Targeted high concentration botulinum toxin A injections in patients with Raynaud's phenomenon: a retrospective single-centre experience.

Raynaud's phenomenon is a vasospastic condition affecting hands and feet which may lead to rest pain, ischemic ulcers and gangrene. Botulinum toxin A has been shown to improve peripheral circulation and relieve vasospastic symptoms. Our aim was to assess our treatment outcomes following Botulinum toxin A injections in patients with Raynaud's phenomenon and to explore the importance of toxin concentration and injection sites. Retrospective chart review of patients with primary and secondary Raynaud's syndrome treated with Botulinum toxin A injections and a literature review was conducted. The toxin dose, injection sites, symptom relief, healing of ulcers and complications were assessed. A total of 30 treatment episodes over a 7½ year period were included. All patients had failed medical management. Botulinum toxin A injection was injected primarily in the vicinity of the palmar digital neurovascular bundle. The average total Botulinum toxin A dose injected was 156 U and the concentration was 50 U/ml. All patients reported an improvement in symptoms and healing of digital ulcers. One patient reported a temporary muscle weakness. Six patients had a single treatment episode with long term benefit. Systemic sclerosis patients had an average of 6-month interval between treatment episodes. Higher doses of Botulinum toxin A has been well tolerated with no long term adverse effects. Our study shows that targeted low volume higher concentration Botulinum toxin A injections are effective in treating Raynaud's phenomenon.

The Epidemiology of Scapholunate Advanced Collapse.

Background: Scapholunate advanced collapse (SLAC) is the most common pattern of wrist arthritis. Sparse data exist regarding the SLAC wrist pattern of arthritis. This study aimed to document the epidemiology of advanced SLAC in terms of patients' sociodemographics and possible association with trauma. Methods: Sixty-one patients with severe SLAC wrist were included. Baseline sociodemographic characteristics were reviewed. To evaluate the relationship to injury, this group of cases was compared with a control group of 61 patients with first carpometacarpal osteoarthritis (CMC OA). The following data were collected for both groups: age, gender, history of traumatic injury, history of manual labor, duration of symptoms, and dominant hand involvement. Pearson chi-square tests for categorical variables and independent samples t test for continuous variables were performed to determine differences between groups. Results: Patients with SLAC wrist were more likely to be male (80.3% vs 31.1%; p<0.001), have a history of a traumatic injury (69.5% vs 25.9%, P < .001), have longer symptom duration (10.3 ± 13.3 vs 3.5 ± 2.5 years, P = .001), be involved in a manual labor job (49.0% vs 20.0%, P = .002), and be younger (53.1 ± 10.4 vs 58.3 ± 9.8; P = .006) compared with patients with CMC OA. There was no difference in dominant hand involvement (49.2% vs 53.3%; P = .571) between the groups. Conclusions: This study identified the characteristics of patients with advanced SLAC wrist. Compared with a control cohort of CMC OA, patients with SLAC wrist were more likely to be male, have a history of a traumatic injury, and be younger.

Data from national media reports of 'Acid attacks' in England: A new piece in the Jigsaw.

INTRODUCTION: There has been considerable concern in the UK with what seems to have been an increase in so-called 'Acid Attacks'. The key data sources (Police data, Hospital admissions and Burns unit data) have limitations in capturing the acid attacks comprehensively. Incidents not reported to the police are missed in the Police data. The more serious injuries are included in the hospital admissions data, with no information on people with less severe injuries, not accessing health care. Burns unit data reveals detailed information on the burns treatment but represents only a small percent of all the acid attacks. Our aim was to explore the role of media reports as an additional data source. METHODS: Data was obtained from the public domain using generic online search engines along with a formal medical literature review. Search parameters included any news articles on 'Acid Attacks' printed between 01/01/2016 and 31/12/2017 in England and Articles in National Press only. We compared the data from media reports to the only other data sources available on these crimes which were (a) Crime statistics from police (b) the proportion treated in hospital (c) the subgroup treated in the burns service in the highest incidence location in the UK. RESULTS: Two hundred and Thirty media articles in total were found in the preliminary search. Following the application of the exclusion criteria, sixty attacks were analysed. The demographic data, the geographic data were obtained from the articles and the results were analysed using Microsoft Excel. There were a total of 118 survivors with an average age of 29.5 years and a male to female ratio of 5.1:1. There were no reported deaths. In the assailants group, the average age was 21.6 years with a male to female ratio of 15.7:1. All the data sources revealed higher male survivor predominance. The average age of the survivors was similar in the media reports, police data and the Burns centre data and was higher in the hospital data. Information on assailants and motives, available only on media reports and police data, corroborated well with each other. Media reports gave further information on the circumstances of the incident, the location and the number of survivors per assault, which was not available on any other data source. Though there was a rise in chemical assaults reported in media reports and MPS data in 2017 compared to the previous year, there was no rise in chemical assault related hospital admissions. CONCLUSION: The majority of the survivors were males, which is consistent between all UK data sources. Media reports revealed that the South east of England had the majority of chemical assaults in England. Data from this source provides a further piece in the jigsaw especially in relation to the circumstances, the geographic location of the chemical assault and number of survivors per incident. We acknowledge the limitations of media reporting. In the absence of a formal database for such injuries and incomplete data from various sources, we have to consider all possible data sources to provide new information. We have discussed the utility, pros & cons of media reports as one of the additional sources of information to better understand these injuries.

Inferiorly based lotus petal flap & laser therapy in difficult pilonidal sinus management.

AIM: To assess the efficacy of the lotus petal flap in difficult pilonidal sinus management. BACKGROUND: Pilonidal sinuses may be difficult to treat. Five year recurrence rates range from 18% to 50% Recurrence rates fall with primary closure rather than healing by secondary intention. Techniques such as z-plasty however, distort natal architecture. The lotus petal flap taken from the superior buttock fills dead space whilst conforming to the natural concave appearance of the natal cleft. The contralateral buttock is spared. It is straightforward and reproducible. Multiple perforators make it robust and promote wound healing in this difficult group. METHOD: We present a series of 14 patients who had a lotus petal flap reconstruction following pilonidal sinus excision between 2007 and 2015. The majority of these patients had previous multiple failed attempts at eradication. Recurrence rates, re-operation rates, time for complete healing, wound breakdown, discharge, infection, cosmesis and patient comfort were assessed. RESULTS: Many patients had coarse hair; felt to predispose to recurrence of symptoms, poor hygiene and prolonged wound healing. 50% of patients underwent Alexandrite laser (755 nm wavelength) for a minimum of 6 treatments. There was excellent compliance and good patient outcome. Overall in this complex patient group only 14% had prolonged wound healing and recurrence rates were lower than those in the literature. CONCLUSION: The lotus petal flap is an excellent choice for problematic pilonidal sinus reconstruction. When combined with tumour like excision, meticulous surgical technique and complimentary laser hair removal results can be improved further.