Carbon dioxide laser for precise and bloodless contouring of soft tissue ahead of skin grafting-A case example of technique and benefits

Scarring is a dynamic development as a result of the wound healing process. Post-burn scars are often hypertrophic in nature and thus exhibit a much thicker and firmer scar, often leading to contractures. Various strategies have been implemented by burns surgeons to endeavour to mitigate and improve such symptoms and appearances. Laser therapy in the control of hypertrophic scarring is of continual developing interest within this field. We demonstrate the advantageous, intra-operative use of a carbon dioxide laser for precise contouring of a burn scar prior to skin grafting in a 36 year-old female with hypertrophic scarring following a 65% total body surface area flash flame burn. This method provided a bloodless surgical field with no post-operative complications, good graft take and a favourable cosmetic outcome.

Ten-Year Analysis of Bacterial Colonisation and Outcomes of Major Burn Patients with a Focus on Pseudomonas aeruginosa

A retrospective descriptive study included patients admitted with severe burns over the course of 10 years (2008-2018). Across all patients, there were 39 different species of bacteria, with 23 species being Gram-negative and 16 being Gram-positive bacteria, with also five different species of fungi cultured. Pseudomonas aeruginosa was the most commonly isolated organism, with 57.45% of patients having a positive culture. There was a significant difference in the number of P. aeruginosa isolated from patients that acquired their burns at work, in a garden, inside a vehicle, in a garage or in a public place. In patients that were positive for P. aeruginosa, the number of operations was higher (2.4) and the length of stay was significantly increased (80.1 days). Patients that suffered from substance abuse demonstrated significantly higher numbers of isolated P. aeruginosa (14.8%). Patients that suffered from both mental health illness and substance abuse demonstrated significantly higher numbers of P. aeruginosa isolated (18.5%). In the P. aeruginosa-negative group, there were significantly fewer patients that had been involved in a clothing fire. Furthermore, in the P. aeruginosa-negative patient cohort, the mortality rate was significantly higher (p = 0.002). Since the incidence of P. aeruginosa was also associated with a decreased mortality rate, it may be that patients admitted to hospital for shorter periods of time were less likely to be colonised with P. aeruginosa. This study demonstrates novel factors that may increase the incidence of P. aeruginosa isolated from burn patients.

Review of Burn Resuscitation: Is Plasmalyte® a Comparable Alternative to Ringer's Lactate?

Ringer's lactate has been the most widely used fluid for burn resuscitation for decades. Plasmalyte® (PL), a newer balanced crystalloid, is gaining popularity for use in the critically ill, including patients with burns. This popularity is partly due to the fact that PL theoretically offers a favorable metabolic profile, but may also be attributed to its relatively lower cost. Patients who are critically ill with large burns receive enormous volumes of fluids, especially during the resuscitation period. The choice of balanced crystalloid solution used is likely to have an impact on the metabolic status of patients and their overall outcomes. The choice of fluid for burn resuscitation has been one of the most researched topics in burn care and various types of fluids have been superseded based on research findings. This narrative review examines the evidence guiding fluid management in burns and explores the data supporting the use of balanced crystalloid solutions, in particular PL for burn resuscitation. Our literature search revealed only one study that focused on a direct comparison between PL and standard Ringer's Lactate for burn resuscitation. Based on the limited literature on the use of PL in burns, it is difficult to draw meaningful conclusions. Further research, into the suitability of PL for use in burns, is needed before formulary changes are instituted widely.

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries

BACKGROUND

Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation.

METHODS

In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk.

RESULTS

A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed.

CONCLUSIONS

In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

Perspectives From a Regional Plastic Surgery Centre on Evidence for the Purported Link Between SGLT2 Inhibitors and Fournier's Gangrene

Introduction: The recent report issued by the MHRA indicating an association of Sodium glucose linked transporter type 2 (SGLT2) Inhibitors with the contraction of Fournier's Gangrene (FG), has been drawn with insufficient supporting evidence and without an adequately powered study to make any meaningful assertions or recommendations. We aimed to look specifically at the currently available dataset used to link SGLT2 Inhibitors to FG and highlight what conclusions or inferences can meaningfully be made, in particular the power of any study that would be required to make sensible conclusions.

