A pragmatic randomised controlled clinical study to evaluate the use of silicone dressings for the treatment of skin tears

One of the most common types of skin breakdown in ageing populations is skin tears. The International Skin Tear Advisory Panel advocates for special attention to be paid to dressing selection related to skin tear management. The panel recommends choosing dressings that will promote the maintenance of moisture balance, suit the local wound environment, protect peri-wound skin, control or manage exudate and infection, and optimise caregiver time. It is paramount that dressings protect the fragile nature of the skin associated with those who at heightened risk for skin tear development. To compare the effectiveness of soft silicone dressings (a contact layer and/or foam) for the healing of skin tears with local practices that do not include soft silicone dressings. The study was a pragmatic randomised controlled prospective study. One hundred and twenty-six individuals from two long-term care facilities in Ontario Canada who presented with skin tears were randomised into the treatment group using either soft silicone dressings (a contact layer and/or foam) or the control group using non-adhesive dressings. The current study demonstrated that 96.9% (n = 63) of skin tears in the treatment group healed over a 3-week period compared with 34.4% (n = 21) in the control group. The proportion of wound healing experienced at week 2 was 89.2% (n = 58) in the treatment group compared with 27.9% (n = 17) in the control group. There was a significantly greater reduction in wound surface area relative to baseline in the treatment group (2.9 cm²) compared with the control group (0.6 cm²) (χ² = 21.792 P < .0001) at week 1. Survival analysis data supported that skin tears healed 50% faster in the treatment group (11 days) compared with the control group (22 days) (χ² = 59.677 P < .0001). The expected healing trajectory of acute wounds, including skin tears, if proper wound bed preparation is realised and infection is controlled, is 7 to 21 days. Results of this study suggest the use of silicone dressings support wound healing and aid in wound closure within the expected healing trajectory, with faster complete wound closure and mean healing times compared with non-silicone dressing for the treatment of STs.     

Pigmented villonodular synovitis of the talonavicular joint: A case report and review of the literature

Pigmented villonodular synovitis (PVNS) is a locally aggressive synovial proliferative disorder of unknown aetiology affecting the linings of joints, tendon sheaths, and bursae. A 22-year-old female patient presented with a 3-year history of an increasingly painful swelling on the dorsum of her right foot. Examination revealed a 4 cm × 2 cm swelling that was fluctuant, tender on palpation, unattached to overlying skin and partially mobile. A firm, pedunculated intra-articular lesion from the talonavicular joint was removed at surgery. Histology revealed a nodular lesion of stromal cells and numerous giant cells with villous architecture as well as abundant haemosiderin deposition with foamy macrophages (in keeping with PVNS). The patient is currently under review by the orthopaedic oncology team. Talonavicular joint PVNS is rare. MRI scanning is the optimum investigation. Complete excision is necessary to minimise high risk of recurrence.     

Predicting the effectiveness of virtual reality relaxation on pain and anxiety when added to PCA morphine in patients having burns dressings changes

BackgroundPain arising in burns sufferers is often severe and protracted. The prospect of a dressing change can heighten existing pain by impacting both physically and psychologically. In this trial we examined whether pre-procedural virtual reality guided relaxation added to patient controlled analgesia with morphine reduced pain severity during awake dressings changes in burns patients.MethodsWe conducted a prospective randomized clinical trial in all patients with burns necessitating admission to a tertiary burns referral centre. Eligible patients requiring awake dressings changes were randomly allocated to single use virtual reality relaxation plus intravenous morphine patient controlled analgesia (PCA) infusion or to intravenous morphine patient controlled analgesia infusion alone. Patients rated their worst pain intensity during the dressing change using a visual analogue scale. The primary outcome measure was presence of 30% or greater difference in pain intensity ratings between the groups in estimation of worst pain during the dressing change.FindingsOf 88 eligible and consenting patients having awake dressings changes, 43 were assigned to virtual reality relaxation plus intravenous morphine PCA infusion and 43 to morphine PCA infusion alone. The group receiving virtual reality relaxation plus morphine PCA infusion reported significantly higher pain intensities during the dressing change (mean = 7.3) compared with patients receiving morphine PCA alone (mean = 5.3) (p = 0.003) (95% CI 0.6–2.8).InterpretationThe addition of virtual reality guided relaxation to morphine PCA infusion in burns patients resulted in a significant increase in pain experienced during awake dressings changes. In the absence of a validated predictor for responsiveness to virtual reality relaxation such a therapy cannot be recommended for general use in burns patients having awake dressings changes.     

