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Copyright 2025 - Integrated Care Services Association

Hand-held devices (CardioChek®, Mission®) to smart phones (elemark™, 1drop™) for self-testing of blood cholesterol - J Bolodeoku MBBS, MSc, MBA, DPhil, FRCPath, FRSB

Self-monitoring or testing of blood cholesterol (SMBC) using hand-held devices or smartphones will be helpful in a number of distinct ways:

  • Helping both the patient and clinician in being able to ascertain high or low levels of cholesterol and thereby make the necessary therapeutic adjustments.
  • Providing the patients with the chance to more routinely detect or confirm whether their cholesterol levels are decreasing or increasing, without having to visit the lipid clinics.
  • Allowing clinicians to track and monitor patients’ cholesterol levels remotely
  • The SMBC devices will also provide patient education and disease management information in providing trends of their cholesterol and uric acid profiles and help motivate the patients.

There is a need for more real-world experience in the use of these devices in the management of these patients in the primary and outpatient settings to fully understand the true benefit and impact these devices in the management of patients undergoing therapeutic intervention. As self-monitoring of blood glucose is routine in the management of patients with diabetes mellitus, hopefully, self-monitoring of blood lipids will become routine in the management of patients undergoing treatment and monitoring of their lipid profiles.

Hand-Held devices (CardioChek® and Mission®)

Devices for measuring cholesterol for self-monitoring blood cholesterol devices such as the Mission®, BeneCheck™ Plus, CardioChek® PA, Veri-Q, 3in1 are on the market. They measure a number of lipid fractions (total cholesterol, triglycerides, high density lipoprotein, low density lipoprotein) and ratios on whole blood, plasma or serum collected from the finger or venous blood using reflectance or biosensor technology with single-use, disposable, dry reagent test strips, rotors or cassettes.

Hand-Held devices - Precision, accuracy, comparison, and biological variation

The precision (within and within-run precision) for the CardioCheK® PA, was 3.7% for total cholesterol and 6.2% for HDL-C for level 1 concentration and 3.6% for TC and 3.5% for HDL-C for level 2 concentration1. An evaluation by the UK NHS Purchasing and Supply Agency of the CardioChek® PA, showed for TC an imprecision of 12%, for HDL-cholesterol 22% and for TG 14%2. In a recent study, the precision of the CardioChek® PA was 5.4 – 8.3% for TC, 3.4% – 5.5% for HDL-C, 9.4% – 14.0% for LDL-cholesterol3. These values are marginally higher than the Cholesterol Reference Method Laboratory (CRMLN) cholesterol certification criteria for total cholesterol (TC) is < or = 3%, for and high density lipoprotein-cholesterol (HDL-C) is < or = 4% and for and low density lipoprotein-cholesterol (LDL-C) < or = 4% and HDL-C < or = 4% and the National Cholesterol Education Programme (NCEP) recommended precision performance criteria for laboratory TC is < or = 3% and HDL-C < or = 6%4,5.

Figure 1. Showing Mission® and CardioChek® hand-held devices for self-testing cholesterol.

The within person day to day variation in a healthy volunteer was assessed using the CardioChek®, for total cholesterol 9.4%, for triglyceride 23%, for HDL-cholesterol 7.0% and for LDL-cholesterol 14%6. The results were consistent with lipid concentrations described in the literature for healthy volunteers showing CV% ranges for total cholesterol of 2.5% - 10.9%, for HDL-cholesterol is 3.6% - 12.4%, for LDL-cholesterol 7.8% - 13.6% and for triglyceride 12.9% - 40.8%7-10.

When the CardioChek® PA was directly compared to a laboratory method using venous samples to determine device accuracy, the conclusion was that the device produced clinically equivalent values when compared to the same patients’ samples analysed in a reference laboratory and operated within industry accuracy standards1.

