Seat belt breast injury: a reconstructive approach to managing unilateral bisected breast deformity.

Seat belt breast deformity can result in significant aesthetic, functional and psychosocial sequelae. Although seat belt breast deformity is well documented, there is a lack of literature describing their reconstructive management. We describe the surgical management of a 63-year-old woman presenting with stage 2b seat belt breast deformity, who underwent scar revision, repositioning of the nipple-areola complex and contralateral breast reduction using Wise-pattern incisions based on superior pedicles. She made an excellent recovery with an improved aesthetic result.

Acute horseshoe abscess of the hand after corticosteroid injection to treat trigger thumb.

Local corticosteroid injections are frequently used in the management of trigger finger. We present a case of a 56-year-old woman who developed an acute horseshoe abscess of the hand after injection of corticosteroid and local anaesthetic into the left thumb. This was managed successfully with intravenous antibiotics, operative intervention and early mobilisation. This case highlights the possible complications that can occur with such a minimally invasive procedure. The pathophysiology behind this condition is explained by communication between the radial and ulnar bursae. Knowledge of the anatomy of the hand and its variants is therefore essential to assist in diagnosis. Prompt clinical diagnosis and surgical management is required to avoid disastrous complications.

High risk device registries: Global value, costs, and sustainable funding.

BACKGROUND: Well-designed implant registries have been shown to be a worthwhile investment, from both a health and economic perspective. However, many registries do not attain desirable capture rates or lack sufficient funding, potentially leading to premature termination. This study aims to provide information about rarely discussed, yet pivotal topics regarding the long-term survival of implant registries, focusing on costs, funding models, and the role of stakeholders. METHODS: Worldwide, relatively recently developed breast device (BD) registries were compared to long-standing, orthopaedic (OD) and cardiovascular device (CD) registries. A standardised questionnaire was sent to the registries' designated representatives with key positions, discussing start-up costs, costs of maintenance, value of investment, governance, stakeholders, funding, and sustainability. RESULTS: Thirteen registries were included, originating from nine countries (seven BD registries, five OD registries, one CD registry). In general, start-up costs were comparable, and younger registries were more expensive to maintain. Numerous stakeholders showed interest in registry outcomes. However, only 50% of the registries reported a sustainable funding structure. CONCLUSION: This study provides a global perspective on implantable device registries. All registries provided important information, serving three unique purposes by evaluating the quality of healthcare provided, the quality of all registered devices, and processing recall information. Yet, only half of the registries were certain of sustainable funding, and thus their future existence. It is of utmost importance to bring this to the attention of all parties involved.

Secondary Merkel Cell Carcinoma Arising From a Graft Donor Site.

Merkel cell carcinoma (MCC) is a highly aggressive cutaneous neuroendocrine tumour that is increasing in incidence. We report a case of a 92-year-old white man on long-term immunosuppression for temporal arteritis who presented with a Merkel cell tumour on his left cheek. A wide local excision was performed and the defect was reconstructed with a full-thickness skin graft. Four years later, the patient re-presented with a Merkel cell tumour arising from the right supraclavicular donor site. To our knowledge, this is the first report of a recurrence of MCC into a donor site. This has important implications as a reminder of planning fresh surgical instruments and needle inoculation for reconstruction if there is any clinical suspicion of MCC to prevent iatrogenic spread.

International importance of robust breast device registries.

BACKGROUND: Breast implants are high-risk devices that have been at the epicenter of much debate and controversy. In light of the Poly Implant Prothèse crisis, data registries among 11 national societies around the world are cooperatively calling for the urgent need to establish robust national clinical quality registries based on international best practice within a framework of international collaboration. METHODS: A survey was conducted on the historic and current status of national breast device registries. Eleven countries participated in the study, illustrating different data collection systems and registries around the world. Data collection was designed to illustrate the capabilities of current national registries, with particular focus on capture rate and outcome reporting mechanisms. RESULTS: A study of national breast implant registries revealed that less than half of the participating countries had operational registries and that none of these had adequately high data capture to enable reliable outcome analysis. The study revealed that the two most common problems that discouraged participation are the complexity of data sets and the opt-in consent model. CONCLUSIONS: Recent implant crises have highlighted the need for robust registries. This article argues the importance of securing at least 90 percent data capture, which is achievable through the opt-out consent model. Since adopting this model, the Australian Breast Device Registry has increased data capture from 4 percent to over 97 percent. Simultaneously, it is important to foster international collaboration from the outset to avoid duplication of efforts and enable the development of effective international early warning systems.

