Getting it right first time: national survey of surgical site infection 2019.

INTRODUCTION: Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery. METHODS: Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure. RESULTS: A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates. CONCLUSIONS: The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

Lessons from rhinology and facial plastic surgery clinical negligence claims in England 2013-2018.

OBJECTIVE: This study reviewed all rhinology clinical negligence claims in the National Health Service in England between 2013 and 2018. METHOD: All clinical negligence claims held by National Health Service Resolution relating to rhinology in England between 1 April 2013 and 1 April 2018 were reviewed. RESULTS: There were 171 rhinology related claims with a total estimated potential cost of £13.6 million. There were 119 closed claims (70 per cent) with a total cost of £2.3 million, of which 55 claims resulted in payment of damages. Over three quarters of all rhinology claims were associated with surgery (n = 132). Claims associated with endoscopic sinus surgery had the highest mean cost per claim (£172 978). Unnecessary pain (33.9 per cent) and unnecessary operation (28.1 per cent) were the most commonly cited patient injuries. CONCLUSION: Patient education and consent have been highlighted as key areas for improvement from this review of rhinology related clinical negligence claims. A shift in clinical practice towards shared decision making could reduce litigation in rhinology.

Litigation in breast surgery: unique insights from the English National Health Service experience.

BACKGROUND: The increase in medical negligence claims against the National Health Service (NHS) over the past decade has had a detrimental impact on limited financial and human resources that could otherwise be available for direct clinical care. The aim of this study was to review litigation claims in breast surgery as part of the national Getting It Right First Time quality improvement initiative, with the aim of identifying opportunities to improve clinical practice and patient safety. METHODS: All general and plastic surgical claims notified to NHS Resolution between April 2012 and April 2018 were reviewed. Claims related specifically to breast surgery were retrieved manually, and case summaries were analysed independently by two breast surgeons. RESULTS: From 6915 claims, 449 relating to breast surgery were identified and reviewed. The mean(s.d.) claimant age was 46(13) years. The median number of claims over the 6-year period per NHS trust was 2 (range 0-22). The most frequent causes of litigation were dissatisfaction with cosmetic outcome (121 claims, 26.9 per cent) and patient-reported delays in diagnosis (121, 26.9 per cent). A large proportion of claims related to breast implant surgery (78, 17.4 per cent), and issues regarding consent/communication were common (69, 15.4 per cent). The estimated annual cost of breast surgery litigation claims ranged from £5.57 to £9.59 million (€6.35-11.02 million). CONCLUSION: Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.

What can be learned from litigation in otology? A review of clinical negligence claims in England 2013-2018.

BACKGROUND: Litigation in the National Health Service continues to rise with a 9.4 per cent increase in clinical negligence claims from the period 2018 and 2019 to the period 2019 and 2020. The cost of these claims now accounts for 1.8 per cent of the National Health Service 2019 to 2020 budget. This study aimed to identify the characteristics of clinical negligence claims in the subspecialty of otology. METHODS: This study was a retrospective review of all clinical negligence claims in otology in England held by National Health Service Resolution between April 2013 and April 2018. RESULTS: There were 171 claims in otology, 24 per cent of all otolaryngology claims, with a potential cost of £24.5 million. Over half of these were associated with hearing loss. Stapedectomy was the highest mean cost per claim operation at £769 438. The most common reasons for litigation were failure or delay in treatment (23 per cent), failure or delay in diagnosis (20 per cent), intra-operative complications (15 per cent) and inadequate consent (13 per cent). CONCLUSION: There is a risk of high-cost claims in otology, especially with objective injuries such as hearing loss and facial nerve injury.

Getting It Right First Time: the national survey of surgical site infection rates in NHS trusts in England.

INTRODUCTION: Surgical site infections are associated with increased morbidity and mortality in patients. The Getting It Right First Time surgical site infection programme set up a national survey to review surgical site infection rates in surgical units in England. The objectives were for frontline clinicians to assess the rates of infection following selected procedures, to examine the risk of significant complications and to review current practice in the prevention of surgical site infection. METHODS: A national survey was launched in April 2017 to assess surgical site infections within 13 specialties: breast surgery, cardiothoracic surgery, cranial neurosurgery, ear, nose and throat surgery, general surgery, obstetrics and gynaecology, ophthalmology, oral and maxillofacial surgery, orthopaedic surgery, paediatric surgery, spinal surgery, urology and vascular surgery. All participating trusts prospectively identified and collected supporting information on surgical site infections diagnosed within the six-month study period. RESULTS: Data were received from 95 NHS trusts. A total of 1807 surgical site infection cases were reported. There were variations in rates reported by trusts across specialties and procedures. Reoperations were reported in 36.2% of all identified cases, and surgical site infections are associated with a delayed discharge rate of 34.1% in our survey. CONCLUSION: The Getting It Right First Time surgical site infection programme has introduced a different approach to infection surveillance in England. Results of the survey has demonstrated variation in surgical site infection rates among surgical units, raised the importance in addressing these issues for better patient outcomes and to reduce the financial burden on the NHS. Much work remains to be done to improve surgical site infection surveillance across surgical units and trusts in England.

