Western Infirmary Research Articles

Effect of Triclosan‐Coated Sutures on Incidence of Surgical Wound Infection after Lower Limb Revascularization Surgery: A Randomized Controlled Trial. By Turtiainen et al. DOI:10.1007/s00268‐012‐1655‐4

This prospective, randomized, multicenter, double-blind, parallel group trial by Dr. Turtiainen and her associates in Finland [1] was designed to investigate the potential effect of an antibacterial triclosan-coated suture on the incidence of wound infection in patients undergoing reconstructive vascular surgery. In producing a negative result, the investigators have clarified the role, or lack thereof, of this approach to wound infection. They raise at least two important topics that need to be discussed. The first is the relative dearth of articles in the medical literature reporting negative results, and the other is the matter of wound infections associated with vascular surgery. In general terms, the reluctance of investigators (and journals) to publish negative results contributes significantly to the imbalances that lead to reporting bias. This bias is now assuming more importance than previously because we increasingly depend on meta-analyses to guide medical care via the development and use of guidelines and protocols. The absence of negative studies in the literature inevitably leads to the production of conclusions from such analyses that are biased toward the positive. To reduce such misleading tendencies, the publication of carefully designed and wellconducted studies such as this one should be encouraged even when the results are negative [2]. The problem studied in the article by Turtiainen et al. [1]—infection associated with reconstructive vascular surgery—is a source of particular anxiety because of its potentially disastrous consequences, especially in this age of methicillin-resistant Staphylococcus aureus (MRSA) and health care-associated infections. The consequences of infection can be catastrophic. ‘‘... outcomes often worse than those of the natural history of the condition that led to implantation [of the graft]’’ [3]. Infection of a prosthetic conduit not uncommonly leads to limb loss or death. Add to this mix the propensity of groin wounds disproportionately to be affected and the preponderance of diabetic patients involved and we understand why vascular surgeons should be so concerned about this topic. The incidence of surgical-site infections (SSIs) after vascular surgery varies widely from one publication to another, as does the definition of wound infection. The incidence reported here is not out of keeping with other reports. Vascular surgery is often regarded largely as ‘‘clean’’ surgery in that incisions are made through apparently uncontaminated tissue, and the procedures do not involve opening any hollow viscus. Published audits of wound infection in vascular surgery report wide variations in wound infection rates. Those at the lower end probably involve a certain amount of selection bias as authors strive to demonstrate the excellence of their practice. Studies such as the one published here almost certainly give a more accurate picture of the real world. Clear definition of what constitutes an SSI and impartial, blinded follow-up are important aspects of this accuracy. It seems possible that infection rates outside the confines of a trial (where patients are known to receive more error-free care) are even higher than those discovered here. So what is to be done about the problem of wound infection in vascular surgery? It seems that there is no magic bullet yet, and we therefore must depend upon rigorous application of techniques and policies that are well established. Appropriate prophylactic antibiotics, meticulous maintenance of intraoperative sterility, accurate surgical technique avoiding excessive dissection and cautery, and most importantly careful patient selection have major roles in the minimization of this substantial risk. P. Rogers (&) Western Infirmary, Glasgow G11 6NT, UK e-mail: pn.rogers@btinternet.com

A move towards individualization of patient treatment regimens in colorectal cancer

Colorectal DiseaseVolume 14, Issue 2 p. 255-256 Correspondence A move towards individualization of patient treatment regimens in colorectal cancer A. G. M. T. Powell, A. G. M. T. Powell Department of Experimental Therapeutics, Institute of Cancer Science, University of Glasgow, 2nd Floor McGregor Building, Western Infirmary Glasgow, Glasgow G11 6NR, UKSearch for more papers by this authorJ. Edwards, J. Edwards Department of Experimental Therapeutics, Institute of Cancer Science, University of Glasgow, 2nd Floor McGregor Building, Western Infirmary Glasgow, Glasgow G11 6NR, UKSearch for more papers by this authorP. G. Horgan, P. G. Horgan Academic Unit of Surgery, College of Medical, Veterinary and Life Sciences, University of Glasgow, Royal Infirmary, Glasgow G4 0SF, UK E-mail: [email protected]Search for more papers by this author A. G. M. T. Powell, A. G. M. T. Powell Department of Experimental Therapeutics, Institute of Cancer Science, University of Glasgow, 2nd Floor McGregor Building, Western Infirmary Glasgow, Glasgow G11 6NR, UKSearch for more papers by this authorJ. Edwards, J. Edwards Department of Experimental Therapeutics, Institute of Cancer Science, University of Glasgow, 2nd Floor McGregor Building, Western Infirmary Glasgow, Glasgow G11 6NR, UKSearch for more papers by this authorP. G. Horgan, P. G. Horgan Academic Unit of Surgery, College of Medical, Veterinary and Life Sciences, University of Glasgow, Royal Infirmary, Glasgow G4 0SF, UK E-mail: [email protected]Search for more papers by this author First published: 12 September 2011 https://doi.org/10.1111/j.1463-1318.2011.02818.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume14, Issue2February 2012Pages 255-256 RelatedInformation