Labia Majora Hypertrophy

A case involving hypertrophy of the labia majora is described. A married 34-year-old mother of a 5-year-old daughter reported that from adolescence, her large labia majora and its protuberance have resembled male genitalia even when she is wearing a slip. For that reason, in the summer, she is ashamed of her appearance and thus has avoided swimming pools and beach areas. With the patient in supine position, the crural creases were marked. The marks were drawn 1 cm apart medially into the medial part of the labia majora parallel to the natural vulvar crease. The estimated amount of skin and fat to be removed was marked. In this case, more skin and fat needed to be removed from the left side than from the right side. The surgery was performed using sedation and local anesthesia as with outpatient surgery. To avoid excessive bleeding of this area, profuse infiltration was performed using 200 ml of anesthetic solution. Resection of the skin and fat in the area was performed with two hooks holding the area up to avoid introducing the scalpel too deeply. Only the superficial fat was removed. After meticulous hemostasia, two layers of 3/0 absorbable running sutures were placed, one in the deep fat and another in the subdermis, until the wound edges were approached. A 5/0 mononylon running suture closed the skin. These sutures provided strong support to all this very mobile area, avoiding dead spaces and bleeding because postoperative compressive bandages are difficult to hold in this region. The patient was instructed to wash the area four times a day. The surgery was ambulatory, with the patient returning to her province the day after surgery, then coming back for a control visit on postoperative day 10. On postoperative day 1, a moderate edema was observed but no hematoma. The stitches were removed on day 10 after surgery. The postoperative evolution of the case was uneventful. The sensitivity of the labia majora’s interior aspect was preserved. With legs open, the labia majora closed the entrance to the vagina without showing the labia minora. A moderate edema was observed 4 weeks after surgery, and 6 months after surgery, the patient’s external genitalia had reached a normal appearance. At 4 months after surgery, the scars were barely noticeable.     

Lowering the pivot point of sural neurofasciocutaneous flaps to reconstruct deep electrical burn wounds in the distal foot

Due to the thinness of the skin and soft tissues in the foot, tendons and bones tend to become exposed and necrotic after injury; therefore, it is difficult to reconstruct foot injuries, especially distally. Reconstruction with free skin flaps is highly risky as it demands technologies and equipment, while patients suffer greatly from the use of cross-leg skin flaps. Sural neurofasciocutaneous flaps are often used for reconstruction of wounds in the lower leg, malleolus, and the proximal end of the foot but are not feasible for wound repair in the distal foot; this is because, with the pivot point of 5–7 cm above the tip of the lateral malleolus, the flaps are not able to cover defects in the distal foot. In this study, we used a sural neurofasciocutaneous flaps with a lowered pivot point for reconstruction of distal foot wounds caused by electrical burns. An ultrasound flow detector and Doppler flow imaging were used to detect the diameter, the perforating point and the blood flow of the lateral retromalleolar perforator. Twelve patients with the perforator diameter greater than 0.6 mm and the peak systolic flow more than 0.15 m/s were included. The pivot point of sural neurofasciocutaneous flaps was lowered to 0–3 cm above the tip of the lateral malleolus and the size of the flaps ranged from 6 cm × 5 cm to 12 cm × 18 cm. Eleven of the 12 flaps survived completely. One flap developed necrosis approximately 1 cm at the far point but was managed successfully by daily dressing. We demonstrated that lowering the pivot point of sural neurofasciocutaneous flaps is feasible for reconstruction of distal foot injury with the advantages of reliable blood supply and easy operation. The use of Doppler flow imaging provides useful information for the design of the flaps.     

