anxiety, through the use of VR teaching. METHODS: A total of 14 foundation doctors were divided into two groups. One group underwent departmental teaching. The second group underwent departmental teaching and VR FIIT. We assessed the doctors via two methods. First, time taken to complete tasks correctly in trauma simulations was compared. Second, the doctors completed a self-reported level-based assessment questionnaire regarding anxiety and stress around trauma calls. RESULTS: The VR FIIT intervention group were able to complete each task on average 118s faster than the standard group. The standard group missed essential tasks such as C-spine immobilisation. The VR FIIT group self-reported significantly lower levels of anxiety related to trauma calls. CONCLUSION: VR teaching improves foundation doctor performance at managing simulated major trauma patients and decreases foundation doctor anxiety towards management and exposure of these clinical situations.

Are on-the-day group and save samples required for elective shoulder, hip and knee arthroplasties?

INTRODUCTION: Historically, patients undergoing an elective hip, knee or shoulder arthroplasty regularly required blood transfusions. Improved surgical techniques and perioperative optimisation have significantly decreased the requirement for blood transfusions. Currently, our patients have two group and save samples taken: one six weeks preoperatively and one on admission. This study aims to determine whether a second group and save is required prior to primary elective hip, knee or shoulder arthroplasty. METHODS: All cases of elective arthroplasty from a single centre were retrospectively analysed over a 16-month period. Each case was reviewed to determine those who had a group and save at preassessment, group and save at the time of the operation and the timing and number of blood products transfused. RESULTS: A total of 711 elective arthroplasty procedures were completed with 48 patients requiring a transfusion during their admission. 9.9% of hip arthroplasty patients, 3.8% of knee arthroplasty patients and 4.9% of shoulder arthroplasty patients required a transfusion. The majority of the transfusions occurred at least 24 hours postoperatively with 0.84% of patients requiring an intraoperative transfusion. DISCUSSION: The vast majority of transfusions were delivered more than 24 hours following the procedure, demonstrating that routinely cross-matched blood products are superfluous to requirements. It is our suggestion that a formal group and save be completed only if the need for a blood transfusion is formally established, leading to a significant cost saving, a reduction in clinical work load and patients having to undergo fewer procedures.

Separate pathways for cellular uptake of ferric and ferrous iron.

Separate pathways for transport of nontransferrin ferric and ferrous iron into tissue cultured cells were demonstrated. Neither the ferric nor ferrous pathway was shared with either zinc or copper. Manganese shared the ferrous pathway but had no effect on cellular uptake of ferric iron. We postulate that ferric iron was transported into cells via beta(3)-integrin and mobilferrin (IMP), whereas ferrous iron uptake was facilitated by divalent metal transporter-1 (DMT-1; Nramp-2). These conclusions were documented by competitive inhibition studies, utilization of a beta(3)-integrin antibody that blocked uptake of ferric but not ferrous iron, development of an anti-DMT-1 antibody that blocked ferrous iron and manganese uptake but not ferric iron, transfection of DMT-1 DNA into tissue culture cells that showed enhanced uptake of ferrous iron and manganese but neither ferric iron nor zinc, hepatic metal concentrations in mk mice showing decreased iron and manganese but not zinc or copper, and data showing that the addition of reducing agents to tissue culture media altered iron binding to proteins of the IMP and DMT-1 pathways. Although these experiments show ferric and ferrous iron can enter cells via different pathways, they do not indicate which pathway is dominant in humans.