Epithelioid sarcoma‐like (pseudomyogenic) hemangioendothelioma,clinically mimicking dermatofibroma,diagnosed by skin biopsy in a 30‐year‐old man

Epithelioid sarcoma‐like (pseudomyogenic) hemangioendothelioma (ESHE) represents a rare soft tissue and bone tumor that typically presents as nodule(s) in the distal extremities of young adults. The nodules traverse several tissue planes simultaneously and can involve the dermis, subcutis, skeletal muscle and bone. ESHE shares clinical and microscopic features with epithelioid sarcoma (ES), and, accordingly, is commonly misdiagnosed as ES. However, unlike ES, which has a poor prognosis, ESHE commonly follows an indolent course. Herein, we report a case of ESHE diagnosed by skin biopsy that clinically mimicked a dermatofibroma. We also provide clinical photographs of the lesions in various stages of development, representing information that has not been previously published, to our knowledge.     

Prevalence of lower limb venous disease in surgeons: a case study and results of a survey by the BAOMS Reconstruction Surgical Subspecialty Interest Group

We report a case of venous leg ulceration in a reconstructive oral and maxillofacial surgeon. An online survey was created by the British Association of Oral and Maxillofacial Surgeons (BAOMS) Reconstruction Surgical Subspecialty Interest Group (SSIG), primarily to target head and neck surgeons, to investigate the perceived risk and occurrence of venous leg disease. Two respondents had received treatment for lower limb venous disease thus compromising their ability to work, while 13 had symptoms of early venous disease. Our study shows an interesting area of concern for occupational health in surgeons, particularly in those carrying out long operations, as will be the case for members of the Reconstruction SSIG.     

Guidebook for Nutrition Counselors

Background: Because accurate measures of recumbent length are essential to assess growth and energy requirements of mobility-impaired individuals with cerebral palsy (CP), a reliable and simple method of estimating recumbent length is required. Prediction of recumbent length from knee height in this population has not yet been investigated.

Objectives: i) To correlate direct measures of recumbent length in mobility-impaired individuals having lower leg extremity cerebral palsy (LECP) involvement with indirect measures of recumbent length calculated using knee-height prediction equations and ii) to determine if knee height is a reliable predictor of recumbent length in this population.

Methods: Subjects (n=34; 15F, 19M), aged 6 to 30 years, were participants in a six-month nutrition rehabilitation program. All subjects had varying degrees of LECP involvement. Recumbent length to the nearest 0.5 cm was measured by standardised techniques. Knee height was measured to the nearest 0.5 centimetre using sliding callipers. Equations based on normal, healthy individuals with application to mobility-impaired or handicapped individuals were used to predict recumbent length from knee height.

Results: Direct measures of recumbent length of subjects significantly correlated with indirect measures calculated using knee height prediction equations (R=0.88, p≤0.0001). In addition, knee height of these subjects was a reliable predictor of recumbent length (R²=0.78, p<0.0001).

Conclusions: Results suggest that knee height may be a reliable predictor for recumbent length in this population.     

Late Results Following Treatment of Deep Burns of the Hands

During a 10-year period, 467 patients with burns involving the hands have been treated, 290 of whom during the past 5 years. Two groups of patients were examined: the first were those who had received treatment between 1967 and 1971 using the exposure method and the reconstruction with skin grafts only after the spontaneous scparation of the eschars, and the second, using the closed method and early or late excision of the necrotic tissue followed by covering with split-thickness grafts. In this second group are included also those patients whose burns can be classified as medium depth at the time of admission but in whom experience has shown that one is dealing with lesions with a tendency to become deeper during the post-burn period. For these cases a dermabrasion of the lesions was performed without covering with free grafts. In the es subjected to surgery using the technique of tangential excision and dermabrasion in order to reach the more difficult areas such as the interdigital spaces, dermabrasion was only performed between the 2nd and the 28th day. The removal of the burned tissue was followed by covering with free grafts, except in those cases in which the depth was in doubt. The results obtained have demonstrated that in the first group the scars have led to serious invalidating consequences which have necessitated long and complex surgical reconstruction programmes. In the second group almost complete function has been restored with the aid of only minimal surgical correction, most often in the interdigital spaces. We would like to emphasize the usefulness of surgery in those cases on the borderline between medium and full thickness. The tendency of these lesions to become deeper has often led to scars which are very similar to those following the deep lesions.     

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia: a retrospective study

Symptomatic superficial femoral artery (SFA) disease presenting either with severe claudication or critical limb ischaemia is treated with bypass surgery and traditionally has been the ‘goldstandard’ procedure. Surgical bypass using autogenous vein or prosthetic grafts as a conduit is well accepted and there are comparable patencies and limb salvage rates with either conduit.1There have been considerable advances in the last two decades in percutaneous endovascular technology for the treatment of SFA disease. The techniques that have been developed include percutaneous balloon angioplasty and stenting, with variable results.2,3 Despite having three different options, namely surgical bypass, balloon angioplasty and stenting, none is superior to the other.Although the five-year primary patency rate of femoropopliteal above-the-knee bypass with autogenous saphenous vein is 70%, this method of treatment is invasive with long incisions in the lower extremities and a peri-operative complication rate of 12%.4 Vascular surgeons have become more experienced with catheter-based technology and due to the minimal invasiveness of the procedure, both patients and vascular surgeons are increasingly attracted to endovascular procedures. Mwipatayi et al.5 and Nguyen et al.6 found stenting resulted in equivalent outcomes when compared to balloon angioplasty alone, but Laird et al.7 found that self-expanding nitinol stents were associated with better angiographic results and improved patency compared with balloon angioplasty alone.Randomised, controlled trials comparing bypass surgery and balloon angioplasty alone generally showed similar outcomes in terms of amputation-free survival but in the short term, surgery was more expensive than angioplasty.8 Another study comparing surgical bypass with balloon angioplasty and stenting showed better primary patency for the stent group (67%) than the bypass group (49%) and there were higher re-intervention rates in the bypass group.9Since there are conflicting data in the literature regarding the success of different methods of treatment of SFA disease and there is a lack of consensus guidelines on the optimum management of SFA disease, the aim of this study was to compare the results of stenting and surgical bypass in the local environment with regard to limb salvage rates in patients with severe leg ischaemia.     

