Do we need routine antibiotics for hand surgery?

Both the incidence of hand trauma, and the demand for elective hand surgery, continue to rise in the UK. The incidence of surgical site infection (SSI) following hand surgery is around 5%. Traditionally, antibiotic prophylaxis at the time of surgery has been used to reduce the risk of SSI, however with growing concerns about antimicrobial resistance and antibiotic overuse, there is a need to examine whether routine antibiotics are truly necessary for all surgery in the hand. In this session, we present the current guidelines and evidence base for the use of antibiotics in hand surgery, and discuss how we might change practice in the future

Extracorporeal shockwave therapy for the treatment of lower limb intermittent claudication: Study protocol for a randomised controlled trial (the SHOCKWAVE 1 trial)

© 2017 The Author(s). Background: Peripheral arterial disease (PAD) has a population prevalence of 4.6% with intermittent claudication (IC) presenting as one of the earliest and most common symptoms. PAD has detrimental effects on patients' walking ability in terms of maximum walking distance (MWD) and pain-free walking distance (PFWD). Research has suggested extracorporeal shockwave therapy (ESWT) may induce angiogenesis in treated tissue; therefore, our objective is to assess the tolerability and efficacy of ESWT as a novel treatment of intermittent claudication. Methods/design: Patients with unilateral claudication will be randomised to receive either ESWT (PiezoWave 2 shockwave system) or sham treatment to the calf muscle bulk three times per week for 3 weeks. All patients are blinded to treatment group, and all assessments will be performed by a masked assessor. Treatment tolerability using a visual analogue scale, ankle-brachial pressure index, MWD, PFWD and safety will all be formally assessed as outcome measures at baseline and at 4, 8 and 12 weeks follow-up. Discussion: This trial will be the first of its kind in terms of methodology in relation to ESWT for intermittent claudication. A double-masked randomised controlled trial will provide useful information about the potential for the use of ESWT as a non-invasive treatment option and the need for further robust research. Trial registration: ClinicalTrials.gov, NCT02652078. Registered on 17 October 2014

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

BackgroundElectrochemotherapy 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 & MethodsThe 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.ResultsTwo 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. ConclusionThere 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

Electrochemotherapy vs radiotherapy in the treatment of primary cutaneous malignancies or cutaneous metastases from primary solid organ malignancies: A protocol for a systematic review and meta-analysis

Electrochemotherapy has emerged as a valuable tool in the treatment of cutaneous malignancies that are unamenable to surgical resection. Despite growing recognition and recommendation in national guidelines, to date, no Level 1 evidence exists comparing its use to radiotherapy in the management of cutaneous malignancies. A systematic review and meta-analysis will be undertaken in line with the Cochrane Handbook and Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and checklist. A comprehensive search strategy will be applied to MEDLINE, Embase, CINAHL, CENTRAL and ClinicalTrials.gov from the time period from inception to December 2021. Supplementary searches of the grey literature will also be undertaken. Studies in humans which compare treatment with electrochemotherapy to radiotherapy and report tumour response with at least a 4-week follow-up will be eligible. Studies will be included regardless of publication language or country of origin. Screening of studies and data extraction will be undertaken independently by two authors. Our primary outcome will be tumour volume response according to Response Evaluation Criteria in Solid Tumors. We will also extract any secondary outcomes reported, such as patient-reported outcome measures, pain, toxicity/adverse events and progression-free survival. Included studies will be assessed for risk of bias using recognized tools. Evidence quality will be appraised using the Grading of Recommendations, Assessment, Development and Evaluation approach. If studies are of acceptable clinical homogeneity and suitable data is extracted, a meta-analysis will be performed. If adequate data are present, various subgroup analyses will be performed. Publication bias will be assessed using a funnel plot and Egger’s test

Dermoscopy as an adjunct to surgical excision of non-melanoma skin lesions: a systematic review and meta-analysis

Context: Non-melanoma skin cancers (NMSC) have an incidence of 152,000 cases per year in the UK which continues to rise. Incomplete excision rates for NMSC are estimated to be around 10% and result in patients having a higher risk of recurrence or having to undertake further treatment. Objective: To determine whether the use of dermoscopy as an adjunct to clinical examination could improve the rates of incomplete excision in non-melanoma skin lesions.Method of literature search: Electronic literature search of MEDLINE, EMBASE and 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 for a total of 592 patients were included, with five of these studies reporting on basal cell carcinomas and one reporting 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%. Limitations: The number of studies included is small, with three of the studies from the same authors. Studies included are non-randomised 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

Considerations for a Post-Surgical Wound Dressing Aligned with Anti-Microbial Stewardship Objectives: A Scoping Review

Background: Most surgical wounds heal by primary intention or secondary intention. Surgical wounds can present specific and unique challenges including wound dehiscence and surgical site infection, 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 to reduce antimicrobial resistance and align with antimicrobial stewardship. Aim: To explore the published evidence identifying general considerations/criteria for a post-surgical wound dressings in terms of overcoming potential wound healing challenges (including infection) whilst also supporting Anti-Microbial Stewardship (AMS) objectives.Methods: A scoping review examining evidence published from 1954 to 2021, conducted by two authors acting independently. Results were synthesised narratively and have been reported in line with PRISMA-ScR. Results: A total of 819 articles were initially identified and were subsequently filtered to 178 articles for inclusion in the assessment. The search highlighted six key areas associated with post-surgical wound dressings: wound infection, wound healing, physical attributes related to comfort, conformability and flexibility, fluid management (e.g., blood and exudate), pain and skin damage.Discussion: This scoping review has highlighted several unique challenges for post-surgical wound dressings and areas that require further investigation to enhance clinical outcomes. Of particular importance is the impact of SSIs remaining a significant burden and that some antimicrobial dressings reduce the risk of resistant microorganisms so as such can be successfully aligned with an AMS strategy. 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 anti-microbial dressings should be aligned with AMS programs and alternatives to active anti-microbials be investigated