Mobile biatrial thrombus in a patient with mitral stenosis under heparin infusion

A 58-year-old female patient with complaints of sudden presenting pain and pallor on her left foot was referred to our clinic for urgent embolectomy. On her cardiovascular examination there was an apical grade 2/6 systolic murmur and a grade 2/4 diastolic murmur. The presenting electrocardiography revealed atrial fibrillation with rapid ventricular response. She underwent emergent femoro-popliteal embolectomy. Transthoracic echocardiography showed a mobile 1.4 x 1.7-cm sized left atrial thrombus, mild mitral regurgitation and 9 mmHg mean gradient on mitral valve after embolectomy. Unfractioned (UF) heparin infusion was initiated immediately after surgery. After three days, the control transthoracic echocardiography revealed left atrial thrombus and also a large 'snake-like' thrombus waving in right atrium. The patient underwent biatrial thrombectomy and mitral valve replacement. When she became haemodynamically stable, a bilateral lower limb venous Doppler ultrasonographic study was performed. This study indicated a thrombus formation in the deep veins of the left leg. The origin of the right atrial thrombus was probably a snapped piece of thrombus from the calf deep-veins after the initiation of intravenous UF heparin. In summary, we have reported an extremely rare case of biatrial thrombus in a patient under UF heparin infusion.     

筋膜皮下组织瓣加植皮术修复足部创面

目的：探讨小腿逆行筋膜皮下组织瓣加植皮术修复足部创面的应用情况。方法：应用小腿逆行筋膜皮下组织瓣加植皮术修复13例足部创面缺损,筋膜皮下组织瓣面积为12cm×7cm～8cm×4cm。结果：1例筋膜瓣边缘坏死面积1.5cm2,经换药处理后愈合,12例筋膜瓣全部成活。结论：应用小腿逆行筋膜皮下组织瓣加植皮术修复足部创面缺损,不损伤主要血管,操作方便,皮瓣成活率高,值得推广。     

Sudden death due to massive pulmonary thromboembolism after pneumonectomy; report of a case

A 76-year-old woman underwent a left pneumonectomy for a primary adenocarcinoma. On the fourth postoperative day, when walking to the toilet, she suddenly developed syncope followed by dyspnea and cardiopulmonary arrest. Although we performed cardiopulmonary resusciation, she died 1 hour later. With her family's approval, we performed autopsy. We found massive pulmonary thromboembolism was identified in the right main artery. To prevent postoperative thromboembolic complications, we use postoperatively continuous intravenous heparin sodium infusion (5,000-6,000/24 h) for the patients underwent thoracotomy and examine the ultrasonography for deep vein thrombosis before they begin to walk.     

Continuous inferior mesenteric ganglion block for the control of abdominal pain.

BACKGROUND AND OBJECTIVES: A 71-year-old woman was referred for control of intractable left-sided abdominal pain and constipation caused by stage 2B rectosigmoid colon cancer. She was treated with an intravenous morphine sulfate infusion at 4 mg/h which made her drowsy and lethargic. Because the distal colon is innervated by the inferior mesenteric sympathetic ganglion, it was hypothesized that a continuous block of this ganglion would provide both pain control and increased intestinal motility. METHODS: The patient was placed in a prone position, and a Tuohy needle was placed at an entry site 7 cm lateral to the L3 spinous process. The needle was advanced 2 cm anterior to the L3 vertebral body with fluoroscopic guidance. An 18-gauge indwelling catheter was placed through the needle and a continuous infusion with 0.1% bupivacaine was maintained for 4 days. RESULTS: The patient obtained immediate pain relief and bowel motility. She remained awake and comfortable throughout the duration of therapy. She was discharged home 3 days after stopping the infusion and required a minimal amount of opioids. CONCLUSION: Continuous inferior mesenteric ganglion block may be an option in providing relief for pain caused by distal colon pathology.     