Minimally invasive parathyroidectomy for primary hyperthyroidism guided by intra-operative parathyroid hormone monitoring

s / International Journal of Surgery 10 (2012) S1–S52 S32 ABSTRACTS course of IA mean free T4 was 30 pmol/L and 11.4 pmol/L respectively (range: 9.4 to 22.7 pmol/L). There were no adverse effects to IA. Therewere no complications following surgery. Conclusions: Iopanoic acid is safe and effective in rapidly controlling thyrotoxicosis prior to total thyroidectomy. 0623: SESTA-MIBI SCANS, CAN THEY PREDICT INTRATHYROID PARATHYROID ADENOMA? Rachel French, R.K. Maitra, Vijay Kurup. North Tees University Hospital, Stockton-on-Tees, UK Aim: To evaluate the role of sesta-mibi scans in predicting intrathyroidal parathyroid adenoma in primary hyperparathyroidism. Method: Retrospective analysis of parathyroidectomies performed in a distric general hospital during the last 6 years(2005-11). Sesta-mibi scans were performed pre-operatively in all patients with primary hyperparathyroidism. Where no adenoma was identified during exploration of neck, a hemithyroidectomy was performed on the side suggested by sestamibi scan. Results: 78 patients had exploration of neck, 82% female, 18% male, with a mean age 62 years. Sestamibi was positive in 60 patients and 54 had parathyroid adenoma identified on exploration. 6 patients after a failed neck exploration underwent hemithyroidectomy . Histology revealed intrathyroidal parathyroid adenoma in 5 patients(83%) . Out of 18 patients with negative scans 14 had an adenoma removed. Sestamibi scans had a sensitivity of 81% and positive predictive value of 98.3%. Conclusion: Sestamibi scan helped to identify 5patients with intrathyroidal parathyroid adenoma when neck exploration was negative. When no adenoma is visible on exploration a hemithyroidectomy at the side suggested by the scan is justified. 0681: MINIMALLY INVASIVE PARATHYROIDECTOMY FOR PRIMARY HYPERTHYROIDISM GUIDED BY INTRA-OPERATIVE PARATHYROID HORMONE MONITORING Alison Lyon , O.O. Komolafe , Christopher Wilson . University of Sydney, Sydney, Australia; Western Infirmary, Glasgow, UK Aim: Intra-operative parathyroid hormone (PTH) levels can demonstrate successful removal of a parathyroid adenoma during minimally invasive parathyroidectomy. However, this technique remains controversial due to variations in blood sampling and excision criteria. In this study, we explored the success rate of our technique. Methods: A consecutive series of 92 patients with histologically confirmed primary hyperparathyroidism was analysed retrospectively. All were treated with a minimally invasive technique. Serum PTH levels were checked prior to gland removal and twenty minutes after gland removal to confirm a decrease of greater than 50%, which was considered to indicate a curative procedure. Results: The median pre-operative PTH level was 14.35ng/L (interquartile range (IQR) 10.7-20.3). The two week post operative median level was 5.4ng/L (IQR 3.4-7) and median adjusted calcium level was 2.39mmol/L (IQR 2.28-2.5). The average intraoperative PTH decrease was 75.6%. Of the 92 patients, 8 (8.7%) required multiple gland removal due to adenoma location differing to that indicated by preoperative imaging (3 were retrosternal). The biochemical cure rate within this cohort was 98%. 2 patients had no intraoperative PTH drop and persisting hypercalcaemia. They underwent further imaging and curative surgery. Conclusion: Intra-operative PTH monitoring is a useful adjunct to minimally invasive parathyroidectomy. 0721: PATIENT OUTCOME FOLLOWING LAPAROSCOPIC BILATERAL ADRENALECTOMY Carol Watson, Craig Parnaby, Patrick ODwyer. Gartnavel General Hospital,

Quality Improvement Service: Multidisciplinary Antimicrobial Ward Rounds: Impact on prescribing in medical and elderly care wards in West Glasgow hospitals: Category: Clinical lesson

Prudent antimicrobial prescribing is fundamental to reducing antimicrobial resistance, preventing the development of hospital acquired infections, preventing adverse effects related to antimicrobials and reducing antimicrobial costs. In May 2009, antimicrobial ward rounds consisting of an infectious disease (ID) consultant and an antimicrobial pharmacist were commenced in 2 hospitals within NHS Greater Glasgow and Clyde: Gartnavel General Hospital and the Western Infirmary. The ward rounds aim to promote prudent antimicrobial prescribing, promote adherence to the Greater Glasgow and Clyde Infection Management Guidelines whilst also providing support and advice to prescribers, nurses and pharmacists.

