Does surgical volume affect outcome after primary and revision knee arthroplasty? A systematic review of the literature.

BACKGROUND: In 2009 there were 72,980 primary and 4565 revision knee arthroplasties performed in England and Wales [1]. Given the large number of procedures done annually any factors that may influence outcome and benefit the patient must be considered seriously. OBJECTIVES: To find out whether a relationship exists between hospital and surgical volume and patient outcomes for primary and revision knee arthroplasty. A systematic review of the literature was performed to evaluate the current evidence using the PRISMA criteria [2]. DATA SOURCES: A computerised literature search was performed on the electronic databases PubMed, Medline, Embase and CINAHL between 1973 and 2011. STUDY ELIGIBILITY CRITERIA: All abstracts, in the English language, pertaining to either surgical or hospital volume and outcome after primary and revision knee arthroplasty between 1973 and 2011 were considered. Outcomes of interest included morbidity, mortality, clinical and economic outcomes. CONCLUSIONS: Both the orthopaedic and surgical specialties literature demonstrates a clear and consistent relationship between both surgeon and hospital volume with outcome, higher volume being associated with improved patient outcomes. In view of the literature consideration should be given to whether all orthopaedic operations should be carried out by all surgeons in all hospitals.

Does using the WHO surgical checklist improve compliance to venous thromboembolism prophylaxis guidelines?

BACKGROUND: Using the World Health Organisation (WHO) surgical checklist has been shown to improve the safety of patients undergoing surgery. Its effect on the compliance to venous thromboembolism (VTE) guidelines has not been established before. Our objective was to assess if using the WHO checklist improved compliance to VTE prophylaxis guidelines. METHODS: Compliance to NICE VTE guidelines were prospectively assessed in all general surgery patients over two separate audit periods, before and after 6 months of the routine use of the WHO checklist. Correct completion of the checklist was verified. RESULTS: 370 patients (173 [47%] male, 197 [53%] female, mean age 61.6 yrs). Non compliance to NICE VTE guidelines was reduced form 16/233 (6.9%) to 3/137 (2.1%) after introduction of the checklist (p = 0.046 Fisher exact test). Non compliance was reduced in both emergency and elective procedures. CONCLUSIONS: Establishment of the WHO checklist for routine use in all general surgery patients may significantly improve VTE guideline compliance of all general surgery patients.

Potential therapeutic applications of recombinant, invasive E. coli.

An invasive Escherichia coli expressing the inv gene from Yersinia pseudotuberculosis was used as a vector for protein delivery to mammalian epithelial cells. Upon incubation with beta1-integrin-expressing mammalian cells, the bacteria are internalized, allowing bacteria-encoded proteins to function from within the mammalian cell. These bacteria are eventually processed in the host phagosome where they are destroyed. Expression of listeriolysin O from Listeria monocytogenes in the bacterium and its subsequent release into the phagosome triggers the breakdown of the membrane, allowing the release of the bacterial content into the cytosol of host cells. Using this vector, we demonstrate delivery of a gene and intact, functional proteins into mammalian cells in which beta1-integrin is expressed and accessible. At a ratio of bacteria/mammalian cells compatible with the survival of the mammalian cells, protein delivery can be observed in the entire cell population in vitro, while gene transfer is far less efficient. Protein delivery can also be achieved in vivo in mouse tumour models and can be detected at least 96 h after inoculation. Functional, natural E. coli proteins are delivered in the process and can provide therapeutic benefit in vivo, when associated with prodrugs. This therapeutic effect is associated with infiltration of neutrophils, eosinophils, macrophages and to a lesser extent dendritic cells in the tumour mass.