A novel way to treat skin tears

Skin tears are one of the most commonly treated wounds in the elderly population. In their most basic form, they are essentially traumatic random pattern flaps. We postulate that the injured blood flow to these skin flaps should be ignored and the tissue should be treated as a skin graft. A case report is presented of an 86‐year‐old female with an 8 × 3·5 cm skin tear to her right upper extremity after a hip fracture. In addition to conventional wound closure strips re‐approximating the tissues, a disposable negative pressure wound therapy device was placed to act as bolster. Upon its removal on day 5, the opposed skin tear tissue was found to be 100% viable. We therefore propose that this update may be an improvement over classical skin tear treatments and should be followed up with a case series.     

Simultaneous laceration of external iliac artery and vein complicating anterior vaginal wall sling operation for stress urinary incontinence

Case report  We report a case of simultaneous injury of right external iliac artery and vein by a needle carrier that was inserted from the suprapubic area down to the vaginal lumen during anterior vaginal wall sling procedure. Discussion  The risk factors and measures to be taken to avoid this life threatening complication are discussed.     

联合远端蒂的下肢内侧复合皮瓣的临床应用

目的探讨联合远端蒂的下肢内侧复合皮瓣在足部套状撕脱伤创面修复中的应用价值。方法应用膝内侧皮瓣游离移植联合隐神经营养血管筋膜蒂皮瓣转移修复足部皮肤套状撕脱伤6例。皮瓣切取面积最大为12cm×45cm,最小为8cm×30cm。结果5例皮瓣全部成活,1例皮瓣边缘部分坏死,经换药及游离植皮后愈合。术后随访5～24个月,皮瓣外形满意,血供良好,均恢复保护性感觉,患足能负重行走,按足部疾患治疗结果评分标准评定,平均70分。结论联合远端蒂的下肢内侧复合皮瓣血供良好,皮瓣切取面积大．可恢复感觉功能,适合修复足部皮肤套状撕脱伤。     

Ultrasound‐guided catheterisation of the subclavian vein: freehand vs needle‐guided technique

The objective of this prospective, randomised study was to examine the impact of a multi‐angle needle guide for ultrasound‐guided, in‐plane, central venous catheter placement in the subclavian vein. One hundred and sixty patients were randomly allocated to two groups, freehand or needle‐guided, and then 159 catheterisations were analysed. Cannulation of the first examined access site was successful in 96.9% of cases with no significant difference between groups. There were three arterial punctures and no other severe injuries. Catheter misplacements did not differ between the groups. Higher success rates within the first and second attempts in the needle‐guided group were observed (p = 0.041 and p = 0.019, respectively). Use of the needle guide reduced the access time from a median (IQR [range]) of 30 (18–76 [6–1409]) s to 16 (10–30 [4–295]) s; p = 0.0001, and increased needle visibility from 31.8% (9.7%–52.2% [0–96.67]) to 86.2% (62.5%–100% [0–100]); p < 0.0001. A multi‐angle needle guide significantly improved aligning the needle and ultrasound plane compared with the freehand technique when cannulating the subclavian vein. Use of the guide resulted in faster access times and increased success at the first and second attempts.     

