Estimation of wound surface area: an evaluation of medical professionals' assessment in a plastic surgery unit.

The percentage of skin graft take following the resurfacing of burn injuries is routinely calculated in a subjective fashion, in order to make management decisions. Given the gravity of decisions made based on this clinical assessment of graft check, it is notable that limited research has been carried out on this subject. No standardised subjective assessment tools exist to measure surface area of graft take in a manner similar to that of Wallace's Rule of Nines or Lund and Browder. This study set out to examine the accuracy of visual assessments of graft take within the multidisciplinary team regularly making assessments of newly grafted burn wounds. A total of 15 digitally drawn images were used to assess 36 staff members' estimations of percentage of surface area. The results showed a wide variation in estimation in all staff types, including senior burns surgeons, who were found to underestimate surface area by as much as 30%. The British Burns Association has removed 'healing time' as an outcome measurement from its guidance, as it recognises how hard it is to make a standardised assessment of wound healing. This study demonstrates the difficulty in subjectively assessing surface area and makes some suggestions for further research and clinical applications of technology to aid assessment.

Intralesional corticosteroids and diathermy ablation for the management of anogenital granulomatosis: a retrospective cohort study.

BACKGROUND: Anogenital granulomatosis (AGG) is a rare, chronic condition that presents as progressive inflammation and lymphoedema of the anogenital region in both male and female patients. No guidelines exist for the management of AGG. Systemic immunosuppressants are the current cornerstone of medical therapy for AGG, but results from case series with small numbers of patients have reported variable responses. AIM: To investigate whether intralesional corticosteroid injections with or without diathermy ablation (ILC +/- DA) would provide effective control of symptoms over a 6-month period in patients diagnosed with AGG. METHODS: This retrospective observational cohort study enrolled 11 patients with AGG consecutively treated with ILC +/- DA at a single centre. The primary outcome was defined as a statistically significant decrease in mean disease severity score, at both 1 and 6 months post-treatment. The secondary outcome was a statistically significant association between reduction in disease severity score at 6 months post-treatment and any potentially confounding factors. Wilcoxon sign-ranked tests and ordinal logistic regression analysis were applied to assess the data. Ancillary outcomes are also reported, including whether patients experienced adverse effects post-treatment and if patients experienced recurrence at any point beyond 6 months post-treatment. RESULTS: Compared with pretreatment disease severity scores, there was a statistically significant decrease in disease severity scores at both 1 and 6 months post-treatment (P = 0.01). No significant association was found between identified confounding factors and reduction in disease severity score at 6 months post-treatment. Of the 11 patients, 1 patient experienced an episode of cellulitis within 1 week of treatment. Five patients never experienced a recurrence of symptoms during a mean follow-up period of 28 months post-treatment, while all six patients who did experience recurrence of symptoms reported that when the symptoms returned, at a mean of 8 months post-treatment, they were milder than before the treatment. CONCLUSION: To our knowledge, this is the first study to investigate ILC +/- DA for patients with AGG. Our results indicate this could be an effective treatment for AGG. We would recommend comparative and longitudinal studies to further explore this treatment.

Prophylactic antibiotics at the time of elective cholecystectomy are effective in reducing the post-operative infective complications: a systematic review and meta-analysis.

BACKGROUND: The objective of this article is to evaluate the role of prophylactic antibiotics in preventing the infective complications in patients undergoing elective laparoscopic cholecystectomy (ELC). METHODS: A systematic review of the literature on the published randomized, controlled reporting the role of prophylactic antibiotics in preventing the infective complications in patients undergoing ELC was undertaken using the principles of meta-analysis. RESULTS: Twenty-five RCTs on 6,138 patients evaluating the infective complications in patients undergoing ELC were systematically analysed. There were 3,099 patients in antibiotics group and 3,039 patients in no-antibiotics group. The risk of surgical site infection (SSI) [odds ratio (OR), 0.75 (95% CI, 0.52-1.07), P=0.11], distant infection [OR, 0.66 (95% CI, 0.21-2.14), P=0.49] and residual abscess [OR, 0.93 (95% CI, 0.23-3.81), P=0.92] was lower in the antibiotics group but statistical significance was not reached. However, the risk of overall all type of infective complications was statistically lower [OR, 0.69 (95% CI, 0.50-0.95), P=0.02] in the antibiotics group. Subsequently, this was reflected into the reduced length of hospitalization [standardized mean difference (SMD), -0.32 (95% CI, -0.54--0.10), P=0.004] in the antibiotics group. CONCLUSIONS: Use of prophylactic antibiotics at the time of induction in patients undergoing ELC has clinically proven advantage of reducing the post-operative infective complications.

Use of ketamine sedation for the management of displaced paediatric forearm fractures.

AIM: To determine if ketamine sedation is a safe and cost effective way of treating displaced paediatric radial and ulna fractures in the emergency department. METHODS: Following an agreed interdepartmental protocol, fractures of the radius and ulna (moderately to severely displaced) in children between the age of 2 and 16 years old, presenting within a specified 4 mo period, were manipulated in our paediatric emergency department. Verbal and written consent was obtained prior to procedural sedation to ensure parents were informed and satisfied to have ketamine. A single attempt at manipulation was performed. Pre and post manipulation radiographs were requested and assessed to ensure adequacy of reduction. Parental satisfaction surveys were collected after the procedure to assess the perceived quality of treatment. After closed reduction and cast immobilisation, patients were then followed-up in the paediatric outpatient fracture clinic and functional outcomes measured prospectively. A cost analysis compared to more formal manipulation under a general anaesthetic was also undertaken. RESULTS: During the 4 mo period of study, 10 closed, moderate to severely displaced fractures were identified and treated in the paediatric emergency department using our ketamine sedation protocol. These included fractures of the growth plate (3), fractures of both radius and ulna (6) and a single isolated proximal radius fracture. The mean time from administration of ketamine until completion of the moulded plaster was 20 min. The mean time interval from sedation to full recovery was 74 min. We had no cases of unacceptable fracture reduction and no patients required any further manipulation, either in fracture clinic or under a more formal general anaesthetic. There were no serious adverse events in relation to the use of ketamine. Parents, patients and clinicians reported extremely favourable outcomes using this technique. Furthermore, compared to using a manipulation under general anaesthesia, each case performed under ketamine sedation was associated with a saving of £1470, the overall study saving being £14700. CONCLUSION: Ketamine procedural sedation in the paediatric population is a safe and cost effective method for the treatment of displaced fractures of the radius and ulna, with high parent satisfaction rates.

Barriers to staff reporting adverse incidents in NHS hospitals.

Our study assessed barriers to reporting adverse incidents (AIs). Adverse incident reporting (AIR), although it is a pillar of risk management, has a wide variation in staff perception and usage. A questionnaire was used in five NHS hospitals to assess 267 members of multidisciplinary team (MDT) staff usage of AIR. Thirty-three percent of staff had never reported an adverse incident (AI). Fourty-one percent of staff had missed opportunities to report AIs due to a poor response to previous reports. The group who missed opportunities had a significantly higher proportion of not having received feedback to their previous AI (p=0.03). In the group who had received training, 79% had submitted an AI. This was significantly higher than the group who had not received training (63%, p=0.02). Our study revealed that training and feedback following AIR are two major factors that could improve confidence in and use of AI reporting.