A comparative study was carried out to compare the lipid profile (total cholesterol, HDL-cholesterol and triglycerides) estimation between the Mission® ACON and CardioChek® PA, two cholesterol self-testing devices using finger prick (capillary) samples. Sixteen paired capillary blood samples were collected into microvettes (system for capillary blood collection) and the blood sample was pipetted using capillary transfer tubes and applied to the test devices on the Mission® ACON and CardioChek® PA devices respectively. The total cholesterol values estimated using the Mission® ACON device were generally higher than the values with CardioChek® PA ranging from -0.3 to + 10.0 mmol/L, with an average of +4.50 mmol/L. The HDL-cholesterol values estimated using the Mission® device were mostly higher than the values with CardioChek® PA ranging from - 3.1 to + 7.7 mmol/L, with an average of +1.12 mmol/L. The triglyceride values estimated using the Mission® device were mostly lower than the values with CardioChek® PA usually ranging from -19.6 to + 6.5 mmol/L, with an average of -0.2 mmol/L. In conclusion both the Mission® ACON and the CardioChek® PA lipid testing devices were easy to use and required a similar amount of blood. The analysis times were similar, and the total cholesterol and HDL-cholesterol estimates of the Mission® ACON device were, on average, 17% and 4% higher than the estimates from the CardioChek® PA. Whilst the triglycerides of the Mission® ACON device were on average 17% lower than the CardioChek® PA11.

Smart Phones (elemark™ and 1 drop)

Smart phones with their technological features (such as high-quality cameras, connectivity, and computational power) have increasingly led to their integration into a wide range of analytical sensing systems. Detection via smartphone is commonly based on various forms of optical measurements – including bright-field, colorimetric, luminescence, and/or fluorescence. The high resolution of the embedded complementary metal oxide semiconductor image sensor cameras enables high pixel density for optical monitoring, while the high computational power facilitates real-time image analysis because smart phone-based PoC platforms have been extensively reviewed in the past few years12.

elemark™

The elemark™ lipid check is a smart phone-based in vitro diagnostic device for rapid self-testing of lipid parameters. The elemark™ system includes the elemark™ analyser and the SD LipidoCare™ lipid test strip (figure 2)13.

Figure 2. Device components. (A) elemark™, (B) elemark™ lipid check, (C) elemark™ lipid check cholesterol test strip, (D) connection of the elemark™ lipid check to a compatible mobile device in the shown direction, (E) button is pushed to lock the elemark™ lipid check.

There was very high correlation for TC, HDL-cholesterol and TG results from the elemark™ device with those of laboratory method using the AU5800 Analyzer (Beckman Coulter Inc., IN, USA)13.

The precision of the elemark™ determined was 3.0% – 5.3% for TC, 4.3% – 6.2% for HDL-C and 5.5% – 14.4% for LDL-cholesterol3. These values were marginally higher that the Cholesterol Reference Method Laboratory (CRMLN) cholesterol certification criteria for total cholesterol (TC) is < or = 3%, for and high density lipoprotein-cholesterol (HDL-C) is < or = 4% and for and low density lipoprotein-cholesterol (LDL-C) < or = 4% and HDL-C < or = 4% and the National Cholesterol Education Programme (NCEP) recommended precision performance criteria for laboratory TC is < or = 3% and HDL-C < or = 6%4,5.

The within person day to day variation in a healthy volunteer was assessed using the elemark™ and its CV% fell within the CV% described in the literature: with a total cholesterol 5.0%, HDL-cholesterol 13%, LDL-cholesterol 13% and triglyceride 30%6. Consistent with lipid concentrations described in the literature for healthy volunteers showing CV% ranges for total cholesterol of 2.5% - 10.9%, for HDL-cholesterol is 3.6% - 12.4%, for LDL-cholesterol 7.8% - 13.6% and for triglyceride 12.9% - 40.8%7-10.

1drop™

1drop™ is an in-vitro diagnostic medical device that utilises the camera/flash function on a smartphone to measure different biomarkers of the body. With single membrane technology, plasma separation and enzyme reactions taking place simultaneously, so even just a small drop of blood can give a deep insight into one’s health. This device is paired with a smartphone app, allowing users to constantly check their results as well as explore measurements of newly added biomarkers.

Figure 3. Figure showing photograph Galaxy J3 with the specially designed smartphone cover and membrane containing dried reagents (1drop™ TC total cholesterol test cartridge)

Recently, we evaluated the performance (intra-individual variation, intra-assay precision and comparative data) of the 1drop™ smart phone in measuring total cholesterol. 1 drop™ Smartphone is a smart phone (figure 1) used to determine total cholesterol. In this pilot study, on a healthy volunteer, the 1 drop™ demonstrated a within in person variation CV% of total cholesterol of 7.3% and an intra-assay precision of 6%14. These values were marginally higher that the Cholesterol Reference Method Laboratory (CRMLN) cholesterol certification criteria for total cholesterol (TC) is < or = 3%, for and high density lipoprotein-cholesterol (HDL-C) is < or = 4% and for low density lipoprotein-cholesterol (LDL-C) < or = 4% and HDL-C < or = 4% and the National Cholesterol Education Programme (NCEP) recommended precision performance criteria for laboratory TC is < or = 3% and HDL-C < or = 6%4,5.

