Considerations for an ideal post-surgical wound dressing aligned with antimicrobial stewardship objectives: a scoping review.

OBJECTIVE: Most surgical wounds heal by primary or secondary intention. Surgical wounds can present specific and unique challenges including wound dehiscence and surgical site infection (SSI), either of which can increase risk of morbidity and mortality. The use of antimicrobials to treat infection in these wounds is prevalent, but there is now an imperative to align treatment with reducing antimicrobial resistance and antimicrobial stewardship (AMS). The aim of this review was to explore the published evidence identifying general considerations/criteria for an ideal post-surgical wound dressing in terms of overcoming potential wound healing challenges (including infection) while supporting AMS objectives. METHOD: A scoping review examining evidence published from 1954-2021, conducted by two authors acting independently. Results were synthesised narratively and have been reported in line with PRISMA Extension for Scoping Reviews. RESULTS: A total of 819 articles were initially identified and subsequently filtered to 178 for inclusion in the assessment. The search highlighted six key outcomes of interest associated with post-surgical wound dressings: wound infection; wound healing; physical attributes related to comfort, conformability and flexibility; fluid handling (e.g., blood and exudate); pain; and skin damage. CONCLUSION: There are several challenges that can be overcome when treating a post-surgical wound with a dressing, not least the prevention and treatment of SSIs. However, it is imperative that the use of antimicrobial wound dressings is aligned with AMS programmes and alternatives to active antimicrobials investigated.

Extracorporeal shockwave therapy for diabetic foot ulcers: a feasibility study.

OBJECTIVE: The purpose of this study was to assess the feasibility of delivering extracorporeal shockwave therapy (ESWT) to patients with diabetic foot ulcers (DFUs). It also aimed to explore any potential clinical effect of ESWT on wound healing and investigate whether ESWT offers any patient-reported benefits. METHOD: In this single-centre, mixed methods feasibility study, patients with a DFU who met the eligibility criteria underwent ESWT three times over a seven-day period. Primary outcome was feasibility of delivering the intervention. Secondary outcomes included wound size, number of DFUs healed at 12 weeks and quality of life (QoL). Semi-structured interviews explored participants' experience of undergoing ESWT. RESULTS: Of 106 patients screened, 24 (22.6%) were recruited. Following recruitment, two patients were withdrawn from the study with 22 patients included in the final analysis. The mean attendance at clinic was 90.9% and 65.1% for follow-up. The mean score for acceptability and tolerability was 9.86±0.48 (95% confidence interval (CI): 9.62-10.01) and 9.15±2.57 (95% CI: 7.87-10.42), respectively. There were no serious adverse events or side-effects. Of the DFUs, 45.5% healed during follow-up and QoL scores improved until eight weeks. Key themes identified from the qualitative interviews were: desire for fast healing; improved QoL; flexibility of new treatments; and accessibility of transport. CONCLUSION: This study has shown that it is possible to recruit and retain patents into a single-arm study of ESWT for DFUs. This study supports development of a large randomised control trial to determine the clinical and cost-effectiveness of ESWT for DFU healing.

Extracorporeal shockwave therapy compared with standard care for diabetic foot ulcer healing: An updated systematic review.

Emerging evidence suggests that extracorporeal shockwave therapy (ESWT) may improve time to DFU healing. The aim of this review was to appraise the evidence on role of ESWT in DFU healing and impact of different ESWT doses. Databases were searched for trials comparing ESWT plus standard care to standard care alone in participants with DFUs. Search results were reviewed by two independent reviewers. The Cochrane Risk of Bias 2 tool and GRADE approach was used to assess bias and certainty. The primary outcome was time to healing. The search identified 345 papers after duplicates removed. Six trials consisting of 471 participants were included. There was unclear or high risk of bias across all domains. Time to ulcer healing was probably shorter in patients treated with ESWT compared with standard ulcer care alone (GRADE: low certainty). Patients treated with ESWT were more likely to heal at 20 weeks post-ESWT compared with those treated with standard ulcer care alone (GRADE: low certainty). There was significant heterogeneity. ESWT remains a promising new treatment but the translation into routine clinical practice is still limited by the low certainty of evidence surrounding its effectiveness, case selection and optimum dose.