Is the same brace fit for all? The length of abduction bar in Steenbeek foot abduction brace for Indian children—A pilot study

PurposeWe measured the foot size and shoulder width in North Indian children with idiopathic clubfoot and calculated the corresponding metal rod length for abduction brace. The differences in the foot length in unaffected, unilateral and bilateral clubfeet were also measured.Patient and methodsTwo sets of measurements were taken on each child: feet size and shoulder width. Using statistical analysis, the following were compared: Differences in the manual prescribed and our calculated SFAB bar length, foot size in unilateral clubfoot and unaffected foot and both feet in bilateral clubfoot.ResultsThere were 156 patients with 76 unilateral (37 left + 39 right) and 80 bilateral feet. The mean prescribed bar length for foot sizes 8–14 in the Steenbeek manual is 30.18 cm. The mean predicted bar length worked out to be 22.33 cm in our series (p < 0.001). In unilateral clubfoot, the mean foot length (11.9 cm) when matched with unaffected foot (12.6 cm) was comparable (p = 0.08). Bilateral clubfeet lengths (12.29 cm versus 12.3 cm) were also comparable (p = 0.978).ConclusionsThere was significant difference between the prescribed and the predicted bar length in foot sizes 8–14 with a smaller bar length measurement of Indian children. The Ponseti treated unilateral club foot length matched the unaffected foot. The foot lengths in bilateral feet disease were also similar.     

Stump pain relieved by continuous intravenous ketamine infusion therapy

We experienced a case of stump pain relieved by continuous intravenous ketamine infusion therapy. A 59-year-old male had his left first through fourth toes amputated because a giant iron plate at work fell on his left foot fifteen years ago. Thereafter he had refractory spontaneous burning pain and night pain on his stump. On examination, we found his left foot skin hard, lustrous, and with sweating disturbance, allodynia and hyperpathia. As intravenous administrations of ketamine 10 mg and thiamylal 50 mg were positive as a drug challenge test, we performed intravenous ketamine infusion at 1 mg.kg-1.hr-1 for 1 hour and a half. After this treatment, his visual analogue scale (VAS) improved dramatically to 0 mm, and night pain, allodynia and hyperpathia disappeared for three days. Thereafter stump pain was relieved to the level of VAS 20 mm. Therefore we diagnosed his stump pain as central pain of neuropathic origin. We suspect that continuous intravenous infusion of ketamine, a noncompetitive blocker of N-methyl-D-aspartic acid receptor, might be an effective and useful alternative treatment in a patient with refractory stump pain.     

Surgical debridement,maggot therapy,negative pressure wound therapy,and silver foam dressing revive hope for patients with diabetic foot ulcer: A case report

Introduction and importanceDiabetic foot ulcers (DFUs), as one of the most debilitating complications of diabetes, can lead to amputation. Treatment and management of d DFUs are among the most critical challenges for the patients and their families.Case presentationThe present case report is of a 63-year-old man with a 5-year history of uncontrolled type 2 diabetes who has had DFU for the past three years on three sites of the left external ankle in the form of two deep circular ulcers with sizes of 6 × 4 cm and 6 × 8 cm, the sole as a superficial ulcer with a size of 6 × 3 cm, and the left heel as a deep skin groove. Moreover, the left hallux was completely gangrenous. The patient's ulcers were infected with Staphylococcus aureus and multidrug-resistant Pseudomonas aeruginosa. The patient was transferred to our wound management team. DFU was treated and managed using a combination of surgical debridement, maggot therapy, the Negative Pressure Wound Therapy (NPWT), and silver foam dressing. After three months and ten days, the patient's ulcers completely healed, and he was discharged from our service with the excellent and stable condition.Clinical discussionDFUs are caused by various pathological mechanisms, the monotherapy strategy would lead to a very low level of recovery. Therefore, DFU management requires multimodal care and interdisciplinary treatment.ConclusionBased on the present case report study's clinical results, wound-care teams can use the combination therapy applied in this case report to treat refractory DFU.     