In the comparative study, the total cholesterol estimates of the 1 drop™ device were on average 6%, 13% and 23% more than the total cholesterol estimates of the Mission®, Prima 3in1 and CardioChek®, respectively14.

More recently, we estimated total cholesterol in 48 healthy blood donors using their finger prick (capillary samples). The estimated total cholesterol ranged between 2.8 – 8.9 mmol/L, with a mean of 4.8 mmol/L (data on file). This data was comparable to data seen in a normal population normal cholesterol range of 2.75 – 7.59 mmol/L, with a mean of 4.87 mmol/L (see figure 4). In addition, the intra-assay precision for total cholesterol determined was 5.9% (data on file). This value was marginally higher that the Cholesterol Reference Method Laboratory (CRMLN) cholesterol certification criteria for total cholesterol (TC) which is < or = 3%3,4

Figure 4. Showing histogram of total cholesterol estimated using traditional analyser method (upper half) and using 1 drop™ smart phone (lower half)

In conclusion, both the hand-held devices (Mission® and CardioChek®) and the smart phones (elemark™ and 1drop™) self-monitoring blood cholesterol devices correlate very well with the traditional laboratory cholesterol methods. Even though it appears that both the precision criteria (CRMLN and NCEP) are quite stringent for the portable hand-held and smart phone self-monitoring blood cholesterol devices, as all of the devices exceeded the expected analytical precision for TC of < or = 3%, for HDL-C of < or = 4%/6% and for LDL-C of LDL-C < or = 4%, they have a reasonable precision profile and they can be used very well by patients.

Real Life Usage

In the management of patients with hyperlipidaemia, it is the normal practice that after initiating pharmacological interventions such as statins, fibrates, bile acid sequestrants and more recently, PCSK9 inhibitors, the patients are expected to have a follow up laboratory test done at some appropriate time point. Patients will usually have these blood tests done at the local hospital laboratory or General Practice (GP) who would have the blood sample sent to the local hospital laboratory prior to their visit in order to have the cholesterol estimations ready for their out-patient visit. This way of conducting blood cholesterol measurements is not optimum as most clinicians are usually making a judgement call on one blood lipid profile estimation when the more optimum procedure will be to make the call after a review of more than one lipid profile. This would require the patient to attend the local hospital laboratory or General Practice (GP) at least more than once (route A in figure 1), this could be quite a bother to patients and therefore the question is, can portable hand-held self-monitoring of blood cholesterol (SMBC) (route B in figure 1) be of benefit in the management of these patients?

In a randomised study, investigating the value of home monitoring of lipids, one group of patients received the hand-held device (CardioChek® PA) and measured and reported their lipid levels for 6 months using a phone call (B), whilst the other group had their lipid levels measured in the usual way in the traditional laboratory setting (A).

The results showed that mean LDL-C decreased from 186 mg/dL (4.8 mmol/L) to 117 mg/dL (3.0 mmol/L) in the usual care group (A), whilst a similar reduction of LDL-C decrease from 162 mg/dL (4.2 mmol/L) to 105 mg/dL (2.7 mmol/L) was observed in the patients using the home monitoring (B), there was no significant difference between the mean changes. In addition, there was also no significant difference between the two groups with regards to mean changes in HDL-C and triglycerides15.

This review highlights that with the hand-held devices and smart phones that estimate total cholesterol, using the precision criteria (CRMLN and NCEP) for total cholesterol of < or = 3%, have a reasonable precision ranging between 3.0% - 7.3%. The estimates compared and correlated very well with the traditional laboratory cholesterol methods. Furthermore, they have been used in a home monitoring setting and compared well with the estimates obtained in the usual care in the traditional laboratory setting. More studies are required to demonstrate the benefit of self-testing of cholesterol in patients using these hand-held and smart phone devices.

References:

  1. Whitehead SJ, Ford C, Gama Rousseau. A combined laboratory and field evaluation of the Cholestech LDX and CardioChek® PA point of care testing lipid and glucose analysers. Ann Clin Biochem 2013; 51 (1) : 54–67
  2. Centre for Evidence Based Purchasing. CEO catalogue search. London. Department of Health http://www.healthcheck.nhs.uk/document.php?o=11
  3. Bolodeoku J, Pinkney S, Imprecision evaluation of self-monitoring of blood cholesterol (SMBC) handheld point of care testing devices: elemark™ and CardioChek® PA. Ann Clin Lab Res Vol. 7 No. 1: 290
  4. National Cholesterol Education Program Laboratory Standardization Panel. Current status of blood cholesterol measurement in clinical laboratories in the US. Clin Chem 1988; 34: 193-201
  5. National Cholesterol Education Program Laboratory Standardization Panel. Recommendations for measurement of high-density lipoprotein cholesterol; executive summary. Clin Chem 1995; 41 : 1427-1433
  6. Bolodeoku J. Biological Variation of Self-Monitoring of Blood Cholesterol (SMBC) Using Portable Handheld Point of Care Testing Devices: 3in1, Cardio Chek PA and Elemark™. Curr Trends Med Diagn Meth 2018: CTMDM-106. DOI: 10.29011/ CTMDM-106.100006
  7. Hammond J, Wentz P, Statland BE, Phillips JC, Winkel P. Daily variation of lipids and hormones in sera of healthy subjects. Clinica Chimica Acta 1976; 73 (2) : 347 – 352
  8. Demacker PNM, Schade RWB, Jansen RTP, Laar AV. Intra-individual variation of serum cholesterol triglycerides and high-density lipoprotein cholesterol in normal humans. Atherosclerosis 1982; 45 (3) : 259 – 266
  9. Gidding SS, Stone NJ, Bookstein LC, Laskarzewski PM, Stein EA. Month to month variability of lipids, lipoproteins and apolipoproteins and the impact of acute infection in adolescents. The Journal of Pediatrics 1998; 133 (2) : 242 – 246
  10. Bookstein L, Gidding SS, Donovan M, Smith FA. Day to day variability of serum cholesterol, triglyceride and high-density lipoprotein cholesterol levels. Arch Intern Med 1990; 150 (8) : 1653 – 1657
  11. Clark S, Bolodeoku J. Self-cholesterol measuring devices Mission® and CardioChek®: total cholesterol, triglycerides. High density lipoprotein (HDL) – cholesterol estimations in whole blood samples. Biomed J Sci & Tech Res 35 (4) – 2021. BJSTR.MS.ID.005735
  12. Arumugam S, Colburn DAM, Sia SK. Biosensors for Personal Mobile Health: A System Architecture Perspective. Adv Mater Technol. 2020 Mar;5(3):1900720. doi: 10.1002/admt.201900720. Epub 2019 Nov 20. PMID: 33043127; PMCID: PMC7546526.
  13. Yun K, Lee J, Choi J, Song I-U, Chung Y-A. Smartphone based point of care lipid blood test performance evaluation compared with a clinical diagnostic laboratory method. Appl Sci. 2019, 9, 334; doi:103390/app9163334
  14. Bolodeoku J, Clark S, Anyaeche C. Self-monitoring of blood cholesterol 9SMBC) using the total cholesterol testing cartridge on the 1 drop™ smartphone. Biomed J Sci & Tech Res 29 (2)-2020 BJSTR.MS.ID.004760
  15. Alkouli MA, Carry BJ, Jarrett H, Sirna SJ. Management of hypercholesterolaemia utilizing a home lipid monitoring system; preliminary findings. J Clin Lipid 2013; 7 (3) : 254 – 255

Content provided by John Bolodeoku
MBBS, MSc, MBA, DPhil, FRCPath, FRSB

Address:
Lipid Clinic, Department of Cardiology
Basingstoke & North Hampshire Hospital
Aldermaston Road, Basingstoke
Hampshire, United Kingdom
RG24 9NA
This email address is being protected from spambots. You need JavaScript enabled to view it.

Tel No. +44 7765401135

Physiotherapy in a Chronic Pain Service - Mr Gavin Walsh: Lead Specialist Physiotherapist at the Chelsea and Westminster Hospital

Assessments and treatments for Musculoskeletal pain conditions have traditionally strived to identify structural or movement impairments which can be fixed. Developments in subjective questioning, physical examination and diagnostic investigation have provided great success for the majority of acute injuries and pain. The biomedical model has been the dominant model for many a year and for the most part has provided good value from the National Health service, for those seeking help.

