their prenatal population who were positive for D antigen to have unexpected, clinically important antibodies.' To fail to screen all pregnant women for unexpected antibodies is unacceptable. RONA PEPPER BRENTON WYLIE New South Wales Red Cross Blood Transfusion Service, Sydney, New South Wales 2000, Australia I Chamberlain G. Normal antenatal management. BMJ 1991;302:
774-87. (30 March.) 2 Americati Association of Blood Banks. Technical manual. 10th ed. Arlington, VA: American Association of Blood Banks, 1990:883. 3 Hardy J, Napier JAF. Red cell antibodies detected in antenatal tests on rhesus positive women in south and mid Wales, 1948-1978. Brj Obstet Gvnaecol 1981;88:91-100.
sacks normally used for refuse that has not been contaminated with sharps, endangering porters and others who help with the disposal process. Injuries acquired in this way have been reported at this hospital. Three further points therefore merit debate: firstly, sharps containers are relatively small (and costly) and should be used only for small sharp objects. Secondly, syringes and other soft contaminated refuse, should go into cheap and capacious plastic sacks or bin liners. Finally, a needle can be removed from a syringe in perfect safety, especially if fingers rather than forceps are used. I believe that these suggestions would improve safety; they would also save money. E A FRENCH Dcpartment of Hacmatology,
Univcrsity Hospital, Nottingham NG7 2UH
AUTHOR'S REPLY,-When a clinical account of a big subject is written, sometimes the enforced condensation of material leads those working on particular subjects to think that they have been forgotten. They have not, but space precludes their mention. Percentage reaction rate to blood transfusions measured by immunisation after a first and reaction to a second transfusion (derivedfrom Giblett') Blood group system
First transfusion Second traoisfusion
Rhesus Kell
Duffy Kidd MNS
6-988 0410 0-052 0-013 0-010
5 814
0-037 0-034 0010 0-005
At most antenatal clinics we test for all the private antibodies, as well as ABO and rhesus ones; the idea that I discount rhesus antibodies other than anti-D must spring from a misreading of my article as I purposely described the testing of all rhesus antibodies. Of the other antibodies in Drs Pepper and Wylie's list, Kell antibodies occasionally cause a clinical problem, but the others impinge on the management of pregnant women in diminishing amounts (table). GEOFFREY CHAMBERLAIN
Department of Obstetrics and (Gynaecology, St George's Hospital Medical School, London SW 17 ORE I Giblett ER. Erythocyte antigens and antibodies. In: Williams WJ, Beatler E, Ersler AJ, Lichtman MA, eds. Hematology. New York: McGraw-Hill, 1983.
Preventing needlestick injuries SIR,-Professor D C Anderson and colleagues are right to discuss the problem of preventing needlestick injuries.' It really was high time that the assumptions underlying some of the recommendations in current guidelines were reexamined. I suggest that another recommendation, which appears in the BMA's booklet2 and elsewhere, merits similar questioning. This is the advice that needles and syringes should not be separated after use but disposed of as a single unit. Firstly, if an unsheathed needle is a potential hazard for those who may come into contact with it later, as Professor Anderson and colleagues point out, how much more dangerous is a needle rigidly mounted on the end of a syringe? Secondly, sharps containers should not be overfilled. I doubt whether anyone has ever seen an overfilled sharps box containing nothing but needles. I suspect, however, that many people have seen sharps boxes overfilled by being used for syringe-needle combinations. Regrettably, when sharps boxes are overfilled in this way needlesyringe combinations find their way into the plastic
BMJ VOLUME 303
17 AUGUST 1991
I Aniderson L)C, Blower AL, Ganguli LA, PackerJMV. Preventing
needlestick inijuries. BMJ 1991;302:769-70. (30 Miarch.) 2 BMA. A code of practice for the safe use and disposal of sharps. London: BMA, 1990.