Methods: World literature review of SGLT2 Inhibitors and FG was performed. With a subsequent 10-year review of cases of FG seen in a regional burns and plastics centre. Data was collected retrospectively from the coding department at Whiston Hospital for all patients with necrotising fasciitis. An electronic document management system was used to identify patients with FG specifically as well as their diabetes state and medication history.

Results: Seventy-eight patients were admitted with FG, of whom 32 had diabetes mellitus (DM). Of those with DM none was taking an SGLT2 Inhibitor, 17 patients were taking metformin, a further nine patients were taking a second line medication and 14 required insulin injections.

Discussions: DM is a known major risk factor for FG, which is clearly observed in our patient cohort. The risk of patients with DM developing FG is irrespective of the medication patients are taking. The current articles and reports published have little ground to claim an association between SGLT2 Inhibitors and FG and are missing the crucial message that needs to be conveyed to the public: that DM is a major risk factor for FG and patients suffering with diabetes need to be extra vigilant.

Photodynamic antimicrobial chemotherapy coupled with the use of the photosensitizers methylene blue and temoporfin as a potential novel treatment for Staphylococcus aureus in burn infections

Photodynamic antimicrobial chemotherapy (PACT) is a novel alternative antimicrobial therapy that elicits a broad mechanism of action and therefore has a low probability of generating resistance. Such properties make PACT ideally suited for utilization in localized applications such as burn wounds. The aim of this study was to determine the antimicrobial activity of MB and temoporfin against both a S. aureus isolate and a P. aeruginosa isolate in light (640 nm) and dark conditions at a range of time points (0–20 min). A Staphylococcus aureus isolate and a Pseudomonas aeruginosa isolate were treated in vitro with methylene blue (MB) and temoporfin under different conditions following exposure to light at 640 nm and in no-light (dark) conditions. Bacterial cell viability [colony-forming units (c.f.u.) ml⁻¹] was then calculated. Against P. aeruginosa, when MB was used as the photosensitizer, no phototoxic effect was observed in either light or dark conditions. After treatment with temoporfin, a reduction of less than one log (7.00×10⁷ c.f.u. ml⁻¹) was observed in the light after 20 min of exposure. However, temoporfin completely eradicated S. aureus in both light and dark conditions after 1 min (where a seven log reduction in c.f.u. ml⁻¹ was observed). Methylene blue resulted in a loss of S. aureus viability, with a two log reduction in bacterial viability (c.f.u. ml⁻¹) reported in both light and dark conditions after 20 min exposure time. Temoporfin demonstrated greater antimicrobial efficacy than MB against both the S. aureus and P. aeruginosa isolates tested. At 12.5 µM temoporfin resulted in complete eradication of S. aureus. In light of this study, further research into the validity of PACT, coupled with the photosensitizers (such as temoporfin), should be conducted in order to potentially develop alternative antimicrobial treatment regimes for burn wounds.

100 Assessing the Admission Proforma: A Multi-Cycle Audit Evaluating the Quality of Documentation of The Burnsadmission Proforma At the Regional Mersey Burn Unit

Introduction

A thoroughly completed Burns Proforma can provide vital information for the effective management of a burn and enables the sharing of information with other members of the multidisciplinary team.

Aim

We aimed to assess the quality of record-keeping of the new Burns Proforma, compared it with the previous cycle, and identified areas of improvement.

Method

Data on 76 fields on version 4.0 of the Mersey Burns Proforma was collected for 92 patients between January and February 2020. The data was compared to cycle 1of the audit collected in July 2019.

Results

Assessing the 61 comparable fields between audit cycles, 58 fields (95%) improved while 3 (5%) deteriorated. 21 fields achieved a completion rate greater than 80%. Vital information such as history, comorbidities, and drug history achieved 100% completion, up from 94%, 94%, and 95%, respectively. Total body surface area (TBSA) increased to 93% from 83%, the use of the Lund & Browder chart remained the same, treatment plan documentation increased to 95% from 91%, documentation of admission increased from 24% to 51%, consultant confirmation of TBSA increased to 10% from 5%, but this requires further improvement. Comments stated the proforma was clearer and provided a flowchart layout which made documentation easier.

Conclusions

The Burns Admission Proforma has made significant improvements. Working with the nursing staff and consultant body, we aim to improve our completion rates of vital information further. It sets a high standard for data collection and presents itself as a useful tool for other Burns Units across the United Kingdom.

Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature

INTRODUCTION

Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns.

RESULTS

An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes.

DISCUSSION

The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers.

CONCLUSIONS

More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

Recommendations for influenza vaccination in burns patients based on a systematic review of the evidence

Severe burn injury is a serious systemic insult that can lead to life threatening secondary infections. Immunosuppression, inhalation injury and prolonged length of hospital stay are factors which predispose patients to severe respiratory tract infections. Furthermore, evidence shows that burns can put one at risk of infection long after the original injury. Currently in the United Kingdom, the annual National Flu Immunisation programme outlines guidance for groups who are deemed high risk and therefore eligible for the influenza vaccine. At present, no guidance exists for administration of the influenza vaccine in burn injured patients, despite knowledge of immunosuppression. The aim of this literature review is to examine the evidence for associations between burn injury and influenza and where available, evaluate efficacy of influenza vaccines in this cohort. In addition, literature was searched for the effectiveness of the influenza vaccine in patients 65 years and above, and in patients admitted to the intensive care unit (ICU); two domains common to patients with severe burns. Three papers were found to suggest increased susceptibility to influenza following burn injury, however no papers studying the effectiveness of the influenza vaccine in this group were found. Several studies demonstrated improved outcomes in patients over 65 years and patients admitted to ICU. Following evaluation of the evidence, this review advocates for the consideration of hospitalized burn patients for the influenza vaccine. We suggest avoidance of vaccine administration in the acute burn phase. Further prospective clinical trials would be required to validate these findings.

A Rule of Thumb for Hand Burns: Categorization and Mapping of Proportional Surface Area Involvement

Hand burns are common and often complex injuries, requiring referral to specialist centers. The patient’s thumbprint is a rapid means of accurately assessing hand burn surface area. This study aimed to establish categories and evaluate sites of hand burn surface area in order to facilitate comparison of hand burns. Sixteen burns involving the hand and wrist among 14 patients referred to a burns center were retrospectively categorized by burn mechanism, burn thickness, and hand burn surface area. The burn surface area in the clinical record was compared with that calculated by the thumbprint method and the rule of thumb diagram. Burn surface area in the clinical record was either “1%” or “<1%” in 9 of 16 cases. In contrast, the surface area was <1 thumbprint (T) in six burns, two were between 1 and 5T, three were 5 to 10T, two were 10 to 20T, two were 20 to 50T, and one was greater than 50T. The median thumbprint burn surface area was 1.5T (range 0.20–80T), which corresponds to 0.05% TBSA. The hand areas with the highest burn frequency per unit area were the dorsum of the hand and dorsum of the index finger, with relative sparing of the palm and palmar surface of the digits. Hand burns surface area varies widely, and thumbprint evaluation with categories and mapping allows finer distinction between the surface area proportions and specific sites involved, even in a small series of hand burns.

Is the use of a powered dermatome an aerosol-generating procedure (AGP)? Implications for personal protection against COVID-19 virus

Introduction:

Many healthcare workers have contracted SARS-CoV-2 during the pandemic, many cases of which have resulted in severe illness and death. No studies have assessed the potential for powered dermatomes to generate aerosol, an essential technique in burns and plastic surgery. The primary aim of the present study was to capture video footage to illustrate the potential for a powered dermatome to generate significant spray and hence aerosol.

Methods:

We utilised a simulated skin graft harvest experimental method. Fluorescein-stained saline was used with ultraviolet (UV) backlighting to demonstrate fluorescent spray from a popular brand of air-powered dermatome. Ultra-slow-motion (960 frames/s) video was used to demonstrate the oscillation of the dermatome blade and the origin within the machine of any spray generated, and the extent of spray generated.

Results:

The key finding from this study is the captured video footage linked with this paper. Droplets of various sizes are seen spraying out from the leading edge at the sides where the blade oscillates. UV backlighting provides a clear demonstration of the dermatome generating fine spray.

