Surgery

Appropriate antibiotics in dog bite injuries: an audit study Background: Dog bite injuries are a common presentation to Accident and Emergency. In the United Kingdom ~250,000 people attend emergency units each year as a result of dog wounds. Currently, there is a lack of consistency in the approach and management of such wounds across plastic surgery units in the United Kingdom. Method: A retrospective review of medical record of patients who were admitted under the care of the Plastic Surgery Department at University Hospital North Midlands NHS Foundation Trust with dog-bite wounds between January and December 2018. Results: Of the 69 patients that were included in the study, 14 (20%) of them had been prescribed antibiotics that were ineffective and against antimicrobial guidelines. Following liaison with the antimicrobial governance team and input from NICE guidelines, the trust's MicroGuide Antibiotic Prescribing Guidelines App was updated. A reaudit from November 2019 to February 2020 showed that there was 100% compliance with guidance. Conclusion: Updating the University Hospital of North Midlands NHS Trust's MicroGuide antibiotic prescribing guidelines for the treatment of dog-bite injuries resulted in 100% of patients being treated with the correct antibiotic. Given the polymicrobial nature of animal-bite wounds, and the high levels of resistance demonstrated by organisms commonly found in such injuries, this increased compliance with guidelines helps minimize patient suffering, morbidity, length of stay, and disability, while reducing costs incurred. The intervention should be implemented within other units within the United Kingdom who similarly lack clear, detailed guidelines, in order to maximize treatment continuity and patient outcomes nationwide.

Mesenteric lymphadenopathy in COVID-19 infection (Jammu and Kashmir sign) as a presenting sign in adult: case report Introduction: Mesenteric lymphadenopathy in an adult with gastrointestinal COVID-19 infection is a very rare. Ultrasonography is helpful in the diagnosis of mesenteric lymphadenopathy in COVID-19 infection. Presentation of Case: A 33-year-old man presented with recurrent abdominal pain of 5 days duration. Ultrasonography and computed tomography of abdomen documented findings of the diffuse mesenteric lymphadenopathy, mostly on the left upper abdomen followed by right upper abdomen. Real time-polymerase chain reaction for SARS-CoV-2 was found reactive. Patient was managed by the local protocol and had regression of mesenteric lymphadenopathy. Discussion: This is a first kind of case report where an adult patient having gastrointestinal COVID-19 infection presented with mesenteric lymphadenopathy only and named as the "Jammu and Kashmir sign (JK sign) in COVID-19 infection." Conclusion: Mesenteric lymphadenopathy in an adult with COVID-19 infection is very rare. This may be the only presenting sign in gastrointestinal COVID-19 infection.

Grafting a spherical hidradenitis-affected scrotal raw area using a sterile glove: a case report describing the Al Lahham technique Introduction: Hidradenitis suppurative (HS) is a chronic inflammatory skin condition that can be resistant to medical treatment, in which case the surgical option stands out as the only solution. In this paper, we present a case of severe hidradenitis treated surgically, and we introduce a simple way to secure a graft on a big circumferential area. Presentation of case: Our case is a severe form of HS involving both the axillary, the inguinal region and the scrotum that required multistaged surgery; the challenge was in the final stage, that is the grafting of the scrotum. To secure the graft on a big circumferential area we used our own technique that is simple and can be conducted in any hospital setting. Discussion: Surgical treatment of HS includes wide debridement and reconstruction with grafts or flaps. Using a piece of sterile glove to secure the graft is useful because of its stretchable properties that can compress the graft and the ability to maintain a moist environment that promotes healing, with making slits it can also help in draining excess fluids. Conclusion: We recommend testing this technique when grafting the scrotum or any circumferential area to secure the grafts.

Delivering high quality documentation on operative consent forms: a UK major trauma center Quality Improvement Project Background: Royal College of Surgeons guidelines exist on the importance of full, accurate and legible completion of consent forms as a key part of the process of gaining informed consent. In addition to this, consent forms serve as an important medico-legal document to protect clinicians and patients should problems arise. It is therefore in all parties' interests that they are correctly completed. It was noted that consent forms within the Royal London Hospital Plastic Surgery department were often not correctly completed. A Quality Improvement Project was undertaken to improve the completion of consent forms within the department. Materials and methods: Common problem areas on consent forms were identified and Quality Improvement (QI) methodology was used to design the study including selection of appropriate outcome, process and balancing measures. Baseline information on completion of: (1) patient details, (2) consultant details, (3) legibility, (4) use of abbreviations in description of operation/complications, and (5) patient signatures was collected. Four weekly interventions were made which were accompanied by 4 further data collection cycles. A further reaudit took place 4 months following the completion of the project to establish whether improvements had been sustained. Results: Over the 5 QI data collection cycles the average completion of the 3 outcome measures rose from 59% to 93% and 4 months later was sustained at 91%. Outcome measure 1 (legibility of documentation) rose from 62% to 100%. Outcome measure 2 (omission of abbreviations) rose from 33% to 79%. Outcome measure 3 (patient signature) rose from 81% to 100%. Conclusion: This Quality Improvement Project led to a significant and sustained improvement in quality of completion of consent forms within the department with the most marked improvement in omission of abbreviations. This quality improvement methodology could easily be adapted for other surgical specialities.

