Whiston Hospital is an acute general hospital in Whiston, Merseyside, though its postal address places it in adjacent Prescot. The hospital, along with St Helens Hospital, is managed by the St Helens and Knowsley Teaching Hospitals NHS Trust.
IgA vasculitis (IgAV) is an autoimmune disease that affects the small vessels of the skin, joints, gastrointestinal (GI) tract, and kidneys. In the long term, IgAV associated with nephritis (IgAV-N) can progress to kidney failure. Evidence-based clinical studies of IgAV-N are few, leading to huge variations in treatment approaches and suboptimal outcomes. The wealth of emerging efficacious treatments for IgA nephrology brings new opportunities to this disease. The aim of this report is to describe the proceedings of a multiprofessional collaborative workshop convened to identify the barriers to developing high quality evidence for patients with IgAV-N. A multiprofessional group consisting of 53 attendees from 13 countries met. The meeting was represented by a variety of professional backgrounds, including lay attendees, with different levels of expertise (32% professors and 19% midcareer doctors). Using predefined aims, key themes were extracted, and an action plan developed. Consensus was obtained that there is sufficient similarity between adults and children in terms of the organs involved, pathophysiology, histological features, and likely response to treatment. Important differences included the greater spontaneous improvement in children and worse kidney outcomes in some populations. It was agreed that patients at greatest risk of kidney failure should be the primary focus of initial clinical trials. Important considerations included the following: diagnostic classification for adult onset IgAV, observational data, evidence of scientific similarity to IgA nephropathy (IgAN), an age-inclusive approach to trial design, systemic disease secondary end points, and the inclusion of patient-reported outcomes. This manuscript communicates an expert-informed pathway to high-quality evidence for IgAV-N.
INTRODUCTION:Tattoos are increasingly common and may be encountered overlying planned surgical incision sites. This is particularly relevant in hand and upper limb surgery, where tattoos are frequent and highly visible. Tattoos in standard approach lines raise aesthetic and ethical considerations. Despite this, little is known about current surgical attitudes towards tattoo preservation. We assessed current practice among hand and upper limb surgeons when tattoos lie within the preferred incision. METHODS:An electronic survey was distributed to hand and upper limb surgeons trained via plastic or orthopaedic surgery programmes. Respondents reviewed a standardized scenario showing a tattoo over the anterior distal forearm incision for distal radius fixation and selected their preferred approach. Specialty, seniority and level of training were recorded. RESULTS:There were 225 responses; 175 (78%) were senior surgeons (post-Certificate of Completion of Training/consultant). Orthopaedic surgeons comprised 181 (80%) and plastic surgeons 44 (20%). Overall, 173/225 (77%) would incise directly through the tattoo. Tattoo-preserving options were less common, comprising incision along the tattoo margin 34/225 (15%) and raising a skin flap 7/225 (3.1%). CONCLUSION:Upper limb surgeons predominantly favour standard incisions through tattoos rather than preservation. Given limited commentary in the literature and potential aesthetic and psychological implications, we propose the ART algorithm (assess safety-review size-talk to the patient) to structure decision-making and support preoperative discussion of incision placement during consent.