Conclusion:

Our study demonstrates that powered dermatome usage is likely to generate aerosol from blood or blood-contaminated fluid, but does not demonstrate or quantify to what extent this may be clinically relevant in terms of viral transmission potential. We suggest ways to reduce the risk of spray from dermatomes including limiting donor-site bleeding and avoiding a wet donor area.

Lay Summary

A dermatome is a device used by surgeons to harvest split skin grafts (SSGs). SSGs are an essential component of burns and reconstructive plastic surgery. Aerosol-generating procedures (AGPs) have implications for transmission of viruses including COVID-19. It has not previously been formally assessed whether use of a dermatome should be classified as an AGP. This study uses a fluorescent dye in the context of simulated surgery using a dermatome to see if any, and how much, fine spray is generated from the device and also utilises ultra-slow-motion videography to see how any spray may be generated. At the heart of this study is the included video footage that demonstrates considerable fine spray generation which suggests it is best to assume that dermatomes are likely to generate some degree of aerosol depending on the clinical scenario and how it is used. However, this information does not translate to providing any information about the risk of transmission of the virus from using a dermatome, especially in relation to COVID-19, and separate research would be required to answer this.

Identifying patient concerns during consultations in tertiary burns services: development of the Adult Burns Patient Concerns Inventory

OBJECTIVES

Identifying the issues and concerns that matter most to burns survivors can be challenging. For a number of reasons, but mainly relating to patient empowerment, some of the most pressing concerns patients may have during a clinical encounter may not naturally be the focal point of that encounter. The Patient Concerns Inventory (PCI) is a tried and tested concept initially developed in the field of head and neck cancer that empowers patients during a clinical encounter through provision of a list of prompts that allows patients to self-report concerns prior to consultation. The aim of this study was to develop a PCI for adult burns patients.

DESIGN

Content for the PCI was generated from three sources: burns health-related quality of life tools, thematic analysis of one-to-one interviews with 12 adult burns patients and 17 multidisciplinary team (MDT) members. Content was refined using a Delphi consensus technique, with patients and staff members, using SurveyMonkey.

SETTING

Within outpatient secondary care.

PARTICIPANTS

Twelve adult burns patients and MDT members from two regional burns centres.

RESULTS

A total of 111 individual items were generated from the three sources. The Delphi process refined the total number of items to 58. The main emergent domains were physical and functional well-being (18 items), psychological, emotional and spiritual well-being (22 items), social care and social well-being (7 items) and treatment-related concerns (11 items).

CONCLUSIONS

The Adult Burns Patient Concerns Inventory is a 58-item, holistic prompt list, designed to be used in the outpatient clinic. It offers a new tool in burn care to improve communication between healthcare professionals and patients, empowering them to identify their most pressing concerns and hence deliver a more focused and targeted patient-centred clinical encounter.

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.

Autologous fat grafting for scars, healing and pain: a review

INTRODUCTION

Current guidelines suggest a multimodal approach to treating scars but there is no gold standard for treatment; however, there is exciting therapeutic potential for the use of autologous fat grafting (AFG). Functional and aesthetic improvements have been reported, including pain relief and scar quality improvement.

AIMS

To explore the current evidence regarding the use of AFG in hypertrophic and painful scars.

METHODS

A systematic review of the literature was conducted using 11 MeSH terms in PubMed, Medline and EMBASE. English studies that used AFG to treat scars in human participants were included.

RESULTS

A total of 746 studies were found and 23 studies (from 2008 to 2016) were included: five studies were evidence level V; nine studies were evidence level IV; eight were evidence level III; and one study was evidence level II. A total of 1158 patients were assessed for improvement in scar characteristics including colour, thickness, volume, pain and restoration of function at affected sites, following treatment. Positive outcomes were noted for all parameters and a significant improvement in AFG's analgesic effect was recorded in 567 out of 966 patients, P < 0.05.

DISCUSSION

AFG is a minimally invasive and safe approach to treating scars, a promising alternative to surgical excision. The technique of blunt cannula insertion optimises the release of scar retraction, which contributes to the analgesic effect of this treatment method. The evidence supports current theories of mesenchymal stem cell's regenerative and anti-inflammatory properties responsible for scar healing. There are limited high quality studies to support its use and future randomised controlled trials should be conducted.