Morbidity in pediatric burns, toxic shock syndrome, and antibiotic prophylaxis: a retrospective comparative study.

The prophylactic use of antibiotic for pediatric burns has been suggested as a possible means of reduction of toxic shock syndrome. In our study, we review 1250 burn cases during a 16-year period (1983-1999). There was a change in protocol during this period (after 1991, all pediatric burn received prophylactic antibiotics irrespective of presentation), thus creating 2 groups: our control who received antibiotics when clinically necessary and our cases who received antibiotics as routine prophylaxis. Our results show no statistical difference between the 2 groups both in signs of morbidity and signs of potential toxic shock syndrome. We conclude that prophylactic antibiotic use is unnecessary and the use of antibiotics should be guided on a case by case basis according to symptoms.

Cold finger: urban frostbite in the UK.

A 24-year-old man, presented to the accident and emergency (A&E) department 48 h after a social evening where excess alcohol had been consumed. He had fallen asleep outside then made a visit to the A&E department once his finger became painful. His diagnosis was frostbite.

Further evidence for treatment of recalcitrant neuropathy of the upper limb with autologous vein wrapping.

The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not uncommon, and its management is both challenging and difficult. Autologous vein graft wrapping is an alternative technique, and it is recommended for the treatment of recalcitrant upper limb nerve compression in which 2 or more previous surgical procedures have failed to resolve the problem. Each patient underwent both subjective and objective evaluation. To our knowledge, this is the largest reported single series of vein wrapping cases in the upper limb outside the United States and the first to report results using the well-validated patient evaluation measure.

Progress toward optical biopsy: bringing the microscope to the patient.

The investigation of many lung diseases currently requires bronchoscopic or surgical histopathological tissue biopsy. This creates risks for patients and entails processing costs and delays in diagnosis. However, several mainly probe-based biophotonic techniques that can image solitary lesions and diffuse lung diseases are fuelling a paradigm shift toward real-time in vivo diagnosis. Optical coherence tomography (OCT) uses near-infrared light in a process analogous to ultrasonography to image the mucosal and submucosal tissue boundaries of the bronchial tree. With 15-µm resolution, early work suggests it can differentiate between neoplasia, carcinoma in situ, dysplasia, and metaplasia based around epithelial thickness and breaches in the basement membrane. Probe-based confocal laser endomicroscopy (pCLE) has superior resolution but less penetration than OCT and employs blue argon laser light to fluoresce the endogenous elastin of (1) the acinar scaffold of the peripheral lung and (2) the basement membrane lying under bronchial mucosa. Initial studies suggest that the regular fibre arrangement of the basement membrane is altered in the presence of overlying malignant epithelium. pCLE produces detailed representations of the alveolar septal walls, microvessels, and some inflammatory cells. A third device, the endocytoscope, is a contact microscope requiring contrast agent to provide subcellular resolution of bronchial mucosa. Further development of these "optical biopsy" techniques and evaluation of diagnostic sensitivity and specificity of the acquired images are needed before they can be considered effective methods for eliminating the need for, and thus risks of, pinch biopsy to enable real-time diagnosis to streamline management.

Surprise met in minor ops.

The case of a woman who was initially diagnosed as having a sebaceous cyst but who died from metastatic lung carcinoma 2 weeks after her initial 'minor op' procedure. Minor surgical procedures are increasingly being performed by specialist nurses and by general practitioners in primary care. However, such non-experts may lack the resources to cope with surprises such as was found in this case. It is, therefore, imperative that adequate training and support is provided as the model of care changes.