A novel device for preoperative skin preparation to reduce the risk of injury and surgical site infection during lower limb surgery.

Surgical site infection (SSI) continues to be a feared complication of surgery but especially orthopaedic surgery where a superficial SSI has been estimated to add nine days to the hospital stay and an average of £2500 to the cost. Despite the efficacy of all skin preparation agents being maximal at around 10 minutes no current system, apart from the double prep method attributed to Sir John Charnley, allows adequate control of bacteria. Current techniques of skin preparation require lifting of the limb with an associated risk of injury to theatre operatives. In order to provide for longer duration of contact, potentially better antisepsis and to remove the dangers inherent in lifting the limb we developed a novel system for limb antisepsis prior to surgery. To demonstrate efficacy we performed a single blind randomised controlled trial powered to demonstrate non-inferiority. We demonstrated a significant benefit of the device in terms of bactericidal effect. Whilst only recently entering full production, we would recommend the system as a significant improvement over current techniques of limb antisepsis.

Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery.

Introduction In 2010 a care bundle was introduced by the Department of Health (DH) to reduce surgical site infections (SSIs) in England. To date, use of the care bundle has not been evaluated despite incorporating interventions with resource implications. The aim of this study was to evaluate the DH SSI care bundle in open colorectal surgery. Methods A prospective cohort design was used at two teaching hospitals in England. The baseline group consisted of 127 consecutive patients having colorectal surgery during a 6-month period while the intervention group comprised 166 patients in the subsequent 6 months. SSI and care bundle compliance data were collected using dedicated surveillance staff. Results Just under a quarter (24%) of the patients in the baseline group developed a SSI compared with just over a quarter (28%) in the care bundle group (p>0.05). However, compliance rates with individual interventions, both before and after the implementation of the bundle, were similar. Interestingly, in only 19% of cases was there compliance with the total care bundle. The single intervention that showed an associated reduction in SSI was preoperative warming (p=0.032). Conclusions The DH care bundle did not reduce SSIs after open colorectal surgery. Despite this, it is not possible to state that the bundle is ineffective as compliance rates before and after bundle implementation were similar. All studies evaluating the effectiveness of care bundles must include data for compliance with interventions both before and after implementation of the care bundle; poor compliance may be one of the reasons for the lower than expected reduction of SSIs.

Access to medicines by child refugees in the East Midlands region of England: a cross-sectional study.

OBJECTIVES: To explore access to primary healthcare and drug therapy by refugee children in the East Midlands region of England. DESIGN: Interviews with refugees with children and a control group of British parents with children. SETTING: East Midlands region of England. PARTICIPANTS: 50 refugees with children and a control group of 50 parents with children. MAIN OUTCOME MEASURES: Number of medicines used by children in the last month and the past 6 months. Health of parents and children. Registration with a general practitioner (GP). RESULTS: All families in both groups were registered with a GP. There was no difference in the number of children in the two groups experiencing illnesses .In the last month, 30 refugee children received 60 medicines and 31 control children 63 medicines. In the past 6 months, 48 refugee children received 108 medicines and 43 control children 96 medicines. There was no difference between the two groups of children in relation to the likelihood of receiving any medicines in either the last month (P=0.839) or the past 6 months (p=0.81). Children in the refugee group were more likely to receive prescribed medicines for the last month (p=0.008) and the past 6 months (p<0.001). They were also less likely to receive over the counter (OTC) medicines in the past 6 months (p=0.009). CONCLUSIONS: The refugee children in this study in the East Midlands had access to primary healthcare, medicines and a family doctor. They were more likely to receive prescribed medicines and less likely to receive OTC medicines, especially paracetamol.

Analysis of rewarming curves in Raynaud's phenomenon of various aetiologies.

This study investigated whether a modified Cold Provocation Test could distinguish between 86 normal subjects and 31 patients with Raynaud's phenomenon or 59 with hand arm vibration syndrome (HAVS). Of the HAVS subjects, 56 were seen for medical reports as they were involved in litigation. Their assessments were done in a different location but the same protocol was used. A standardised cold stress was used to reduce the finger temperature to 15 degrees C or less without inducing reflex hyperaemia. This test had acceptable repeatability for subjects without HAVS with an intra-class correlation of 0.7. Baseline temperature, temperature rise in the first 30 seconds and the time taken to rewarm by 5 degrees C were measured. Patients with Raynaud's phenomenon and HAVS had cooler hands than controls. HAVS patients rewarmed most in the first 30 seconds. Patients with Raynaud's phenomenon take longer to rewarm by 5 degrees C than controls or those with HAVS (P<0.001). A baseline difference of >7.5 degrees C between the temperature of the digit and that of the room is unlikely to occur in patients with Raynaud's phenomenon or HAVS. A temperature gain of > or =2.2 degrees C in the first 30 seconds on rewarming combined with a low baseline temperature strongly suggests HAVS. This modified cold provocation test may differentiate between patients with Raynaud's phenomenon, HAVS and controls but this observation requires independent verification in subjects not involved in litigation and tested in the same facility.

A randomised controlled trial to compare postoperative pain in children undergoing tonsillectomy using cold steel dissection with bipolar haemostasis versus coblation technique.

OBJECTIVE: To measure postoperative pain levels in children undergoing tonsillectomy, by two different techniques, cold steel dissection and coblator dissection. The hypothesis - that coblator dissection may be associated with less postoperative pain. DESIGN: Prospective, randomised, double blind trial. SETTING: Single centre, secondary care Children's Hospital. PARTICIPANTS: Children aged between 4 and 16 years, undergoing tonsillectomy, or adeno-tonsillectomy. EXCLUSION CRITERIA: children already taking regular analgesia and those who experienced postoperative bleeding. Seventy-nine children were recruited, nine were excluded. MAIN OUTCOME MEASURES: We compared analgesia requirements during the first 10 days, and also the return to normal eating and drinking. These were assessed, using a validated pain scale. All analgesic administration in hospital and at home was compared. The return to normal eating & drinking patterns, was also compared. RESULTS: Whilst in the 24 h postoperatively there was no significant difference in the pain scores between the two groups, the coblator group required less potent analgesia. No statistical difference was identified between the two groups following discharge, except on the sixth postoperative day, when the coblator group had lower pain scores. This may represent chance, rather than a clear difference. CONCLUSION: The findings do not confirm the hypothesis that tonsillectomy undertaken in children, with the coblator device, is associated with lower levels of postoperative pain, but do indicate that less analgesia is required by the coblator patients in the first 12 h postoperatively.

Statistical discrimination in the presence of selection effects.

Discrimination between diseases is a complex task. Cases may present contradictory information and diseases can present with unusual or atypical symptoms. In many diagnostic problems the recorded diagnosis is either a true diagnosis, based on hard evidence, or a working diagnosis, not necessarily equivalent to the true underlying disease with an associated level of uncertainty. This problem is often confounded since the type of diagnosis given may be subjected to selection effects. Much medical data is categorical in nature, hence existing techniques for identifying selection effects are inappropriate. This paper provides a method of obtaining a single parameter modelling, the probability of giving a true diagnosis dependent on the nature of the true disease, thereby offering a simple measure for the presence of selection effects. When the size of the data is limited identifiability problems exist with calculating this parameter, however this paper shows how a sensitivity analysis based on the profile likelihood can be used to identify the presence of selection effects even in this difficult situation.