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Collagenase injection was approved in Europe for use in the treatment of Dupuytren's disease in 2011. Reported adverse effects include skin tears, swelling, pain and complex regional pain syndrome. Here, we present a case of a rare complication of phalangeal fracture following treatment with collagenase clostridium and the resultant digital amputation. An 81-year-old man was treated for a 25-year history of progressively disabling Dupuytren's disease of his left middle and ring fingers. Nine days post-manipulation he presented with persistent pain and swelling and was diagnosed with a displaced fracture of the proximal phalanx of his ring finger. Following discussion of surgical options and potential outcome, he elected to undergo amputation of the digit. He has experienced good treatment results in his middle finger and has no significant functional impairment as a result of this complication. Those offering collagenase injection in the management of Dupuytren's disease should be aware of this potential complication and it should be included in the consent process.

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PURPOSE: Cancer-related fatigue (CRF) biology remains poorly understood. Responsible mechanisms may be central or peripheral and originate anywhere from the brain to muscle fiber. Objective measurement is complex and previously limited to specialized laboratories. Portable electroencephalography (EEG) and electromyography (EMG) may enhance objective measurement. This study evaluated the feasibility and acceptability of portable EMG-EEG in CRF assessment. METHODS: A prospective observational feasibility study compared ten outpatients with inoperable, treatment-naïve non-small cell lung cancer and CRF to ten healthy volunteers. All completed a sustained isometric hand-grip contraction at 30% maximal level until self-perceived exhaustion. 128-channel EEG and 2-channel EMG signals of forearm muscles were recorded. Device acceptability was evaluated by questionnaire. RESULTS: The task was evaluated in two stages; first and last 20 s. CRF cohort perceived exhaustion earlier than volunteers (mean 137 ± 76 s vs 208 ± 51 s). As fatigue progressed, EMG amplitude increased significantly (CRF p = 0.02; volunteers: p = 0.04) in both groups as did EMG beta band power (CRF p = 0.008; volunteers: p = 0.006). The increase was significantly less in CRF (amplitude p = 0.032; beta power: p = 0.014). EEG beta band power in the contralateral motor cortex increased significantly (CRF p = 0.03; volunteers: p = 0.019) in both cohorts but to greater extent (p = 0.024) in CRF. One hundred percent device acceptability was reported. CONCLUSIONS: A laboratory-based evaluation was successfully adapted to the outpatient setting during routine visits. High acceptability supports clinical utility. In CRF, a higher degree of cortical activation was required to drive a much lower level of muscle performance. This suggests impairment of both central and peripheral mechanisms in CRF.

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The authors wished to obtain a 'snapshot' of the range of practice in the management of split skin graft donor sites in the British Isles. Material/Methods Questionnaires were sent to all British consultants and locum consultant plastic surgeons on July 1, 2006. Of the 357 questionnaires, 279 were returned (a response rate of 78%). Results Alginates were the most popular dressings, especially in adult donor sites - first choice for 167 respondents (60%). Adhesive fabrics were less popular - first choice for small adult donor areas for 46 respondents (16%). Plastic film dressings and Biobrane were even less popular - being the first choice for small and large donor areas, respectively, in children (for approximately 5% of respondents). Ten percent of respondents said they avoid paraffin gauze and another 10% avoid plastic film dressings in all cases. Five percent avoid hydrocolloid and another 5% avoid adhesive fabric in all cases. Conclusion on the basis of these results, the authors feel that any future study of donor-site dressings should incorporate the most commonly used dressing (alginate) as a control.

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OBJECTIVES: We report a rare case of burns following the use of automated air-fresheners. METHODS: We present a case report with a brief overview of the literature relating to burns associated with air-fresheners. The mechanism and treatment of these types of injuries are also described. RESULTS: A 44 year-old female was admitted under the care of the burns team following burns secondary to an exploding air-freshener canister. The patient sustained burns to the face, thorax and arms resulting in a seven-day hospital admission. The burns were treated conservatively. CONCLUSIONS: To our knowledge this is one of the few documented cases of burns as a result of air-fresheners. As they become more ubiquitous, we anticipate the incidence of such cases to increase. As such, they pose a potential public health concern on a massive scale.

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UNLABELLED: The authors wished to obtain a 'snapshot' of the range of practice in the management of split skin graft donor sites in the British Isles. MATERIAL/METHODS: Questionnaires were sent to all British consultants and locum consultant plastic surgeons on 1 July 2006. Of the 357 questionnaires, 279 were returned (a response rate of 78%). RESULTS: Alginates were the most popular dressings, especially in adult donor sites--first choice for 167 respondents (60%). Adhesive fabrics were less popular--first choice for small adult donor areas for 46 respondents (16%). Plastic film dressings and Biobrane were even less popular--being the first choice for small and large donor areas, respectively, in children (for approximately 5% of respondents). Ten percent of respondents said they avoid paraffin gauze and another 10% avoid plastic film dressings in all cases. Five percent avoid hydrocolloid and another 5% avoid adhesive fabric in all cases. CONCLUSION: On the basis of these results, we feel that any future study of donor-site dressings should incorporate the most commonly used dressing (alginate) as a control.

