The assessment and management of diabetes related lower limb problems in India - an action research approach to integrating best practice

Background: In this article the authors explore the current issues and barriers related to achieving successful outcomes to diabetic foot complications in India. This was achieved by engaging clinicians in taking ownership of the problems and facilitating them in the identification of solutions to action change in clinical practice. Methods: This was accomplished through facilitating participants in this study via a process of problem identification and planning, the first phases of an action research cycle approach. The methods of data collection were focus groups, observations and individual conversations. The data were analysed using a thematic framework. Findings: Based on the practitioner's experiences and opinions, key themes were identified. These themes had the potential to inform the changes needed in clinical practice, to overcome barriers and embed ownership of the solutions. Five themes were identified highlighting: concerns over a fragmented service; local recognition of need; lack of standardised care pathways; lack of structured assessment and an absence of annual foot screening. Combined, the issues identified were thought to be important in preventing timely assessment and management of foot problems. Conclusion: It was unanimously agreed that a formalised process of foot assessment should be developed and implemented as part of the subsequent phases of the action research process, which the authors intended to take forward and report in a further paper. The aim of which is to guide triage, education, care pathways, audit and evaluation of outcomes. Facilitation of the clinicians in developing a program and screening tool to implement and teach these skills to others could be an important step in reducing the number of high-risk cases that are often resulting in the amputation of limbs

Effect of exogenous zinc supply on photosynthetic rate, chlorophyll content and some growth parameters in different wheat genotypes

A two-year field experiment was conducted to study the effect of three zinc levels 0, 20 kg ZnSO4 ha−1 and 20 kg ZnSO4 ha−1 + foliar spray of 0.5% ZnSO4 solution on plant height, leaf area, shoot biomass, photosynthetic rate and chlorophyll content in different wheat genotypes. Increasing zinc levels was found to be beneficial in improving growth and physiological aspects of genotypes. Soil application + foliar spray proved to be the best application in improving all the parameters. Zinc application brought about a maximum increment limit of 41.8% in plant height, 101.8% in leaf area, 86% in shoot biomass and 51.1% in photosynthetic rate irrespective of stages and year of study. A variation was found to occur among genotypes in showing responses towards zinc application and PBW 550 was found to be more responsive

Evaluation of some promising wheat genotypes (Triticum aestivum L.) at different zinc regimes for crop production

Zinc is essentially required for crop growth and its insufficient supply to the plants may severely limit the yield traits of a crop. A field experiment was performed during rabi season of 2009–10 and 2010–11 to evaluate the performance of different wheat genotypes under different levels of zinc namely 0 kg ZnSO4 ha−1, 20 kg ZnSO4 ha−1 and 20 kg ZnSO4 ha−1 along with foliar spray of 0.5% solution of ZnSO4. Genotypes responded positively in terms of tiller number, grain and biological yield, spikelet length, spikelet number, grain number and thousandgrain weight. The best response was observed with the application of 20 kg ZnSO4 ha−1 along with foliar spray of 0.5% solution of ZnSO4. Zinc application brought about a maximum increase of 58.6% in tiller number, 63.7% in thousand-grain weight, 40.5% in biological yield, 66.1% in grain yield irrespective of genotypes and the year of study. Wheat genotypes exhibited a variation in their performance which has been exploited in this study. Genotypes UP-262, PBW-175, PBW-343 were found to be superior for one or the other yield contributing factors

Pedicle transfer in oral cavity reconstruction

In head and neck reconstructions when a free flap is used intra orally to provide the lining its vascular pedicle has to be transferred to the neck for anastomosis. This has to be performed in such a way that the pedicle does not get kinked or twisted. The pedicle is enrolled in a split open glove from its point of entry into the flap till its proximal most part. In order to prevent twisting of the vessels and to maintain orientation, the glove is wrapped in such a way that the imprint on the glove is on the visualized surface. The glove wrapped pedicle is passed from inside the oral cavity while an artery clamp passed from the neck wound through the submandibular or subcutaneous tunnel holds the tip of the glove component and guides it safely to the neck without exerting any traction on the flap or the pedicle vessels

Two in one: Double free flap from a single free fibula osteocutaneous unit

In the past two decades, the advancement in the microsurgical techniques has revolutionised the reconstruction of post-oncological head and neck defects. Free fibula osteocutaneous flap (FFOCF) has been considered as the treatment of choice by many for mandible reconstruction. The improvement in the surgical resection and adjuvant treatment has improved the survival rates even in patients with advanced cancer. Simultaneously the reconstruction is addressed towards more functional and aesthetic aspects to improve the quality of life in these patients. In this respect, a double free flap is advocated in certain cases of extensive composite oromandibular defects (COMDs). But in our institute, we have managed two such cases of extensive COMD with a single FFOCF unit - fibula bone with a skin paddle for inner lining and a perforator-based skin paddle from the proximal part of the FFOCF unit, anastomosed separately for outer cover. Compared to two separate free flaps, this method has the advantage of single donor site and reduction in reconstruction time. Though the technique of divided paddle, deepithelisation and supercharging has been mentioned for FFOCF, no such clinical cases of two free flaps from a single FFOCF unit have been mentioned in the literature

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap – An alternative to free flap for suprastructure maxillectomy with external skin defect

Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background: Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations. Materials and Methods: It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases). Results: All flaps in which cephalic vein was used survived completely. Conclusion: Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases