Undressing the choice of dressings.

There is a vast number of wound dressings to choose from, which can make selecting the most suitable dressing for a wound a daunting prospect. This article highlights how the wound can guide the doctor's decision. Although all wound dressings are intended to achieve optimal wound healing and protection from contamination, they do so to varying degrees depending on the qualities of the dressing and the wound itself. This article looks at a range of dressings, from traditional to newer dressings, and evaluates their benefits and contraindications to help determine where they are best suited for use in wound management.

Adverse events of local treatment in long-term head and neck rhabdomyosarcoma survivors after external beam radiotherapy or AMORE treatment.

BACKGROUND: Radiotherapy is a well-known cause of adverse events (AEs). To reduce AEs, an innovative local treatment was developed in Amsterdam: Ablative surgery, MOuld brachytherapy and surgical REconstruction (AMORE). AIMS: (1) to determine the prevalence of AEs in HNRMS survivors and (2) to compare AEs between survivors treated with the international standard: external beam radiotherapy (EBRT-based: London) and survivors treated with AMORE if feasible, otherwise EBRT (AMORE-based: Amsterdam). METHODS: All HNRMS survivors, treated in London or Amsterdam between January 1990 and December 2010 (n = 153), and alive ⩾ 2 years post-treatment were eligible (n = 113). A predefined list of AEs was assessed in a multidisciplinary clinic and graded according to the Common Terminology Criteria for Adverse Events. RESULTS: Eighty HNRMS survivors attended the clinic (median follow-up 10.5 years); 63% experienced ⩾ 1 severe or disabling event, and 76% had ⩾ 5 AEs (any grade). Survivors with EBRT-based treatment were, after adjustment for site, age at diagnosis, and follow-up duration, at increased risk to develop any grade 3/4 event or ⩾ 5 AEs (any grade) compared with survivors with AMORE-based treatments (p = 0.032 and 0.01, respectively). Five year overall survival (source population) after EBRT-based treatment was 75.0%, after AMORE-based treatment 76.9%, p = 0.56. CONCLUSION: This study may serve as a baseline inventory and can be used in future studies for prospective assessments of AEs following the introduction of novel local treatment modalities. AMORE-based local treatment resulted in similar overall survival and a reduction of AEs secondary to local treatment.

Toxic epidermal necrolysis (TEN): the Chelsea and Westminster Hospital wound management algorithm.

Toxic epidermal necrolysis syndrome (TEN) is a potentially catastrophic exfoliative muco-cutaneous disorder first described by Lyell in 1956. It represents the most extensive form of Steven-Johnson syndrome. TEN is defined varyingly around the globe, but in the United Kingdom the consensus opinion describes the process as involving >30% of the total body surface area. It can rapidly become more extensive and threatens life. The estimated annual incidence is approximately 1-2 cases per million population. The risk of mortality increases with surface area involved and meta-analysis of the literature shows this risk to be between 16% and 55%. Over a six month period the Chelsea and Westminster Hospital Burns Service treated five consecutive patients with more than 80% total body surface area involvement or a more than 80% mortality risk, using the severity-of-illness score for toxic epidermal necrolysis (SCORTEN). All patients were treated according to the Chelsea and Westminster Hospital wound management algorithm with excellent outcome and no mortalities. The aim of this paper is to propose a generic TEN wound management algorithm according to the severity of skin lesions, using a simple wound grading system.

Prospective randomized controlled trial: fibrin sealant reduces split skin graft donor-site pain.

BACKGROUND: Pain at split skin graft donor sites is common. Fibrin sealant has been demonstrated to reduce time to hemostasis at wound sites, and patients receiving this treatment were incidentally noted to report less pain. This study aimed to evaluate pain and incapacity in split skin graft donor sites treated with and without fibrin sealant. METHODS: Fifty patients requiring thigh donor-site split skin grafts were prospectively randomized to receive either a self-adhesive fabric dressing alone or fibrin sealant plus the self-adhesive fabric dressing as primary donor-site dressings. External secondary dressings were the same. Patients were blinded with regard to treatment group. Using visual analogue scales (scored 0 to 5), patients rated their donor-site pain and incapacity for 14 days postoperatively. Secondary endpoints were length of hospital stay and duration of requirement for dressings. RESULTS: Forty patients were included in the study analysis and completed self-reported pain and incapacity scores. Twenty received the fibrin sealant plus self-adhesive fabric dressing and 20 received the fabric dressing only (controls). Patients using the fibrin sealant plus the dressing reported significantly less pain (mean score, 0.42 versus 1.60, p < 0.001) and significantly less incapacity (mean score, 0.48 versus 1.71, p < 0.001). Patients allocated to the fibrin sealant group recorded shorter lengths of stay and faster time to discontinuation of dressing, though statistical significance was not achieved. CONCLUSION: Patients whose split skin graft donor sites were dressed with fibrin sealant plus self-adhesive fabric dressing experienced significantly less pain and incapacity than patients with self-adhesive fabric dressings alone, allowing a more rapid return to normal activity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Correcting the typical Apert face: combining bipartition with monobloc distraction.

