Achieving 18-week waiting times in elective hand surgery.

OBJECTIVE: The Department of Health proposed an 18-week referral-to-treatment time (RTT) as a measure of high quality healthcare, to be achieved by December 2008. In 2007, referrals for elective hand surgery, to the Plastic Surgery Hand Service, were either direct or indirect. Direct referrals were from the general practitioner (GP). Indirect referrals were from other specialties, to which patients had been initially referred. We audited the RTT in elective hand surgery patients to see if 18-week waiting times could be achieved. DESIGN: The RTT for 152 patients who had elective hand surgery in 2007 were audited prospectively and retrospectively. After the initial audit, managers responsible for the 'Choose & Book' (CAB) GP referral system, managers responsible for 'Action on Orthopaedics' and colleagues who referred, were contacted, to explain the difficulties in meeting the 18-week wait target. The audit cycle was repeated prospectively in 2008 with the audit of a further 94 patients. SETTING: This audit took place in a district general hospital, in the United Kingdom. MAIN OUTCOME MEASURE: The main outcome measure was referral-to-treatment time. RESULTS: The mean RTT for direct referrals decreased from 15 to 12 weeks and that for indirect referrals decreased from 43 to 24 weeks (p < 0.0001). The difference in the average RTT for direct and indirect referrals remained statistically significant (p < 0.0001), in both audit cycles. CONCLUSIONS: The attempts to reduce the RTT, in both groups of patients, did not decrease the average RTT for indirect referrals, to within government targets. Increase in GP awareness of the limitations of the CAB system and availability of local hand surgery services, may help to reduce inappropriate referrals. However we are aware that a multispecialty approach is required to ensure that hand surgery referrals are passed on to plastic surgery as soon as possible.

The microbiological impact of pre-operative biliary drainage on patients undergoing hepato-biliary-pancreatic (HPB) surgery.

BACKGROUND: The merit of pre-operative biliary drainage in managing hepatic, biliary or pancreatic patients remains unclear with previous studies demonstrating significant increases in bacterobilia. AIMS: To establish if pre-operative biliary drainage was associated with (i) a change in bacterial flora, (ii) post-operative sepsis and (iii) to ascertain if a modification of antibiotic prophylaxis was warranted. METHODS: Data were collected on 331 patients undergoing hepatic, biliary or pancreatic surgery for malignant obstruction between August 2000 and June 2005. Microbiological data from intra-operative bile, post-operative wounds, blood cultures, urine and sputum were analysed. All episodes of pre-operative endoscopic retrograde cholangiopancreatography (ERCP), stenting and percutaneous drainage were documented. RESULTS: One hundred and sixty two patients had ERCP prior to surgery and 154 had surgery only. In comparison to patients who had surgery alone stented patients had significantly increased rates of bacterobilia (40 vs. 85%) and fungobilia (8 vs. 34%, both P < 0.001). Pre-operative biliary drainage significantly increased post-operative sepsis, wound infections and prolonged in-patient stay (P < 0.05). The most common organisms cultured were coliforms and enterococcus with percutaneous transhepatic cholangiography (PTC) highly significant for the development of MRSA sepsis. CONCLUSIONS: Pre-operative biliary drainage is associated with a high incidence of bacterobilia and fungal colonization. Pre-operative biliary drainage should be utilized selectively, with modification of antibiotic prophylaxis according to patient characteristics.

Recognition-directed supramolecular assemblies of metal complexes of terpyridine derived ligands with self-complementary hydrogen bonding sites.

The synthesis and X-ray structures of three metal complexes with terpyridine-derived ligands that contain amino-pyrimidine and amino-pyrazine moieties are presented. They have been designed in view of directing their self-assembly into specific supramolecular arrays through molecular recognition interactions. The solid-state structures indeed reveal extensive hydrogen-bonded networks. The Co complex 4a with PF6- counterions builds a two-dimensional infinite interwoven grid through strong double hydrogen bonds (d(N-H-N) =2.918-3.018 A) between the amino groups and the N atoms of the rings, with all H-bonding sites saturated. Changing the anions to BF4- in 4b leads to a similar infinite but partially broken grid with a quarter of the H-bonding sites unsaturated (d(N-H-N)=2.984-3.206 A). In the case of the Zn complex 12 with triflate anions, half of the hydrogen bonds are formed. Only one of the two orthogonal ligands has hydrogen bonds (d(N-H-N) = 3.082, 3.096 A) to the neighbouring complexes and thus builds linear, supramolecular, polymeric chains. These structural differences are mainly attributed to crystal-packing effects caused by the different anions. The data presented here may also be regarded as a prototype for the generation of organised arrays through sequential self-assembly processes.