Use of perioperative prophylactic antibiotics following excision of ulcerated skin lesions in the UK: a national, multispeciality survey of clinicians.

Skin cancer is the most common malignancy in the UK, and up to a third of lesions are ulcerated at the time of excision. Ulceration has been shown to increase the risk of developing surgical site infection following excision, with some studies finding infection rates of 33%. However, no specific guidelines for the use of antibiotic prophylaxis in such cases exist. We surveyed 129 clinicians (covering Dermatology, Plastic Surgery, Ear, Nose and Throat Surgery, and Oral and Maxillofacial Surgery) who all excise skin lesions on a regular basis. There was significant variability in their practice with regard to antibiotic prophylaxis, with 9% always prescribing them and 19% never prescribing them. Variation exists both among and between specialities. This variation increases the risk of antimicrobial resistance and shows a paucity of good clinical evidence, indicating that a well-designed clinical trial is needed to guide future practice.

The local physiological effects of a single-use topical negative pressure device in healthy volunteers: the PICO-1 study.

OBJECTIVE: This study aimed to investigate the effects of a single-use negative pressure wound therapy (sNPWT) device on tissue perfusion, oxygenation and pressure in the intact skin of healthy volunteers. METHOD: Healthy volunteers wore a PICO sNPWT device (Smith+Nephew, UK) on their right medial calf for one week. Perfusion, tissue oxygenation and tissue pressure were recorded in superficial and deep tissues over a period of seven days. At the baseline visit, measurements were recorded before and after dressing application without activation. Macrovascular flow and transduced needle pressure measures were recorded at 0 minutes, 30 minutes and 60 minutes after device activation. Superficial tissue perfusion and both oxygenation measures were recorded continuously over the hour following activation. All outcome measures were repeated at 24 hours and again after seven days, both with the dressing and following dressing removal. RESULTS: The device was associated with a measurable increase in perfusion of the limb in 12 healthy volunteers. Superficial tissue oxygenation adjacent to the dressing was reduced during wear, while deeper tissue demonstrated an increase in oxygenation levels. Superficial skin perfusion was observed to differ between skin overlying muscle and that overlying bone. Pressure in tissue underneath the dressing pad was increased throughout dressing wear and returned to baseline levels on dressing removal. CONCLUSION: sNPWT produced measurable changes in local physiology in healthy volunteers with intact skin, despite the absence of a wound. Effects may differ according to anatomical site and the composition of underlying tissues. Other factors that promote healing were not explored in this study. DECLARATION OF INTEREST: This study was funded by Smith+Nephew investigator-initiated grant IIS 684. The funder had no input into study design, conduct, analysis, manuscript preparation or dissemination. The authors have no conflicts of interest to declare.

The impact of surgical site infection on hospitalisation, treatment costs, and health-related quality of life after vascular surgery.

Surgical site infections (SSI) substantially increase costs for healthcare providers because of additional treatments and extended patient recovery. The objective of this study was to assess the cost and health-related quality of life impact of SSI, from the perspective of a large teaching hospital in England. Data were available for 144 participants undergoing clean or clean-contaminated vascular surgery. SSI development, length of hospital stay, readmission, and antibiotic use were recorded over a 30-day period. Patient-reported EQ-5D scores were obtained at baseline, day 7 and day 30. Linear regressions were used to control for confounding variables. A mean SSI-associated length of stay of 9.72 days resulted in an additional cost of £3776 per patient (including a mean antibiotic cost of £532). Adjusting for age, smoking status, and procedure type, SSI was associated with a 92% increase in length of stay (P < 0.001). The adjusted episode cost was £3040. SSI reduced patient utility between baseline and day 30 by 0.156 (P = 0.236). Readmission rates were higher with SSI (P = 0.017), and the rate to return to work within 90 days was lower. Therefore, strategies to reduce the risk of surgical site infection for high-risk vascular patients should be investigated.

