Volume 5 Issue 2
From the Editor
This issue really should have something of interest for every orthopaedic surgeon. The breadth of our specialty is truly remarkable and the reports from our specialist society meetings demonstrate the energy of the organisers and participants, their international reach and the inclusion of the whole team. The steadily rising number of attendees at their conferences is a tangible measure of their success.
We have articles on education, professional development and medico-legal issues, but the core theme is basic science. We provide you with up-dates on the fundamental process of fracture healing and the evidence to support our approach to articular cartilage regeneration. Professor Tim Board is the guest editor and has written on the continuing conundrum of avascular necrosis of the femoral head where we still struggle to understand the causes or provide optimal treatment.
The “Getting it right first time” programme now encompasses many specialties though orthopaedics led the way. Rachel Yates explains the rationale of the process that supports clinicians taking the lead to improve outcomes and reduce variation based on sound evidence. It is vital that we take responsibility for stewardship of our resources, but we need to understand how to assess the cost effectiveness of our surgery. Belen Corbacho explains the importance of the QALY and what data you should consider when assessing health technology interventions.
Few things depress a surgeon more than a patient presenting with early infection after knee replacement. The impact on the patient can be catastrophic and it is vital that the right decisions are made as quickly as possible. Rhidian Morgan-Jones provides a clear and logical approach.
There is no doubt that you will want easy access to your copy of “JTO” and refer back to previous editions. We are excited to announce that you can now download the journal via the JTO App – just search for JTO @ BOA on the App Store or Google Play.
Phil Turner - BOA Vice President Elect
Reference Lists
The Use of QALYs in the Economic Evaluation of Orthopaedics Treatments
References
1. National Institute for Health and Care Excellence. Guide to the methods of technology appraisal. London: NICE: 2013.
2. Dolan P, Gudex C, Kind P, Williams A. A social tariff for EuroQol: results from a UK general population survey: Centre for Health Economics University of York, UK; 1995.
3. Devlin N, Shah K, Feng Y, Mulhern B, van Hout B. Valuing health-related quality of life: an EQ-5D-5L value set for England. 2016.
4. Manca A, Hawkins N, Sculpher MJ. Estimating mean QALYs in trial‐based cost‐effectiveness analysis: the importance of controlling for baseline utility. 2005;14(5):487-96.
5. Williams MA, Williamson EM, Heine PJ, Nichols V, Glover MJ, Dritsaki M, et al. Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation.Health Technol Assess. 2015 2015/03/09;19(19).
6. Handoll H, Brealey S, Rangan A, Keding A, Corbacho B, Jefferson L, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults.Health Technol Assess. 2015 2015/03/31;19(24).
7. Carr AJ, Cooper CD, Campbell MK, Rees JL, Moser J, Beard DJ, et al. Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial]. 2015.
8. Costa ML, Achten J, Plant C, Parsons NR, Rangan A, Tubeuf S, et al. UK DRAFFT: a randomised controlled trial of percutaneous fixation with Kirschner wires versus volar locking-plate fixation in the treatment of adult patients with a dorsally displaced fracture of the distal radius.Health Technol Assess. 2015 2015/02/26;19(17).
9. Cooke M, Marsh J, Clark M, Nakash RA, Jarvis RM, Hutton JS, et al. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage: the CAST trial. 2009;13(13):1-121.
10. Lamb SE, Lall RS, Hansen Z, Castelnuovo E, Withers EJ, Nichols VP, et al. A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain: the back skills training (BeST) trial. 2010;14(41):1-281.
11. Murray DW, MacLennan GS, Breeman S, Dakin HA, Johnston L, Campbell MK, et al. A randomised controlled trial of the clinical effectiveness and cost-effectiveness of different knee prostheses: the Knee Arthroplasty Trial (KAT). 2014.
12. McCarthy C, Mills P, Pullen R, Richardson G, Hawkins N, Roberts C, et al. Supplementation of a home-based exercise programme with a class-based programme for people with osteoarthritis of the knees: a randomised controlled trial and health economic analysis. 2004;8(46):iii-iv, 1-61.
13. Wiertsema SH, van Dongen JM, Geleijn E, Schothorst M, Bloemers FW, de Groot V, et al. Evaluation of a new Transmural Trauma Care Model (TTCM) for the rehabilitation of trauma patients: a study protocol. 2017;17(1):99.
