Phenytoin Induced Purple Glove Syndrome: An Effective Management Technique.

Background: Purple glove syndrome (PGS) is a rare condition characterized by limb edema, discoloration, and pain associated with intravenous and oral phenytoin administration. The pathophysiology is poorly understood, and there is no established treatment. Simple cases have previously been managed with hyaluronidase subcutaneous injections, with more severe cases resulting in compartment syndrome, debridement, or even amputation. Methods/Results: In this case report, a 2-year-old boy with status epilepticus developed PGS after receiving intravenous phenytoin via a cannula on the dorsum of the right hand. The patient was successfully managed by locally infiltrating subcutaneous hyaluronidase diffusely to the affected area, titrating its dose to effect, rather than aiming to adhere to any specific dosing limitation. The child was reviewed daily by the Plastic Surgery team until being discharged, and focal lesions began to demarcate after 48 hours, with epidermal loss but no deeper trauma. The epidermis peeled within one month, with healthy underlying skin found underlying when followed up in clinic. Conclusions: This case illustrates that subcutaneous administration of hyaluronidase and titrating to effect provides an effective and safe treatment for treating distal cases of early PGS in children.

Bilateral risk-reducing mastectomy and reconstruction-A 12-year review of methodological trends and outcomes at a tertiary referral centre.

INTRODUCTION: Bilateral risk-reducing mastectomy (BRRM) involves removal of healthy breast tissue to substantially decrease the risk of developing breast cancer in individuals with greater susceptibility due to a strong family history or genetic mutation. This retrospective study evaluates cases of BRRM and associated reconstruction performed at a tertiary centre, with emphasis on mastectomy and reconstructive trends. METHODS: A retrospective review of all BRRM cases performed between January 2010 and May 2022 was conducted, with two separate cohorts corresponding to the earlier (group 1) and later (group 2) portion of the time-period. Data collected included demographics, genetic test results, family history of breast/ovarian cancer, co-morbidities, mastectomy type, reconstruction type, surgical histopathology findings and post-operative complications. RESULTS: A total of 82 patients (group 1 = 41, group 2 = 41) underwent BRRM. The proportion of nipple-sparing mastectomy increased from 14.6% to 56.1% between the two time periods with a reduction in skin-sparing mastectomies from 75.6% to 20.3% (p<0.001). Of the 80 patients who opted to undergo reconstruction, there was a significant decrease in combined flap-implant reconstructions (19.51% to 0%, p<0.01). Importantly, for implant-only reconstruction, there were significant increases in prepectoral approaches (p = 0.0267) and use of acellular dermal matrix (ADM) (48.15% to 90.63%, p<0.001). CONCLUSION: This study documents recent increases in nipple-sparing techniques for BRRM compared to more traditional skin-sparing methods. Concurrently, reconstruction following RRM has become predominantly implant-based without a flap, coinciding with more widespread usage of ADM. This is consistent with national trends towards fewer complex autologous procedures.

The "Domino Flaps" Concept: Functional Composite Reconstruction for Traumatic Transmetacarpal Thumb Amputation.

Complex transmetacarpal thumb amputation remains a challenging reconstructive injury. Optimal reconstructive options aim to achieve a neo-thumb with optimal length, sensitivity, stability, and an aesthetically functional result. In cases when immediate replantation of the amputated digit is not possible, a temporary ectopic replantation with staged reconstruction can be deployed. We report our experience of a complex transmetacarpal thumb amputation managed with a staged "domino flap" concept. The first stage involved an ectopic replantation of the amputated digit with a second stage replantation 3 weeks later. Domino flap refers to the requirement of a further reconstruction due to the defect at the donor sites. In this case, the replant is accompanied by 2 domino flap reconstructions with the dorsalis pedis composite free flap to reconstruct the first metatarsal and an anterior tibial artery propeller perforator flap to reconstruct the composite flap donor site.

Combining the Grisotti Flap With a Secondary Dermoglandular Pedicle for Partial Breast Reconstruction Following Contiguous Central-Inferior Segment Breast Cancer Excision.

A 61-year-old patient (38DD) with multifocal invasive ductal carcinomas requested breast-conserving surgery. An innovative two pedicle combination using a laterally-based Grisotti flap and an inferomedially-based secondary pedicle was designed to reconstruct a combined central breast (NAC included) and inferior segment resection defect. Satisfactory cosmesis with clear resection margins was achieved.

Virtual Reality Simulator Use Stimulates Medical Students' Interest in Orthopaedic Surgery.