Cardiovascular and musculoskeletal response to supervised exercise in patients with intermittent claudication.

OBJECTIVE: Intermittent claudication occurs in 20% of the population older than 70 years, and treatment includes a supervised exercise program (SEP). Whereas there is evidence demonstrating walking improvements after an SEP, there are conflicting data on the physiologic changes behind this. This study aimed to explore and to identify the potential cardiovascular and musculoskeletal changes with exercise. METHODS: This was a single-center study at a vascular unit in England. Following written informed consent, 109 patients were recruited for an SEP, three times per week for 12 weeks. Outcome measures included walking distances, quality of life, cardiorespiratory fitness, flow-mediated dilation, and muscle strength and endurance. For normal data, paired sample t-tests were performed to compare baseline data to all time points for significance. For nonparametric data, Wilcoxon signed rank tests were performed. Significance was set at P < .05. The association between functional improvement (ie, walking distance at 3 months after the SEP) and metabolic response and patients' characteristics was determined by multivariable regressions. RESULTS: Maximum walking distance significantly improved from baseline by 117% at 1 week, 143% at 4 weeks, and 143% at 12 weeks after exercise. Claudication distance also significantly improved from baseline by 222% at week 1, 393% at week 4, and 452% at week 12. Quality of life significantly improved at all time points in seven of nine domains of the 36-Item Short Form Health Survey and two of five domains of the Vascular Quality of Life questionnaire. Markers of cardiorespiratory fitness significantly improved at all time points. Flow-mediated dilation demonstrated a 50% improvement, but this was not statistically significant. Muscle strength and muscle endurance significantly improved at all time points. Multivariate regression demonstrated that the ventilatory anaerobic threshold and the physical component summary score for quality of life predicted improvements in 12-week walking distance. CONCLUSIONS: This study identified that the ventilatory anaerobic threshold and physical component summary scores from quality of life were the best predictors of improvement in an SEP. Future studies should prioritize these outcomes and assess whether different SEPs have similar effects. Cardiorespiratory fitness was also a predictor of outcome and should be prioritized in future studies alongside traditional measures.

The Intrarater and Interrater Reliability of Measures Derived from Cardiopulmonary Exercise Testing in Patients with Abdominal Aortic Aneurysms.

BACKGROUND: Patients with abdominal aortic aneurysms (AAAs) often have low exercise tolerance due to comorbidities and advanced age. Cardiopulmonary exercise testing (CPET) is predictive of postoperative morbidity and mortality in patients with AAA. We aimed to assess the intrarater and interrater reliability of both treadmill-based and cycle ergometer-based CPET variables. METHODS: Patients with an AAA (>3.5 cm) were randomized to a treadmill or bike CPET. Patients were asked to perform two separate CPETs seven days apart after a familiarization protocol. All CPETs were carried out using a ramp cycle or modified Bruce treadmill protocol with breath-by-breath gas analysis. RESULTS: Twenty-two male and 2 female patients, aged 73.6 ± 6.0 years, completed the study. Intrarater analysis (intraclass correlation coefficients) demonstrated high reliability on both the treadmill and bike for ventilatory anaerobic threshold (r = 0.834 and r = 0.975, respectively). All other CPET variables demonstrated high intrarater reliability on both modalities, bar the highest point for the ventilatory slope of oxygen (VE/VO2) on the treadmill (substantial agreement r = 0.755). Furthermore, interrater reliability demonstrated high agreement for ventilatory anaerobic threshold on both the treadmill and cycle (r = 0.983 and r = 0.905, respectively). All other CPET variables demonstrated high intrarater reliability on both modalities, with the exception of VO2Peak on the cycle ergometer (fair agreement r = 0.400). CONCLUSION: CPET in patients with AAAs is a reliable tool test and among CPET test reviewers for common testing modalities/protocols. These findings provide further support for the use of CPET, especially treadmill walking, as a clinical measure of perioperative cardiorespiratory fitness in patients with AAAs.