Antiepileptic drug combinations—Have newer agents altered clinical outcomes?

In 2000, 332 (20.5%) of 1617 patients registered with the Western Infirmary Epilepsy Unit required antiepileptic drug (AED) polytherapy to remain seizure-free for at least 1 year. The analysis was repeated 10 years later. Of 2379 seizure-free patients, 20.4% (n=486 - 254 women, 232 men, aged 18-95 years [median age 49 years]) were receiving combination therapy. Two AEDs were taken by 395 (81.3%) patients in 2010, and by 287 (86.4%) in 2000. Sodium valproate with lamotrigine was the commonest of 64 successful pairings. As a combination, mean daily doses of both AEDs were lower (n=96; sodium valproate 1200 mg, lamotrigine 155 mg) than when sodium valproate was taken with carbamazepine or levetiracetam (n=42; 1621 mg; p<0.001), and lamotrigine was combined with topiramate or levetiracetam (n=33; 430 mg; p<0.001), suggesting possible synergism. In 2010, a higher percentage of patients (n=85) remained seizure-free on 3 AEDs (17.5% in 2010, 12.7% in 2000) in 57 separate regimens. Only 0.9% (n=3) of patients in 2000, and 1.2% (n=6) in 2010 responded to 4 AEDs. Levetiracetam (n=109; 10.2%) and topiramate (n=81; 7.6%) were the newer agents most commonly represented in successful combinations. These data tend to imply that drug substitution rather than addition has largely led to these marginally improved results. In the last decade, when used as adjunctive therapies, newer agents appear not to have impacted substantially on the likelihood of producing seizure freedom. An alternative approach to AED development may be required to change this disappointing scenario.

Levetiracetam monotherapy—Outcomes from an epilepsy clinic

Introduction Levetiracetam (LEV) is a broad spectrum antiepileptic drug (AED) with a unique mechanism of action. This retrospective audit explores outcomes in patients commenced on LEV monotherapy at the Epilepsy Unit at the Western Infirmary, Glasgow, Scotland from 1st January 2001 until 30th June 2009. Methods LEV monotherapy was started in 228 patients (89 men, 139 women, aged 12–81 years [median 28 years]). Of these, 161 (70.6%) had partial-onset seizures, 59 (25.9%) had idiopathic generalized epilepsies (35 primary generalized tonic–clonic seizures [PGTCS], 20 juvenile myoclonic epilepsy, 4 juvenile absence epilepsy), and 8 (3.5%) had unclassified GTCS. Initial dosing was 250 mg twice daily for 2 weeks, followed by 500 mg twice daily. Patients were reviewed every 6–8 weeks. If required, the LEV dose was titrated in 500 mg increments to a maximum tolerated or effective dose. Results In total, 112 (49.1%) patients remained seizure-free for ≥1 year on a median LEV dose of 1000 mg/day (range 500–3000 mg/day). Patients were more likely to achieve seizure freedom with LEV as a first monotherapy (81 of 149 [54.4%]), as opposed to switching from another AED (31 of 79 [39.2%]; p = 0.03). In this latter group, seizure freedom was more likely in those who switched after failing their 1st or 2nd AED ( n = 39 of 64 [60.9%]), compared to later in the treatment schedule ( n = 2 of 15 [13.3%]; p = 0.029). Patients reporting <5 seizures (70 of 118) prior to starting LEV were more likely to become seizure-free than those with ≥5 seizures (42 of 110; p = 0.001). Thirty-six (15.8%) patients had a ≥50% seizure reduction over 1 year; 43 (18.9%) were classified as having a <50% improvement, but elected to continue on LEV. The drug was withdrawn in 37 (16.2%) patients (30 side effects, 7 lack of efficacy). Eighteen (7.9%) patients reported intolerable neuropsychiatric symptoms (7 aggression, 7 mood swings, 2 irritability, 2 depression). Other side effects leading to drug withdrawal included sedation ( n = 5) and lethargy ( n = 4). Conclusion Seizure freedom was achieved in around half the patients on a median LEV dose of 1000 mg/day. This was more likely to occur in those taking the drug as first monotherapy, and in those with <5 pre-treatment seizures. Around 50% of those who discontinued LEV due to side effects developed neuropsychiatric symptoms.