PURPOSE: To investigate whether the use of a VR arthroscopic simulator can influence medical students' attitudes toward a career in orthopaedic surgery. METHODS: Twenty-five medical students completed seven unsupervised sessions on a VR hip-arthroscopic simulator. All participants completed a pre-simulator and post-simulator pseudo-anonymized questionnaire consisting of 10 questions: six 10-point Likert scale questions addressing their interest in orthopaedics, surgery, and arthroscopy; and four 5-point Likert scale questions addressing their attitudes toward simulation. Prepaired and postpaired datasets were analyzed using Wilcoxon signed rank test. RESULTS: Interest in both orthopaedics and surgery was found to increase after simulator use (orthopaedics: 5.3 ± .3 to 8.4 ± .2, P = .0001; surgery: 5.8 ± .3 to 9.0 ± .2; P = .0001). It was also found that simulator use increased participants' interest in arthroscopy (5.4 ± .3 to 8.0 ± .3; P = .0001) and hip-arthroscopy (5.0 ± .3 to 7.6 ± .3; P = .0001). Participants reported they were more likely to attend endoscopic and arthroscopic surgical lists after simulator use (endoscopic: 6.9 ± .3 to 8.4 ± .2; P = .0003; arthroscopic: 5.9 ± .3 to 8.4 ± .2; P = .0001). After using the simulator, participants felt more strongly that VR simulation is a valuable training modality (P = .0025), that simulation should be a mandatory part of orthopaedics and surgical training (P = .0001 and P = .0001), and that access to VR simulators improves the quality of surgical training (P = .0024). CONCLUSIONS: These results demonstrate that exposure to VR arthroscopic simulation increased medical students' interest in orthopaedics, surgery, and arthroscopy, without the need for direct supervision. Following VR simulator use, students reported they were more likely to engage with training opportunities, including arthroscopic and endoscopic surgery. CLINICAL RELEVANCE: Understanding factors that stimulate interest in orthopaedic surgery may help programs attract the broadest pool of potential trainees.

The automation of doctors and machines: A classification for AI in medicine (ADAM framework).

The advances in artificial intelligence (AI) provide an opportunity to expand the frontier of medicine to improve diagnosis, efficiency and management. By extension of being able to perform any task that a human could, a machine that meets the requirements of artificial general intelligence ('strong' AI; AGI) possesses the basic necessities to perform as, or at least qualify to become, a doctor. In this emerging field, this article explores the distinctions between doctors and AGI, and the prerequisites for AGI performing as clinicians. In doing so, it necessitates the requirement for a classification of medical AI and prepares for the development of AGI. With its imminent arrival, it is beneficial to create a framework from which leading institutions can define specific criteria for AGI.

What can we learn from supermarkets? An application of the Poisson distribution (order-up-to) model to improve blood culture bottle supplies.

BACKGROUND: The order-up-to inventory model is a method for identifying and maintaining the optimal product level for items that that hold value over time and have recurring demand. Typically, supermarkets utilise it to manage stock-levels of non-perishable goods. LOCAL PROBLEM: This project aimed to improve blood culture bottle supplies following reports by junior doctors of shortages when dealing with septic/unwell patients. METHODS: Data regarding blood culture bottle use was acquired from four hospitals within one trust in London (245 wards). The mathematical 'order-up-to' inventory model (an iterative Poisson distribution) was applied to the 6 months' data. INTERVENTIONS: The model found three predictable levels of demand to stock wards with no shortages in 99.3% of circumstances (based on historical data). Wards were stocked with blood culture bottles as per their required demand. RESULTS: A collection method and infrastructure was designed to implement the new policy and was applied to a London tertiary centre. A review of doctors, nurses and ward-managers found significant improvements in supply with no shortages since the model was applied. Issues with the dataset were identified for intensive therapy unit / high dependency unit. CONCLUSIONS: The 'order-up-to' inventory model provides a useful tool within hospitals for improving stock levels of blood cultures bottles and with that the satisfaction of trainees and patient safety.

A case at crossroads-urological presentation, cardiac complication and haematological diagnosis: should imaging be pursued prior to orchidectomy at all costs?

This case report explores the interesting case of a 71-year-old gentleman who presented with a testicular lump following trauma. Ultrasound imaging of the testicle demonstrated malignancy and subsequently orchidectomy was listed. Due to a scheduling difficulty, this was prioritized ahead of his whole-body computed tomography scan. Intraoperatively, he developed electrocardiogram changes suggestive of a non-ST elevated myocardial infarction. Post-operative imaging demonstrated a diffuse large B-cell lymphoma encroaching the heart and greater vessels. This case report highlights the importance of preoperative imaging, even where it may prove challenging. We assess the adequacy of current guidelines within the UK on imaging for new testicular malignancies.

