Major liver surgery in a Jehovah’s Witness patient: challenges for safe surgery

Jehovah’s Witnesses presenting for major surgery run the risk of major bleeding, which is complicated by the refusal to accept blood transfusion. We present a case of a 63-year-old woman, a Jehovah’s Witness, who was diagnosed with hepatocellular carcinoma and advised for curative laparoscopic liver segmentectomy. Due to the risk of significant intraoperative haemorrhage, her perioperative care was coordinated in a multidisciplinary manner. Informed consent requires the physician to advise on the material risks of undertaking major surgery without blood transfusion and the possible alternatives. Conflicting ethical issues of patient autonomy and beneficence related to refusal of blood products also arise. Perioperative strategies to minimise blood loss, maximise haematopoiesis and tolerance of anaemia to facilitate safe surgery in such patients are also presented. Written patient consent obtained.

Simplified noncultured autologous cell grafting for the treatment of chronic nonhealing ulcers: the six-well plate technique

Chronic recalcitrant ulcers are associated with severe morbidity, and there are few effective treatment options available. Living skin substitutes are an important form of adjuvant therapy to enhance healing of such wounds. We investigated a novel, simplified, noncultured, autologous, cell grafting procedure, using a six-well plate technique, to treat chronic recalcitrant wounds. This was a prospective pilot study that involved harvesting an ultrathin split-skin graft from the gluteal region, which was washed, separated and prepared in six different wells to obtain an autologous mixture of keratinocytes, melanocytes and fibroblasts; this was subsequently applied directly to the wound using a hyaluronic acid (HA) matrix. Eight patients with a total of 14 ulcers were recruited. The primary endpoint assessed was the percentage of re-epithelialization of the ulcers. Secondary endpoints included quality of life and wound bed indices. At baseline, the median wound surface area was 7.4 cm(2) (mean 17.6 ± 23.6 cm(2) , range 0.5-80.0 cm(2) ) with a median duration of 18 months (mean 70.2 ± 95.9, range 3-216 months). The median wound surface area was reduced by 74.3%, from 7.4-1.9 cm(2) , at the final visit. Overall, 28.3% of the ulcers achieved complete healing, and 71.3% of the ulcers had reduction in wound size. Post-graft, there was also improvement in secondary wound bed parameters and all quality of life domains of the Cardiff Wound Impact Schedule. These results suggest that this noncultured autologous six-well technique might be beneficial for treating recalcitrant ulcers.

Revised classification/nomenclature of vitiligo and related issues: the Vitiligo Global Issues Consensus Conference

During the 2011 International Pigment Cell Conference (IPCC), the Vitiligo European Taskforce (VETF) convened a consensus conference on issues of global importance for vitiligo clinical research. As suggested by an international panel of experts, the conference focused on four topics: classification and nomenclature; definition of stable disease; definition of Koebner's phenomenon (KP); and 'autoimmune vitiligo'. These topics were discussed in seven working groups representing different geographical regions. A consensus emerged that segmental vitiligo be classified separately from all other forms of vitiligo and that the term 'vitiligo' be used as an umbrella term for all non-segmental forms of vitiligo, including 'mixed vitiligo' in which segmental and non-segmental vitiligo are combined and which is considered a subgroup of vitiligo. Further, the conference recommends that disease stability be best assessed based on the stability of individual lesions rather than the overall stability of the disease as the latter is difficult to define precisely and reliably. The conference also endorsed the classification of KP for vitiligo as proposed by the VETF (history based, clinical observation based, or experimentally induced). Lastly, the conference agreed that 'autoimmune vitiligo' should not be used as a separate classification as published evidence indicates that the pathophysiology of all forms of vitiligo likely involves autoimmune or inflammatory mechanisms.

Spleen-preserving distal pancreatectomy

INTRODUCTION

Splenectomy is routinely performed in conventional distal pancreatectomies. Spleen removal with its possible sequelae of infections and haematological complications has prompted the development of spleen-preserving techniques. This study aimed to evaluate the safety and clinical outcomes of distal pancreatectomy with preservation of the spleen.

METHODS

A retrospective review of 24 consecutive patients who underwent spleen-preserving distal pancreatectomy in a tertiary care hospital was conducted.

RESULTS

There were 17 female and seven male patients, and the mean age was 47 (range 14-77) years. Median American Society of Anesthesiologists score was II (range I-III) . The indications were as follows : mucinous cystadenoma (n = 7), serous cystadenoma (n = 6), insulinoma (n = 3), intraductal papillary mucinous tumour (n = 2), pseudocyst (n = 3), papillary cystic adenoma (n = 1), neuroendocrine neoplasm (n = 1), and metastatic carcinoma of the thyroid (n = 1). Two patients developed postoperative pancreatic fistula and another two patients developed postoperative ileus with spontaneous resolution. Mean operative time was 172 (range 105-250) minutes. Mean length of postoperative hospital stay was 6.7 (range 5-11) days. There was no perioperative mortality in this series.

CONCLUSION

Spleen-preserving distal pancreatectomy can be safely performed with low morbidity, and should be considered in the surgical management of distal pancreatic disease.

