Acinetobacter calcoaceticus-Acinetobacter baumannii complex species in clinical specimens in Singapore.

This study was performed to determine the prevalence, distribution of specimen sources, and antimicrobial susceptibility of the Acinetobacter calcoaceticus-Acinetobacter baumannii (Acb) species complex in Singapore. One hundred and ninety-three non-replicate Acb species complex clinical isolates were collected from six hospitals over a 1-month period in 2006. Of these, 152 (78·7%) were identified as A. baumannii, 18 (9·3%) as 'Acinetobacter pittii' [genomic species (gen. sp.) 3], and 23 (11·9%) as 'Acinetobacter nosocomialis' (gen. sp. 13TU). Carbapenem resistance was highest in A. baumannii (72·4%), followed by A. pittii (38·9%), and A. nosocomialis (34·8%). Most carbapenem-resistant A. baumannii and A. nosocomialis possessed the bla(OXA-23-like) gene whereas carbapenem-resistant A. pittii possessed the bla(OXA-58-like) gene. Two imipenem-resistant strains (A. baumannii and A. pittii) had the bla(IMP-like) gene. Representatives of carbapenem-resistant A. baumannii were related to European clones I and II.

Forgotten digital tourniquet: salvage of an ischaemic finger by application of medicinal leeches.

Individual finger tourniquets are appropriate to the management of a wide range of conditions presenting to an accident and emergency department. They are simpler and more comfortable to use than upper arm pneumatic tourniquets and commercially available digital tourniquets are not readily available in the accident and emergency unit. However, if a finger tourniquet is overlooked, ischaemia of the digit results, and gangrene may follow if the problem is not defused early enough, leading to potential disaster. We present one case where a digit was salvaged after 4 days of tourniquet application, using medicinal leeches.

Percutaneous trigger finger release: the 'lift-cut' technique.

One hundred and eighty patients with 240 trigger digits were treated by percutaneous release using a 'lift-cut' technique. All patients were reviewed at 3 months following release. Overall, 94% achieved an excellent or good result. Ten patients experienced recurrent symptoms and required a subsequent open release. There was no clinical evidence of digital nerve or flexor tendon injury. We recommend this technique as a safe and effective outpatient procedure.

Tissue reaction to titanium debris following Swanson arthroplasty in the hand: a report of two cases.

Silicone abrasion particles are known to cause inflammatory changes following Swanson arthroplasty. Titanium grommets were introduced to protect the implants from wear and abrasion. Two cases with histological evidence of symptomatic titanium particulate tissue inflammation following Swanson joint replacement with grommets are presented.

The Mexican hat splint--a new splint for the treatment of closed mallet finger.

A new splint for the treatment of closed mallet finger injuries is described. This is a modified aluminium-foam ('Zimmer') splint, which takes account of the skin circulation at the distal interphalangeal joint, and is specifically designed to alleviate the potential problems which can be seen with the traditional 'mallet finger' splints.

No sense; no sensibility--a tale of two adult hairdrier burns.

Hot air burns resulting from hairdriers held against the skin are rare. The largest published clinical series relates to burns in children injured by the use of hairdriers at home. Adults are assumed not to be at risk because the pain associated with thermal injury would normally stimulate acute action to prevent further skin damage. We present two adult patients in whom the normal protective mechanisms were inactive. There was loss of consciousness resulting from an epileptic fit in one case, and the local absence of sensation in a flap used to reconstruct a breast after mastectomy, in the other. The temperatures generated by hairdriers were experimentally assessed and the results are reviewed. We emphasize that hairdriers are a potentially dangerous source of hot air and can cause burns.

Correction of developmental breast abnormalities with a permanent expander/implant.

Patients with developmental breast abnormalities often present to the plastic surgeon at a young age. We report our experience with 4 cases of unilateral breast abnormality (3 hypoplastic and 1 tuberous) treated with a Becker permanent expander/implant. Our approach is to insert the expander/implant, expand intermittently to keep pace with growth of the other breast and remove the filling valve under local anaesthesia on maturity. The techniques and advantages of this approach are illustrated and discussed.

The "mini-Bier's block": a new technique for prevention of tourniquet pain during axillary brachial plexus anaesthesia.

Tourniquet cuff pain is a significant cause of morbidity following regional anaesthesia of the upper limb. We describe a simple new technique for effectively anaesthetizing the area under a pneumatic tourniquet (the "mini-Bier's block"), which permits comfortable surgery under axillary block anaesthesia even if the local block is incomplete. We report a controlled study of 40 patients in whom statistically significant tourniquet cuff pain relief was obtained in patients receiving an additional low-dose intravenous injection of local anaesthetic localized beneath the cuff. This technique ensures that the safe axillary approach to the brachial plexus can always be used with avoidance of pain from the pressure of the tourniquet cuff.

Breast implant materials: sense and safety.

