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Background: Patient reported outcomes (PROs) are important for the assessment of the effectiveness of surgical interventions. If patient reported outcome measures (PROMs) are used to prioritise resources then it is important to ensure that the instruments are scientifically valid. This review aims to assess whether the currently available PROMs in hand surgery adhere to international development guidelines and whether they incorporate the use of item response theory (IRT) or Rasch Analysis (RA). Methods: A systematic review was performed to identify all PROMs that are relevant to the field of hand surgery. An a priori protocol with strict inclusion and exclusion criteria was followed. Only instruments developed in the English language were included. A comprehensive search of nine databases was undertaken. The development methodology of the identified instruments was then analysed, followed by examination of the domain content and initial psychometric validation of each instrument. Results: A total of 3,039 article citations were retrieved, 139 citations went on to a full text review. A total of 24 patient reported outcome instruments were identified. This consisted of 10 regional upper limb, six hand and/or wrist specific and a further eight condition specific instruments. Documentation of the details of PROM development was lacking for many instruments. Conclusion: The field of hand surgery has many instruments available but few fulfil international development guidelines or use IRT or RA psychometric techniques. There are limitations in either the breadth of the domains explored or the developmental methodology used in all currently available instruments.

Background Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case–control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children. Methods Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach. Results Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P < 0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P < 0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057. Conclusion Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Background: There are a number of site-specific patient-reported outcome measures (PROMs) for hand conditions used in clinical practice and research for assessing the efficacy of surgical and nonsurgical interventions. The most commonly used hand-relevant PROMs are as follows: Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH (qDASH), Michigan Hand Questionnaire (MHQ), Patient Evaluation Measure (PEM), Upper Extremity Functional Index (UEFI), and Duruoz Hand Index (DHI). There has been no systematic evaluation of the published psychometric properties of these PROMs. Methods: A PRISMA-compliant systematic review of the development and validation studies of these hand PROMs was prospectively registered in PROSPERO and conducted to assess their psychometric properties. A search strategy was applied to Medline, Embase, PsycINFO, and CINAHL. Abstract screening was performed in duplicate. Assessment of psychometric properties was performed. Results: The search retrieved 943 articles, of which 54 articles met predefined inclusion criteria. There were 19 studies evaluating DASH, 8 studies evaluating qDASH, 13 studies evaluating MHQ, 5 studies evaluating UEFI, 4 studies evaluating PEM, and 5 studies evaluating DHI. Assessment of content validity, internal consistency, construct validity, reproducibility, responsiveness, floor/ceiling effect, and interpretability for each PROM is described. Conclusions: The psychometric properties of the most commonly used PROMs in hand research are not adequately described in the published literature. DASH, qDASH, and MHQ have the best-published psychometric properties, though they have either some poor psychometric performance or incompletely studied psychometric properties. There are more limited published data describing the psychometric properties of the UEFI, PEM, and DHI.

Introductionpatient-reported outcome measures (PROMs) are instruments used to measure outcomes and experiences of healthcare from the patient perspective. The specific methodology used to develop a PROM should be communicated to establish the quality of the instrument. This mixed methods protocol describes the development of a cross-cultural, internationally applicable PROM for hand conditions, the HAND-Q.Methods and analysisThe multiphase approach used for this study has been previously used with the development of other PROMs by our team (eg, BODY-Q, BREAST-Q, CLEFT-Q, FACE-Q). In Phase I, we establish what important concepts matter to patients with hand conditions. A conceptual framework is developed from a systematic review of existing PROMs in the field and an extensive international qualitative study. Interpretive description is the qualitative approach used. Item generation is based on the qualitative data. The preliminary scales will be created for each theme identified in the conceptual framework. These scales will be refined by cognitive debriefing interviews with participants and expert input. Phase II involves a large international sample of patients with varied hand conditions completing the field-test version of the HAND-Q. The scales will be refined using the modern psychometric approach of Rasch Measurement Theory. Analysis will result in a shortened set of clinically meaningful and scientifically robust HAND-Q scales.Ethics and disseminationThis study is coordinated at Flinders University (Adelaide, Australia) where it has ethics board approval for phase I and phase II. Findings will be published in peer-reviewed journals and presented at local, national and international conferences.