Unfortunately, evidence would inform us that approximately 15-25% of acute pain presentations persist to become a chronic condition; long after tissue healing is complete. Whilst it is important to ensure there is no significant sinister pathology causing the painful symptoms it is often detrimental to keep the treatment focused on fixing a structural problem through passive treatments and multiple diagnostic investigating. As with other long term health conditions (eg diabetes) the focus should shift towards helping people live well with pain in order to positively influence its impact on their lives. Waiting for the pain to stop inevitably leads to more pain and secondary physical and psychological problems. Such as muscle weakness, joint stiffness, weight gain, anxiety, depression and disengagement from important life activities.

We know that people in pain have tried very hard to ‘fix’ their pain problem, often at great time and financial sacrifice. When people attend an interdisciplinary pain service they are offered an alternative Biopsychosocial model of care. The aim of which is to help them begin rebuilding their lives alongside their painful symptoms, utilising expert medical, physical and psychological knowledge.

We start most interventions with education modules. We teach people about the pain system and the difference between acute pain that’s essential and adaptive to keeping us safe, and chronic or persistent pain which is less adaptive and providing too much protection. We explore how other factors such as stress and sleep interact to amplify the pain experience and influence a person’s ability to make steps towards recovery. When people realise that persistent pain is not a sign of new or on going damage and they can be less fearful of the impact it might have then they can start to move and be more active and engaged in their lives despite it.

Helping people to understand the meaning of their symptoms and what the MRI findings mean, relative to findings we see in pain free populations. Helping people to move with confidence and build strength to be a better partner, parent or employee are what an interdisciplinary pain service strives to deliver.

Where can we improve? Appropriate early intervention is paramount. Over reliance on medication and passive medical intervention alone is not working for some pain sufferers. We need to look at optimising the skills and experience of the Allied Health Professions workforce. First contact practitioners with specialist pain experience can help people at the start of their problem not years down the line when chronicity is established. Improved pathways across primary, secondary and tertiary care services to ensure knowledge and expertise is shared across the sector. Investment in support for long term conditions at a community level so that those that need the support can access it over the long term rather than reacting to crisis and flare up situations. Life can be better for Persistent Pain sufferers, if the people and the health system can step towards the Biopsychosocial model of care.

Delivering Physiotherapy during COVID times: Like everybody, physiotherapists have had to be innovative with its response to work force pressures whilst continuing to provide support to the people with persistent pain. The up scaling of video conferencing and telehealth has had its challenges but for the most part the on-going support to people in pain during these difficult times has been invaluable. Face to face and virtual Physiotherapy services have advanced rapidly during COVID and we have to hope the positive changes that have been implemented continue to form part of the future strategy for the management of persistent pain and other long term health conditions. 

Content provided by Mr Gavin Walsh:
Lead Specialist Physiotherapist at the Chelsea and Westminster Hospital

Evolution of Multidisciplinary Services for Chronic Pain - by Dr Bianca Kuehler, Consultant Pain Management

The doctor's role

Multi-disciplinary pain clinics are nothing new. The founding-father of pain management Dr John Bonica who devoted his career to the study of pain, believed in a team approach, incorporating various specialties to treat acute and chronic pain. Therefore the first pain multi-disciplinary clinics were already established in the 1950s.

In July 2020 the International Association for the Study of Pain published a revised definition of pain. The definition is: ‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” This definition and the original one from 1964 make it clear why it is so important to address the management of chronic and even acute pain from a multidisciplinary approach, taking into consideration the underlying medical condition and the complexity of each patient’s emotional condition, cultural background, previous treatments and genetic components.

Unfortunately, even in today’s multidisciplinary pain clinics, the biological/medical model delivered by medical doctors often comes first and when all the medical interventions and treatments are not successful a referral to the psychologist and physiotherapists is made. This linear model, with the patient being handed down the line, starting with the doctor and ending with therapies, does not always benefit the patients maximally. Ideally, the patient meets or gets input from the entire treatment team (doctor, physiotherapist psychologist and nurses) right from the start and a treatment plan should be formulated together.

Sometimes the best developments happen during the most difficult times and due to the COVID-19 situation we found ourselves with a huge back-log of patients. Two thirds of the doctors were deployed elsewhere. Despite these difficulties we tried to keep our service running and called most scheduled patients independent of our usual speciality. Afterwards all the patients and pathways were discussed with the team and a treatment plan was developed. We found that this actually improved patient care and now we do continue with this model.