14. Devlin NJ, Parkin D, Browne J. Patient‐reported outcome measures in the NHS: new methods for analysing and reporting EQ‐5D data. 2010;19(8):886-905.
15. Devlin NJ, Brooks R. EQ-5D and the EuroQol Group: Past, Present and Future. 2017:1-11.
16. Janssen M, Birnie E, Bonsel G. Quantification of the level descriptors for the standard EQ-5D three-level system and a five-level version according to two methods. 2008;17(3):463-73.
17. Pickard AS, De Leon MC, Kohlmann T, Cella D, Rosenbloom S. Psychometric comparison of the standard EQ-5D to a 5 level version in cancer patients. 2007;45(3):259-63.
18. Janssen MF, Birnie E, Haagsma JA, Bonsel GJ. Comparing the standard EQ-5D three-level system with a five-level version. 2008;11(2):275-84.
19. Smith MD, Drummond M, Brixner D. Moving the QALY forward: rationale for change. 2009;12:S1-S4.
Bisphosphonate - associated Femoral Fractures: Lessons Learnt
References
1. Drake MT, Clarke BL, Khosla S et al. Bisphosphonates: mechanism of action and role in clinical practice. Mayo Clinc Proc. Sep 2008;83(9):1032-1045. doi: 10.4065/83.9.1032
2. Khan SA, Kanis JA, Vasikaran S et al. Elimination and biochemical responses to intravenous alendronate in postmenopausal osteoporosis. J Bone Miner Res. 1997 Oct;12(10):1700-7.
3. Whyte MP. Atypical femoral fractures, bisphosphonates, and adult hypophosphatasia. J Bone Miner Res. 2009 Jun;24(6):1132-4. doi: 10.1359/jbmr.081253.
4. Lenart BQ Lorich CG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med. 2008;358(12):1304-1306.
5. Neviaser AS, Lane JM, Lenart BA et al. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008;22(5):346-350.
6. Odvina CV, Zerwekh JE, Rao DS et al. Severely suppressed bone turnover: A potential complication of alendronate therapy. J Clin Endocrinol Metab. 2005;90(3):1897-1899.
7. Shane E, Burr D, Abrahamsen B et al. Atypical Subtrochanteric and Diaphyseal Femoral Fractures: Second Report of a Task Force of the American Society for Bone and Mineral Research. Journal of Bone and Mineral Research, Vol.29,No.1, January 2014 p1-23 DOI: 10.1002/jbmr.1998
8. Shane E, Burr D, Ebeling PR et al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010 Nov;25(11):2267-94. doi: 10.1002/jbmr.253.
9. Abrahamsen B. Bisphosphonate adverse effects, lessons from large databases. Curr Opin Rheumatol 2010 Jul;22(4):404-9. doi: 10.1097/BOR.0b013e32833ad677.
10. Black DM, Kelly MP, Genant HK et al. Bisphosphonates and Fractures of the Subtrochanteric or Diaphyseal Femur. N Engl J Med 2010; 362:1761-1771. DOI: 10.1056/NEJMoa1001086
11. No author named. Alendronate – risk of low energy femoral shaft fracture. Prescriber Update 30(4):25,November 2009
12. Rizzoli R, Akesson K, Bouxsein M et al. Subtrochanteric fractures after long-term treatment with bisphosphonates: a European Society on Clinical and Economic Aspects of Osteoporosis and Osteoarthritis, and International Osteoporosis Foundation Working Group Report. Osteoporos Int. 2011 Feb;22(2):373-90. doi: 10.1007/s00198-010-1453-5. Epub 2010 Nov 18.
13. Wells GA, Cranney A, Peterson J et al. for preventing fractures caused by osteoporosis in postmenopausal women. Cochrane database, September 2011.
14. Thompson R, Phillips JRA, Moran CG. Atypical femoral fractures and bisphosphonate treatment. Experience in two large teaching hospitals. JBJS (Br) 2012; 94(3): 385-390.
15. No author named. Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (amended), NICE technology appraisal guidance [TA161], 2011.
16. Stepan JJ, Burr DB, Pavo I et al. Low bone mineral density is associated with bone microdamage accumulation in postmenopausal women with osteoporosis. Bone 2007,41:378–385.
17. Black DM, Schwartz AV, Ensrud KE et al for the FLEX Research Group. Effects of continuing or stopping alendronate after 5 years of treatment. the fracture intervention trial long-term extension (FLEX): a randomized trial. JAMA. 2006;296(24):2927-2938. doi:10.1001/jama.296.24.2927.
