Management of conflict injuries to the upper limb. Part 2: reconstruction and managing complications.

This is the second of a two-part review article on the management of conflict injuries, focused on the reconstructive strategies for bone, nerve and soft tissue and to provide guidance on assessing and managing common complications associated with complex upper limb injuries. Following assessment and early surgical management, the conflict casualty will require further wound evaluation and planning prior to definitive reconstruction of limb injuries. Surgical management of the upper limb injury should aim, where possible, to preserve the limb and allow functional reconstruction. The principles of the second look procedure are to assess wound progression, further reduce the risk of infection and plan definitive reconstruction with adequate soft tissue cover. The prerequisites for successful surgical reconstruction are a stable patient, combined orthoplastic surgery expertise supported by physiotherapists and hand therapists.

Case Report and Review of Paracoccus yeei - A Novel Cause of Peritoneal Dialysis Peritonitis in the United Kingdom.

Peritoneal dialysis (PD) peritonitis poses a significant healthcare problem. Most cases are caused by Gram-positive organisms. Newer molecular diagnostic techniques have now enabled identification of previously unrecognized organisms, fully characterizing disease. We present the first case of Paracoccus yeei PD peritonitis reported in the United Kingdom (UK). A 70-year-old woman with chronic renal failure requiring PD presented with abdominal pain and cloudy dialysate. She was systemically well, with a normal white cell count and elevated C-reactive protein at 176. PD fluid was remarkable for 4495 polymorphonuclear leukocytes, 107 monocytes, and 10 red blood cells/cm3. No organisms were seen on microscopy. She was diagnosed with PD peritonitis and treated empirically with intraperitoneal vancomycin and oral levofloxacin. After two days, small, nonhemolytic gray-white colonies grew on blood agar. Gram stain of culture showed Gram-negative cocco-bacilli with O-shaped morphology. Phenotypic identification using matrix-assisted laser desorption ionization-time of flight mass spectrometry (Biomerieux) identified P. yeei (identification probability 99.9%). The isolate was sent to the reference laboratory for confirmation and antimicrobial susceptibility testing (AST). At present, there are no European Committee on Antimicrobial Susceptibility Testing (EUCAST) clinical breakpoints to guide AST. Proposed minimum inhibitory concentration (MIC) values were determined using broth dilution method interpreted using EUCAST nonspecies-specific PK-PD breakpoints (where available). The isolate was reported as sensitive to quinolones (ciprofloxacin MIC 0.25 mg/L), piperacillin-tazobactam (MIC 2 mg/L), and meropenem (MIC 0.008 mg/L). P. yeei is an aerobic environmental organism found in soil. It has been associated with PD peritonitis in immunosuppressed patients, although this is the first case in the UK. It is possible that true burden of disease is under-represented, and novel molecular techniques have now enabled identification of this previously unknown organism. In this case, her dog could be a potential source, and good hand hygiene may prevent further infections.

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine.

The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.