Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience.

PURPOSE: Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization. METHODS: Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health. RESULTS: Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications. CONCLUSIONS: Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.

Analysis of Plastic Surgery Consultations in a High-Volume Paediatric Emergency Department: A Quality Improvement Initiative.

INTRODUCTION: Consult services influence emergency department (ED) workflow. Prolonged ED length of stay (LOS) correlates with ED overcrowding and as a consequence decreased quality of care and satisfaction of health team professionals. To improve management of paediatric ED patients requiring plastic and reconstructive surgery (PRS) expertise, current processes were analyzed. METHODS: Patient characteristics and metrics of PRS consultations in our paediatric ED were collected over a 3-month period. Data analysis was followed by feedback education intervention to ED and PRS staff. Data collection was then resumed and results were compared to the pre-intervention period. RESULTS: One hundred ninety-eight PRS consultations were reviewed, mean patient age was 6.3 years. Most common (52%) diagnoses were burns and hand trauma; 81% of PRS referrals were deemed appropriate; 25% of PRS consults were requested after hour with no differences in patient characteristics compared to regular hours; 60% of consultations involved interventions in the ED. Time between ED registration and PRS consultation request (116.5 minutes), quality of procedural sedation (52% rated inadequate), and overall ED LOS (289.2 minutes) were identified as main areas of concern and addressed during feedback education intervention. Emergency department LOS and quality of sedation did not improve in the post-intervention period. CONCLUSION: The study provides detailed insights in the characteristics of PRS consultation in the paediatric ED population. Despite high referral appropriateness and education feedback intervention, significant inefficiencies were identified that call for further collaborative efforts to optimize quality of care for paediatric ED patients and improve satisfaction of involved healthcare professionals.

INTRODUCTION: Les services de consultation ont une influence sur le cheminement à l'urgence. Une durée de séjour prolongée à l'urgence est corrélée avec le surpeuplement de l'urgence et, par conséquent, une diminution de la qualité des soins et de la satisfaction des équipes de professionnels de la santé. Pour améliorer la prise en charge des patients à l'urgence pédiatrique qui ont besoin de compétences en chirurgie plastique et reconstructive (CPR), les chercheurs ont analysé les processus actuels. MÉTHODOLOGIE: Les chercheurs ont colligé les caractéristiques des patients et les mesures des consultations en CPR dans une urgence pédiatrique sur une période de trois mois. Ils ont suivi l'analyse des données d'une intervention de rétroaction au personnel de l'urgence et de la CPR. Par la suite, ils ont repris la collecte de données pendant trois mois et l'ont comparée à la période précédant l'intervention. RÉSULTATS: Les chercheurs ont examiné 198 consultations en CPR, chez des patients d'un âge moyen de 6,3 ans. Les diagnostics les plus courants (52 %) étaient les brûlures et les traumatismes de la main. Les chercheurs ont considéré 81 % des orientations en CPR comme appropriées. Ils ont constaté que 25 % des consultations en CPR ont été demandées après les heures de travail, sans que les caractéristiques de patients soient différentes de celles demandées pendant les heures normales. Ils ont remarqué que 60 % des consultations étaient liées à des interventions à l'urgence. Ils ont déterminé que le délai entre l'inscription à l'urgence et la demande de consultation en CPR (116,5 minutes), la qualité de la sédation lors de l'intervention (52 % étaient classées comme inappropriées) et la durée globale du séjour à l'urgence (289,2 minutes) étaient les points les plus préoccupants et ont été abordés lors de l'intervention de rétroaction. La durée du séjour à l'urgence et la qualité de la sédation ne se sont pas améliorées après l'intervention. CONCLUSION: L'étude fournit des points de vue détaillés des caractéristiques de la consultation en CPR au sein de la population à l'urgence pédiatrique. Malgré le taux élevé d'orientations appropriées et l'intervention de rétroaction, les chercheurs ont constaté d'importantes inefficacités qui justifient plus d'efforts de collaboration pour optimiser la qualité des soins auprès des patients à l'urgence pédiatrique et pour accroître la satisfaction des professionnels de la santé en cause.