18. Diab DL, Watts NB. Bisphosphonate drug holiday: who, when and how long. Ther Adv Musculoskelet Dis. 2013 Jun; 5(3): 107–111. doi: 10.1177/1759720X13477714
19. Kavanaugh A, Ruderman E. ACR Hotline March 22, 2010, Current on 2014
20. Bhadada SK, Sridhar S, Muthukrishnan J et al. Predictors of atypical femoral fractures during long term bisphosphonate therapy: a case series & review of literature. Indian J Med Res. 2014 Jul; 140(1): 46–54.
21. Girgis CM and Seibel MJ. Atypical femur fractures: a review of the evidence and its implication to clinical practice. Ther Adv Musculoskelet Dis. 2011 Dec; 3(6): 301–314. doi: 10.1177/1759720X11416270
22. Goh SK, Yang KY, Koh JS et al. Subtrochanteric insufficiency fractures in patients on alendronate therapy: a caution. J Bone Joint Surg (Br). 2007 Mar;89(3):349-53.
23. Kwek EB, Goh SK, Koh JS et al. An emerging pattern of subtrochanteric stress fractures: a long-term complication of alendronate therapy? Injury 2008 Feb;39(2):224-31. doi: 10.1016/j.injury.2007.08.036. Epub 2008 Jan 28.
24. Ernat J, Song D, Fazio M et al. Radiographic changes and fracture in patients having received bisphosphonate therapy for 5 years at a single institution. Military Medicine. 180,12:1214,2015.
25. Donnelly E, Saleh A, Unnanuntana A et al. Atypical Femoral Fractures: Epidemiology, Etiology, and Patient Management. Curr Opin Support Palliat Care. 2012 Sep; 6(3):348-354. doi: 10.1097/SPC.0b013e3283552d7d
FRCS (T&O): a Trainee's and Educationalist's Perspective on Exam Preparation
References
1. FRCS Section 1 – Trauma and Orthopaedic Surgery. Limb, D. British Orthopaedic Trainees Association. Retrieved from http://www.bota.org.uk/frcs-trauma-orthopaedic-surgery/ (accessed 21 March 2017).
2. UK and Ireland In-Training Examination (UKITE) British Orthopaedic Association. Retrieved from https://www.ukite.org.uk (accessed 21 March 2017).
3. Orthobullets.com educational resource for orthopaedic surgeons. Retrieved from http://www.orthobullets.com (accessed 21 March 2017).
4. Miller MD. Review of Orthopaedics, 7th edn. New York: Saunders. 2016.
5. Rickets. Retrieved from http://www.orthobullets.com/basic-science/9031/rickets (accessed 21 March 2017)
6. Banaszkiewicz PA, Kader DF. Postgraduate Orthopaedics: The Candidate’s Guide to the FRCS (Tr & Orth) Examination. 3rd edn. Cambridge University Press. 2016.
7. Joint Committee on Intercollegiate Examinations. Retrieved from https://www.jcie.org.uk/Utils/DocumentGenerator.aspx%3FType%3DCMS%26docID%3D58ea3ec7-de60-41609d15d8757f511d14&rct=j&frm=1&q=&esrc=s&sa=U&ved=0ahUKEwirlsbEhdDMAhUa6xoKHYkxCy8QFggUMAA&usg= AFQjCNFFcppNTiZnSQzp-wCXEDPQu6DfCQ (accessed 21 March 2017).
8. Sweller J, Van Merrienboer JJ, Paas FGWC. Cognitive architecture and instructional design. Educ Psychol Rev. 1998 Sept; 10:251–296.
9. Murre JMJ, Dros J. Replication and analysis of Ebbinghaus' forgetting curve. PLoS One. 2015 Jul; 10:e0120644.
10. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving students' learning with effective learning techniques: promising directions from cognitive and educational psychology. Psychol Sci Public Interest. 2013 Jan; 14:4–58.
11. Bjork EL, Bjork RA. Psychology and the real world: essays illustrating contributions to society. Chapter 5, Making things hard on yourself, but in a good way: creating desirable difficulties to enhance learning. New York: Worth Publishers. 2009.
12. Rowland CA. The effect of testing versus restudy on retention: a meta-analytic review of the testing effect. Psychol Bull. 2014 Nov; 140: 1432–1463.