Unusual presentation of metastatic malignant melanoma: a case report Introduction: The presentation of metastatic lesion of malignant melanoma (MM) may be unusual, as this case, in which the lesions were multicystic swelling over right arm and necrotized swelling at right chest wall. Identifying the unusual variants of MM is important to allow application of the most appropriate treatment strategies before something wrong happens. Methods: This case report has been prepared following the SCARE guideline 2018, a surgical case report guidelines. Presentation of the case: A 60-year-old man presented with a 14-month history of swelling on right arm and anterior chest wall with the chief complain of blackish discharge from the latter. Six months ago, he amputated his right thumb for melanoma after a histopathology evaluation. It was an unusual presentation of a metastatic lesion of MM. On the basis of the histopathology report, the final diagnosis of our patient was subcuticular metastatic MM which has a very poor prognosis. According to TNM classification, the final diagnosis of the case was T4bN0M1a. Although he has been under regular follow-up, the lesions are still present and his health condition is deteriorating. Discussion: Metastatic melanomas are often rare; their misdiagnosis potentially jeopardizes patients' health and survival, and have medico-legal implications. Melanoma often has a protracted disease course, in which patients have a disease-free period following surgical excision of the primary tumor, only to discover visceral metastases—months, years, or even decades later. Melanoma metastasis is an ominous sign as it generally predicts a poor prognosis. This case is an unusual presentation of metastatic melanoma where, with the elaboration of history and proper examination of lesion, the diagnosis of metastatic melanoma was made. Conclusion: Metastatic MM has a very poor prognosis and an early diagnosis with clinical presentation is very essential in a country where health facilities are not well developed. Knowing the unusual variants of MM is important to allow application of the most appropriate treatment strategies before something wrong happens.

An excuse to misuse? Evaluating the use of prophylactic antibiotics in elective skin graft surgery: a systematic review and meta-analysis Introduction: Plastic surgeons may opt to administer prophylactic perioperative antibiotics in elective skin graft surgeries to curtail the risk of surgical site infections (SSI). However, the use of antibiotics brings the risk of adverse events or antibiotic resistance and evidence comparing the risk versus benefit is still lacking. Thus, there are no specific guidelines regarding the use of antibiotics prophylaxis in skin graft surgery and the potential for misuse of antibiotics is high. Methodology: A systematic literature search was conducted to retrieve all articles comparing the use versus nonuse of "prophylactic antibiotics" in "skin graft surgery" on March 29, 2020. All comparative study designs were considered for inclusion. The primary outcome was occurrence of SSI. A meta-analysis using the Mantel-Haenszel method with random effect model was used to pool the effect estimates from included studies. Result: A total of 1403 articles were identified, of which, 6 were included in the meta-analysis. The 6 articles included were all comparative studies (5 RCTs and 1 cohort study) and reported the outcomes of 391 patients and 404 grafts. A total of 202 patients received prophylactic antibiotics and 202 patients did not receive antibiotics. All 6 studies were included in the meta-analysis. The overall pooled effect estimates comparing treatment groups showed no significant difference for outcomes in terms of SSI (odds ratio: 0.43; 95% confidence interval: 0.18, 1.02; I2 0%; P=0.06). Conclusion: Incidence of SSI in elective skin graft surgery is relatively low. Our data shows there is limited utility in the use of prophylactic antibiotics to prevent clinically significant SSI in patients undergoing elective skin graft surgery. However, there are still only a small number of studies conducted on the topic to date, and more work is required before definitive conclusions can be used.

Improving ceiling of care decisions and documentation for oncology patients Hospitalized medically unwell patients can be at risk of in-hospital cardiac arrest and previous studies have demonstrated poor survival after in-hospital cardiac arrests, even despite cardiopulmonary resuscitation (CPR). The rate of success is even lower in patients with metastatic malignancy. Since CPR remains the standard treatment for in-hospital cardiac arrest patients, a "do not attempt cardiopulmonary resuscitation" order (DNACPR) needs to be in place to avoid inappropriate resuscitations in patients with poor chances of in-hospital cardiac arrest survival. More recently, ceiling of care documents such as a Medical Advance Plan have also been developed to provide clinicians a framework for individualised treatment escalation. In this study, we examined the uptake of both national National Confidential Enquiry into Patient Outcome and Death (NCEPOD) and local guidelines to ensure that all acutely admitted oncology patients at a single centre had a CPR status and a Medical Advance Plan.

COVID-19 and orthopedic surgery education: experience from Algeria The COVID-19 pandemic has had a significant impact on the Algerian orthopedic surgery residency programs. Medical education has been negatively impacted. From an educational standpoint, teaching conferences for residents have been suspended. Grand rounds and in-person meetings have also been cancelled to comply with social distancing recommendations. In addition, most orthopaedic departments reduced the number of days per week worked by each resident and the number of residents in the hospital at any one time. Adapted measures must be taken to face this unprecedented challenge and ensure the continuity of training for our residents. The new technology solutions such as webinars should be integrated to the residents' academic programs. Finally, maintaining resident wellbeing is an important factor to consider.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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