Acute lumbar paraspinal compartment syndrome: a systematic review.

While still a rare entity, acute lumbar paraspinal compartment syndrome has an increasing incidence. Similar to other compartment syndromes, acute lumbar paraspinal compartment syndrome is defined by raised pressure within a closed fibro-osseous space, limiting tissue perfusion within that space. The resultant tissue ischaemia presents as acute pain, and if left untreated, it may result in permanent tissue damage. A literature search of 'paraspinal compartment syndrome' revealed 21 articles. The details from a case encountered by the authors are also included. A common data set was extracted, focusing on demographics, aetiology, clinical features, management and outcomes. There are 23 reported cases of acute compartment syndrome. These are typically caused by weight-lifting exercises, but may also result from other exercises, direct trauma or non-spinal surgery. Pain, tenderness and paraspinal paraesthesia are key clinical findings. Serum creatine kinase, magnetic resonance imaging and intracompartment pressure measurement confirm the diagnosis. Half of the reported cases have been managed with surgical fasciotomy, and these patients have all had good outcomes relative to those managed with conservative measures with or without hyperbaric oxygen therapy. These good outcomes were despite significant delays to operative intervention. The diagnostic uncertainty and subsequent delay to fasciotomy result from the rarity of this disease entity, and a high level of suspicion is recommended in the appropriate setting. This is particularly true in light of the current popularity of extreme weight lifting in non-professional athletes. Operative intervention is strongly recommended in all cases based on the available evidence.

Mandibular phosphaturic mesenchymal tumor-mixed connective tissue variant in a young girl.

Phosphaturic mesenchymal tumor-mixed connective tissue variant (PMTMCT) is an extremely rare tumor associated with tumor-induced osteomalacia. The majority occur in middle age and arise from the extremities. This report describes a young girl with PMTMCT arising in the mandible and with no evidence of paraneoplastic syndrome.

The keystone flap: not an advance, just a stretch.

BACKGROUND: The keystone flap is being promoted as an advance in oncological surgical reconstruction. Wound closure with this island flap involves two V-Y advancements toward the center and along the long axis of the island, at right angles to the line of maximum tension when the wound is closed. It is implied that the long-axis advancements enable closure by relaxing the entire flap of skin, allowing it to be stretched more easily along the short axis. We undertook a study to test this hypothesis. METHODS: We measured tension and extension along perpendicular axes in nine freshly excised specimens of human skin. We held the longitudinal axis fixed while stretching the skin along the transverse axis. We then released the longitudinal axis and measured the resultant drop in transverse tension. Finally, we increased the transverse tension to approximately its previous level, and measured the new transverse extension. RESULTS: There was significant interdependence between longitudinal and transverse tensions. The fall in transverse wound tension associated with longitudinal release varied with starting tensions and with the original site and orientation of the specimen. In the five cases where the longitudinal release was from the in vivo length, the mean increase in transverse stretch attributable to the release was 0.6 mm (95% confidence interval 0.1-1.1 mm). DISCUSSION: The increase in transverse stretch that can be achieved by releasing skin from its longitudinal in vivo length appears trivial, raising questions about the rationale for the use of the prototypical (type 1) keystone flap in wound closure.

DNA polymorphisms and renal disease: a critical appraisal of studies presented at the annual ERA/EDTA and ASN conferences in 2004 and 2005.

Countless studies try to associate single DNA polymorphisms with disease, while there is growing evidence that many of these studies are of flawed design. Based on the Journal of the American Society of Nephrology (JASN) requirements for gene-disease association study quality, the abstracts presented at the two major international nephrology conferences in 2004 and 2005 organized by the European Renal Association/European Dialysis and Transplantation Association (ERA/EDTA) and American Society of Nephrology (ASN) are analysed to show how this problem affects nephrology. Over time, average sample numbers have increased, as have the numbers of abstracts compliant with the JASN requirements. This indicates a potential beneficial effect of the published stricter guidelines on study quality. Alternative options include pre-registration of studies in dedicated databases, secondary assessment of association studies through meta-analysis and participation in network approaches, such as the Human Genome Epidemiology Network (HuGE Net) and the Renal Genome Network.