13. Cepeda NJ, Vul E, Rohrer D, Wixted JT, Pashler H. Spacing effects in learning: a temporal ridgeline of optimal retention. Psychol Sci. 2008 Nov; 19:1095–1102.
14. Mamede S, van Gog T, Moura AS, de Faria RMD, Peixoto JM, Rikers RMJP, Schmidt HG. Reflection as a strategy to foster medical students' acquisition of diagnostic competence. Med Educ. 2012 Apr; 46:464–472.
How I ... Manage the Acutely Infected TKR?
References
1. Zimmerli W., Trampuz A., Ochsner P. Prosthetic joint infections. N Eng J Med 2004; 351 (16):1645-54.
2. McPherson EJ, Woodson C, Holtom P, Roidis N, Shufelt C, Patzakis M., Periprosthetic total hip infection: outcomes using a staging system. Clin Orthop Relat Res. 2002 Oct ;(403):8-15
3. Deirmengian C, Kardos K, Kilmartin P, Cameron A, Schiller K, Parvizi J. Combined measurement of synovial fluid α-Defensin and C-reactive protein levels: highly accurate for diagnosing periprosthetic joint infection. J Bone Joint Surg Am. 2014 Sep 3;96(17):1439-45
4. Zmistowski B, Restrepo C, Huang R, Hozack WJ, Parvizi J., Periprosthetic joint infection diagnosis: a complete understanding of white blood cell count and differential. J Arthroplasty. 2012 Oct; 27(9):1589-93.
5. Ghanem E, Parvizi J, Burnett RS, Sharkey PF, Keshavarzi N, Aggarwal A, Barrack RL., Cell count and differential of aspirated fluid in the diagnosis of infection at the site of total knee arthroplasty. J Bone Joint Surg Am. 2008 Aug; 90(8):1637-4
6. Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P, Gundle R, Berendt A One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother. 2009 Jun; 63(6):1264-71.
7. Kuiper JW, Vos SJ, Saouti R, Vergroesen DA, Graat HC, Debets-Ossenkopp YJ, Peters EJ, Nolte PA. Prosthetic jointassociated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients. Acta Orthop. 2013 Aug;84(4):380-6
8. Khan W., Morgan-Jones R., Debridement: defining something we all do., Journal of Trauma & orthopaedics, Vol. 04, Issue 01, p48-50 March 2016
Legg-Calve-Perthes Disease: 100 Years of Controversy: But Could the Answers be Forthcoming?
References
1. Perthes G. 1910. Uber arthritis deformans juvenilis. Dtsch Z Chir, 107, 111-159.
2. Calve J. 1909. Sur une forme particuliere de pseudocoxalgie greffee sur de deformations caracteristiques de l’extremite superieure de femur. Rev Chir, 30, 54-8.
3. Legg AT. 1910. An Obscure Affection of the Hip-Joint. Boston Med Surg J, 17, 162(7), 202-204.
4. Perry DC, Machin DMG, Pope D, Bruce CE, et al. 2012. Racial and Geographic Factors in the Incidence of LeggCalvé-Perthes Disease: A Systematic Review. Am J Epidemiol, 175(3), 159-66.
5. Tripathy S, Sen R, Dhatt S, Goyal T. 2010. Legg-Calvé-Perthes Disease Current Concepts. Orthop, 11(1)
6. Metcalfe D, Van Dijck S, Parsons N, Christensen K, Perry DC. 2016. A twin study of Perthes Disease. Pediatrics, 137(3). Epub ahead of print
7. Gordon EJ, Schoenecker, PL, Osland JD, Dobbs MB, Szymanski DA, Luhmann SJ. 2004. Smoking and socioeconomic status in the etiology and severity of Legg-Calve-Perthes’ disease. J Pediatr Orthop B, 13, 367–370.
8. Mata SG, Aicua EA, Ovejero AH, Grande MM. 2000. Legg-Calve-Perthes disease and passive smoking. J Pediatr Orthop, 20, 326–330.
9. Burwell RG, Dangerfield PH, Hall DJ, Vernon CL, Harrison MH. 1978. Perthes' disease: An anthropometric study revealing impaired and disproportionate growth. J Bone Joint Surg Br. 60-B(4), 461-77.
10. Perry DC, Pope D, Bruce CE, Dangerfield P, Hall AJ, Platt MJ. 2013. Hyperactivity and the psychological burden of Perthes disease: a case-control study. J Pediatr Orthop, 33(6), 644-9
11. Kim HK, Aruwajoye O, Stetler J, Stall A. 2012. Effects of non-weight-bearing on the immature femoral head following ischemic osteonecrosis: an experimental investigation in immature pigs. J Bone Joint Surg, 94(24), 2228-2237.