Extracorporeal Shockwave Therapy for Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis.

BACKGROUND: Diabetes mellitus is one of the most common chronic diseases worldwide. Diabetic foot ulcers (DFUs) occur in over 10% of diabetic patients and are associated with high morbidity. Clinical trials have shown benefit from extracorporeal shockwave therapy (ESWT) in a DFU healing. This systematic review aims to assess the currently available evidence examining the efficacy of ESWT on healing of DFU. METHODS: Electronic databases including PubMed, Ovid MEDLINE, Web of Science, Embase, CINAHL Plus, Cochrane Central Registry of Controlled Trials, and Clinical Trials Registry were searched up to November 2017 for terms related to ESWT in DFU. Articles were identified, and data were extracted by 2 independent reviewers onto Review Manager 5.3 software. RESULTS: This review included 5 trials of 255 patients published between 2009 and 2016. Three studies compared ESWT to standard wound care, and 2 studies compared ESWT to hyperbaric oxygen therapy (HBOT). All studies contained unclear to high risk of bias assessed by the Cochrane Risk of Bias Tool. ESWT was superior to standard wound care at complete wound healing (odds ratio [OR] 2.66 95% confidence interval [CI] 1.03, 6.87, I2 0%) and time to healing (64.5 ± 8.06 days versus 81.17 ± 4.35 days). DFU healing improved more with ESWT than HBOT (OR 2.45 95% CI 1.07, 5.61 I2 28%). There was variable evidence of effect on the blood flow perfusion rate. Infection rate and amputation rate were not reported. CONCLUSIONS: This systematic review concludes that ESWT has the potential to improve healing in DFUs, although there is, as yet, insufficient evidence to justify its use in routine clinical practice. The meta-analysis has a high risk of bias and is unlikely to reflect true effect size because of problematic risk of bias in included studies. This review highlights the variable quality of methodology of trials and dosing of shockwave therapy and the need for robust adequately powered research into this promising therapy.

A pilot feasibility randomised clinical trial comparing dialkylcarbamoylchloride-coated dressings versus standard care for the primary prevention of surgical site infection.

A surgical site infection (SSI) may occur in up to 30% of procedures and results in significant morbidity and mortality. We aimed to assess the feasibility of conducting a randomised controlled trial (RCT) examining the use of dialkylcarbamoylchloride (DACC)-impregnated dressings, which bind bacteria at the wound bed, in the prevention of SSI in primarily closed incisional wounds. This pilot RCT recruited patients undergoing clean or clean-contaminated vascular surgery. Participants were randomised intraoperatively on a 1:1 basis to either a DACC-coated dressing or a control dressing. Outcomes were divided into feasibility and clinical outcomes. The primary clinical outcome was SSI at 30 days (assessed using Centers for Disease Control criteria and Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria and duration of inpatient Stay scoring methods). This study recruited 144 patients in 12 months at a median rate of 10 per month. Eligibility was 73% and recruitment 60%. At 30 days, there was a 36.9% relative risk reduction in the DACC-coated arm (16.22% versus 25.71%, odds ratio 0.559, P = 0.161). The number needed to treat was 11 patients. A large-scale RCT is both achievable and desirable given the relative risk reduction shown in this study. Further work is needed to improve the study protocol and involve more centres in a full-scale RCT.

Use of photograph-based telemedicine in postoperative wound assessment to diagnose or exclude surgical site infection.

