Live book 9

Candidate Shift — Hand Infections & Ganglion: Drain Tenosynovitis Urgently, Incise Felons Safely, Excise the Ganglion Stalk (Addendum Summary, Ch 8)Treat Kanavel-positive flexor tenosynovitis as a surgical emergency (sheath irrigation/drainage), incise felons longitudinally sparing the neurovascular bundle, and excise ganglion cysts down to the joint-capsule stalk.Candidate Shift — Hyperhidrosis: Climb the Conservative Ladder; Sympathectomy at R3/R4 Only, Sparing T2 (Addendum Summary, Ch 8)Treat focal hyperhidrosis stepwise (topical, iontophoresis, botulinum toxin, oral agents) and reserve VATS sympathectomy for refractory palmar disease — at R3/R4, strictly sparing the T2/stellate ganglion.Practice Shift — Diabetic Foot: Urgent Source Control First, WIfI for Staging — Never the Other Way Round (Table 8.1, Pathway 8E)Sequence diabetic foot care by urgency: debride severe infection within 24 hours without waiting for staging or vascular workup, then stage with SVS WIfI, revascularize promptly below the printed pressure thresholds, and pair bone-biopsy-guided antimicrobials with off-loading.Practice Shift — Hidradenitis Suppurativa: Biologic Continued Through Surgery; Keloid: Never Excise Without Adjuvant (Addendum §12.1, Row 5)Treat Hurley II–III hidradenitis with biologic therapy continued uninterrupted through deroofing or wide excision — not repeated drainage and short antibiotic courses, and not stopping the biologic for surgery — and never excise a keloid without immediate adjuvant therapy.Practice Shift — High-Risk BCC/cSCC and DFSP: Mohs or Complete Margin Assessment (Addendum §12.1, Row 3)Match margin control to risk in non-melanoma skin cancer: standard 4 mm / 4–6 mm excision for low-risk BCC and cSCC, Mohs or complete circumferential margin assessment for high-risk facial tumors and DFSP — and PD-1 blockade instead of mutilating resection in borderline-resectable cSCC.Practice Shift — Melanoma: Excisional Biopsy, Breslow-Set Margins, SLNB for T1b (Addendum §12.1, Row 1)Biopsy pigmented lesions by full-thickness excision with a 1–3 mm margin, set wide-excision margins strictly by Breslow thickness, and perform SLNB together with the wide excision for T1b cN0 melanoma — no shave biopsies, no 3–5 cm radical margins, no routine elective node dissection.Practice Shift — Soft-Tissue Mass: MRI and Planned Core Biopsy Before Any Excision (Addendum §12.1, Row 4)Image and core-biopsy any deep, firm, fixed or >5 cm soft-tissue mass before touching it — contrast MRI and a multiple-pass core biopsy along the planned incision, with multidisciplinary sarcoma planning — and never shell out a suspected sarcoma in the office.Practice Shift — Stage III Melanoma: No Routine CLND for Microscopic Disease, Neoadjuvant Immunotherapy for Macroscopic (Addendum §12.1, Row 2)Stop completing every positive sentinel node basin: microscopic pN1a melanoma gets nodal ultrasound surveillance plus adjuvant systemic therapy, and macroscopic resectable Stage III disease gets neoadjuvant immunotherapy before resection.Stepwise Clinical Decision Pathway — Cutaneous Oncology, Sarcoma, Complex Wounds & Burns (§12.2)Work the cutaneous oncology pathway in four steps: biopsy suspicious pigmented lesions whole and stop for MRI + core-needle biopsy on any red-flag soft-tissue mass, run melanoma excision by Breslow margins with the microscopic-versus-macroscopic nodal split, carry hidradenitis biologics through wide excision, and resuscitate burns by the ABA protocol with early escharotomy and excision.