SIR,-The correspondence stimulated by our article on preventing needlestick injuries' shows that the issue of resheathing is not one that can be resolved by arbitrary decree. As Jagger et al stated, "recapping is hazardous, but the relevant question is whether recapping is more hazardous than handling exposed needles."2 Many people are injured and killed on pedestrian crossings, where the relevant danger is concentrated; yet no one would suggest that these crossings should be avoided. Some specific points made by correspondents demand a response. Dr Christopher Valentine and Ms Philippa Bright (4 May) seem to have missed a critical point.' For venepuncture, the main hazardous procedure under discussion, it is virtually always necessary to remove the needle before the blood is transferred to sample containers; the process of removing and disposing of the needle must surely be safer once it is resheathed. Incidentally, this need to remove the needle after venepuncture before transferring the sample is ignored in the BMA's poster on the subject, which has been widely circulated recently. Evidently most people prefer not to touch a contaminated exposed needle directly. We agree with Dr Paul N Goldwater (29 June) that workers in the Medical Research Council's HIV Clinical Trials Centre, especially, should heed the results of his clinical trial, which clearly pointed to the value of a resheathing device.' Mr Robin P Choudhury and Ms Susan J Cleator (29 June) rightly point out' a flaw in our quotation of Jagger et al's work, in which rates of resheathing are not known2 4; as most studies point to rates in excess of 60%, however, our crude calculation of protection versus injury from resheathing is probably an underestimate. We were interested to note that in Mr Choudhury and Ms Cleator's study of medical students-who are among the most technically incompetent at venepuncture-injury rates were the same in those who did and did not resheath needles. Dr T C Aw and colleagues (1 June) made much of some problems encountered by only the most incompetent operator'; anyone without a steady hand and eye should surely not be attempting venepuncture in the first place. A "two handed scoop" technique or holding the Saf-T-Cap while using it for resheathing is unnecessary and bad practice. Dr Malcolm Gatley and Ms Margaret Worsley (11 May) also make much of technical competence in an emergency-this is why we advocated providing resheathing devices in emergency areas.' They concede that the practices advocated are desirable in theory; surely this is a good place to start, especially where theory and human behaviour are concordant. We do not understand their reference to needles falling off-
perhaps they mean sheaths, though in our experience this is very uncommon: most can be wedged home safely while held at the hilt, and quality control of sheaths and needles is generally good. Mr David R Morgan of the BMA (11 May) quotes four organisations (the World Health Organisation, Centers for Disease Control, Department of Health, and BMA) as all agreeing that "the risks from resheathing are too great"'; in fact, three seem simply to have copied the fourth (the Centers for Disease Control). We were interested that in his survey nine of 24 occupational health doctors resheathed needles-that is, 38% of those doctors least likely to ignore official guidance. It is a particular worry that the WHO advocates not resheathing, as in much of the Third World (and some of the Second and First Worlds) containers that meet British Standard 7320 are unavailable or unaffordable, or both. Official bodies should take this into account and at least concede that where such expensive containers are not available a safe resheathing technique should be adopted. By the same token, the financial and other arguments put forward by Dr E A French (this issue) for separating the (resheathed) needle from the syringe and disposing of the syringe in a contaminated waste bag should be given some weight. We believe that these and related issues will not simply go away through the arbitrary use of directives; we hope that someone will organise a comparative trial in two similar NHS districts, one of which introduces an official policy of safe resheathing and the other a policy of safe nonresheathing; accurate data on resheathing and on injury rates at all stages should be collected prospectively. The issue should be resolved by science rather than stridor. D C ANDERSON
Department of Medicine L GANGULI
Department of Medical Microbiology, University of Manchester, Hope Hospital, Salford M6 8HD
JPACKER Department of Public Health Medicine, Salford Health Authority, Eccles M30 ONJ I Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. B.MJ 1991;302:769-70. (30 March.) 2 Jagger J, Hunt EH, Brand-Elnaggar J, P'earson RD. Rates of needlestick injuryr caused by various devices in a university hospital. N EnglJ7 Med 1988;319:284-8. 3 Correspondence. Preventing needlestick injuries. B3MJ 1991; 302:1079 (4 May), 1147 (11 May), 1336-7 (1 June), 1602-3 (29 June);303:419,(17 August). 4 Jagger J, Hunt EH, Pearson JD. Recapping used needles: is it worse than the alternative?)J Infect Dis 1990;162:784-5.
Surgeons who undertake surgery for colorectal cancer SIR,-Messrs C S McArdle and D Hole presented data on postoperative mortality of patients with colorectal cancer. They concluded that there were "significant variations in patient outcome among surgeons" and that such "differences compromised survival."' We are not convinced that their data and statistical analysis provide sufficient evidence for their conclusion for several reasons. Firstly, no overall assessment was made of the significance of the differences among surgeons in their patients' outcome. The authors' table I shows that postoperative mortality ranged from 8% to 30% (important enough for the authors to mention in their summary). However, a x2 test for heterogeneity2 does not give a significant result (x2= 14: df= 12: p>025). These rates are unadjusted, but we doubt whether adjusting them would greatly reduce their variation: it did not do so for the hazard rate ratios in the authors' table VII. Secondly, no allowance seems to have been made for the lack of independence and multiple significance testing inherent in the 52 comparisons
419
774-87. (30 March.) 2 Americati Association of Blood Banks. Technical manual. 10th ed. Arlington, VA: American Association of Blood Banks, 1990:883. 3 Hardy J, Napier JAF. Red cell antibodies detected in antenatal tests on rhesus positive women in south and mid Wales, 1948-1978. Brj Obstet Gvnaecol 1981;88:91-100.