Variability in plasma concentrations of methylprednisolone 6 days after intrasynovial injection of methylprednisolone acetate in racing horses: A field study.

BACKGROUND: Methylprednisolone (MP) acetate is a commonly used corticosteroid for suppression of inflammation in synovial structures in horses. Its use is often regulated in equine sports by plasma MP concentrations. OBJECTIVES: To describe variability in MP plasma concentrations after MP acetate injection in different synovial structures and with co-administration with hyaluronic acid (HA). STUDY DESIGN: Field study in actively racing horses in three disciplines (Thoroughbred, Standardbred and Quarter Horse). METHODS: Seventy-six horses (15 Thoroughbreds, 20 Standardbreds and 41 Quarter Horses) were included in the study. Injection of any synovial structure with a total body dose of 100 mg MP acetate was permitted, data were grouped according to the synovial structure injected and co-administration with HA. Plasma was collected before injection and at 6 days post-injection. Per cent censored data (below the limit of quantification) for each synovial structure were determined, and summary statistics generated by Robust Regression on Order. Differences between synovial structures and co-administration with HA were identified by ANOVA with Tukey's post hoc testing. RESULTS: The MP plasma concentration at 6 days for injection for the entire group (mean ± standard deviation [s.d.], pg/mL) was 96 ± 104. Metacarpophalangeal (MCP) plasma concentrations contained 86% censored data and could not be included in the statistical analysis. The carpal joints (CJO) group had a lower plasma MP concentration (P<0.05) than the distal tarsal joints (DTJ) or medial femorotibial (MFT), the no HA (NHA) group had a lower plasma MP concentration (P<0.05) than HA. MAIN LIMITATIONS: The synovial structures injected varied by racing discipline, so this study was unable to identify any differences between disciplines. CONCLUSIONS: Practitioners should be aware that injection of DTJ, CS and MFT joints, and combining MP acetate with HA may prolong its clearance, and withdrawal times for competition in regulated equine sports.

Does clinical trial participation improve outcomes in patients with ovarian cancer?

INTRODUCTION: Treatment on a clinical trial is considered to be beneficial to oncology patients. However, supportive evidence for this is scarce. Trial effect describes the phenomenon of improved health outcomes in patients treated with standard of care (SOC) on trial compared to those receiving SOC outside of a clinical trial. We evaluated trial effect in patients with ovarian cancer treated at our tertiary cancer centre. METHODS: We performed a retrospective cohort study of patients with ovarian cancer treated at The Christie National Health Service Foundation Trust. Patients treated on one of three first-line clinical trials: (SCOTROC-4, ICON-5, ICON-7) were matched (for age, International Federation of Gynaecology and Obstetrics stage, surgical status and performance status) with individuals receiving the same SOC off trial. Survival was calculated using Kaplan-Meier methodology. RESULTS: 60 patients were evaluated; 30 on trial and 30 on SOC off trial. The median progression-free survival (PFS) was 21.8 months (control group) and 25.9 months (trial group), median overall survival (OS) was 64.3 months (control group) and 68.9 months (trial group). There was no difference in PFS (log-rank test: HR 0.87 (95% CI 0.48 to 1.54), p=0.6) or OS (log-rank test: HR 0.87 (95% CI 0.46 to 1.64), p=0.7) between groups. CONCLUSIONS: Patient survival was similar regardless if treated on trial or as SOC. Our findings do not support trial effect, at least in a tertiary cancer centre. Clinical trial participation in specialised cancer centres promotes best practice to the benefit of all patients. These findings may impact discussions round consent of patients to trials and organisation of oncology services.

Patient satisfaction with the use of an enhanced recovery programme for primary arthroplasty.