Harrison Shaw McCallum

After qualifying, Harrison Shaw McCallum undertook house officer appointments at the Western Infirmary and at Stobhill General Hospital, both in Glasgow. He then served in the Royal Air Force in...

The risk of osteoporosis experienced by patients

The Fracture Liaison Service (FLS) was established in the Western Infirmary, Glasgow in 1999. This service provides patients over 50 years who present with new low trauma fractures, assessment for treatment for the secondary prevention of fractures. The FLS is effected by Osteoporosis Nurse Specialists who visit the orthopaedic ward and fracture clinic daily to invite patients to attend for DXA and assessment at the one stop clinics. Since 2007, the FLS has extended its strategy to link with radiology and receive monthly reports of people sustaining vertebral fractureswhodonot traditionally present toorthopaedicunits. In the first 8 years of the FLS, 11096 patients were processed through the FLS. 29% of these patients had sustained wrist fractures and 24% hip fractures. 21% refused assessment, some due to illness or non-attendance at the clinic. Of the remaining 79% of patients, 39% were recommended bisphosphonate treatment, 30% calcium & vitamin D alone, 3% other treatments including Strontium but 28% did not require any treatment following their DXA scan and assessment. Patients can be referred on to physiotherapy exercise classes and for falls assessment if required. Education is essential for those diagnosed with osteoporosis and patients are all offered the opportunity to attend an osteoporosis education afternoon approximately one year after diagnosis and feedback from these meetings is excellent.

119 Chronic change in BNP after myocardial infarction adds no additional prognostic information over that gained from a once-off assessment of BNP

Elevated B-type natriuretic peptide (BNP) has been shown to be strongly predictive of adverse outcome following myocardial infarction (MI). Chronic change in BNP after MI is less well studied and it is not known whether this adds any additional prognostic information Method In 1995, individuals who had sustained an index myocardial infarction in the preceeding were invited to attend the Western Infirmary, Glasgow to undergo screening; this included blood sampling, medical history and echocardiography. BNP levels were also assessed. A second round of screening was subsequently performed in 1998. All deaths up to 31 December 2006 were collated from the General Register Office for Scotland. Results Four hundred and eighty-one patients had BNP levels measured in both the 1995 and 1998 screening. Baseline median (IQR) BNP was 33.0 (51.8) pg/ml. Baseline BNP, was strongly predictive of outcome; the quartile with the highest BNP level had adjusted HR for all cause mortality of 3.15 (1.78–5.58) compared to the lowest quartile. Absolute change (A) in BNP between the screening visits was normally distributed with a mean change of +25.3±100.4 pg/ml, and ranged from −233 to+1151 pg/ml. There was no significant relationship between baseline BNP and subsequent A BNP; baseline log BNP did not correlate with A BNP (r=0.035, p=0.479). ABNP added no further prognostic information; the quartile with the highest change (mean change +114.2±162.9 pg/ml) was not predictive of outcome compared to the lowest quartile change (mean change −36.3±38.4) with an adjusted HR of 1.17 (0.68–2.00) for all cause mortality. Crude mortality was slightly higher in this group (30% vs 22%, p=ns), but not significantly so. Conclusion BNP is a strong predictor of adverse outcome, even when assessed many years after MI. However, direct comparison of BNP measurements taken many years apart adds no further prognostic information, even if there are marked increases or decreases in levels.

James Somerville Campbell

In 1942 James Somerville Campbell (“Jimmy”) enlisted in the Royal Navy as a radio operator and saw active service on aircraft carriers before studying medicine. As a houseman at the...

William Francis Toomey

William Francis Toomey (“Bill”) qualified in Glasgow and served in the Royal Air Force as flight lieutenant and later deputy senior medical officer in Lincolnshire. After returning to Glasgow as...

John Magoveny King

After house jobs in Greenock Royal Infirmary and Glasgow Western Infirmary, John Magoveny King (“Jack”) was called up to the Royal Army Medical Corps, serving first as a regimental medical...