12. Stuhlberg SD, Cooperman DR, Wallensten R. 1981. The natural history of Legg-Calvé-Perthes disease. J Bone Joint Surg Am, 63, 1095-1108.
13. Herring JA, Kim HT, Browne R. 2004. Legg-Calve-Perthes disease. Part II: Prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg Am, 86-A(10), 2121-2134.
14. Joseph B, Price CT. 2011. Principles of containment treatment aimed at preventing femoral head deformation in Perthes Disease. Orthop Clin N Am, 42, 317-327.
15. Catterall A. 1971. The natural history of Perthes’ disease. J Bone Joint Surg Br, 53(1), 37-53
16. Joseph B, Varghese G, Mulpuri K, Narasimha Rao K, Nair NS. 2003. Natural evolution of Perthes disease: a study of 610 children under 12 years of age at disease onset. J Pediatr Orthop, 23(5), 590-600.
17. Mose K. 1980. Methods of measuring in Legg-Calve-Perthes disease with special regard to the prognosis. Clin Orthop Relat Res, 150, 103-109.
18. Siddesh ND, Shah H, Tercier S, Pai H, Nair S, Joseph B. 2014. The sphericity deviation score: a quantitative radiologic outcome measure of Legg-Calve-Perthes disease applicable at the stage of healing and at skeletal maturity. J Pediatr Orthop, 34(5), 522-528.
19. Nelson D, Zenios M, Ward K, Ramachandran M, Little DG. 2007. The deformity index as a predictor of final radiological outcome in Perthes' disease. J Bone Joint Surg Br, 89(10), 1369-74.
20. Wiig O, Terjesen T, Svenningsen S. 2007. Inter-observer reliability of the Stuhlberg classification in the assessment of Perthes disease. J Child Orthop, 1(2), 101-105.
21. Dimeglio A, Canavese F. 2011. Imaging in Legg-Calve-Perthes Disease. Orthop Clin North Am, 42(3), 297-302.
22. Neal D, O'Brien J, Burgess J, Kim HW, International Perthes Study Group. 2015. Quantitative assessment of synovitis in Legg-Calve-Perthes disease using gadolinium-enhanced MRI. J Pediatr Orthop B, 24(2), 89-94.
23. Brech GC, Guarnieiro R. 2006. Evaluation of physiotherapy in the treatment of Legg-Calve-Perthes disease. Clinics, 61(6), 521-528.
24. Saran N, Varghese R, Mulpuri K. 2012. Do femoral or Salter innominate osteotomies improve femoral head sphericity in Legg-Calve-Perthes disease? A meta analysis. Clin Ortho Relat Res, 470(9), 2383-2393.
25. Wiig O, Terjesen T, Svenningson S. 2008. Prognostic factors and outcome of treatment in Perthes’ disease: a prospective study of 368 patients with five-year follow-up. J Bone Joint Surg Br, 90(10), 1364-1371.
26. Terjesen T, Wiig O, Svenningsen S. 2012. Varus femoral osteotomy improves sphericity of the femoral head in older children with severe form of Legg-Calve-Perthes disease. Clin Orthop Relat Res, 470(9):2394-2401.
27. Joseph B, Rao N, Mulpuri K, Varghese G, Nair S. 2005. How does a femoral osteotomy alter the natural evolution of Perthes disease? J Pediatr Orthop B, 14(1), 10-15.
28. Wichlacz W, Sotirow B, Sionek A, Czop A. 2004. Surgical outcome for children in the early phase of Perthes’ disease. Ortop Traumatol Rehabil, 6(6), 712-717.
29. Young ML, Little DG, Kim HK. 2012. Evidence for using bisphosphonate to treat Legg-Calvé-Perthes disease. Clin Orthop Relat Res, 470(9), 2462-75.
30. Herrera-Soto JA, Price CT. 2011. Core decompression and labral support for the treatment of juvenile osteonecrosis. J Pediatr Orthop, 31(2), S212-216.
