Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine.

This pilot study found that a future RCT to investigate the effect of using the SAS in a decisive approach may demonstrate a difference in postoperative care. However, significant changes to the design are needed if differences in clinical outcome are to be achieved reliably. These would include a wider array of postoperative interventions implemented using a quality improvement approach in a stepped wedge cluster design with blinded collection of outcome data.

Idiopathic neck and chest wall flushing could cause disabling effects on patients' quality of life. We aimed to evaluate the effectiveness of botulinum toxin-A (BTA) in the management of idiopathic neck and chest wall flushing. This was a pilot prospective clinical study of patients with severe idiopathic neck and anterior chest wall flushing. Two mouse units of BTA were injected intracutaneously with a maximum dose of 100 units per patient per session. The dermatology life quality index is used as the primary outcome measure. Twenty-two patients were included in the study (18 women, four men) with an average age of 26 years (range 18-48). Twenty patients (90.9%) had immediate improvement with almost complete resolution of their flushing. At four weeks follow-up, 18 of 22 patients were included in the final analysis, significant improvement in quality of life was achieved, and mean baseline dermatology life quality index score 7.78 (SD 3.25) improved significantly to 4.23 (SD 3.44) with a mean difference of 3.56 (SD 4.6; 95%, confidence interval 1.27, 5.84) with paired samples t-test 3.29 (d.f. 17) P < 0.004. BTA may provide an effective treatment in the management of idiopathic neck and chest wall flushing.

The rarity and variable presentation of primary hyperparathyroidism can make its diagnosis a challenge - especially in the developing world where malnutrition may mask hypercalcaemia. Our case report is of a 25-year-old Yemeni woman who presented at AL Buraihi General Hospital with a pathological fracture of the right femur and a past history of multiple limb fractures. The diagnosis of primary hyperparathyroidism was suspected after full history and examination. It was then confirmed biochemically by raised PTH and serum calcium levels, and radiologically by ultrasonography of the patient's neck, which demonstrated a right inferior parathyroid adenoma. The patient underwent open reduction and internal fixation of her right femoral fracture but suffered a fracture of her left femur which was treated conservatively so as not to delay parathyroidectomy. Post-operatively, the patient suffered from transient hypocalcaemia, which was treated medically, and eventually went on to make a full recovery.