The Mersey Burns App: evolving a model of validation

INTRODUCTION

'Mersey Burns App' is a smartphone/tablet application that aids in the assessment of total burn surface area (TBSA) and calculation of fluid resuscitation protocols in burns. This paper presents two studies assessing the speed and accuracy of calculations using Mersey Burns (App) in comparison with a Lund and Browder chart (paper) when a burn is assessed by medical students and clinicians.

METHODS

The first study compared the speed and accuracy of TBSA and resuscitation calculation for a photograph of a burn with App and paper using burns and plastics and emergency medicine trainees and consultants. Developing on some of the feedback and results of that study, a second study was then carried out using burns-naive medical students assessing a fully simulated burn with both modalities. Preference and ease of use of each modality were assessed anonymously.

RESULTS

The clinician study showed a lower variance in TBSA and fluid calculations using the App (p<0.05). The student study showed no difference in mean TBSA estimations (p=0.7). Mean time to completion of calculations was faster and calculations were more likely to be correct with the App (p<0.001). Students favoured the App in the following categories: preference in emergency setting, confidence in output, accuracy, speed, ease of calculation, overall use and shading (p<0.0001).

CONCLUSIONS

Mersey Burns App can facilitate quicker and more accurate calculations than Lund and Browder charts. Students also preferred the App. This suggests a useful role for the App in the care of patients with burns by inexperienced staff.

Clinical review: the critical care management of the burn patient

Between 4 and 22% of burn patients presenting to the emergency department are admitted to critical care. Burn injury is characterised by a hypermetabolic response with physiologic, catabolic and immune effects. Burn care has seen renewed interest in colloid resuscitation, a change in transfusion practice and the development of anti-catabolic therapies. A literature search was conducted with priority given to review articles, meta-analyses and well-designed large trials; paediatric studies were included where adult studies were lacking with the aim to review the advances in adult intensive care burn management and place them in the general context of day-to-day practical burn management.

VACUETTE(®) for burn depth assessment--a simple and novel alternative use for a ubiquitous phlebotomy device

The depth of any burn wound is an important determinant of its management and outcome. It also governs the outcome of wound healing and scarring making initial depth assessment extremely vital. Various methods both invasive and non-invasive have been described in literature for burn depth estimation. We describe a useful adjunct to clinical burn depth assessment, a VACUETTE(®) venous blood sampling device. This single cheap, ubiquitous and sterile device usually used for phlebotomy allows subjective assessment of the most useful parameters in the assessment of burn wounds, including, capillary refill, evaluation of sensation to blunt and sharp stimuli including pain.

A quick and effective method of limb preparation with health, safety and efficiency benefits

INTRODUCTION

Pre-operative limb preparation (PLP) usually involves lifting the limb and holding it in a fixed 'static' posture for several minutes. This is hazardous to theatre staff. Furthermore, 'painting' the limb can be time consuming and difficult areas such as between toes and fingers may remain unsterile. We demonstrate the time efficiency and asepsis achieved using the 'sterile bag' preparation technique. An additional advantage is the ability to prepare and anaesthetise a limb prior to theatre, increasing efficiency substantially for units with a large throughput of cases, such as day-case hand surgery lists.

METHODS

We monitored the duration of PLP in 20 patients using the 'sterile bag' technique compared to 20 patients using a conventional 'painting' method. Additionally, microbiology samples acquired from prepared upper limbs of 27 sequential patients operated on by a single surgeon over a two-month period were sent for culture immediately prior to commencement of surgery.

RESULTS

The mean duration of the 'sterile bag' PLP was significantly lower than that of the conventional method (24 seconds vs 85 seconds, p=0.045). The technique can take as little as ten seconds (n=1). Final microbiology reports showed no growth for any of the 27 patients from whom a culture sample was taken.

CONCLUSIONS

The sterile bag technique is effective in achieving asepsis, has the potential to increase theatre efficiency and reduces manual handling hazards compared to the conventional method. It is now taught to all theatre staff in our hospital during manual handling training. It can be undertaken in approximately ten seconds with practice for the upper limb.