sacks normally used for refuse that has not been contaminated with sharps, endangering porters and others who help with the disposal process. Injuries acquired in this way have been reported at this hospital. Three further points therefore merit debate: firstly, sharps containers are relatively small (and costly) and should be used only for small sharp objects. Secondly, syringes and other soft contaminated refuse, should go into cheap and capacious plastic sacks or bin liners. Finally, a needle can be removed from a syringe in perfect safety, especially if fingers rather than forceps are used. I believe that these suggestions would improve safety; they would also save money. E A FRENCH Dcpartment of Hacmatology,
Univcrsity Hospital, Nottingham NG7 2UH
AUTHOR'S REPLY,-When a clinical account of a big subject is written, sometimes the enforced condensation of material leads those working on particular subjects to think that they have been forgotten. They have not, but space precludes their mention. Percentage reaction rate to blood transfusions measured by immunisation after a first and reaction to a second transfusion (derivedfrom Giblett') Blood group system
First transfusion Second traoisfusion
Rhesus Kell
Duffy Kidd MNS
6-988 0410 0-052 0-013 0-010
5 814
0-037 0-034 0010 0-005
At most antenatal clinics we test for all the private antibodies, as well as ABO and rhesus ones; the idea that I discount rhesus antibodies other than anti-D must spring from a misreading of my article as I purposely described the testing of all rhesus antibodies. Of the other antibodies in Drs Pepper and Wylie's list, Kell antibodies occasionally cause a clinical problem, but the others impinge on the management of pregnant women in diminishing amounts (table). GEOFFREY CHAMBERLAIN
Department of Obstetrics and (Gynaecology, St George's Hospital Medical School, London SW 17 ORE I Giblett ER. Erythocyte antigens and antibodies. In: Williams WJ, Beatler E, Ersler AJ, Lichtman MA, eds. Hematology. New York: McGraw-Hill, 1983.
Preventing needlestick injuries SIR,-Professor D C Anderson and colleagues are right to discuss the problem of preventing needlestick injuries.' It really was high time that the assumptions underlying some of the recommendations in current guidelines were reexamined. I suggest that another recommendation, which appears in the BMA's booklet2 and elsewhere, merits similar questioning. This is the advice that needles and syringes should not be separated after use but disposed of as a single unit. Firstly, if an unsheathed needle is a potential hazard for those who may come into contact with it later, as Professor Anderson and colleagues point out, how much more dangerous is a needle rigidly mounted on the end of a syringe? Secondly, sharps containers should not be overfilled. I doubt whether anyone has ever seen an overfilled sharps box containing nothing but needles. I suspect, however, that many people have seen sharps boxes overfilled by being used for syringe-needle combinations. Regrettably, when sharps boxes are overfilled in this way needlesyringe combinations find their way into the plastic
BMJ VOLUME 303
17 AUGUST 1991
I Aniderson L)C, Blower AL, Ganguli LA, PackerJMV. Preventing
needlestick inijuries. BMJ 1991;302:769-70. (30 Miarch.) 2 BMA. A code of practice for the safe use and disposal of sharps. London: BMA, 1990.