Objectives: Critical limb ischaemia (CLI) requiring infra-inguinal bypass is a common presentation to the vascular surgery service. A significant number of CLI patients also present with anaemia as a comorbidity, the impact of which is unknown. We reviewed the impact of anaemia on mortality and amputation in patients who underwent infra-inguinal bypass surgery. Methods: Demographic data from all patients who underwent infra-inguinal bypass surgery for CLI at the Flinders Medical Centre & Repatriation General Hospital, South Australia between January 2005 and January 2010 were recorded. Haemoglobin (Hb) level, serum creatinine (SCr) level, mortality and amputation events were also recorded for retrospective analysis. Results: 190 patients (141M, 49F) who underwent infra-inguinal bypass surgery over a 5 year period were analyzed. 100 (53%) of these patients had mild anaemia (mean Hb 113 g/L, mean for females 103 g/L, mean for males 116 g/L). Those who presented with anaemia were more likely to have diabetes and renal dysfunction as comorbidities. Anaemia had a significant negative impact on mortality with 30% deaths in those who were anaemic compared to 15.6% deaths in those without anaemia odds ratio (OR) 1.76, 95% CI: 0.90 - 3.48, p < 0.01. This relationship was similar when looking at amputation as an outcome; with the number of amputations in those who were anaemic preoperatively 14% vs 6.7% in those who were not anaemic, OR 2.56, 95% CI: 1.00 - 6.54, p = 0.05. The negative impact of anaemia on mortality 43.5% vs 18.8% was also noted in patients who did not have diabetes or impaired renal function as a comorbidity p < 0.05. Conclusions: Anaemia is a common comorbidity in patients presenting with CLI and it predicts poor outcomes after infra-inguinal bypass. The role of transfusion is debatable, but it is clear that this group of patients requires careful management during the perioperative period to ensure they are medically optimized.

Standardized post-operative protocols reduce variation and enhance efficiency in patient care. Patients may benefit from these initiatives by improved quality of care. This matched case-control study investigates the effect of a multidisciplinary criteria-led discharge protocol for uncomplicated appendicitis in children.Key protocol components included limiting post-operative antibiotics to two intravenous doses, avoidance of intravenous opioid analgesia, prompt resumption of diet, active encouragement of early ambulation and nursing staff autonomy to discharge patients that met assigned criteria. The study period was from August 2015 to February 2016. Outcomes were compared with a historical control group matched for operative approach.Outcomes for 83 patients enrolled to our protocol were compared with those of 83 controls. There was a 29.2% reduction in median post-operative length of stay in our protocol-based care group (19.6 versus 27.7 h; P0.001). The rate of discharges within 24 h improved from 12 to 42%. There was no significant difference in complication rate (4.8 versus 7.2%; P = 0.51). Mean oral morphine dose equivalent per kilogram requirement was less than half (46%) that of control group patients (P0.001). Mean number of ondansetron doses was also significantly lower. Projected annual direct cost savings following protocol implementation was AUD$77 057.Implementation of a criteria-led discharge protocol at our hospital decreased length of stay, reduced variation in care, preserved existing low morbidity, incurred substantial cost savings, and safely rationalized opioid and antiemetic medication. These protocols are inexpensive and offer tangible benefits that are accessible to all health care settings.

Once clinically manifested as a swollen limb, lymphedema can be difficult to manage. Our focus thus must shift from reactive treatment to proactive management and prevention. On the basis of strong evidence in the literature, lymphedema specialists now encourage exercise as it can improve lymphatic drainage through muscle pump action. However, exercise may increase the lymph load on the vulnerable limb. We aimed to examine whether low level sporting compression is a reasonable recommendation for those with early stage lymphedema by measuring whether sporting compression (SC) tights decrease limb extracellular fluid as measured by Bio-impedance Spectroscopy (BIS) and Perometry in legs following exercise in both healthy controls and those with early stage lymphedema. A group of normal subjects (n=10) and a group of Stage 1 (ISL) lymphedema patients (n=9) were enrolled. Efforts were made to match participants in each group. For those with unilateral lymphedema, the non-affected leg was used as a control. All were measured using BIS, Perometry and Indurometry before and after exercise both with and without sporting compression clothing. The exercise regime was standardized and involved treadmill walking at increasing rates within each person's activity limitation. SC tights were shown to significantly decrease the fluid build up caused by exercise in lymphedema-affected limbs as measured with BIS (p=0.0302). Perometry measurements showed that SC caused a significant decrease in limb volume post exercise of the whole cohort (p=0.0081) and of the control Group B (p=0.0348). Our findings support the notion that SC may provide a socially acceptable and effective means of lymphedema control during exercise for early lymphedema management.

Refereed/Peer-reviewed

We present a case of a man who experienced night sweats, abdominal pain and fever for over 3 months, with incomplete response to broad-spectrum intravenous antibiotics. Although CT imaging was insufficient to identify the cause for his chronic abdominal pain, the abnormality of a ‘misty mesentery’ was crucial in guiding further investigation. The final diagnosis of chronic appendicitis was made through laparoscopic and pathological examination. This case highlights the utility of a collaborative diagnostic effort between disciplines. Chronic appendicitis can cause lingering abdominal pain. Early recognition and appropriate referral can save patients months and even years of unnecessary suffering.

Small bowel obstructions (SBOs) are common in patients who have undergone Ileal J-pouch-anal anastomosis (IPAA) surgery. SBO may be caused by stenosis of the diverting ileostomy, volvulus, internal hernia, adhesive bands, anastomotic stricture 1 or intra-abdominal adhesions. 2 Functional outlet obstruction is an important alternative diagnosis to consider in a patient post-IPAA presenting with obstructive symptoms. Recognition of this condition can prevent unnecessary surgery and save the patient from presenting repeatedly with obstructive symptoms.

The authors present a case of spontaneous delayed periprosthetic breast haematoma in a woman taking Rivaroxaban.