OBJECTIVE: This study aims to assess whether a clinician reviewing photographs of a wound was an acceptable substitute for clinical review in order to identify or exclude surgical site infection (SSI). METHOD: We undertook a mixed methods study consisting of a qualitative public involvement exercise and a prospective, non-randomised, single-centre study of patients undergoing clean or clean-contaminated vascular surgery. For the qualitative study, two semi-structured focus group interviews were conducted. For the prospective study, patients were invited to attend a wound review at 5-7 days and 30 days postoperatively. At review, wounds were scored by a study nurse or doctor, according to the ASEPSIS scale. Anonymised wound photographs were taken and independently reviewed, and ASEPSIS scored by two independent investigators blinded to the original 'clinical review' ASEPSIS score. RESULTS: In the qualitative study, three female patients were interviewed across two dates. Emerging themes included the burden of SSI, hospital follow-up and telemedical follow-up. A total of 37 patients with a mean age of 61.14 years were included in the quantitative analysis. There was a total of 53 wound reviews. There was >85% agreement between photograph and clinical reviewers in all categories except erythema. The specificity of photograph review for diagnosis of SSI was 90%. The intraclass correlation coefficient for total ASEPSIS score was R=0.806 (95% CI 0.694, 0.881), indicating strong reliability between reviewers. CONCLUSION: Our data shows that, in the assessment of SSI, there is good correlation between face-to-face clinical and remote photographic review. Incorporating this method of wound assessment into a postoperative follow-up care pathway may save patients and clinicians from unnecessary hospital visits, particularly when conducting health research.

A systematic review of muscle morphology and function in intermittent claudication.

OBJECTIVE: Intermittent claudication (IC) is frequently associated with deterioration in walking capacity and physical function, and it can often result in an impairment in balance. Whereas supervised exercise is recommended by the National Institute for Health and Care Excellence as the first-line treatment, the mechanism behind walking improvement is poorly understood. The existing literature suggests that there may be some physiologic change to the skeletal muscle contributing to the functional impairment, but these data are conflicting. We therefore sought to undertake a systematic review to clarify the muscle properties of patients with IC. METHODS: A systematic review of randomized and nonrandomized trials that investigated the role of muscle function in patients diagnosed with IC was undertaken using MEDLINE, Cochrane Central Register of Controlled Trials, and Embase databases. The searches were limited from 1947 to June 2016 in the English language. RESULTS: The search yielded a total of 506 articles, of which 206 were duplicate articles. Of the remaining 300, a total of 201 were excluded from full-text analysis; 99 full-text articles were assessed for eligibility, with 30 articles deemed appropriate for inclusion in the review. There were four main categories of functional outcome measures: muscle strength, muscle size, muscle fiber type, and muscle metabolism. A total of 2837 patients were included in the study. Nine studies reported on muscle strength, incorporating isometric, concentric, eccentric, and endurance measures. Eight studies reported on muscle size, incorporating circumference, computed tomography scans, and ultrasound imaging techniques. Eleven studies reported on muscle fibers, incorporating fiber type proportions, fiber size, and capillarity measures. Seven papers reported on muscle metabolism, incorporating adenosine diphosphate recovery and phosphocreatine recovery measures. CONCLUSIONS: Previous literature has found clear evidence that strength (of the calf and thigh musculature) and calf characteristics are related to mortality and functional declines. However, this review has demonstrated the vast array of muscle groups assessed and multiple methods employed to determine strength; therefore, it is unclear exactly what measure of "strength" is impaired. Furthermore, the underlying morphologic causes of potential changes in strength are unclear. This information is essential for designing optimal exercise interventions. The data acquired during this systematic review are heterogeneous, with a substantial lack of high-quality intervention-based studies. Future research should endeavor to establish standardized testing procedures and to implement randomized controlled trials for targeted therapeutic interventions.

Extracorporeal Shockwave Therapy for Peripheral Arterial Disease: A Review of the Potential Mechanisms of Action.

BACKGROUND: Lower limb peripheral arterial disease (PAD) affects 20% of population over 65 years. Extracorporeal shockwave therapy (ESWT) has recently emerged as a novel, safe, and effective treatment option. This review aims to assess the mechanism of action by which ESWT improves symptoms in patients with PAD. METHODS: MEDLINE and EMBASE databases were searched in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Any article investigating the mechanism of action of ESWT in PAD was considered for inclusion. RESULTS: The systematic review of the current literature yielded 8 relevant articles reporting studies on animal models of hind limb ischemia or on patients with PAD. These articles described the effects of ESWT on angiogenesis, arteriogenesis, vasculogenesis, endothelial nitric oxide synthase, lower limb micro/macrocirculation, and atherosclerosis. CONCLUSION: ESWT increases the expression of angiogenic, arteriogenic, and vasculogenic factors, reduces vessel wall stenosis, and improves limb perfusion. However, most of the evidence is based on animal studies. Future research should focus on elucidating the mechanism of action of ESWT in PAD patients.

