Usman Khalid

The association of noise and surgical-site infection in day-case hernia repairs.

INTRODUCTIONnSurgical-site infections (SSIs) are associated with an increased duration of hospital stay, poorer quality of life, and an marked increase in cost to the hospital. Lapses in compliance with aseptic principles are a substantial risk factor for SSI, which may be attributable to distractions such as noise during the operation. The aims of this study were to assess whether noise levels in the operating room are associated with the development of SSI and to elucidate the extent to which these levels affect the financial burden of surgery.nnnMETHODSnProspective data collection from elective, day-case male patients undergoing elective hernia repairs was undertaken. Patients were included if they were fit and at low risk for SSI. Sound levels during procedures was measured via a decibel meter and correlated with the incidence of SSI. Data analysis was performed with IBM SPSS (IBM, Armonk, NY).nnnRESULTSnNoise levels were substantially greater in patients with SSI from time point of 50 minutes onwards, which correlated to when wound closure was occurring. Additional hospital costs for these patients were £243 per patient based on the National Health Service 2013 reference costing.nnnCONCLUSIONnDecreasing ambient noise levels in the operating room may aid in reducing the incidence of SSIs, particularly during closure, and decrease the associated financial costs of this complication.

The influence of socioeconomic deprivation on outcomes in pancreas transplantation

Socioeconomic deprivation is an important factor in determining poor health and is associated with a higher prevalence of many chronic diseases including diabetes and renal failure, with poorer outcomes of their treatments.

The influence of socioeconomic deprivation on outcomes in pancreas transplantation in England: Registry data analysis

Socioeconomic deprivation is associated with poorer outcomes in chronic diseases. The aim of this study was to investigate the effect of socioeconomic deprivation on outcomes following pancreas transplantation among patients transplanted in England. We included all 1270 pancreas recipients transplanted between 2004 and 2012. We used the English Index of Multiple Deprivation (EIMD) score to assess the influence of socioeconomic deprivation on patient and pancreas graft survival. Higher scores mean higher deprivation status. Median EIMD score was 18.8, 17.7, and 18.1 in patients who received simultaneous pancreas and kidney (SPK), pancreas after kidney (PAK), and pancreas transplant alone (PTA), respectively (P = .56). Pancreas graft (censored for death) survival was dependent on the donor age (P = .08), cold ischemic time (CIT; P = .0001), the type of pancreas graft (SPK vs. PAK or PTA, P = .0001), and EIMD score (P = .02). The 5‐year pancreas graft survival of the most deprived patient quartile was 62% compared to 75% among the least deprived (P = .013), and it was especially evident in the SPK group. EIMD score also correlated with patient survival (P = .05). When looking at the impact of individual domains of deprivation, we determined that “Environment” (P = .037) and “Health and Disability” (P = .035) domains had significant impact on pancreas graft survival. Socioeconomic deprivation, as expressed by the EIMD is an independent factor for pancreas graft and patient survival.

A simple and effective strategy for improving junior doctors' knowledge of intravenous fluid therapy

(unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Clinical Audit 2014:6 1–4 Clinical Audit Dovepress

Locum doctors: Patient safety is more important than the cost

We would like to commend the author on such a thoughtprovoking paper1 about issues that are raised in every NHS Trust across the UK with regards to locum doctors. With the implementation of the EWTD and reduction in trainee numbers, it is inevitable that rotas across the country will have vacancies or gaps. Various ways are used to try and fill these gaps, the most costly method being the use of an external locum doctor via an agency. Often there are in-house doctors who would be willing to provide the cover for that shift if the Trust was to provide them with a ‘reasonable’ rate. However, the significantly ‘lower’ rates offered by the Trust to their own in-house doctors for these shifts, has resulted in more doctors choosing to look for extra work via a locum agency. We agree with the author that patient safety is paramount and far more important than money. To this end, we would like to propose that the method to resolve patient safety would be for the Trusts to pay their own in-house doctors a ‘reasonable and competitive’ rate for the vacant shifts. This would not only provide continuity of care but increase patent safety, as the doctor would be working in a familiar environment with knowledge of the hospital’s local policies and protocols.

Correspondence to: Bilirubin; a diagnostic marker for appendicitis

We read this article1 with great interest. In the article it is stated that the observed Bilirubin rise is due to a combination of inflammatory cytokines and endotoxins causing cholestasis. These are known to be inflammatory mediators within the sepsis cytokine cascade, hence any cause of intra-abdominal sepsis may result in their increase and a resultant hyperbilirubinaemia. Is it also not plausible that in the presence of sepsis, dehydration and impaired fluid balance may account for the resultant hyperbilirubinaemia? Therefore on this basis alone, Bilirubin cannot be a diagnostic marker of just acute appendicitis but it may serve as a diagnostic marker of any intra-abdominal sepsis. Indeed we agree with the authors that any test (whether its laboratory based or radiological) must be used in conjunction with the clinical picture of the patient. Although Bilirubin may provide an additional tool in aiding the diagnosis of acute appendicitis, we would argue that the inclusion of this test is unlikely to change the rates of surgical intervention and negative appendicectomy rates. The diagnosis of acute appendicitis still remains a challenge for the emergency General Surgeon and thus far the Alvarado scoring system has probably shown to be the most consistent in predicting the accuracy of diagnosis of acute appendicitis.