Martin Brodie: epilepsy expertise and whisky wisdom

Martin Brodie: epilepsy expertise and whisky wisdom

Interobserver Reliability of Classification Systems to Rate the Quality of Femoral Neck Fracture Reduction

We compared the interrater reliability of five classification systems and surgeons' global impressions of the quality of femoral neck fracture reduction. Six orthopedic trauma surgeons, six orthopedic nontrauma surgeons, and six orthopedic residents from three sites each rated 50 radiographs of postoperative femoral neck fractures fixated with cannulated screws or a sliding hip screw, using their overall impression, the Garden Index, Lowell's criteria, Lindquist and Tornkvist's criteria, the Western Infirmary Glasgow (WIG) angle, and standards established by a working group of orthopedic trauma surgeons. Reliability estimates for the Garden Index, Lowell's criteria, and the working group standards all fell within the range of moderate agreement [intraclass correlation coefficient (ICC) range 0.41-0.48], with no instrument achieving higher reliability than reviewers' overall impressions (ICC 0.49, 95% CI 0.39-0.61). Reviewers reached only fair agreement using Lindquist and Tornkvist's criteria and the WIG angle (kappa = 0.27 and 0.39, respectively). Trauma surgeons consistently achieved higher agreement than did nontrauma surgeons and trainees. Future studies using quality of reduction as an outcome measure or exploring the prognostic importance of reduction quality should measure this with trauma surgeons' overall impression, rather than with less experienced assessors or using one of the alternative instruments.

Training and Consistency in Stroke Assessments

See related article, pages 2507–2511 and 2557–2559. Stroke is a global disease. It needs global tools for description and outcome assessment, common definitions for risk factors, common definitions for complications such as symptomatic hemorrhage, and common investigation protocols. Research into treatments for stroke depends on enrollment of large numbers of patients, possible only through international cooperation. Wide variation in initial stroke severity requires us to describe the population that we enroll. The National Institutes of Health Stroke Scale is now the most widely used scale for measuring stroke severity in clinical trials1 and lies second only to the modified Rankin Scale for choice as a primary end point.2 This trend to homogeneity is important; consistency in language is required within trials and to interpret their results. For example, use of common …

Ten Years Experience of In-Center Thrice Weekly Long Overnight Hemodialysis

Published studies suggest that longer hemodialysis (HD) sessions are associated with improved morbidity and mortality, but few centers offer long sessions. The Western Infirmary renal unit has offered long overnight hemodialysis (LOH) (6 to 7 h) thrice weekly since 1998. The aim of this study was to describe patients who chose LOH and compare outcomes with patients on conventional hours (4 to 5 h) HD. Patients who ever had LOH for three or more consecutive sessions were identified (n = 146). Indices of urea reduction ratio (URR), anemia, hyperphosphatemia, and predialysis BP (BP) control in a subgroup of all patients on LOH for at least 1 yr since 2004 were compared with age, sex, and diabetes-matched controls undergoing conventional duration HD. The mean age at the time of starting LOH was 51.8 yr and 74.7% started with a functioning arteriovenous fistula. Median duration of continuous LOH was 1.6 yr. Of those no longer on LOH, only 33.3% reverted to conventional hours HD (mean duration LOH 2.2 yr). When comparing LOH and conventional HD cohorts, there was increased URR and mean hemoglobin with a trend toward lower mean erythropoietin index. There was a trend toward fewer phosphate binder tablets but no difference in mean serum phosphate, BP, or number of prescribed antihypertensive medicines. LOH is a well tolerated hemodialysis option, associated with improved URR and better control of anemia.

“What is wrong with emotional upset?” – 50 years on from the Platt Report

James Spence deserves great credit for his work with mothers and babies and his contributions to our understanding of “the purpose of the family”,1 but he was not the first...

Jehoiada John Brown

Jehoiada John Brown (“Joyda”) was a well known and highly respected physician and clinical scientist, who worked in the Medical Research Council Blood Pressure Unit in the Western Infirmary in...

Thomas Henry Learmont Bryson

Thomas Henry Learmont Bryson (“Tom”) qualified from Glasgow University in 1953. On the first day of house jobs, at the Western Infirmary Glasgow, he went to theatre to assist and...

Treatment of severe psoriasis with infliximab.

Psoriasis is a chronic, immune mediated inflammatory disease characterized by increased cell signalling via cytokines and chemokines on a background of up-regulated gene expression. There is substantial evidence that psoriasis should be regarded as more than a cutaneous disease; major psychological morbidity and increased mortality from cardiovascular disease and cancer are increasingly recognized. Improved understanding of the genetic and immunological mechanisms underpinning psoriasis has occurred concurrently with the development of targeted biological therapies including infliximab. These newer therapeutic approaches can be very effective but their long term safety profile is not yet fully determined.