High-valve vapor-permeable film dressing versus fine mesh gauze dressing on skin graft donor areas in diabetic patients: a prospective randomized controlled trial

The use of split-thickness skin grafts (STSG) as a reconstructive technique in the diabetic foot is common. Studies on the ideal dressing for donor-site care have not included subjects such as diabetics who have wound-healing problems. The aim of this study was to determine the efficacy of high-valve water vapor transmission rate (WVTR) polyurethane film dressing in the management of the STSG donor site compared to the clinical standard fine mesh gauze dressing in diabetic patients. Twenty diabetic patients were observed for healing, scarring, and pain. Healing times were recorded. Pain was monitored using a visual analog pain scale and recorded. Scarring of the donor sites was assessed using the Vancouver scar scale 6 months after surgery. The WVTR dressing was found to be significantly better than mesh gauze dressing for the healing of STSG donor sites. Healing occurred more rapidly and with less pain. Moreover, it has some advantages of dry wound dressings such as ease of application and follow-up. Dressings should retain enough moisture to stimulate good healing and yet should not cause maceration to the surrounding skin, and also should not cause allergic reactions. In this study it was shown that high-valve WVTR polyurethane film dressing provided many qualities of the ideal split-thickness skin graft donor-site dressing.     

逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复足踝部软组织缺损

目的报道逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复足踝关节周围软组织缺损的手术方法和临床效果。方法对48例足踝关节周围皮肤软组织缺损的患者采用逆行胫后动脉穿支蒂隐神经营养血管(肌)皮瓣修复,单纯逆行胫后动脉穿支蒂隐神经营养血管皮瓣39例,肌皮瓣9例;其中胫后动脉穿支筋膜蒂神经营养血管皮瓣29例,胫后动脉穿支血管蒂营养血管皮瓣19例,软组织缺损大小12 cm×9 cm~4 cm×3 cm,皮瓣面积13 cm×9.5cm~6 cm×5 cm。结果 43例皮瓣完全存活,5例皮瓣远端部分坏死,经积极换药、清创植皮修复。皮瓣术后轻度肿胀,无感染及淤血,皮瓣蒂部无臃肿。术后随访6~18个月,皮瓣质地优良,肢体外形与功能恢复满意,供区植皮术后恢复保护性感觉。结论胫后动脉穿支蒂隐神经营养血管皮瓣血供可靠,质地优良,是修复足踝关节周围软组织缺损的良好选择。     

Hemorrhagic shock 3 days after catheterization from the axillary vein

A 72-year-old woman presented pulmonary embolism. Continuous intravenous administration of heparin was controlled with values of activated clotting time targeted from 150 to 180 s. On the sixth intensive care unit (ICU) day, a central vein (CV) catheter was inserted through the right axillary vein. On the ninth ICU day, her blood pressure dropped and her right breast was obviously larger than the left. Chest computed tomography showed a large hematoma under the greater pectoral muscle. CV catheterization under anticoagulant therapy is risky for bleeding, but catheterization of the internal jugular vein rarely leads to hemorrhagic shock, even if it causes airway obstruction. The axillary vein is in a compartment filled with loose tissue. As there is no structure to cover the bleeding site, the hematoma would expand from the lateral region of the thorax to near the fifth or sixth rib, to which greater and smaller pectoral muscles are attached. Ultrasound-guided catheterization from the axillary vein is introduced as a new and promising alternative to that from the subclavian vein because of its safety, but we should be conservative about applying the axillary approach to patients with anticoagulant therapy, especially in case of an unskilled operator, and be aware of the possibility of late-onset bleeding.     

游离髂腹股沟皮瓣在足部皮肤缺损中的应用

目的探讨游离髂腹股沟皮瓣修复足部皮肤缺损的效果。方法应用游离髂腹股沟皮瓣修复6例足部皮肤缺损患者,缺损面积5cm×5cm-6cm×12cm。结果5例皮瓣全部成活;1例出现静脉危象,手术探查后见皮瓣小部分坏死,经换药后痊愈。6例均获随访,时间3—12个月。受区皮瓣质地柔软,厚度适中,弹性好,外观及功能均满意。结论选用游离髂腹股沟皮瓣修复足部皮肤缺损可获得满意的临床效果。