Correspondence to: International medical graduates among top US transplant surgeons

We would like to commend the authors on such an interesting and thought-provoking letter [1]. We believe that this is timely, given the recent political changes (and presumed implications of such changes) within UK of “Brexit” and the US of the election results. We believe that IMGs represent an invaluable resource to the UK and US of healthcare professionals, including doctors and surgeons. Within the UK, IMGs represent over a quarter of the doctors within the NHS, and specialist practice remains ‘heavily dependent’ on doctors who have ‘trained abroad’ [2] and this number has increased over the years. Goldacre et al. [2] showed that of the consultants appointed between 1992 and 2001 to surgical specialties, nearly 30% had trained abroad, twice the proportion when compared with consultants appointed before 1992. Fazel et al. [3] showed that surgery was the most popular chosen specialty for specialist training amongst UK graduates and IMGs. Hence the data represented in this letter of 30% of US transplant surgeons being IMGs is not surprising [1]. Indeed within our transplant unit, 6 of the 7 consultant transplant surgeons are IMGs. Given the predicted political climate with anticipated decreases in the number of IMGs training within the UK and US, and the fact that these countries are both heavily reliant on such migrants for their healthcare and surgical workforce, universities and professional bodies may need to improvise their strategies for recruitment in the near future. Decreasing the number of IMGs will add to the already over-stretched NHS that suffers from vast rota gaps and vacancies, and relies heavily on locum doctors, a significant proportion of whom are IMGs. A reduced number of IMGs is also likely to have a negative impact on the quality of expertise and body of knowledge, supported by the fact that those who have worked abroad, especially in South Africa or Australia, often feel that the experience they have acquired abroad holds them in good stead amongst their peers [4]. We strongly believe that continuing to employ IMGs here in the UK will only enhance the clinical and academic impact of the healthcare received within the NHS.

The impact of distance from transplant unit on outcomes following kidney transplantation

BACKGROUNDnFollowing transplantation, many patients travel long distances for follow-up care. Many studies have examined the influence of distance from transplant centre on access to transplantation, but few have examined post-transplant outcomes.nnnMATERIALS AND METHODSnDistance from transplant centre was calculated for all kidney transplant recipients transplanted over a 5-year period. Outcomes measured were rates of acute rejection, graft and patient survival.nnnRESULTSnComplete follow up data was available for 571 of the 585 kidney transplants performed over the study period. Distance from home to transplant centre ranged from 1.3 to 257.4xa0km (median 33.7xa0km). Patients were divided into quartiles according to their distance from the transplant centre. Distance from the transplant centre did not influence rates of acute rejection (pxa0=xa00.102). One-year graft survival for nearest and farthest quartiles was 99% and 97% respectively and five-year graft survival was 78% and 89% respectively (log rank p-value of 0.212). There were no differences in patient survival at 1 and 5 years between the nearest and farthest groups.nnnCONCLUSIONnDistance from transplant centre does not affect early outcomes following kidney transplantation. The centralized practice which involves a low threshold for rapid assessment and readmission of patients post-transplantation appears to provide good outcomes for kidney transplant recipients.

Correspondence to: Financial impact of surgical training on hospital economics: An income, analysis of 1184 out-patient clinic consultations

We would like to commend the authors on such an interesting and thought-provoking paper in terms of the implications for surgical training. As surgical trainees, we have seen too often service provision taking priority over training opportunities and often have felt the need to stay in hospital during out of hours to gain the necessary additional experience. A surgical trainee’s needs are not that complex. Within the service provision part of the job, we achieve plenty of time seeing patients on the ward or in clinic, which is an important part of training. However, what suffers is the operative experience required in theatre. Trainees are now involved in less and less operations1,2 and this change in culture has the potential to result in poorer patient outcomes in the long-term through less experienced consultants. Indeed trainees, who have worked abroad, especially in South Africa or Australia, often feel that the experience they have acquired abroad holds them in good stead amongst their peers.3 In addition to this, there are clear differences amongst trusts and trainers with regards to the level of training and support they provide. We strongly agree with the authors’ suggestion that trusts should compete for trainees and we advocate that trusts who have consistently failed to support trainees or facilitate in their training should not be allowed to receive any further trainees.