***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias A prospect i ve r and omised trial was carried out to compare the efficacy of method of scrubbing the operative site for ten minutes with an antiseptic  ( GpA ; n = 68 ) with a simplified method where the antiseptic was merely painted onto the operation site  ( GpB ; n = 67 ) . The median age , sex distribution and the types of procedures done in each group were similar as was the antibiotic policy . There were a total of 11 patients who got infected , 6 in the group A and 5 in the group B. No significant difference could be demonstrated in the infection rates between the two groups . It is concluded that the old method of prolonged scrubbing the operation site can safely be omitted to a more simplified version The purpose of this study was to compare a traditional two-step method of preoperative skin preparation using aqueous iodophors with a one-step method using an iodophor-in-alcohol solution .  Sixty patients having clean total joint surgery were r and omly divided into two preoperative skin preparation groups ( 30 in each ) . In one group , the skin was prepared with a traditional five-minute aqueous iodophor scrub followed by the application of an aqueous iodophor solution as a paint . In the other group , the skin was prepared with a one-step application of a water-insoluble iodophor-in-alcohol solution applied as a paint . Bacterial colony counts were made by sampling the incision area with culture plates before skin preparation and just prior to wound closure . The one-step application of a water-insoluble iodophor-in-alcohol solution was equally as effective as the traditional scrub- and -paint preparation in reducing the number of bacteria about the operative site . The water-insoluble preparation also result ed in significantly improved drape adhesion as compared to the st and ard scrub- and -paint procedure . The one-step water-insoluble iodophor-in-alcohol solution fulfills the requirements for an operative site skin preparation and significantly improves drape adhesion . It is more convenient , easier to apply , less time consuming , and potentially less expensive than the traditional scrub- and -paint method One hundred one adult orthopedic surgical patients were studied in a r and omized , prospect i ve clinical trial to compare the effectiveness of the st and ard povidone-iodine scrub and paint with povidone-iodine painting alone for presurgical skin preparation . No infections occurred in either group . The scrub-plus-paint group showed a 0.601 logarithmic reduction in bacteria counts , compared with 0.622 with painting alone . Further , 36.8 % of the patients in the scrub-plus-paint group had skin counts that actually increased after preparation , compared with 13.8 % of patients in the paint-only group . The preparation bacterial counts among in patients , who received preoperative hexachlorophene showers , were significantly lower than that of out patients , who did not receive preoperative showers . The data support the use of the preoperative hexachlorophene shower and the omission of scrubbing from the surgical skin preparation technique An effective presurgical preparation is an important step in limiting surgical wound contamination and preventing infection . The purpose of this study was to evaluate residual bacterial skin contamination after surgical skin preparation in foot and ankle surgery to determine if current techniques are satisfactory in eliminating harmful pathogens . Fifty consecutive patients having surgical procedures of the foot and ankle were studied . Each lower extremity was prepared r and omly with either a one-step povidone-iodine topical gel or a two-step iodophor scrub followed by a povidone-iodine paint . After preparation and draping , cultures were obtained at three locations : the hallux nailfold , web space between the second and third , and fourth and fifth toes , and the anterior ankle ( control ) . In the gel group , positive cultures were obtained from 76 % of halluces , 68 % of toes , and 16 % of controls . In the scrub and paint group , positive cultures were obtained from 84 % of halluces , 76 % of toes , and 28 % of controls . Numerous pathogens were cultured , with Staphylococcus epidermidis being the most prevalent . Based on the findings of the current study , presurgical skin preparation with a povidone-iodine based topical bactericidal agent is not sufficient in eliminating pathogens in foot and ankle surgery . The unique environment of the foot and its resident organisms may play a role in the higher infection rates associated with surgery of the foot and ankle BACKGROUND Antiseptic preoperative skin site preparation is used to prepare the operative site before making a surgical incision . The goal of this preparation is a reduction in postoperative wound infection . The most straightforward technique necessary to achieve this goal remains controversial . STUDY DESIGN A prospect i ve r and omized trial was design ed to prove equivalency for two commonly used techniques of surgical skin site preparation . Two hundred thirty-four patients undergoing nonlaparoscopic abdominal operations were consented for the trial . Exclusion criteria included presence of active infection at the time of operation , neutropenia , history of skin reaction to iodine , or anticipated insertion of prosthetic material at the time of operation . Patients were r and omized to receive either a vigorous 5-minute scrub with povidone-iodine soap , followed by absorption with a sterile towel , and a paint with aqueous povidone-iodine or surgical site preparation with a povidone-iodine paint only . The primary end point of the study was wound infection rate at 30 days , defined as presence of clinical signs of infection requiring therapeutic intervention . RESULTS Patients r and omized to the scrub- and -paint arm ( n = 115 ) and the paint-only arm ( n = 119 ) matched at baseline with respect to age , comorbidity , wound classification , mean operative time , placement of drains , prophylactic antibiotic use , and surgical procedure ( all p > 0.09 ) . Wound infection occurred in 12 ( 10 % ) scrub- and -paint patients , and 12 ( 10 % ) paint-only patients . Based on our predefined equivalency parameters , we conclude equivalence of infection rates between the two preparations . CONCLUSIONS Preoperative preparation of the abdomen with a scrub with povidone-iodine soap followed by a paint with aqueous povidone-iodine can be ab and oned in favor of a paint