Serum Inflammatory Markers and Amputations in Hand Osteomyelitis: A Retrospective Review of 146 Cases.

BACKGROUND: The diagnosis of hand osteomyelitis requires correlation of clinical, radiological, and microbiological findings. The role of serum inflammatory markers in diagnosing and prognosticating hand osteomyelitis remains uncertain. We sought to determine the utility of inflammatory markers in the diagnosis and follow-up of hand osteomyelitis, and their ability to predict outcomes, particularly amputation. METHODS: We retrospectively reviewed 146 patients diagnosed with hand osteomyelitis and with serum inflammatory marker levels measured after the onset of symptoms and within 14 days either side of diagnosis. Blood results at first presentation including white cell count (WCC), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and C-reactive protein (CRP) were reviewed, and associations with amputations assessed. Follow-up markers taken at 15 to 60 days from diagnosis were analyzed where available. RESULTS: Mean WCC and CRP at diagnosis were 9.2 (SD: 4.6) and 30.2 (SD: 42.4) respectively, compared with 8.2 (SD: 3.9) and 30.2 (SD: 42.4) at follow-up. At diagnosis, sensitivity of CRP was 74%, and WCC was 31%. Each marker had a low positive predictive value for amputation at diagnosis (<29%). A rise in CRP between diagnosis and follow-up was associated with an increased risk of amputation compared with a fall in CRP. The finding that WCC and CRP were both normal at diagnosis had a high negative predictive value against amputation (96%). CONCLUSION: C-reactive protein has a higher sensitivity than WCC, NLR, and PLR when used as a diagnostic adjunct in hand osteomyelitis. White cell count and CRP both within reference ranges at diagnosis was highly negatively predictive against amputation.

Survey of plastic surgery trainee attitudes to a career as a burns surgeon: A potential workforce dilemma.

AIM AND METHOD: The aim of this study was to gain insight into potential pitfalls in workforce planning for future consultant burns surgeons. An anonymous online survey was sent to current plastic surgery registrars in the UK to assess their subspecialty career choices, the perceived barriers to a career in burns surgery and possible solutions to these. RESULTS: The response rate was 33%. Of 44 respondents, burns surgery was the primary subspecialty of choice for 2% (n = 1) and the secondary choice for 9% (n = 4). Reasons given for not selecting burns surgery included a lack of exposure to the subspecialty, a perceived narrow scope of clinical practice and a concern about the potential negative impact on personal lifestyle. DISCUSSION AND CONCLUSION: Our results may be extrapolated to demonstrate a potential shortfall in the workforce for burns surgery in the future. To address the perceived barriers highlighted by trainees, a coordinated response at a national and international level is most likely to be successful through the cooperation of burns associations. Possible solutions include increasing burns subspecialty exposure during training, incorporating experience in intensive care into surgical training, and highlighting the numerous research opportunities in burns surgery.

What can we learn from supermarkets? An application of the Poisson distribution (order-up-to) model to improve blood culture bottle supplies.

BACKGROUND: The order-up-to inventory model is a method for identifying and maintaining the optimal product level for items that that hold value over time and have recurring demand. Typically, supermarkets utilise it to manage stock-levels of non-perishable goods. LOCAL PROBLEM: This project aimed to improve blood culture bottle supplies following reports by junior doctors of shortages when dealing with septic/unwell patients. METHODS: Data regarding blood culture bottle use was acquired from four hospitals within one trust in London (245 wards). The mathematical 'order-up-to' inventory model (an iterative Poisson distribution) was applied to the 6 months' data. INTERVENTIONS: The model found three predictable levels of demand to stock wards with no shortages in 99.3% of circumstances (based on historical data). Wards were stocked with blood culture bottles as per their required demand. RESULTS: A collection method and infrastructure was designed to implement the new policy and was applied to a London tertiary centre. A review of doctors, nurses and ward-managers found significant improvements in supply with no shortages since the model was applied. Issues with the dataset were identified for intensive therapy unit / high dependency unit. CONCLUSIONS: The 'order-up-to' inventory model provides a useful tool within hospitals for improving stock levels of blood cultures bottles and with that the satisfaction of trainees and patient safety.

Acute Management of Thermal Hand Burns in Adults: A 10-Year Review of the Literature.

INTRODUCTION: Advances in the evidence base of acute thermal hand burns help to guide the management of these common injuries. The aim of this literature review was to evaluate recent evidence in the field over 10 years. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols methodology was used as a guide for this literature review. PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar were searched for English language articles related to hand burns published between 2009 and 2018 inclusive, and the Cochrane Library was reviewed. Exclusion criteria were as follows: participants younger than 18 years, scar or contracture management, rehabilitation, outcomes assessment, late reconstruction, and electrical or chemical burns. RESULTS: An initial search retrieved 6493 articles, which was narrowed to 403 full-text articles that were reviewed independently by 3 of the authors and categorized. Of 202 included articles, there were 8 randomized controlled trials and 2 systematic reviews. Six evidence-based guidelines were reviewed. Referral of hand burns to specialist centers, use of telemedicine, early excision and grafting, and immediate static splintage have been recommended. Enzymatic debridement results in earlier intervention, more accurate burn assessment, preservation of vital tissue, and fewer skin grafts, and ideally requires regional anesthesia. Guidance on escharotomy emphasizes indication, technique and adequate intervention, and potential for enzymatic debridement. Inclusion of topical negative pressure, dermal regenerative templates, acellular dermal matrices, and noncellular skin substitutes in management has helped improve scar and functional outcomes. DISCUSSION: The results of this literature review demonstrate that multiple national and international societies have published burns guidelines during the decade studied, with aspects directly relevant to hand burns, including the International Society for Burn Injuries guidelines. There are opportunities for evidence-based quality improvement across the field of hand burns in many centers. CONCLUSIONS: More than 200 articles globally in 10 years outline advances in the understanding of acute management of thermal hand burns. Incorporating the evidence base into practice may facilitate optimization of triage referral pathways and acute management for hand burns.

The Impact of COVID-19 on Adult Burn Management in the United Kingdom: A Regional Center Experience.

In this study, we aim to quantify the impact of COVID-19 on burns provision at an adult regional burn center. Two cohorts of patients were identified for comparison: one during the beginning of the COVID-19 lockdown in April 2020 and a comparator cohort in April 2019. There was a 30% decrease in the incidence of adult burns in 2020. The mean total body surface area (TBSA) was 1.8% and 4.3% in 2019 and 2020, respectively. Scald injuries were the commonest mechanism of burns in both cohorts. Depth of burns was deeper in 2019, with 17.6% of patients presenting with deep burns, compared with 9.6% in 2020. Eight percent of patients in 2019 required theater compared with zero patients in 2020. A similar percentage of patients were admitted in both cohorts. In 2019, admitted patients had an average inpatient stay of 0.57 days per TBSA. In 2020, the average stay per TBSA in all patients was 0.6 days and 1.5 days in survivors. In the lockdown period, 54% of patients were followed up by telemedicine. This difficult period has taught us how important a functioning healthcare system is and how we can be better prepared in the future.