Codes 39

PED-PLB-COMP-01 — Bleeding1–2% — Bleeding following Plastibell circumcision as reported in the source seriesPED-PLB-COMP-02 — Infection~0.5–1% — Post-procedural infection as reported in the source seriesPED-PLB-COMP-03 — Delayed / retained ring — age-stratified (mandatory)2–5% — Delayed separation or retention of the Plastibell ringPED-PLB-COMP-04 — Glans / urethral injury<1% — Injury to glans or urethra attributable to the device/procedurePER-DFU-COMP-01 — Infection58% · ≈50–60% — (a) Infected at presentation to specialist centres; (b) ulcers becoming infected over their course — two labelled metricsPER-DFU-COMP-02 — HospitalisationUp to ~20% — DFU patients requiring hospital admissionPER-DFU-CTX-01 — DFU precedes ~80% of diabetes-related amputations; 5-year mortality ~30% (context)CONTEXT ONLY: DFU precedes ~80% of diabetes-related amputations; 5-yr mortality ~30% — This is the reason prevention matters, quoted once.PER-DFU-PREV-01 — Lifetime incidence of DFU19–34% — Proportion of people with diabetes who develop ≥1 foot ulcer during their lifetimePER-DFU-PREV-02 — Annual incidence of DFU~2% per year (2.2% in the UK community study) — New ulcers per year among people with diabetesPER-DFU-PREV-03 — Point prevalence of active DFU6.3% (95% CI 5.4–7.3) — Proportion of people with diabetes with an active foot ulcer at a given timePER-DFU-PREV-04 — Diabetic peripheral neuropathy — prevalencePoint prevalence ≈30% · and · ~50% develop DPN over a lifetime — DPN by clinical/neurophysiological criteria — two different metrics, published split, never blended (Dispute D4)PER-DFU-PREV-05 — PAD among people with a DFU49% — PAD diagnosed (ABI <0.9 in EURODIALE) in patients presenting with a new DFUPER-DFU-PREV-06 — Ulcer composition by perfusion statusNo PAD: 51% · PAD present: 49% · majority · purely ischaemic ulcers are a small minority — EURODIALE 4-stage classification by PAD ± infection at presentationPER-DFU-PROT-01 — Pressure-relieving therapeutic footwear (custom-made / demonstrated pressure relief, worn indoors + outdoors)13.3% vs 25.4% · RR 0.49 (95% CI 0.28–0.84) · halves — Ulcer recurrence with usual footwear — , i.e. roughly recurrencePER-DFU-PROT-02 — The footwear effect is conditional on pressure relief + adherenceOR 2.33 · neither · and — Recurrence when condition was met (in-shoe peak pressure <200 kPa device adherence >80% of steps). Wearing the device is not enough — it must actually offload, and actually be wornPER-DFU-PROT-03 — Home foot-temperature monitoring (daily plantar temperature; act if >2.2 °C difference vs the other foot on 2 consecutive days)Disputed — see D2. · 0.51 · RR 0.78 (0.57–1.08), p=0.133 — not significant · Adopted position: a real but adherence-dependent adjunct — never headline "halves your risk" unqualified — 🔴 Pooled MA of 4 early RCTs: effect ≈ (95% CI 0.31–0.84; absolute recurrence 18.7% vs 30.8%). Largest pragmatic RCT (DIATEMP, n=304, 18 months): primary endpoint ; any-site recurrence RR 0.76 (0.58–1.00), p=0.046; the subgroup who actually reduced activity on a hotspot: RR 0.34 (0.11–0.99).PER-DFU-PROT-04 — Structured foot-care education aloneNo adoptable protective number. · insufficient and inconsistent · Low — Cochrane (12 RCTs): education improves knowledge and short-term self-care behaviour, but evidence that *limited education alone* reduces ulcer incidence is — the one positive ulcer result (RR 0.31) came from a high-bias-risk trial, while the lower-bias-risk trial found RR 1.00 (0.70–1.44). IWGDF nonetheless recommends structured education as a component of care (Strong recommendation, certainty)PER-DFU-PROT-05 — Risk stratification + scheduled foot screeningRisk 0 · yearly · Risk 1 · 6–12-monthly · Risk 2 · 3–6-monthly · Risk 3 · 1–3-monthly · Honesty note: no RCT isolates screening itself as the intervention that reduces ulcer incidence — IWGDF system: (no LOPS/PAD) → screen ; (LOPS or PAD) → ; (LOPS+PAD, or either + deformity) → ; (LOPS or PAD + prior ulcer/amputation/end-stage renal disease) → . Population distribution of categories (JAMA, adapted from Stang & Leese): risk 0 ≈78.6%, risk 1 ≈14.2%, risk 2 ≈4.3%, risk 3 ≈1.8%. — screening works by triggering footwear, education and care intensity; IWGDF grades the stratification/prognosis evidence High, the downstream pathway is what carries the effectPER-DFU-PROT-06 — Integrated foot care (professional foot care + adequate footwear + structured education, repeated: 1–3-monthly if high risk, 3–6-monthly if moderate)No single pooled ulcer-incidence figure verified · amputation · outside this dossier's scope and not quoted — recommended as a package by IWGDF (Strong; Low certainty). The components with numbers are carded separately