with aqueous povidone-iodine alone . This change will result in reductions in operative times and costs BACKGROUND Optimal skin disinfection ensures blood safety . In this study , efficacies of the two-step skin disinfection methods used at Canadian Blood Services ( CBS ) and two one-step methods produced by different manufacturers were compared . STUDY DESIGN AND METHODS In each of the three phases of the study , two methods were compared by disinfection of the antecubital fossae of study subjects . The two-step methods were compared in Phase I : Method A ( isopropyl alcohol scrub and iodine tincture ampule ) and Method B ( isopropyl alcohol and chlorhexidine scrub and isopropyl alcohol and chlorhexidine ampule ) . In Phases II and III , Method B was compared to two different one-step swab sticks containing isopropyl alcohol and chlorhexidine ( Methods C and D ) . Contact plates were applied on each of the subjects before and after disinfection and incubated at 37 degrees C for 24 hours followed by colony counting . RESULTS In 99 % of the subjects , colonies per plate were reduced from approximately 60 to less than 10 after disinfection using any method . Method B was superior to Method A ( p < 0.05 ) but was not significantly different from Methods C and D. Method D was implemented for skin disinfection at CBS with no significant effects on blood product contamination . Skin reactions increased from approximately 0.02 % to approximately 0.62 % after implementation , which were subsequently reduced to approximately 0.04 % . CONCLUSION In this study , isopropyl alcohol and chlorhexidine disinfectants were more efficacious than isopropyl alcohol and iodine . There was no difference in efficacy between one-step and two-step procedures or between methods of application . A one-step chlorhexidine and isopropyl alcohol kit has been successfully implemented at CBS Postoperative surgical site infections contribute significantly to increased patient morbidity and mortality rates and unnecessary hospital costs . Effective and efficient preoperative patient skin preparation is an important perioperative nursing intervention that decreases the number of wound contaminants and reduces the risks for postoperative surgical site infections . This study examined the effectiveness and time and material costs of two preoperative patient skin prep methods ( ie ,  isopropyl alcohol prep/iodophor-impregnated adhesive drape method , iodophor scrub and paint prep/plain adhesive drape method )  . The isopropyl alcohol prep/iodophor-impregnated adhesive drape method clinical ly was as effective as the iodophor scrub and paint prep/plain adhesive drape method , more cost-effective when time and material s were compared , and less cost-effective when material s alone were compared . To make appropriate decisions about the use of preoperative patient skin prep methods , perioperative nurse managers and staff members need to examine and determine whether costs in time or material s have the greater impact on their surgical setting OBJECTIVE To compare the effects of different skin preparation solutions on  surgical-site infection rates .  DESIGN Three skin preparations were compared by means of a sequential implementation design . Each agent was adopted as the preferred modality for a 6-month period for all general surgery cases . Period 1 used a povidone-iodine scrub-paint combination ( Betadine ) with an isopropyl alcohol application between these steps , period 2 used 2 % chlorhexidine and 70 % isopropyl alcohol ( ChloraPrep ) , and period 3 used iodine povacrylex in isopropyl alcohol ( DuraPrep ) . Surgical-site infections were tracked for 30 days as part of ongoing data collection for the National Surgical Quality Improvement Project initiative . The primary outcome was the overall rate of surgical-site infection by 6-month period performed in an intent-to-treat manner . SETTING Single large academic medical center . PATIENTS All adult general surgery patients . RESULTS The study comprised 3,209 operations . The lowest infection rate was seen in period 3 , with iodine povacrylex in isopropyl alcohol as the preferred preparation method ( 3.9 % , compared with 6.4 % for period 1 and 7.1 % for period 2 ; P = .002 ) . In subgroup analysis , no difference in outcomes was seen between patients prepared with povidone-iodine scrub-paint and those prepared with iodine povacrylex in isopropyl alcohol , but patients in both these groups had significantly lower surgical-site infection rates , compared with rates for patients prepared with 2 % chlorhexidine and 70 % isopropyl alcohol ( 4.8 % vs 8.2 % ; P = .001 ) . CONCLUSIONS Skin preparation solution is an important factor in the prevention of surgical-site infections .  Iodophor-based compounds may be superior to chlorhexidine for this purpose in general surgery patients BACKGROUND Deep infection following shoulder surgery is a rare but devastating problem . The use of an effective skin-preparation solution may be an important step in preventing infection . The purpose s of the present study were to examine the native bacteria around the shoulder and to determine the efficacy of three different surgical skin-preparation solutions on the eradication of bacteria from the shoulder . METHODS A prospect i ve study was undertaken to evaluate 150 consecutive patients undergoing shoulder surgery at one institution . Each shoulder was prepared with one of three r and omly selected solutions : ChloraPrep ( 2 % chlorhexidine gluconate and 70 % isopropyl alcohol ) , DuraPrep ( 0.7 % iodophor and 74 % isopropyl alcohol ) , or povidone-iodine scrub and paint ( 0.75 % iodine scrub and 1.0 % iodine paint ) . Aerobic and anaerobic cultures were obtained prior to skin preparation for the first twenty patients , to determine the native bacteria around the shoulder , and following skin preparation for all patients . RESULTS Coagulase-negative Staphylococcus and Propionibacterium acnes were the most commonly isolated organisms prior to skin preparation . The overall rate of positive cultures was 31 % in the povidone-iodine group , 19 % in the DuraPrep group , and 7 % in the ChloraPrep group . The positive culture rate for the Chlora 
    Output:
    
No significant differences were observed between scrubbing before painting vs painting alone in terms of surgical site infection or positive skin culture .
It is believed that there is no need to scrub the surgical site if the skin is visibly clean and /or if the patient has had a pre-operative shower