The successful use of disparate pedicle types for bilateral therapeutic mammaplasties during breast conservation surgery.

This case illustrates the successful use of non-identical pedicles in bilateral therapeutic mammaplasty (TM). A 58-year-old patient presented with a left-sided upper inner quadrant multifocal invasive [no special type (NST)] tumour and a right-sided upper outer quadrant unifocal invasive tubular carcinoma with surrounding ductal carcinoma in situ (DCIS). Her tumour locations necessitated simultaneous bilateral TM using different pedicle types. A superomedial pedicle T-scar breast reduction was undertaken on the right to resect the upper outer quadrant tumour whilst a superolateral nipple transposition pedicle was used on the left breast to enable the wide resection of the two tumours located superomedial to the nipple. The location and size of the tumour also required the use of a secondary infero-medially based pedicle for volume displacement on the left breast. Patient received adjuvant chemotherapy and radiotherapy. A year after surgery the patient has acceptable cosmetic results in terms of symmetry, breast contour and increasingly inconspicuous scars.

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core).

BACKGROUND: Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones. METHODS: Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared. RESULTS: Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05). CONCLUSIONS: Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.

Application of the Lalonde (horizontal-only scar) breast reduction technique for correction of gynaecomastia in dark skinned patients.

Surgical correction of gynaecomastia correction sometimes necessitates skin reduction in addition to resection of glandular tissue and liposuction of the fat deposits. Many skin reduction techniques have been described but all suffer from very noticeable and often poor scars that can manifest as hypertrophic or keloid scars in patients with dark skin. Three large gynaecomastia patients undergoing a modification of the Lalonde "no vertical scar" breast reduction technique designed to reduce the extent of scarring were reviewed. The Lalonde "no vertical scar" technique was successfully applied to three patients of African extraction with acceptable postoperative scarring. A description of the technique and the cosmetic results are presented. The Lalonde technique of female breast reduction can be applied to the treatment of male breast enlargement in patients at high risk of scar complications. It provides an alternative to the more widely used concentric skin reduction techniques. To our knowledge, this is the first report in literature of the application of the Lalonde "no vertical scar" surgical technique to the treatment of gynaecomastia in patients with darkly pigmented skin.

Utilizing the Total Design Method in medicine: maximizing response rates in long, non-incentivized, personal questionnaire postal surveys.

INTRODUCTION: Maximizing response rates in questionnaires can improve their validity and quality by reducing non-response bias. A comprehensive analysis is essential for producing reasonable conclusions in patient-reported outcome research particularly for topics of a sensitive nature. This often makes long (≥7 pages) questionnaires necessary but these have been shown to reduce response rates in mail surveys. Our work adapted the "Total Design Method," initially produced for commercial markets, to raise response rates in a long (total: 11 pages, 116 questions), non-incentivized, very personal postal survey sent to almost 350 women. PATIENTS AND METHODS: A total of 346 women who had undergone mastectomy and immediate breast reconstruction from 2008-2014 (inclusive) at Addenbrooke's University Hospital were sent our study pack (Breast-Q satisfaction questionnaire and support documents) using our modified "Total Design Method." Participants were sent packs and reminders according to our designed schedule. RESULTS: Of the 346 participants, we received 258 responses, an overall response rate of 74.5% with a useable response rate of 72.3%. One hundred and six responses were received before the week 1 reminder (30.6%), 120 before week 3 (34.6%), 225 before the week 7 reminder (64.6%) and the remainder within 3 weeks of the final pack being sent. The median age of patients that the survey was sent to, and the median age of the respondents, was 54 years. CONCLUSION: In this study, we have demonstrated the successful implementation of a novel approach to postal surveys. Despite the length of the questionnaire (nine pages, 116 questions) and limitations of expenses to mail a survey to ~350 women, we were able to attain a response rate of 74.6%.

Postmastectomy Breast Reconstruction With the Totally Autologous Latissimus Dorsi Flap in the Thin, Small-Breasted Woman: Give It More Thought!

