The use of immunosuppressive agents in the management of recalcitrant lower limb ulcers

OBJECTIVE

Lower limb ulcers that are resistant to standard forms of treatment place a significant burden on both patients and health services. There is no widely agreed definition of a recalcitrant ulcer but failure to heal following 6-12 months of focused treatment would identify a small group of patients with highly resistant ulceration. We describe a series of patients with recalcitrant ulceration for which immunosuppressive agents have been used.

METHODS

This is a case series of 13 patients who underwent immunomodulation therapy for lower limb ulcers at a tertiary referral university hospital. Regimens of immunomodulation used mainly ciclosporin and/or cyclophosphamide, with concurrent antibiotic therapy. Case notes and computer systems were analysed by two reviewers. A patient was deemed to have a success if their ulcer fully healed while on immunomodulation therapy.

RESULTS

Over a period of eight years, from 2004-2012, 13 patients underwent immunomodulation therapy. Among these patients there were 18 ulcerated limbs. Ulcer healing occurred in 10 limbs out of 18 (55.6%) and full healing occurred in six patients (46.2%). Ulcers were present for a median of five years (range 2-40 years), with a median diameter of 7.5 cm (range 4-18 cm) before treatment.

CONCLUSION

Treatment of truly recalcitrant ulceration can be very frustrating for both the patient and physician, with poor success from more standard forms of treatment. We report experience with immunomodulation therapy that suggests there may be benefit from using this treatment in a subset of patients with this debilitating disease.

The Lost Opportunities for Surgical Training in the NHS

Surgery is a craft specialty based on gaining sufficient operating theatre experience. The European Working Time Directive was introduced in 1998 to protect the health and safety of employees. However, the progressive reduction in the hours available for surgical training combined with full-shift working patterns have raised fears that we will produce less experienced surgeons in the future.

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review

OBJECTIVES

To determine whether a reduction in working hours of doctors in postgraduate medical training has had an effect on objective measures of medical education and clinical outcome.

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, ISI Web of Science, Google Scholar, ERIC, and SIGLE were searched without language restriction for articles published between 1990 and December 2010. Reference lists and citations of selected articles.

STUDY SELECTION

Studies that assessed the impact of a change in duty hours using any objective measure of outcome related to postgraduate medical training, patient safety, or clinical outcome. Any study design was eligible for inclusion.

RESULTS

72 studies were eligible for inclusion: 38 reporting training outcomes, 31 reporting outcomes in patients, and three reporting both. A reduction in working hours from greater than 80 hours a week (in accordance with US recommendations) does not seem to have adversely affected patient safety and has had limited effect on postgraduate training. Reports on the impact of European legislation limiting working hours to less than 56 or 48 a week are of poor quality and have conflicting results, meaning that firm conclusions cannot be made.

CONCLUSIONS

Reducing working hours to less than 80 a week has not adversely affected outcomes in patient or postgraduate training in the US. The impact of reducing hours to less than 56 or 48 a week in the UK has not yet been sufficiently evaluated in high quality studies. Further work is required, particularly in the European Union, using large multicentre evaluations of the impact of duty hours' legislation on objective educational and clinical outcomes.

Analysis of 100 cases of missing IUD strings

In a study of 100 patients with missing IUD strings 69 women had their IUD in utero (4 were pregnant) and 17 had unnoticed expulsions (4 pregnancies); 9 devices were in the peritoneal cavity and one had perforated the cervix. Since the IUD was in the uterine cavity in the majority of these cases, most contraceptors whose IUD strings disappear can be managed in the office or clinic with relatively simple techniques to locate and remove the device.

Accidental insertion of multiple IUDs

Data are presented for 7 women, each having two IUDs in utero. Five of these patients developed symptoms of abnormal bleeding and/or pelvic pain and 2 were asymptomatic. Three women had received the second IUD because it was assumed the first one had been expelled when the filaments were no longer palpable or visible. Other causes, as well as the prevention, diagnosis, and potential danger of this complication, are discussed.