INTRODUCTION: Enhanced recovery programmes (ErPs) are increasingly being used for arthroplasty. One of the core aims of an ErP is to improve the quality of patient experience. However, there is currently no published evaluation of patient satisfaction in relation to this new programme of care within orthopaedic surgery. The aim of this study was to compare the ErP against the standard care programme (SCP) at one centre. METHODS: A satisfaction survey addressing patient opinions on the key objectives of the ErP was conducted by telephone, using a set script. Of the 226 patients contacted, 143 (63.3%) responded (69 from the ErP and 74 from the SCP). Of the respondents, 71 received a total hip arthroplasty and 72 a total knee arthroplasty. Patients were contacted at a mean time from operation to survey of 27.2 weeks. They were asked to rate satisfaction on a five-point scale and complete the EQ-5D™ health questionnaire (EuroQol, rotterdam, Netherlands) to measure healthcare outcomes. RESULTS: The mean patient satisfaction score of 4.07 for speed of recovery in the ErP group was significantly higher than the SCP group's score of 3.68 (p=0.037). Adjusting for the preoperative health score, the postoperative health score was higher for ErP patients at 74.1 compared with 64.7 for SCP patients (p=0.0029). Furthermore, the percentage of patients who had a better than expected recovery was significantly greater in the ErP group at 85.5% compared with 58.1% (p=0.0004) in the SCP group. CONCLUSIONS: We believe that the previously established reduction in length of hospital stay delivered by ErPs is not achieved at the expense of the patient's experience.

Punch biopsy: a useful adjunct in a rapid diagnosis breast clinic.

INTRODUCTION: Triple assessment of breast lesions usually involves the use of core biopsy (CB) or fine needle aspiration cytology (FNAC). Punch Biopsy (PB) is a technique widely used by dermatologists and can be used in superficial breast lesions with dermal involvement. We studied the utilization of PB in a rapid diagnosis breast clinic. METHOD: We reviewed patients who underwent a PB over a seven and a half-year period from December 2001 to May 2009. The indications for biopsy and the contribution of PB to final diagnosis were studied. RESULTS: The commonest indications were breast lump with skin involvement or ulceration (n = 27), suspected Paget's disease (n = 25), discolouration of breast skin (n = 23), and nodules in the breast skin or surgical scar (n = 18). Final diagnosis was benign in 80 patients and malignant in 20. In 74 patients with benign and 7 patients with malignant diagnoses, PB was the only source of histological diagnosis. CONCLUSION: PB is a valuable adjunct to conventional methods of tissue diagnosis such as CB and FNAC in both benign and malignant breast lesions.

[Imiquimod in treatment of palpebral mycosis fungoides]. / Imiquimod como tratamiento de la micosis fungoide palpebral.

CLINICAL CASE: Our patient was a 37-year-old male with palpebral mycosis fungoides, the most common T-cell cutaneous lymphoma. He had been treated previously with topical corticosteroids. We treated him with Imiquimod cream (5%) three times a week. DISCUSSION: A clinical improvement was obtained with this drug, so we believe immuno-modulating agents need to be considered in the treatment of palpebral mycosis fungoides, especially because of its capacity of being a reflection of leukaemia.

Imiquimod como tratamiento de la micosis fungoide palpebral / Imiquimod in treatment of palpebral mycosis fungoides

Caso clínico: Presentamos el caso de un varón de37 años de edad que presentaba una micosis fungoide,el más frecuente de los linfomas T cutáneos,con localización exclusivamente palpebral quehabía sido tratado previamente con corticoides tópicos.Se instauró un tratamiento con Imiquimod al5% en crema tres veces semanales.Discusión: Con el uso de este medicamento, seconsiguió una gran mejoría clínica del paciente, porlo que consideramos muy importante tener en cuentaeste inmunomodulador para el tratamiento deesta enfermedad, de importancia por su capacidadde leucemización

Clinical case: Our patient was a 37-year-old male with palpebral mycosis fungoides, the most common T-cell cutaneous lymphoma. He had been treated previously with topical corticosteroids. We treated him with Imiquimod cream (5%) three times a week. Discussion: A clinical improvement was obtained with this drug, so we believe immuno-modulating agents need to be considered in the treatment of palpebral mycosis fungoides, especially because of its capacity of being a reflection of leukaemia

Mionecrosis por Clostridium de curso fatal tras la picadura de un ave / Fatal course Clostridium caused myonecrosis after bird bite

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[Lacrimal duct obstruction treated with lacrimonasal stent]. / Obstrucción de vía lagrimal tratada mediante stent lacrimonasal.