Darier's disease in Singapore

BACKGROUND

Darier's disease is a rare, dominantly inherited genodermatosis. Although it has been well studied in caucasians, very little is known about the clinical spectrum of this disorder among Asians.

OBJECTIVES

To determine the demographic and clinical profile of Asian patients with Darier's disease.

METHODS

This is a retrospective study of all new cases of Darier's disease seen in our centre over a 20-year period (1982-2002). Results Twenty-four nonrelated cases of Darier's disease were studied. The incidence rate was 3.1 per million per decade. The gender distribution was 19 males and five females, and the ethnic origin was 21 Chinese, two Malays and one Nepalese. The peak age of onset was between 11 and 20 years. Sun exposure exacerbated the disease in 13 of the patients, and three had neuropsychiatric disorders. The disease affected predominantly seborrhoeic areas in 19 patients, flexural in three, acral in one and was segmental in one patient. Hand involvement was common and included palmar pits in nine patients, acrokeratosis verruciformis in four and nail changes in 12 patients. Haemorrhagic macules were not seen. Rare features included oral mucosal lesions (two patients) and guttate leucoderma (three patients). Pathogens involved in cutaneous infections included herpes simplex virus, Staphylococcus aureus, Streptococcus species and Morganella morgani. All patients treated with oral retinoids had improvement of clinical signs. In contrast, the response to topical retinoids was poor.

CONCLUSIONS

Compared with western studies, our results show a similar incidence rate, age of onset, distribution of disease patterns and association with neuropsychiatric disorders. Features that differ include co-occurrence of guttate leucoderma, rarity of acrokeratosis, absence of haemorrhagic macules and poor response to topical retinoids.

Viral warts in children seen at a tertiary referral centre

INTRODUCTION

This study aims to determine the epidemiology of viral warts in children seen at a tertiary referral centre and the treatments used.

MATERIALS AND METHODS

This is a retrospective study of viral warts in children aged 12 years and below seen at the National Skin Centre in the year 2000.

RESULTS

There were 302 cases of viral warts, 187 (61.9%) in boys and 115 (38.1%) in girls. The greatest number was seen at age 12 and none were noted in those below 1 year of age. The racial breakdown was as follows: 69.9% Chinese, 13.9% Malays, 11.3% Indians and 4.9% of other ethnic groups. Treatment with liquid nitrogen was used most commonly in 267 (88.4%) cases, with a clearance rate of 48.3%. Electrocautery was used in 11 cases with complete clearance in 8 cases.

CONCLUSION

Viral warts are common in children, but uncommon in infants. There is no difference in distribution of warts among the races in Singapore. Liquid nitrogen and electrocautery are effective treatments of viral warts in children.

Effect of food-simulating liquids on the flexural strength of composite and polyacid-modified composite restoratives

This study investigates the effects of food-simulating liquids on composite and polyacid-modified composite restoratives. Three composite (Z100, Spectrum TPH, and Tetric Ceram) and three polyacid-modified composite (F2000, Dyract AP, and Compoglass) restoratives from the same manufacturers were selected for the study. Flexural strength specimens (25 x 2 x 2 mm) based on ISO 4049 specifications were fabricated according to the manufacturers recommendations. After light polymerization, the specimens were removed from their molds and conditioned for one week at 37 degrees C in the following mediums: (1) deionized water, (2) 0.02 M citric acid, (3) heptane, and (4) 50% ethanol-water solution. Specimens stored in air were used as controls. The sample size was five for each material-medium combination. After conditioning, the specimens were blotted dry, measured, and subjected to flexural strength testing using an Instron Universal Testing Machine with a crosshead speed of 0.05 mm/minute. With the exception of Compoglass, flexural strength of all restoratives after conditioning in heptane was significantly greater than that after conditioning in all other mediums and the control. Although no significant difference in flexural strength values was observed between the different restoratives when the materials were conditioned in heptane or air (control), significant differences were observed between the different restoratives after conditioning in aqueous solutions (water, citric acid, and ethanol-water solution). The flexural strengths of the composites were generally significantly higher than their polyacid-modified counterparts after conditioning in the various aqueous solutions. The detrimental effects of aqueous solutions on flexural strength appeared to be greater with polyacid-modified composite resins than with composite restoratives.

Case reports of linear IgA bullous dermatosis of childhood

Linear IgA bullous dermatosis of childhood (LADC) is an uncommon acquired blistering skin disorder which affects young children. It is characterised by a linear band of IgA at the epidermal basement membrane on direct immunofluorescence. From 1984 to 1988 at the previous skin centre at Middle Road Hospital, and 1989 to 1997 at the present National Skin Centre, a total of 4 cases were seen. All the patients were female and their ages ranged from 5 to 14 years (mean 8 years). There were 2 Chinese, 1 Caucasian and 1 Malay. All presented with an acute onset of blistering of 1 to 3 weeks' duration. Their skin biopsies showed subepidermal bullae with neutrophils, with/without eosinophils and direct immunofluorescence tests revealed linear deposits of IgA along the dermoepidermal junction. All were treated with prednisolone and dapsone with good results. One patient developed dapsone-induced haemolysis and treatment was changed to colchicine. We review the epidemiology, aetiology, current concepts and treatment modalities of this condition.