SIR,-The correspondence stimulated by our article on preventing needlestick injuries' shows that the issue of resheathing is not one that can be resolved by arbitrary decree. As Jagger et al stated, "recapping is hazardous, but the relevant question is whether recapping is more hazardous than handling exposed needles."2 Many people are injured and killed on pedestrian crossings, where the relevant danger is concentrated; yet no one would suggest that these crossings should be avoided. Some specific points made by correspondents demand a response. Dr Christopher Valentine and Ms Philippa Bright (4 May) seem to have missed a critical point.' For venepuncture, the main hazardous procedure under discussion, it is virtually always necessary to remove the needle before the blood is transferred to sample containers; the process of removing and disposing of the needle must surely be safer once it is resheathed. Incidentally, this need to remove the needle after venepuncture before transferring the sample is ignored in the BMA's poster on the subject, which has been widely circulated recently. Evidently most people prefer not to touch a contaminated exposed needle directly. We agree with Dr Paul N Goldwater (29 June) that workers in the Medical Research Council's HIV Clinical Trials Centre, especially, should heed the results of his clinical trial, which clearly pointed to the value of a resheathing device.' Mr Robin P Choudhury and Ms Susan J Cleator (29 June) rightly point out' a flaw in our quotation of Jagger et al's work, in which rates of resheathing are not known2 4; as most studies point to rates in excess of 60%, however, our crude calculation of protection versus injury from resheathing is probably an underestimate. We were interested to note that in Mr Choudhury and Ms Cleator's study of medical students-who are among the most technically incompetent at venepuncture-injury rates were the same in those who did and did not resheath needles. Dr T C Aw and colleagues (1 June) made much of some problems encountered by only the most incompetent operator'; anyone without a steady hand and eye should surely not be attempting venepuncture in the first place. A "two handed scoop" technique or holding the Saf-T-Cap while using it for resheathing is unnecessary and bad practice. Dr Malcolm Gatley and Ms Margaret Worsley (11 May) also make much of technical competence in an emergency-this is why we advocated providing resheathing devices in emergency areas.' They concede that the practices advocated are desirable in theory; surely this is a good place to start, especially where theory and human behaviour are concordant. We do not understand their reference to needles falling off-
perhaps they mean sheaths, though in our experience this is very uncommon: most can be wedged home safely while held at the hilt, and quality control of sheaths and needles is generally good. Mr David R Morgan of the BMA (11 May) quotes four organisations (the World Health Organisation, Centers for Disease Control, Department of Health, and BMA) as all agreeing that "the risks from resheathing are too great"'; in fact, three seem simply to have copied the fourth (the Centers for Disease Control). We were interested that in his survey nine of 24 occupational health doctors resheathed needles-that is, 38% of those doctors least likely to ignore official guidance. It is a particular worry that the WHO advocates not resheathing, as in much of the Third World (and some of the Second and First Worlds) containers that meet British Standard 7320 are unavailable or unaffordable, or both. Official bodies should take this into account and at least concede that where such expensive containers are not available a safe resheathing technique should be adopted. By the same token, the financial and other arguments put forward by Dr E A French (this issue) for separating the (resheathed) needle from the syringe and disposing of the syringe in a contaminated waste bag should be given some weight. We believe that these and related issues will not simply go away through the arbitrary use of directives; we hope that someone will organise a comparative trial in two similar NHS districts, one of which introduces an official policy of safe resheathing and the other a policy of safe nonresheathing; accurate data on resheathing and on injury rates at all stages should be collected prospectively. The issue should be resolved by science rather than stridor. D C ANDERSON
Department of Medicine L GANGULI
Department of Medical Microbiology, University of Manchester, Hope Hospital, Salford M6 8HD
JPACKER Department of Public Health Medicine, Salford Health Authority, Eccles M30 ONJ I Anderson DC, Blower AL, Packer JMV, Ganguli LA. Preventing needlestick injuries. B.MJ 1991;302:769-70. (30 March.) 2 Jagger J, Hunt EH, Brand-Elnaggar J, P'earson RD. Rates of needlestick injuryr caused by various devices in a university hospital. N EnglJ7 Med 1988;319:284-8. 3 Correspondence. Preventing needlestick injuries. B3MJ 1991; 302:1079 (4 May), 1147 (11 May), 1336-7 (1 June), 1602-3 (29 June);303:419,(17 August). 4 Jagger J, Hunt EH, Pearson JD. Recapping used needles: is it worse than the alternative?)J Infect Dis 1990;162:784-5.
Surgeons who undertake surgery for colorectal cancer SIR,-Messrs C S McArdle and D Hole presented data on postoperative mortality of patients with colorectal cancer. They concluded that there were "significant variations in patient outcome among surgeons" and that such "differences compromised survival."' We are not convinced that their data and statistical analysis provide sufficient evidence for their conclusion for several reasons. Firstly, no overall assessment was made of the significance of the differences among surgeons in their patients' outcome. The authors' table I shows that postoperative mortality ranged from 8% to 30% (important enough for the authors to mention in their summary). However, a x2 test for heterogeneity2 does not give a significant result (x2= 14: df= 12: p>025). These rates are unadjusted, but we doubt whether adjusting them would greatly reduce their variation: it did not do so for the hazard rate ratios in the authors' table VII. Secondly, no allowance seems to have been made for the lack of independence and multiple significance testing inherent in the 52 comparisons
419