OBJECTIVE: To analyze a series of patients with lacrimal duct obstruction treated with polyurethane stents. MATERIAL AND METHODS: We studied 125 cases of lacrimal duct obstruction corresponding to 115 patients, of whom 30 were males (26.08%) and 85 females (73.91%). The obstruction involved the right side in 51 cases (40.8%) and the left side in 74 (59.2%). Mean age was 65 +/- 14.64 years. Symptoms included chronic epiphora in 65 patients (52%), acute lacrimal sac inflammation in 33 (26.4%), mucocele in 6 (4.8%) and recurrent conjunctivitis in 4 (3.2%). Seventeen patients came to us diagnosed with lacrimal duct obstruction. Time of follow up was one year. RESULTS: Stents were successfully implanted in 120 cases (96%). Surgical complications included pain in 5.83%, eyelid inflammation in 5%, nasal bleeding in 0.83% and false duct in 0.83%. Functional success was achieved in 82 patients (68.3%), and surgical failure occurred in 38 patients (31.7%). Mean time of stent failure was 178 days. In these cases, inner granulation tissue was found in 63.15% of the cases and mucoid material in 36.85%. The most common postoperative complication was mucocele formation, which ocurred in 7.5% of the patients. CONCLUSIONS: In our experience, polyurethane stent implantation is a good alternative for treating nasolacrimal obstruction, but not as effective as endonasal or external dacryocystorhinostomy.

Obstrucción de vía lagrimal tratada mediante stent lacrimonasal / Lacrimal duct obstruction treated with lacrimonasal stent

Objetivo: Analizar los resultados de la implantación de stents lacrimonasales de poliuretano y las características de los pacientes y las intervenciones realizadas. Material y métodos: Estudio de 125 casos de obstrucción del conducto lacrimonasal en 115 pacientes, 30 varones y 85 mujeres. Obstrucciones del lado derecho 51 (40,8 por ciento) y del lado izquierdo 74 (59,2 por ciento). Edad media de los enfermos: 65 DE 14,61 años. La clínica de los pacientes fue epífora 65 casos (52 por ciento), dacriocistitis aguda 33 (26,4 por ciento), mucocele 6 (4,8 por ciento), conjuntivitis de repetición 4 casos (3,2 por ciento). Un total de 17 pacientes nos fueron remitidos con el diagnóstico de obstrucción de vía lagrimal. El tiempo de seguimiento fue de 1 año. Resultados: Implante realizado con éxito en 120 casos (96 por ciento). Las complicaciones intraoperatorias más importantes fueron dolor 5,83 por ciento, inflamación palpebral 5 por ciento, falsa vía y epistaxis, 0,83 por ciento cada una. La epífora desapareció en 82 casos (68,3 por ciento) y persistió en 38 (31,7 por ciento). Tiempo medio de fallo del stent en este último grupo 178 días. En los stents que fallaron se encontró tejido de granulación en un 63,15 por ciento y material mucoide en 36,85 por ciento. La principal complicación postoperatoria fue mucocele en el 7,5 por ciento de los casos. Conclusiones: Consideramos esta técnica una buena alternativa para el tratamiento de la obstrucción de la vía lagrimal, aunque sin alcanzar los resultados de la dacriocistorrinostomía externa o endonasal (AU)

Objective: To analyze a series of patients with lacrimal duct obstruction treated with polyurethane stents. Material and Methods: We studied 125 cases of lacrimal duct obstruction corresponding to 115 patients, of whom 30 were males (26.08%) and 85 females (73.91%). The obstruction involved the right side in 51 cases (40.8%) and the left side in 74 (59.2%). Mean age was 65 ± 14.64 years. Symptoms included chronic epiphora in 65 patients (52%), acute lacrimal sac inflammation in 33 (26.4%), mucocele in 6 (4.8%) and recurrent conjunctivitis in 4 (3.2%). Seventeen patients came to us diagnosed with lacrimal duct obstruction. Time of follow up was one year. Results: Stents were successfully implanted in 120 cases (96%). Surgical complications included pain in 5.83%, eyelid inflammation in 5%, nasal bleeding in 0.83% and false duct in 0.83%. Functional success was achieved in 82 patients (68.3%), and surgical failure occurred in 38 patients (31.7%). Mean time of stent failure was 178 days. In these cases, inner granulation tissue was found in 63.15% of the cases and mucoid material in 36.85%. The most common postoperative complication was mucocele formation, which ocurred in 7.5% of the patients. Conclusions: In our experience, polyurethane stent implantation is a good alternative for treating nasolacrimal obstruction, but not as effective as endonasal or external dacryocystorhinostomy (AU)

238U 226Ra 210Pb, 232Th and 40K activities in soil profiles of the Flysch sector (Central Spanish Pyrenees).