BACKGROUND: Bipartition distraction is a novel procedure combining frontofacial bipartition and monobloc distraction. Apert syndrome and other syndromic craniofacial dysostoses are often characterized by hypertelorism, with a negative canthal axis and counterrotated orbits. Central midface hypoplasia can result in a biconcave face in both midsagittal and axial planes. Bipartition distraction can correct these facial abnormalities. METHODS: Twenty patients (19 Apert syndrome patients and one Pfeiffer syndrome patient, aged 1.6 to 21 years) underwent bipartition distraction. Severity of appearance was graded preoperatively and postoperatively as mild, moderate, or severe. Functional problems were documented by a multidisciplinary team. Central and lateral midface skeletal advancement were measured. Follow-up ranged from 15 months to 7 years. RESULTS: Bipartition distraction consistently produced more central than lateral facial advancement. Mean central advancement was 13.2 ± 5.9 mm at sella-nasion and 11.7 ± 5.4 mm at sella-A point. Lateral advancement was 4.7 ± 2.8 mm. Unbending the face improved aesthetic appearance. Airway function, eye exposure, and elevated intracranial pressure were improved. Complications included six temporary cerebrospinal fluid leaks (four needing a lumbar drain), five patients with postoperative seizures, five patients requiring Rigid External Distraction frame repositioning, one palatal fistula, one velopharyngeal incompetence, five pin-site infections, one abscess under frontal bone, three cases of sepsis, nine patients with worsened strabismus, two patients with enophthalmos, one patient with partial visual field loss, and three patients who required reintubation because of aspiration. CONCLUSIONS: : Bipartition distraction is an effective procedure with which to differentially advance the central face in Apert syndrome. It improves both function and aesthetics. CLINICAL QUESTION/LEVEL OF EVIDENCE: : Therapeutic, IV.

Complications of frontofacial advancement.

PURPOSE: The purpose of this study was to document the early and late complications associated with frontofacial distraction. METHOD: A systematic review of the literature on complications in craniofacial surgery and a review of records of patients undergoing frontofacial distraction at Great Ormond Street Hospital for Children over a 10-year period were conducted. RESULTS: Complications arising from frontofacial advancement are common. Mortality rates varied between 0 and 4.5 %. There has been a general decline in reported mortality rates with time, and the most recent series report mortalities of less than 1 %. The incidence of significant blood loss (greater than one blood volume) in patients undergoing monobloc osteotomy varied between 5.3 and 9.1 %. CSF leaks following monobloc distraction are common (incidence, 2-20 %). Most of these leaks settle spontaneously. The incidence of frontal bone flap necrosis requiring debridement and a subsequent cranioplasty varied between 3 and 20 %. CONCLUSIONS: The functional and aesthetic benefits of frontofacial distraction are well documented, but these advantages are associated with a significant complication rate. The potential benefits of frontofacial distraction need to be carefully weighed against the potential complications when deciding to recommend surgery.

A multidisciplinary approach to post-bariatric plastic surgery.

Social changes over the last 100 years, but predominantly since the invention of 'fast food' have led to an explosion in obesity. The National Institute for Clinical Excellence advise referral of patients with body mass indices >40 for bariatric surgery. One third of post-bariatric surgery patients achieve massive weight loss necessitating reconstructive body contour surgery. This unique group of patients presents multiple challenges for medical and ancillary practitioners involved in their care. A multidisciplinary approach is essential.

"Asthma": an unusual presentation of cor triatriatum.

We discuss an extremely unusual presentation of a 19-month-old child with cor triatriatum and an intact interatrial septum, who presented for the first time at the age of 16 months with wheezing and repeated lower respiratory tract infections. At surgery, a thick fibromuscular membrane with a 2-3 mm eccentrically placed orifice was identified, and following surgical resection of the membrane the child made an uneventful recovery. This case demonstrates the need for investigating children with "asthma" who do not respond to conventional medical management. A rare but potentially correctable underlying cause may be found.

Pyoderma gangrenosum--case report.

We report the case of a woman of 34 years who had ulcerative colitis and atypical pyoderma gangrenosum. The pyoderma gangrenosum responded to conservative treatment.

Clinical implications of ischaemia-reperfusion injury.

Ischaemia-reperfusion injury (IRI) is a complex interplay between biochemical, cellular, and vascular endothelial factors. The clinical sequelae are organ specific, and may also involve systemic inflammatory responses. In this article, we outline an overview of the pathophysiology of IRI, with direct reference to histological and physiological changes seen in individual organs, and present the data on experimental methods of prevention.