Introduction: Thin women have fewer autologous tissue breast reconstructive options than their higher body mass index counterparts-due to a lack of adequate donor sites. They are therefore usually offered expander/implant techniques. The total autologous latissimus dorsi flap is generally used in "well-padded" individuals, as they have enough fat on their back on which a completely autologous reconstruction could be based. When implant-based reconstruction is contraindicated (for instance due to planned adjuvant radiotherapy) or unacceptable to the patient, the total autologous latissimus dorsi flap can provide adequate tissue volume by utilizing the additional back fat deposits even in the thin, small-breasted patient. This option is often overlooked by many surgeons. Our case series assesses indications and patient and surgeon satisfaction with the cosmetic outcome of this technique. Methods: The oncological and clinical details of 6 patients with breast cancer who underwent total autologous latissimus dorsi myocutaneous flap immediate breast reconstruction by a single surgeon over an 8-year period were reviewed. An objective assessment of satisfaction with the cosmetic result was made by whether any additional surgical interventions (ipsilateral fat grafting/implant augmentation or contralateral liposuction/ reduction) were needed or not. A subjective assessment of breast symmetry by the surgeon using photographic records was also undertaken. The aesthetic outcomes were also objectively quantified using the BCCT.core software, initially developed for assessing the results of breast conservation surgery. Results: All 6 patients had small breasts and a low or normal body mass index. The mastectomies were performed for invasive carcinoma (n = 3) and extensive high-grade ductal carcinoma in situ (n = 3). Four had axillary surgery (2 sentinel lymph node biopsies and 2 axillary clearances), and 3 received adjuvant radiotherapy. All were happy with their reconstructive outcomes, and none suffered major postoperative complications or disease recurrence. None requested or needed any subsequent ipsilateral adjustment or contralateral symmetrizing procedures. Subjectively, the reconstructions provided acceptable or excellent cosmetic results. The cosmetic results were categorized as excellent or good on the BCCT.core scoring system. Conclusion: This underutilized method of totally autologous breast reconstruction in thinner patients with lower body mass indexes yielded good, well-accepted cosmetic results without recourse to adjustment procedures, contralateral balancing surgery, or complex microvascular surgery. We recommend that the total autologous latissimus dorsi flap should be given more consideration when planning immediate breast reconstruction in this challenging group of thin, small-breasted patients.

Condensing embryology teaching for medical students: can it be taught in 2 hours?

INTRODUCTION: Embryology forms a valuable part of the medical school curriculum. However, medical students traditionally struggle with revising embryology and appreciating its relevance. Condensing the teaching content, implementing peer-teaching methods, and increasing clinical focus in curricula have been suggested as methods to improve student engagement. METHODS: Medical students at two universities were taught a condensed version of the embryological curriculum in 2 hours by final-year medical students. Students' confidence with the topics covered in the embryological curricula was assessed using anonymized precourse and postcourse questionnaires. Students were asked to further evaluate the quality, delivery, and content of the teaching in the postcourse questionnaire and were given the opportunity to provide written comments. All questions consisted of a statement stem and a five-point Likert scale. RESULTS: Students scored significantly higher levels of confidence with embryology after implementation of the course. They found the talk to be effectively delivered, clear, and relevant to their examinations. CONCLUSION: We have demonstrated that it is possible to design and produce an embryology teaching program that covers an undergraduate embryology curriculum in a chronological systems-based manner in 2 hours with successful results.

Evaluating the impact of Brexit on the pharmaceutical industry.

INTRODUCTION: The UK Pharmaceutical Industry is arguably one of the most important industries to consider in the negotiations following the Brexit vote. Providing tens of thousands of jobs and billions in tax revenue and research investment, the importance of this industry cannot be understated. At stake is the global leadership in the sector, which produces some of the field's most influential basic science and translation work. However, interruptions and losses may occur at multiple levels, affecting patients, researchers, universities, companies and government. GOALS: By understanding the current state of pharmaceutical sector, the potential effect of leaving the European Union (EU) on this successful industry can be better understood. This paper aims to address the priorities for negotiations by collating the analyses of professionals in the field, leading companies and non-EU member states. RESEARCH METHODS: A government healthcare policy advisor and Chief Science Officer (CSO) for a major pharmaceutical firm were consulted to scope the paper. In these discussions, five key areas were identified: contribution, legislative processes, regulatory processes, research and outcomes, commercial risk. Multiple search engines were utilised for selecting relevant material, predominantly PubMed and Google Scholar. To supplement this information, Government documents were located using the "GOV.UK" publications tool, and interviews and commentaries were found through the Google News search function. CONCLUSION: With thorough investigation of the literature, we propose four foundations in the advancement of negotiations. These prioritise: negotiation of 'associated country' status, bilaterally favourable trade agreements, minimal interruption to regulatory bodies and special protection for the movement of workforce in the life sciences industry.