A new recreational mechanism for the boxer's knuckle: cause for concern?

Traumatic injuries of the metacarpophalangeal joints are a common occurrence in professional and recreational sports such as boxing and martial arts, especially the fourth and fifth metacarpals. Injury usually results from a forceful impact with a clenched fist. The spectrum of injuries varies from simple skin laceration to extensor mechanism disruption, dorsal capsule rupture, metacarpal fractures and carpometacarpal joint injuries. These injuries are well documented in boxers as well as in patients who had been involved in fights and assaults. We report on two patients sustaining similar injuries to the dorsum of the hand but following punching of a recreational 'punching machine'. We describe the patterns of injury encountered and summarise the treatment. For clinical and safety reasons as well as the potential medicolegal implications, we believe it is important to highlight this mechanism of injury.

A liposuction technique for extraction of Bio-Alcamid and other permanent fillers

Bio-Alcamid (Polymekon Research, Brindisi, Italy) is a permanent soft tissue filler that has been injected for the correction of contour deformities. It has a number of indications, including pectus excavatum. Infection and migration seem to be the most common complications with this product. The authors report an illustrative case of pectus excavatum deformity treated with Bio-Alcamid. Results highlight the successful treatment of gel migration with liposuction, which has not been recommended by the manufacturer nor reported in the literature to date.

Congenital vascular malformation associated with multiple cranial, vertebral and upper limb skeletal abnormalities

The association between congenital vascular malformations and altered bone growth, the so-called vascular bone syndrome, is well documented. Various eponymous syndromes each with their individual traits, such as Klippel-Trenaunay, Parkes-Weber and Servelle-Martorell syndrome have been described, along with variations. We report on a previously undescribed case of congenital vascular malformation associated with multiple skeletal abnormalities affecting the skull, vertebrae and right upper limb, and discuss the literature.

Spindle cell liposarcoma of the face: case report and literature review

Liposarcoma is a common soft tissue sarcoma accounting for approximately 20% of all mesenchymal tumours across all ages. Recently, collaborative research in the specialties of pathology and genetics has led to the delineation of several tumour variants with different behaviours and prognoses, one of which includes the very rare spindle cell liposarcoma (SCL) subtype. We present the first case of an SCL arising in the subcutaneous tissue of the forehead of a 78-year-old man. In light of the rarity of this tumour, we describe the tumour and its clinical and pathological characteristics and undertake a literature review to clarify the surgical management and prognosis of SCL, and increase awareness to avoid misdiagnosis of a benign soft tissue neoplasm.

Request for Treatment: the evolution of consent

INTRODUCTION

Request for Treatment (RFT) is a new approach to consent which aims to facilitate patients' understanding of their treatment and addresses some of the flaws highlighted in a literature review of current consent practice. It aims to provide a complete clinical, medicolegal, and documentary framework for consent and places patients at the centre of their care. It also provides doctors with more robust evidence that adequate consent has been obtained, and can be implemented with ease in most clinical scenarios, especially elective surgery.

MATERIALS AND METHODS

A thorough critical analysis and literature review is undertaken looking at the current state of consent world-wide. For the first time, a complete documentary system for 'request for treatment' is devised including Request for Treatment forms (RFTFs) alternatively termed Patient-centred Consent Forms (PCCFs). The arguments for the legal validity and other advantages of RFT are presented.

CASE STUDY

A case with all the documentation of a full consent episode is provided which illustrates RFT in action, demonstrating the simplicity of implementation, and the robustness of the completed RFT form as a source of evidence for both consent and capacity.

CONCLUSIONS

Request for Treatment (RFT) is a request-based model for consent that facilitates patient-centred care. It has a number of advantages including unrivalled documentary evidence of consent in the patient's own handwriting and vocabulary, demonstration of capacity, ease of implementation, and a sound legal basis. For those who may wish to use it, RFT provides a useful and novel patient-centred method of consent, and is likely to protect against negligent consent practice by highlighting patient misunderstandings early and by providing irrefutable documentary evidence that consent has been gained. It may also provide a simple method by which Gillick competence can be assessed and documented. RFT forms are available for download at www.rft.org.uk.