above (footwear PROT-01; education PROT-04). The multidisciplinary-care effect most often quoted is an outcome and is thereforePER-DFU-REC-01 — Recurrence after healing42% at 1 year · 58% at 3 years · 65% at 5 years — Any new ulcer after complete healing of the index ulcer (same or different site)PER-DFU-RISK-01 — Loss of protective sensation (LOPS)Likelihood ratio 11–16 · OR 3.68 — (a) Future ulceration — positive monofilament test; (b) ulcer recurrencePER-DFU-RISK-02 — PADOR 3.10 (95% CI 2.43–3.95) — Ulcer recurrence after healingPER-DFU-RISK-03 — Foot deformityOR 2.51 (95% CI 1.85–3.40) — Ulcer recurrencePER-DFU-RISK-04 — Diabetic peripheral neuropathyOR 1.78 (95% CI 1.45–2.19) — Ulcer recurrencePER-DFU-RISK-05 — Plantar location of the index ulcerOR 2.44 (95% CI 1.41–4.23) — Ulcer recurrencePER-DFU-RISK-06 — Previous foot ulcer (or amputation)The strongest single predictor of ulceration · risk category 3 · remission, not cure — Future ulcerationPER-DFU-RISK-07 — Poor glycaemic control (HbA1c)1.24 (1.05–1.46) · 1.98 (1.65–2.39) · 2.68 (2.13–3.37) · 4.52 (3.62–5.65) — First lower-limb ulcer incidence (dose–response)PER-DFU-SUC-01 — Healing of neuropathic ulcers with good standard careSplit by population (Dispute D3): · 24.2% healed by 12 weeks (95% CI 19.5–28.8) · 30.9% by 20 weeks (26.6–35.1) · ≈30–40% healed at 12 weeks — Complete healing by 12 and 20 weeks; standard care = debridement, dressings, pressure offloading, infection treatment as needed — no advanced adjuncts (trial control arms)PER-DFU-SUC-02 — Healing by 1 year — and the PAD penalty≈77% heal within 1 year · 84% without PAD vs 69% with PAD — Any healing within 1 year of presentation at specialist centresPER-DFU-SUC-03 — Offloading device type and healing81.9% vs 66.1% · RR 1.24 (95% CI 1.09–1.41) · 80–90% — Complete healing of plantar neuropathic ulcers; non-removable (TCC / irremovable walker) vs removable devicesAX-HS-CTX-01 — Recurrence after incision & drainage ALONE in HSNo pooled measured rate exists. — Narrative upper-bound claim in peer-reviewed HS literature: recurrence "up to ~100%" — I&D relieves the acute abscess; it does not treat the disease. Handbook wording is qualitative only: *recurrence after drainage alone is the rule, not the exception.*AX-HS-PREV-01 — HS prevalence — method-dependent(a) ~1% · (b) 0.10% · (c) 0.40% — Prevalence under three different ascertainment methods — see Dispute D4AX-HS-PREV-02 — Armpit-and/or-breast involvement71.8% (444/618) — Share of HS patients with lesions at armpit and/or breast (combined site as published)AX-HS-REC-01 — Wide excision vs limited excision vs deroofingMehdizadeh 2015: · 13.0% (95% CI 5–22) · 22.0% (10–37) · 27.0% (23–31) · Ovadja 2020: · 5.0% (3–9) · 26.0% (16–37) — Recurrence as defined per primary study; two full-text meta-analyses that DISAGREE on magnitude — see Dispute D5AX-HS-RISK-01 — Predictors of recurrence after HS excisionFemale sex (p=.016) · disease caudal to the umbilicus (p=.001) — and significantly increased recurrence — i.e. axillary (supra-umbilical) disease recurred LESS in this datasetAX-HS-SUC-01 — Adalimumab 40 mg weekly (medical therapy)PIONEER I: 41.8% vs 26.0% placebo (P=0.003), n=307 · PIONEER II: 58.9% vs 27.6% placebo (P<0.001), n=326 — HiSCR at week 12 = ≥50% reduction in abscess + inflammatory-nodule count with no increase in abscess or draining-fistula countNCK-KEL-REC-01 — Surgical excision ALONE45–100%NCK-KEL-REC-02 — Excision + adjuvant therapyRecalcitrant · 9% (95% CI 3–25) · 14% (12–17) · 17% (3–56, I²=84%) · 18% (4–53) · 10.66% (95% CI 6.75–15.33) — ear keloids (already recurred after previous treatment), pooled by adjuvant (Zawadiuk 2022, SR, 13 studies, min FU 1 y): brachytherapy · compression · external-beam RT · steroid injections — no statistically significant difference between modalities. Corroboration (all auricular, primary+recalcitrant mixed): excision + compression earring (Tahir 2024, SR/MA, 2,026 keloids)NCK-KEL-REC-03 — Combined protocol (single series)1/16 lesions recurred (6.2%) — the single recurrence was in the patient who stopped wearing the pressure device

Memory 12

ABCDEMelanoma features in a pigmented lesionNERDSSuperficial wound infection / critical colonisationSTONEESDeep / surrounding wound infection (the STONEES pair of NERDS)RICESoft-tissue injury managementKanavel's 4 signsPyogenic flexor tenosynovitis — the four cardinal signsSITSRotator cuff musclesSCALPLayers of the scalpPoRTaBLeCancers metastasising to boneCRABMyeloma featuresCardinal signs of inflammationThe five cardinal signs of inflammationTIME frameworkWound bed preparation (Tamer-supplied list form)LRINECLaboratory Risk Indicator for Necrotizing Fasciitis (name-device score)