Cosmetic breast augmentation, and post-mastectomy breast reconstruction surgery using synthetic implants, have become established in surgical practice over more than 20 years. The operative technique for implant placement have changed somewhat during this time, as many different implant presentations have become available, but the same basic materials have remained in use. We have reviewed the present state of knowledge about breast implant materials with particular reference to the possible connection between polydimethylsiloxane and polyurethane to the so-called "Human Adjuvant Disease", and to carcinogenesis. Problems related to capsular contracture and mammography are also discussed.

Angiolymphoid hyperplasia with eosinophilia associated with tetanus toxoid vaccination.

Three cases of angiolymphoid hyperplasia with eosinophilia are reported at the site of tetanus toxoid vaccination. All presented as nodules on the upper arm, a known adverse effect of the vaccine following superficial inoculation. Histologically the nodules showed numerous small and medium sized vessels, some lined by hyperplastic endothelial cells with perivascular lymphocytic cuffing and an inflammatory infiltrate of plasma cells, eosinophils and scattered mast cells. Lymphoid follicles replete with germinal centres were identified in the dermis and subcutaneous tissue. Immunostaining revealed a polytypic lymphoplasmacytic infiltrate and a curious IgE reticulated pattern within the germinal centres, a feature described in both Kimura's disease and angiolymphoid hyperplasia. The present study suggests that atopic reaction to tetanus toxoid may be an aetiological factor in some cases of angiolymphoid hyperplasia.

Idiopathic scrotal calcinosis: a possible aetiology reaffirmed.

Idiopathic scrotal calcinosis is characterised by the presence of multiple firm scrotal nodules of unknown or disputed aetiology. Only 55 cases have been reported in the literature since the first description by Lewinski (1883). We report an additional five patients. We have reviewed the literature exhaustively and our findings support the suggestion that the lesions of "idiopathic" scrotal calcinosis result simply from dystrophic calcification of epidermal cysts.

A simple modification of the pin-prick test for the assessment of burn depth in children.

The clinical assessment of burn depth can be particularly difficult in children. A new technique is described for applying the pin-prick test in children. It is simple to perform, causes no distress, and has consistently given reliable results. A personal series of 196 cases is presented, with a 95 per cent diagnostic accuracy.

Tumour thickness in malignant melanoma: the limitations of frozen section.

This paper reports a prospective study to compare maximal tumour thickness values of the same lesion obtained by frozen and paraffin sections in 20 patients with malignant melanoma over a one-year period. Significant differences were found between tumour thickness values obtained by frozen section and paraffin section. There was no constant relationship between the two sets of values. As present prognostic and therapeutic criteria are based on tumour thickness measurements obtained from paraffin sections, we recommend that clinical decisions should not be based on results obtained from frozen sections.

Lower limb skin loss: simple outpatient management with meshed skin grafts with immediate mobilization.

Traumatic skin loss is a common problem in elderly patients presenting to an accident and emergency department. The authors report their experience with 25 patients in whom pretibial wounds were debrided, and covered with skin grafts taken under local anaesthetic and meshed by hand. All were immediately mobilized and discharged home. Healing was satisfactory in every case and there were no complications. All the patients found the treatment acceptable, and were delighted to avoid admission to hospital. This is a simple and effective outpatient procedure which can readily be carried out in the accident and emergency department.

Subtotal premaxillectomy; a salvage procedure in selected cases of bilateral cleft lip and palate.

Subtotal premaxillectomy with preservation of the posterior plate of the premaxilla and the premaxillary-vomerine suture line was carried out in six selected cases of severe bilateral cleft lip and palate between the ages of four and eight years. The long term results are shown and it is concluded that although the procedure does not seem to affect mid-facial growth adversely, it should be reserved for very selective cases and only as a last resort.

The pathogenicity of coagulase negative staphylococcus in the presence of silicone rubber implants.

Coagulase negative staphylococci have long been thought to be harmless skin commensals. However they are now recognised as important pathogens in patients who have undergone insertion of prosthetic devices. We present three patients with infection following the insertion of silicone polymer prostheses, in whom a coagulase negative staphylococcus was the pathogen. All responded to antibiotic treatment. It is important to alert the bacteriologist to the presence of an implanted prosthesis when wound swabs are sent from an area showing clinical signs of infection. The coagulase negative staphylococci may otherwise be regarded falsely as merely skin contaminants.

The control of carotid arterial haemorrhage in head and neck surgery by balloon catheter tamponade and detachable balloon embolisation.

Radical surgery in the neck is hazardous after irradiation. Rupture of the carotid artery may lead to uncontrollable haemorrhage. Reported mortality rates following this serious complication are between 18% and 50% (Heller and Strong, 1979). We describe a simple method for controlling acute carotid haemorrhage using a standard Fogarty biliary catheter, with selective detachable balloon embolisation for permanent occlusion of the carotid artery.