A molten metal, high-pressure injection injury of the hand.

A case of high-temperature, high-pressure injection injury of the hand is reported. The injury is particularly severe in that it involves both a high-temperature thermal insult and a pressure effect, either of which, alone, can result in major disability. It is evident that the high temperature of the injected material considerably reduced the pressure required for penetration of the tissues.

Observer agreement in the reporting of knee and lumbar spine magnetic resonance (MR) imaging examinations: selectively trained MR radiographers and consultant radiologists compared with an index radiologist.

PURPOSE: To assess agreement between trained radiographers and consultant radiologists compared with an index radiologist when reporting on magnetic resonance imaging (MRI) examinations of the knee and lumbar spine and to examine the subsequent effect of discordant reports on patient management and outcome. METHODS: At York Hospital two MR radiographers, two consultant radiologists and an index radiologist reported on a prospective, random sample of 326 MRI examinations. The radiographers reported in clinical practice conditions and the radiologists during clinical practice. An independent consultant radiologist compared these reports with the index radiologist report for agreement. Orthopaedic surgeons then assessed whether the discordance between reports was clinically important. RESULTS: Overall observer agreement with the index radiologist was comparable between observers and ranged from 54% to 58%; for the knee it was 46-57% and for the lumbar spine was 56-66%. There was a very small observed difference of 0.6% (95% CI -11.9 to 13.0) in mean agreement between the radiographers and radiologists (P=0.860). For the knee, lumbar spine and overall, radiographers' discordant reports, when compared with the index radiologist, were less likely to have a clinically important effect on patient outcome than the radiologists' discordant reports. Less than 10% of observer's reports were sufficiently discordant with the index radiologist's reports to be clinically important. CONCLUSION: Carefully selected MR radiographers with postgraduate education and training reported in clinical practice conditions on specific MRI examinations of the knee and lumbar spine to a level of agreement comparable with non-musculoskeletal consultant radiologists.

The power of words: sources of anxiety in patients undergoing local anaesthetic plastic surgery.

INTRODUCTION: With local or regional anaesthesia being employed for more as well as more complex surgical procedures, an increasing number of patients remain fully conscious during their operation. This is generally perceived as being advantageous to the patient as less time is spent in hospital and the side effects of general anaesthesia are avoided. However, there is no direct measure of the patient experience during 'awake surgery', in particular of which aspects of the process may be distressing. METHODS: Seventy patients undergoing day case plastic surgery under local anaesthesia were asked to complete a short questionnaire immediately following their operation. This was designed to identify specific factors likely to either increase or reduce anxiety during surgery. The questionnaire was initially validated on a pilot group of ten patients. RESULTS: Unsurprisingly, painful stimuli such as injections were identified as potential stressors. More interestingly, the data highlighted that some commonly used surgical terms such as 'knife' and 'scalpel' provoke considerable anxiety in the conscious patient. This varied according to age and sex with younger and female patients being most vulnerable. Other events identified as potential stressors, such as casual conversations and movements among theatre staff, were actually shown to be non-stressful and, in some cases, stress relieving. CONCLUSIONS: Technical jargon used by surgical staff can elevate anxiety levels among patients who are awake for their operation. Careful consideration of the words we use may reduce this, particularly in female patients.

RAPD for the typing of coagulase-negative staphylococci implicated in catheter-related bloodstream infection.

OBJECTIVES: A rapid random amplification of polymorphic DNA (RAPD) technique was developed to distinguish between strains of coagulase-negative staphylococci (CoNS) involved in central venous catheter (CVC)-related bloodstream infection. Its performance was compared with that of pulsed-field gel electrophoresis (PFGE). METHODS: Patients at the University Hospital Birmingham NHS Foundation Trust, U.K. who underwent stem cell transplantation and were diagnosed with CVC-related bloodstream infection due to CoNS whilst on the bone marrow transplant unit were studied. Isolates of CoNS were genotyped by PFGE and RAPD, the latter employing a single primer and a simple DNA extraction method. RESULTS: Both RAPD and PFGE were highly discriminatory (Simpson's diversity index, 0.96 and 0.99, respectively). Within the 49 isolates obtained from blood cultures of 33 patients, 20 distinct strains were identified by PFGE and 25 by RAPD. Of the 25 strains identified by RAPD, nine clusters of CoNS contained isolates from multiple patients, suggesting limited nosocomial spread. However, there was no significant association between time of inpatient stay and infection due to any particular strain. CONCLUSION: The RAPD technique presented allows CoNS strains to be genotyped with high discrimination within 4h, facilitating real-time epidemiological investigations. In this study, no single strain of CoNS was associated with a significant number of CVC-related bloodstream infections.

Distally based double paddle fasciocutaneous island flap following lower limb trauma.

We report a modification of the distally based islanded fasciocutaneous flap that is suited to cover two separate defects following lower limb trauma.