Distributions of natural gamma-emitting radionuclides were determined in three soil profiles developed on Tertiary sedimentary materials in mountain landscapes of the Central Spanish Pyrenees. Radioisotope activities (Bq kg(-1)) lie in the range of 0-53 for 238U; 19-33 for 226Ra; 7-75 for 210Pb; 24-48 for 232Th and 335-562 for 40K. 238U and 210Pb activities show an important variability down the soil profiles. 238U was markedly depleted in all upper soil layers and highly enriched in lower layers of two soil profiles. 210Pb exhibits very dissimilar distribution patterns in all three soils. 226Ra and 232Th had quite uniform depth distributions. 40K showed depletion in both upper and lower layers in one soil profile but remained fairly constant in the other two profiles. 238U/226Ra activity ratios (ARs) have been used to assess equilibrium in the 238U decay chain and as indicators of edaphogenesis in the studied soil profiles. Maintenance of initial proportionality in the ratio of 232Th/238U activities has been assessed through ARs of their progenies. Additionally, a variety of soil properties were measured down the soil profiles. Among soils, variation in radionuclide activies may be due to differences in carbonate content, organic matter and/or grain size. In this environment, soil properties differently affect mobilization of natural radionuclides. The association of some radiologic properties with soil layers suggest a relationship between soil processes and radionuclide distribution.

A multidisciplinary approach to head and neck cancer.

Head and neck cancer and its treatment can leave patients with impaired swallowing and ability to communicate. A multidisciplinary approach from the speech and language therapist and dietician can help the patient maximise their function and identify when additional methods of support are required.

Planar and high-resolution SPECT bone imaging in the diagnosis of facet syndrome.

UNLABELLED: This study's goals were to determine the appearance of potentially symptomatic facet joints on planar and high-resolution SPECT radionuclide bone imaging, relate the relative sensitivity of the two techniques and assess the predictive value in a clinical setting. METHODS: Fifty-eight consecutive patients referred with a diagnosis of possible facet syndrome were imaged during the same visit using both a well-established planar and a SPECT technique developed to emphasize high spatial resolution. The standard of reference included facet injections with a marcaine and steroid mixture, with review of a pain journal completed by the patient included in the followup criteria. RESULTS: In the 43 patients comprising the final study group, 7 were diagnosed with facet syndrome, 5 with abnormal planar images and 7 with abnormal SPECT images. A total of 10 facet joints with abnormal increased uptake were seen on SPECT which were not demonstrated on planar imaging. There was high sensitivity (100% SPECT, 71% planar), but somewhat lower specificity (71% SPECT, 76% planar). The negative predictive value was high (100% SPECT, 93% planar). Radionuclide bone imaging additionally discovered a nonfacet joint etiology for patient symptoms in 16 of the 43 patients. CONCLUSION: Higher spatial resolution SPECT images are better accepted by referring physicians who correlate them with CT or MR images. The high negative predictive value allows radionuclide bone imaging to be used to select appropriate patients to undergo the invasive facet injection procedure.

An electrical model for Periplaneta americana pronotal integument: an epidermal location for hydration-dependent resistance.

Measurements of electrical resistance appear to be useful indicators of porosity and related water permeability in insect cuticle. To develop an adequate understanding of how such measurements relate to the physical and structural properties of the integument, we made detailed determinations of resistance and impedance values for pronotal cuticle in adult male Periplaneta americana. The most consistent estimates were obtained by averaging measurements across the integument on both sides of the midline at several intervals starting 15 min after electrode application. Pronotal resistance varied inversely with water content, from about 10 k omega cm2 in hydrated cockroaches to about 40 k omega cm2 in dehydrated insects. Though the dermal gland canals appear to act as the main conductive pathway across the cuticle, the variable 'barrier' is located in the epidermal layer, since removal of the epidermis from isolated pronota also removes most of the variable component of the integumental resistance. Comparison of measurements between two external electrodes with single-electrode measurements revealed a 'shunt' pathway parallel to the cuticle surface; modelling this shunt suggested that it was variable and located mostly internal to the cuticle, supporting an epidermal location for a variable barrier. Impedance measurements over a range of frequencies showed the integument to be electrically complex, and a model is proposed to account for its properties.