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Intraarticular phalangeal fractures are difficult to treat. The advantages of using dynamic external fixation devices include distraction of impacted fracture fragments and reduction in joint stiffness by allowing early joint mobilization. Previous reports have concentrated on pilon fractures and dorsal fracture dislocations affecting the proximal interphalangeal joint. We report our experience using a dynamic external spring fixator in the management of 15 patients with a variety of fracture patterns affecting the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints. In three cases the device spanned two adjacent joints. Long-term follow-up has shown excellent range of joint movement and no major complications. We consider that this device is an effective tool in the management of a range on complex intraarticular phalangeal fractures.

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The training of surgeons has traditionally been an apprenticeship. In recent times it has become increasingly difficult for trainees to acquire operative skills. The acquisition and refinement of these technical skills by the surgical trainee are central to surgical teaching. Much work has been done looking into the theories of motor skill learning, working on the assumptions that if they are understood then tests may be developed to be used as skill predictors. Two schools of thought exist as to the use of neuropsychological factors in learning fine motor skills but all agree that practice and instructional feedback are essential for the correct acquisition of these essential surgical skills. With the current climate of shortened training and new guidelines its even more important to understand skill acquisition and assist in the learning of new surgical skills.

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INTRODUCTION: The effective management of pain requires a multidisciplinary approach. Previous studies have suggested that around 8% of cancer patients will require interventional techniques from an anaesthetist with special interest in pain management to maximize pain control, although this percentage may increase in the cohort of patients with difficult pain syndromes under the care of specialist palliative care services. We wished to determine the experiences and views of other palliative care physicians with regard to input from specialists in pain management. METHOD: A postal questionnaire was sent to the consultant members of the Association of Palliative Medicine. RESULTS: Most respondents had access to 'as-required' anaesthetist consultations with 72% of respondents feeling that the frequency of consultation was adequate. However, over half of the respondents had used the services of a pain management specialist less than four times in the past year and a quarter of respondents had not been involved in a joint consultation with an anaesthetist in the past year. All respondents felt that the pain management specialist's role included advice on technical procedures but less than 25% felt that their role should extend to advice on prescribing analgesics. DISCUSSION: There are likely to be several reasons for this apparent underutilization of specialist anaesthetist/pain management services. This survey has identified possible factors including lack of formal arrangements, lack of suitable experience and the attitudes of palliative medicine consultants.

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In this first such study in an Irish setting, patients referred to a Hospice Home Care Team were asked where they would prefer to die, and were then followed until death to determine actual place of death, and factors that influenced same. Over 80% expressed a preference to die at home. Almost 50% of those who expressed a preference for a home death actually died there. Of those admitted to hospital or hospice to die, uncontrolled symptoms and inability of family to cope were the main reasons precipitating admission. On closer assessment, it was felt that a significant minority of those admitted could have been cared for at home had additional resources been available in the community. Facilitating choice in place of care for the dying is acknowledged government policy and, as such, greater resources should be made available to community health and social services to support ongoing care at home.

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Some patients with advanced cancer express the wish for an early death. This may be associated with depression. We examined the relations between depressive symptoms and desire for early death (natural or by euthanasia or physician-assisted suicide) in 142 terminally ill patients with cancer being cared for by a specialist palliative care team. They completed the Hospital Anxiety and Depression Scale questionnaire and answered four supplementary questions on desire for early death. Only 2 patients expressed a strong wish for death by some form of suicide or euthanasia. 120 denied that they ever wished for early release. The desire for early death correlated with depression scores. Depressive symptoms were common in the whole group but few were on antidepressant therapy. Better recognition and treatment of depression might improve the lives of people with terminal illness and so lessen desire for early death, whether natural or by suicide.

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An uncontrolled retrospective study was conducted looking at the use of oral controlled-release hydromorphone in palliative care patients. Over a 2-year period 55 patients were switched to hydromorphone therapy, and the efficacy and outcomes were assessed. Urea and electrolyte measurements were also recorded at the time of opioid switch and renal impairment defined as urea > 10.5 mmol/l and/or creatinine > or = 101 mmol/l. This group of 29 patients with abnormal urea and/or creatinine (Group 1) was compared with the remaining 26 patients (Group 2) who had normal urea and creatinine. The major reasons for change to hydromorphone were side-effects (cognitive/drowsiness/nausea) on previous therapy. Following a switch to hydromorphone these side-effects improved in over 80% of patients (n = 55). Comparison between Group 1 and 2 demonstrated a significant difference in renal function but no significant differences in reasons for change, dose of opioids or response to change (over 80% improvement following opioid switch). We conclude that hydromorphone is a flexible second-line alternative to morphine that is particularly useful when intolerable side-effects are experienced with other opioids. In renal impairment (including two patients with end-stage renal failure) we found hydromorphone to be safe and effective. Further clinical and pharmacokinetic studies are required.

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The objectives of this study were (i) to assess the level of knowledge with respect to pain and symptom management among doctors in their first year after graduation and (ii) to measure the impact of a structured teaching programme on their level of knowledge. All 34 newly qualified junior house officers in one teaching hospital were offered a six-session teaching programme in pain and symptom management. A multiple-choice questionnaire was used to assess their level of knowledge at the beginning and at the end of a 6-month period over which the teaching sessions took place. Attendance at and satisfaction with the programme were high. There was a significant improvement in the level of knowledge at the end of the programme, with the greatest improvement in those who attended most sessions. The low scores recorded for the questionnaire administered before the teaching programme suggest that there is a critical need for improved education in palliative care amongst newly qualified doctors. We have shown that a simple in-service case-based teaching programme can meet this need effectively.

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