The diagnosis of infection in chronic leg ulcers: A narrative review on clinical practice

This literature review aimed to provide a narrative review of evidence on validity of clinical and microbial indicators of infection and to gain insights into the diagnosis of infection in chronic leg ulcers (CLUs). A search was conducted in Cinahl, Medline, the Cochrane Library databases, Embase, Web of Science, ScienceDirect, Pubmed, PsycINFO, ProQuest dissertations, and Google Scholar from January 1990 to July 2017. The inclusion criteria were original studies, systematic reviews, and consensus documents focused on “infection” in CLUs, English language, clinical and community settings, and human. The reviewed studies were inconsistent in criteria for infection between investigated wound types and lack of specificity regarding wound types. There were few studies investigating the criteria for diagnosis of infection in leg ulcers. The identification of leg ulcer infection still remains problematic and relies on out‐of‐date and not uniform evidence. Literature in this area was mostly limited to level III and IV evidence based on The Australian National Health and Medical Research Council Levels of Evidence, or expert opinion. This literature review showed seven clinical signs and symptoms that could be diagnostic for infection in CLUs, including: new, increased, or altered ulcer pain; malodour; increased ulcer area; wound breakdown, delayed or non‐healing; and erythema and increased local temperature, whilst the microbial indicators used to diagnose infected leg ulcers were varied and regarded as less important.     

Leg Amputation for an Extensive,Severe and Intractable Sickle Cell Anemia Ulcer in a Brazilian Patient

A 35-year-old African Brazilian patient had sickle cell anemia complicated with recurrent vasoocclusive (VOC) crises and refractory painful leg ulcers for 16 years. The ulcers started over both medial malleoli and expanded gradually. The ulcer on the left leg spread from the foot to the knee circumferentially and was refractory to all forms of therapy within the frame work of multi-disciplinary care. The patient agreed to a below the knee amputation of the left leg. He felt much better after the amputation but developed severe neuropathic phantom pain that was well controlled medically. He could differentiate the sickle cell anemia and ulcer pain from the neuropathic pain. About 6 months after the amputation he had dengue fever with fatal outcome. This is the first report of treatment of refractory sickle cell anemia leg ulcer with amputation and probably the first report of a Brazilian patient with sickle cell anemia and dengue fever.     

Evaluation of divided attention psychophysical task performance and effects on pupil sizes following smoked,vaporized and oral cannabis administration

Establishing science‐based driving per se blood Δ⁹‐tetrahydrocannabinol (THC) limits is challenging, in part because of prolonged THC detection in chronic, frequent users. Therefore, documenting observable signs of impairment is important for driving under the influence of drugs. We evaluated frequent and occasional cannabis smokers' performance on the modified Romberg balance, one leg stand (OLS), and walk and turn (WAT) tasks, and pupil size effects following controlled placebo (0.001% THC), smoked, vaporized and oral (6.9% [~50.4 mg] THC) cannabis administration. Significant effects following inhaled doses were not observed due to delayed tasks administration 1.5 and 3.5 h post‐dose, but significant impairment was observed after oral dosing (blood THC concentrations peaked 1.5–3.5 h post‐dose). Occasional smokers' odds of exhibiting ≥2 clues on the OLS or WAT following oral dosing were 6.4 (95% CI 2.3–18.4) times higher than after placebo, with THC and 11‐hydroxy‐THC blood concentrations individually producing odds ratios of 1.3 (1.1–1.5) and 1.5 (1.3–1.8) for impairment in these tasks, respectively. Pupil sizes after oral dosing under the direct lighting condition were significantly larger than after placebo by mean (SE, 95% CI) 0.4 (0.1, 0.2–0.6) mm at 1.5 h and 0.5 (0.2, 0.2–0.8) mm at 3.5 h among all participants. Oral cannabis administration impaired occasional cannabis users' performance on the OLS and WAT tasks compared to placebo, supporting other reports showing these tasks are sensitive to cannabis‐related impairment. Occasional smokers' impairment was related to blood THC and 11‐hydroxy‐THC concentrations. These are important public health policy findings as consumption of edible cannabis products increases. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.     

Proliferative fasciitis mimicking a sarcoma in a child: A case report

Proliferative fasciitis (PF) is a benign, discrete proliferation of fibroblasts or myofibroblasts in soft tissue. Proliferative fasciitis mostly occurs in adults and is often confused with a sarcoma because of its rapid growth and peculiar histological features. We report a case of PF mimicking a sarcoma which developed in a 13‐year‐old boy, who noticed a painful tumor, with gradual enlargement, in his right lower leg. Magnetic resonance imaging revealed that the tumor measured 34 mm × 20 mm × 41 mm and was located in the subcutaneous tissue. The tumor was surgically resected. Pathologically, the tumor was composed of a proliferation of atypical spindle cells, admixed with larger ganglion‐like cells. Immunohistochemically, the tumor cells were positive for vimentin, cytokeratin, smooth muscle actin, HHF‐35 and Fli‐1. The tumor was subsequently diagnosed as a PF, although it was difficult to differentiate from a sarcoma. Five years after surgery, the postoperative course has been uneventful with no recurrence or metastasis.