Dialkylcarbamoyl Chloride Dressings in the Prevention of Surgical Site Infections after Nonimplant Vascular Surgery.

BACKGROUND: Dressings coated with dialkylcarbamoyl chloride (DACC) are highly hydrophobic and irreversibly bind multiple types of bacteria, trapping them in the dressing and reducing the number of organisms at the wound surface. We aimed to assess the impact of DACC-coated postoperative dressings on the incidence of surgical site infection (SSI) in nonimplant vascular surgery patients. METHODS: Two hundred patients undergoing nonimplant vascular surgery were prospectively recruited at a single vascular center. The initial 100 patients had their operative wounds dressed with conventional dressings followed by 100 patients who received DACC-coated postoperative dressings. Wounds were reviewed at day 5 and day 30 to determine the presence of SSI using the ASEPSIS scoring system. The variation in outcomes between groups was assessed using chi-squared test and logistic regression analysis to assess the effects of other variables, which may affect healing. RESULTS: Between August 1, 2015 and February 29, 2016, a total of 120 men and 80 women were recruited. The mean age was 63 (range 27-97) years, 92% were current or ex-smokers and 45.5% were diabetic. Rate of SSI at 5 days was significantly lower in the DACC group compared with standard dressings (1% vs. 10%, P < 0.05). There was no difference in the rates of SSI at 30 days. Logistic regression suggested that the type of dressing used was the most prominent predictor variable for the presence of early SSI (P = 0.028, odds ratio = 0.09, 95% confidence interval: 0.01-0.77). CONCLUSIONS: DACC-coated dressings were associated with a significant reduction in SSI rates in the early postoperative period.

The Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma: A Systematic Review and Meta-analysis.

Background: Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high metastatic potential. Sentinel lymph node biopsy (SLNB) is used to assess locoregional spread, facilitate staging, and inform prognosis. Positive nodal status is associated with higher recurrence rates and reduced overall survival. Methods: A systematic search was conducted. Eligible articles included patients diagnosed with MCC, who would be candidates for or who had SLNB. The Covidence tool was used for screening and data extraction, including additional treatments, disease-free survival, overall survival, and recurrence. Methodological quality was assessed using the Newcastle-Ottowa Scale criteria. Results: SLNB was associated with increased likelihood of completion lymphadenectomy (223 versus 41), regional radiotherapy (2167 versus 808), and systemic chemotherapy (138 versus 31). Overall survival for patients undergoing SLNB was 81% at 2 years, 75% at 3 years, and 72% at 5 years (odds ratio: 0.79). Hazard ratio for positive SLNB versus negative was 3.36 (P < 0.001). Five-year disease recurrence was 23.3% in patients undergoing SLNB. Conclusions: Lymph node metastases are associated with reduced overall survival and increased recurrence of MCC. Determining nodal status early can inform prognosis, facilitate staging, and determine need for adjuvant treatment. Adjuvant treatments are associated with reduced mortality and improved overall survival; SLNB is an important influencer of their use. Early prophylactic intervention should be considered in MCC in both positive and negative nodal status to improve overall outcomes. Widespread use of SLNB will allow more accurate assessment of the role of nodal status on adjuvant treatment and long-term outcomes.

The cost of keeping warm: a relationship between a rise in the cost of domestic energy and burn injuries caused by personal heating equipment.