31. Hosny GA, El-Deeb K, Fadel M, Laklouk M. 2011. Arthrodiastasis of the hip. J Pediatr Orthop, 31(2), S229-234.
32. Kurup HV, Clarke NM. 2011. Sugioka transtrochanteric valgus osteotomy for hinge abduction in children. J Pediatr Orthop, 31(7), 727-731
Scrubbing Under the Influence
References
1. Kirschner MH, Lang RA, Breuer B, Breuer M, Gronver CS, Zwingers T, Bottrich JG, Arndt A, Brauer Ute, Hintzpeter M, Burmeister MA, Fauteck JD. Transdermal Resorption of an Ethanol and 2-propanolol Containing Skin Disinfectant. Langenbecks Arch Surg 2009; 394: 151-157
2. Parienti JJ, Thibon P, Heller R, Le Roux Y, von Theobald P, Bensadoun H, Bouvet A, Lemarchand F, Le Coutour X. Hand-Rubbing with an aqueous Alcoholic Solution vs Tranditional Hand Scrubbing and 30 Day Surgical Site Infection Rates – A Randomised Equivalence Study. J Am Med Assoc 2002; 288: 722-727
3. Barbut F, Djamjian L, Passot C, Petit JC. Efficacy of 2 Alcohol Based gels and 1 Alcohol Based Rinse for Surgical Hand Disinfection. Infect Control Hosp Epidemiol 2007; 28: 1013-1015
4. Widmer AF, Rotter M, Voss A, Nthumba P, Allegranzi B, Boyce J, Pittet D. Surgical Hand Preparation: State-OfThe-Art. J Hosp Infect 2010; 74: 112-122
5. Marchetti MG, Kampf G, Finzi G, Salvatorelli G. Evaluation of the Bactericidal Effect of Five Products for Surgical Hand Disinfection According to prEN 12054 and prEN 12791. J Hosp Infect 2003; 54: 63-67
6. World Health Organisation: WHO Guidelines on Hand Hygiene in Healthcare, Executive Summary. http://www.who.int/patientsafety/challenge/en/
7. Kampf G, Ostermeyer C, Heeg P. Surgical Hand Disinfection with a Propanol-Based Hand Rub: Equivalence of Shorter Application Times. J Hosp Infect 2005; 59: 304-310
8. Bessonneau V, Thomas O. Assessment of Exposure to Alcohol Vapour from Alcohol-Based Hand Rubs. Int J Environ Res Public Health 2012; 9(3): 868-879
9. Bessonneau V, Clement M, Thomas O. Can intensive Use of Alcohol Based Hand Rubs Lead to Passive Alcoholization? Int J Environ Res Public Health 2010; 7: 3038-3390
10. Below H, Partecke I, Huebner NO, Bieber N, Nicolai T, Usche A, Assadian O, Below E, Kampf G, Parzefall W, Heidecke CD, Zuba D, Bessonneau V, Kohlmann T, Kramer A. Dermal and Pulmonary Absorption from Propan-1ol and Propan-2-ol from Hand Rubs. Am J Infect Control 2012; 40: 250-257
11. Driving Vehicle Licencing Agency: Drink Drive Limit. https://www.gov.uk/drink-drive-limit
12. Turner P, Saeed B, Kelsey MC. Dermal Absorption of Isopropyl Alcohol from a Commercial Hand Rub: Implications for its use in Hand Decontamination. J Hosp Infect 2004; 56: 287-290
Propose Changes to Soft Tissue Injury - Whiplash - Claims Process 2017
References
1. Dalton J (2017) http://www.insurancebusinessmag.com/uk/news/breaking-news/industry-bodies-react-togovernment-whiplash-reforms-60929.aspx
2. Evans D (2017) “Chief Executive: How APIL has been fighting on a number of fronts.” PI Focus March p7
3. Fletcher B (2017) https://www.insurancefraudbureau.org/media-centre/news/2017/ifb-responds-togovernment-whiplash-reforms/
4. Miller I (2017) http://www.piblawg.co.uk/post/2017/02/25/whiplash-injuries-a-tale-of-two-systems1
5. Ministry of Justice(2016) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/581387/reforming-soft-tissueinjury-claims-process.pdf
6. Ministry of Justice (2017) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/581387/reforming-soft-tissueinjury-claims-process.pdf
7. Twambley A (2017) http://accesstojusticeactiongroup.co.uk/access-justice-responds-publication-prisons-courtsbill/
8. Williams D (2017) http://www.axa.co.uk/newsroom/media-releases/2017/response-to-the-reforms-to-thewhiplash-consultation-as-part-of-the-prisons-and-courts-bill/