Surgical factors in the prevention of infection following major lower limb amputation.

OBJECTIVES: Infection following major lower limb amputation is common but surgical influences on the rates of infection are not known. We aim to assess the influence of peri-operative surgical factors on outcome. DESIGN AND METHODS: Review of a prospective database included all patients undergoing a major lower limb amputation from March 2008 to July 2010. Infection was classified using Centre for Disease Control criteria and multivariate analysis performed to identify significant risk factors. RESULTS: 127 patients, median age 78 yrs (31-98) were included. 34.6% of patients developed a wound infection following surgery; 47.7% of which were classed as superficial incisional surgical site infections, with 52.3% being deep incisional surgical site infections. There was a higher infection rate in below knee than above knee amputations (p < 0.001). There was no relationship between the grade of the operating surgeon (p = 0.829), peri-operative antibiotics (p = 0.933), length of operation (p = 0.651), use of nerve catheter (0.267) and the post-operative presence of infection. There was a higher rate of infection with the use of suction drains (p < 0.05). The use of skin clips rather than sutures was associated with an increased rate of infection (p < 0.05). There was an increased need for revision surgery with the use of skin clips, although this was not significant (p = 0.07). CONCLUSIONS: Skin clips and surgical drains adversely influence the risk of infection in major limb amputation and their use should be avoided.

Total parathyroidectomy without autotransplantation for renal hyperparathyroidism.

BACKGROUND: Parathyroidectomy is the standard treatment for renal hyperparathyroidism although controversy exists about the optimal surgical procedure. Total parathyroidectomy without either autotransplantation or thymectomy is one suggested approach. This study reviewed the medium- to long-term results of this procedure. METHODS: A retrospective review was undertaken of patients undergoing total parathyroidectomy between August 2000 and March 2009. The procedure was performed by a single surgeon and median follow-up was 31 (range 1-120) months. RESULTS: Data were obtained on 115 patients with no re-explorations for bleeding or clinical recurrent laryngeal nerve injuries. The rate of postoperative hypocalcaemia on the day after surgery was 15.7 per cent. Thirty-three patients (28.7 per cent) had an undetectable parathyroid hormone level at the end of follow-up. Fourteen patients (12.2 per cent) developed recurrent hyperparathyroidism with a median parathyroid hormone level of 35.4 (range 5.4-200.0) pmol/l. The reoperation rate was 3.5 per cent. Thymectomy tissue, taken if all four glands could not be identified, revealed no parathyroid glands. CONCLUSION: Total parathyroidectomy alone has minimal associated morbidity or mortality, and a good medium- to long-term clinical outcome with a low recurrence rate.

Prior exposure to major flooding increases individual preparedness in high-risk populations.

INTRODUCTION: July 2007 brought unprecedented levels of flooding to the United Kingdom. Health and financial implications were vast and still are emerging. Hydrological disasters will increase in frequency. Therefore, individual preparedness is paramount, as it may mitigate some of the devastating impacts of flooding. Literature on individual preparedness for flooding is scarce, so it is key that current levels of awareness, information gathering, and protective behaviors are investigated. It also is not clear whether being in a high-risk area or having recent exposure to flooding are motivational factors for preparedness. OBJECTIVES: The objectives of this study were to: (1) ascertain whether prior experience with flooding is a strong motivational factor for preparedness for future flooding episodes; and (2) assess preparedness in populations at high risk for flooding. METHODS: A prospective questionnaire survey was sent to individuals living in two towns in the United Kingdom, Monmouth and Tewkesbury. Both towns are deemed to be at significant risk for flooding, and Tewkesbury was severely affected by the July 2007 flooding disaster. Data were obtained from these two populations and analyzed. RESULTS: A total of 125 responses (of 200) were returned, and demographic data indicated no major differences between the two populations. The number of protective behaviors was higher from participants from Tewksbury (flood risk and exposure; p=0.004). Participants from Tewkesbury were more likely to be aware of living in a flood-risk area and of the emergency systems present in the area, and feel prepared for future episodes of major flooding (p=0.03, p=0.005). Awareness of living in a flood risk-area increased the likelihood of being knowledgeable about emergency systems and adopting protective behaviors (p=0.0053, p=0.043). However, feeling prepared for future episodes of flooding was not associated with a strong increase in knowledge gained to prepare for flooding or having an increased number of protective behaviors. CONCLUSIONS: Awareness of being at-risk for flooding is vital for self-protective behavior. Both awareness of risk and recent exposure are motivational for flood preparedness. Recent exposure to flooding increases awareness, but it is unknown how long this effect will last. Recent exposure increases the preparedness of individuals for major flooding 18 months after major flooding and, if it continues, will help mitigate the devastating health, financial, and social effects of major flooding.

Core trainee boot camp, a method for improving technical and non-technical skills of novice surgical trainees. A before and after study.

INTRODUCTION: The transition to surgical training can be a stressful time for trainees and is most evident during national handover periods where new graduates start and senior trainees rotate to new programmes. During this time, patient mortality can increase and Hospital efficiency reduces. This influence is compounded by the impact of working time directives. Intensive, simulation rich training programmes or "Boot Camps" have been postulated as a solution. This article highlights the development of a surgical boot camp for novice surgical trainees and the impact this can have on training. METHOD: A novel surgical boot camp was developed for all trainees within a surgical training region including nine acute NHS trusts. Participating cohort of trainees completed pre and post course questionnaires to assess technical and non-technical skills. RESULTS: 25 trainees attended and completed the pre and post boot camp questionnaire. Significant improvements were seen with technical skills (p = 0.0429), overall non-technical skills (p < 0.001) including leadership (p = 0.022), communication (p = 0.010), situational awareness (p = 0.022), patient handover (p = 0.003), ward round skills (p = 0.005) and outpatient skill (p = 0.002). Trainees reported significantly increased ability to assess and manage a critically unwell patient (p = 0.001) and a trauma patient (p = 0.001). 96% of trainees have utilised the skills they learnt on Boot Camp and all trainees would recommend it as an induction programme. CONCLUSION: Surgical Boot Camps offer a timely chance to develop technical and non-technical skills whilst enhancing a trainee's confidence and knowledge and reduce the patient safety impact of the handover period.

Audit of referral patterns for hernia repair - are general practitioners aware of the changing face of herniorrhaphy?

INTRODUCTION: The objective of this study was to examine referral patterns from general practitioners for groin hernia surgery and to assess their knowledge of services available to their patients. PATIENTS AND METHODS: An anonymous postal questionnaire was sent to 120 general practitioners (GPs) in the South East Wales region who routinely refer patients for inguinal hernia surgery to the Royal Gwent Healthcare NHS Trust. RESULTS: A total of 86 questionnaire replies were returned. There was variation in referral patterns between the GPs with the majority (84%) referring their patients for groin hernia repair to either a general surgeon or as an open referral. Only 14% referred directly to a hernia specialist and none regularly referred to a laparoscopic surgeon. CONCLUSIONS: Referral patterns for inguinal hernia surgery do not reflect services provided in secondary care. Further education is required so that a patient's care can be optimised.