INTRODUCTION: During 2022-2023, the UK found itself in the midst of a domestic energy crisis, with the average domestic gas and electricity bill rising by 75% between 2019 and 2022. As a result, the use of hot water bottles, radiant heaters, and electric blankets increased. An unintended consequence of this may be an increase in burn injuries caused by misfortune, misuse, or the use of items in a state of disrepair. PURPOSE: The aim of this study was to explore any increase in referrals to a single burns centre in England for injuries caused by hot water bottles, radiant heaters, or electric blankets. METHODS: This was a retrospective study of a prospectively maintained database of referrals. All referrals between January 2022 and January 2023 were selected and compared with the same period from 2020-2021 (before the rise in energy prices). Referrals were screened for the terms "hot water bottle," "electric heater," "electric blanket," and "heater." Total referrals in each period, demographic data (age, gender), anatomical location and the mechanism of injury were compared between cohorts. RESULTS: We found a statistically significant increase in the number of burns relating to heating implements between 2020/21 and 2022/23, rising from 54 to 81 (p = 0.03) - a 50% increase in injuries. Injuries in working age adults increased significantly (52% to 69%, p < 0.05). The most frequently injured area was the leg (30%) followed by the hand (18%). The commonest type of injury described was scald (72%). We found a moderately-strong correlation between the number of referrals and the average cost of energy in 2022-23. CONCLUSION: The number of injuries sustained by people using personal heating equipment is significantly increasing, which correlated with the rise in domestic energy prices. The most affected demographic appears to be working age adults, with wider implications around lost work-time yet to be explored. Further prospective, population-based work is indicated to assess the strength of the correlation seen in this study.

Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) protocol.

Aims: Hand trauma, consisting of injuries to both the hand and the wrist, are a common injury seen worldwide. The global age-standardized incidence of hand trauma exceeds 179 per 100,000. Hand trauma may require surgical management and therefore result in significant costs to both healthcare systems and society. Surgical site infections (SSIs) are common following all surgical interventions, and within hand surgery the risk of SSI is at least 5%. SSI following hand trauma surgery results in significant costs to healthcare systems with estimations of over £450 per patient. The World Health Organization (WHO) have produced international guidelines to help prevent SSIs. However, it is unclear what variability exists in the adherence to these guidelines within hand trauma. The aim is to assess compliance to the WHO global guidelines in prevention of SSI in hand trauma. Methods: This will be an international, multicentre audit comparing antimicrobial practices in hand trauma to the standards outlined by WHO. Through the Reconstructive Surgery Trials Network (RSTN), hand surgeons across the globe will be invited to participate in the study. Consultant surgeons/associate specialists managing hand trauma and members of the multidisciplinary team will be identified at participating sites. Teams will be asked to collect data prospectively on a minimum of 20 consecutive patients. The audit will run for eight months. Data collected will include injury details, initial management, hand trauma team management, operation details, postoperative care, and antimicrobial techniques used throughout. Adherence to WHO global guidelines for SSI will be summarized using descriptive statistics across each criteria. Discussion: The Hand and Wrist trauma: Antimicrobials and Infection Audit of Clinical Practice (HAWAII ACP) will provide an understanding of the current antimicrobial practice in hand trauma surgery. This will then provide a basis to guide further research in the field. The findings of this study will be disseminated via conference presentations and a peer-reviewed publication.

The incidence and cost implications of surgical site infection following lymph node surgery for skin malignancy.

BACKGROUND: Lymph node surgery is commonly performed in the staging and treatment of metastatic skin cancer. Previous studies have demonstrated sentinel lymph node biopsy (SLNB) and, particularly, lymph node dissection (LND) to be plagued by high rates of wound complications, including surgical site infection (SSI) and seroma formation. This study evaluated the incidence of wound complications following lymph node surgery and provided the first published cost estimate of SSI associated with lymph node surgery in the UK. PATIENTS AND METHODS: A retrospective cohort study of 169 patients with a histological diagnosis of primary skin malignancy who underwent SLNB or LND of the axilla and/or inguinal region at a single tertiary centre over a 2 year period was conducted. Demographic, patient risk factor, and operation characteristics data were collected and effect on SSI and seroma formation was analysed. Cost-per-infection was estimated using National Health Service (NHS) reference and antibiotic costs. RESULTS: A total of 146 patients underwent SLNB with a SSI rate of 4.1% and a seroma incidence of 12.3%. Twenty-three patients underwent LND with a SSI rate of 39.1% and a seroma incidence of 39.1%. Seroma formation was strongly associated with the development of SSI in both the SLNB (odds ratio (OR) = 18.0, p < 0.001) and LND (OR = 21.0, p = 0.007) group. The median additional cost of care events and treatment of SSI in the SLNB and LND groups was £199.46 and £5187.04, respectively. CONCLUSION: SSI remains a troublesome and costly event following SLNB and LND. Further research into perioperative care protocols and methods of reducing lymph node surgery morbidity is required and could result in significant cost savings to the NHS.