Currently we call about ten to twelve patients in such a remote assessment MDT clinic between four clinicians (nurse, doctor, physiotherapist and psychologist) and afterwards we discuss each plan and pathway. We will need to audit this clinic but so far the patients have a quicker access to pain management programmes, injections or mediation reviews. Some patients get followed up (this usually will be face to face, but this is really not required for every patient), others can be discharged back to their GP’s with advice and a third group will enter a pain management programme, plus doctor’s advice where needed. We don’t know for sure how the future will look like, but we find these assessment clinics are an ideal solution for these difficult times.

As a doctor, I feel that I have been learning a whole lot and we all benefit from each other’s expertise. This new model of working also increases feedback later on in the treatment of patients, when they usually would not have another appointment with us. I feel we have gone from a linear model to a completely rounded one.

 

Content provided by Dr Bianca Kuehler,
Consultant Pain Management
Specialist Doctor in Pain at Chelsea and Westminster Hospital

Off the Cuff politics - Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth)

Young as I like to think I am, I can still remember the days when hospitals had a subliminal military style discipline and a real sense of order. As soon as you walked onto the wards of a London teaching hospital, it became obvious that you had entered another world. Doctors and nurses occupied much more distinctive territory than they do today. In those dim and distant, pre-smart phone days your average clinician wouldn’t think about turning up on a ward round without a stethoscope and his regimental white coat.

Those days have gone. Somewhere in the late noughties, the government decided that white coats should become a thing of the past and that the future would be much better for it. I’m still not convinced they were right.

In the aftermath of this minor but momentous decision, standards of dress plummeted for junior doctors everywhere. Even at the time, a number of colleagues considered the decision a deliberate attempt to de-professionalise doctors but the official motivation had been something else: bacterial infection.

Ties and white coats were deemed a vector for unscrupulous bacteria and it was suggested that patients were being infected by white coat bourne spores. With hindsight, the actual evidence for this theory was tenous to say the least but I think that the people who suffered the most from it were the patients.

A lot of patients aren’t particularly young. Nor are they entirely with it. The elderly pick up on visual cues and the sight of a man in dark suit accompanied by a woman in navy blue and a younger doctor in a white coat was an easy image to get a grip on. It doesn’t really matter if you can’t remember a name or a face. The patients understood the hierarchy and they knew which opinion was the single most significant. The uniforms said it all and when a friend or relative visited the ward and wanted to know who to speak to, they could usually spot a doctor from a maintenance engineer quite easily. I remember as a junior doctor myself a neurosurgical patient passed this disparaging verdict on one of our then consultants: “he looked like someone who had come to do the gardening.” As I remember it, he was a good technician but even today, a lot of patients are looking for something more than that.
There are a lot of people walking up and down the corridor in a typical hospital ward and it’s a lot harder to figure out who is who than it used to be. Some microbiologists have openly stated that the infection risk associated with traditional dress codes has been wildly exaggerated.

There is no evidence that the white coat is a vehicle for the spread of infection, said Stephanie Dancer, a microbiologist at Hairmyres Hospital in East Kilbride. In contrast, “hand-touch contact, airborne delivery, environmental reservoirs, and human carriage are all implicated in transmission”.

In reality, The white coat has been a symbol of the medical profession since it was borrowed from laboratory workers in the mid-19th century. It was widely believed that the colour white would link the profession to such worthy concepts as purity and cleanliness. Many physicians have pointed out that no study has conclusively linked white coats with the spread of infection to patients. Recent evidence has shown that the bacterial load on coat sleeves is equivalent to that found on surgical scrub sleeves after 8 hours of hospital duties. In spite of this, it remains the recommendation of the NHS that healthcare workers should have a dress code of bare-below-elbows outfits. It would have been better to have a trial of the altered dress code for several years before insisting that it should be imposed nationally. By comparing the performance of different units with the old and the new we could have made a more objective judgment as to how best to proceed with modern medicine. No such work was ever done.

Remember that these machinations have implications that go far beyond the risk of bacterial infection. Something more than a mere aesthetic has been lost. The boundaries between clinician and managerial authority have been changed and neither the profession or the public have the same sense of confidence in who knows what or how things should be done.

Content provided by Steven Cutts BSc Hons, MBBS, FRCS (Tr & Orth)
Medical Consultant, Orthopaedics and Trauma Surgery, James Paget, University Hospitals,
NHS Foundation Trust

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