Electrochemotherapy vs radiotherapy in the treatment of primary cutaneous malignancies or cutaneous metastases from primary solid organ malignancies: A systematic review and narrative synthesis.

BACKGROUND: Electrochemotherapy has gained international traction and commendation in national guidelines as an effective tool in the management of cutaneous malignancies not amenable to surgical resection. Despite this, no level 5 evidence exists comparing it to radiotherapy in the treatment of cutaneous malignancies. This systematic review aimed to examine the literature directly and indirectly comparing electrochemotherapy and radiotherapy in the treatment of primary cutaneous malignancies or cutaneous metastases from primary solid organ malignancies. MATERIALS & METHODS: The protocol for this review was registered on the PROSPERO International Prospective Register of Systematic Reviews with the protocol ID CRD42021285415. Searches of MEDLINE, Embase, CINAHL, CENTRAL and ClinicalTrials.gov databases were undertaken from database inception to 28 December 2021. Studies in humans comparing treatment with electrochemotherapy to radiotherapy and reporting tumour response with a minimum four week follow-up were eligible. Risk of bias was assessed using the ROBINS-I tool. Results are provided as a narrative synthesis. RESULTS: Two case series with a total of 92 patients were identified as relevant to this study. Both case series examined patients with cutaneous squamous cell carcinoma. One case series examined elderly patients with predominantly head/neck lesions. The other examined younger patients with predominantly limb lesions who had cutaneous squamous cell carcinoma directly attributable to a rare skin condition. CONCLUSION: There is little literature presenting comparative data for electrochemotherapy and radiotherapy in the treatment of primary cutaneous malignancies or cutaneous metastases. Included studies were marred by serious risk of bias particularly due to confounding. The inherent bias and heterogeneity of the included studies precluded synthesis of a consolidated comparison of clinical outcomes between the two therapies. Further research is required in this domain in the form of clinical trials and observational studies to inform guidelines for electrochemotherapy treatment.

Dermoscopy as an adjunct to surgical excision of nonmelanoma Skin lesions: a systematic review and Meta-analysis.

Background: Nonmelanoma skin cancers (NMSC) have an incidence of 152,000 cases per year in the United Kingdom (UK), which continues to rise. Incomplete excision rates for NMSC are estimated to be around 10 percent and result in patients having a higher risk of recurrence or having to undergo further treatment. Objective: The objective of our study was to determine whether the use of dermoscopy as an adjunct to clinical examination could improve the rates of incomplete excision in NMSC lesions. Methods: Electronic literature search of MEDLINE, EMBASE, and Cochrane Central databases plus manual reference checks of articles on dermoscopy use in surgery between inception and November 2020. Two levels of screening were used on 452 studies. A random effects model was used in the meta-analysis, with the DerSimonian-Laird method used to pool data. Results: A total of six fully extracted studies were included with a total of 592 patients; with five of these studies reported on basal cell carcinomas and one reported on squamous cell carcinomas. The odds ratio of incomplete excision when guided by dermoscopy was 0.29 (95%CI 0.25; 0.34). Heterogeneity was assessed with the I2 statistic and was found to be 0 percent. Limitations: The number of studies included was small, with three of the studies from the same authors. Studies included are nonrandomized and as such hold a significant risk of bias. Conclusion: Incomplete excision rates were reduced when using dermoscopy to mark surgical excision margins in comparison to naked eye evaluation alone.