179 Improving Operative Notes in Upper GI Surgery: An Innovative QI Project Utilising Existing Electronic Hospital Systems

Introduction

Operative notes play a valuable role in ensuring that surgical patients receive consistent and adequate care. There are many inherent difficulties affecting their quality. We performed a QI project to improve surgical operative notes at our centre.

Method

A questionnaire assessing subjective quality of operative notes was sent to all foundation doctors delivering post-operative care. Compliance to each inclusion recommendation in the RCS guidelines was analysed. A standardised template for operative notes was incorporated into the hospital’s electronic records system, compliance was then reassessed.

Results

Questionnaire responses (16) were better for typed vs hand-written notes in all domains: ease of accessing notes, following intra-operative steps, following post-operative plans and frequency of asking for additional information regarding plans. After implementation of the template, mean compliance across 19 RCS parameters improved from 69% (55 operations) to 89% (46 operations). Number of parameters with 100% compliance improved from 2/19 to 8/19. Compliance increased in 14/19 parameters, there was no change in 2/19 (already 100%) and a reduction was seen in 3/19.

Conclusions

Results from our analysis and questionnaire showed that typed notes were favourable when compared to hand-written. The introduction of a standardised electronic template, without investment in new software, improved compliance to RCS guidelines.

Diagnostic value of high-resolution MR imaging in giant cell arteritis

BACKGROUND AND PURPOSE

Clinical indications of giant cell arteritis may be unspecific, and noninvasive diagnosis is often difficult. This study investigated the hypothesis that high-resolution MR imaging of the superficial cranial arteries is a noninvasive imaging technique that can detect the occurrence of giant cell arteritis.

MATERIALS AND METHODS

Contrast-enhanced, high-resolution MR imaging was performed on 64 consecutive patients with suspected giant cell arteritis. Mural thickness, lumen diameter, and a mural contrast enhancement score were assessed with T1-weighted spin-echo images with submillimeter in-plane spatial resolution. The final rheumatologist's diagnosis according to the clinical criteria of the American College of Rheumatology including laboratory tests and results of temporal artery biopsies from 32 patients was used as a "gold standard" for the evaluation of the MR imaging findings.

RESULTS

All of the examinations provided diagnostic image quality. Evaluation of the mural inflammatory MR imaging signs for diagnosing vasculitis resulted in a sensitivity of 80.6% and a specificity of 97.0%. In comparison, histology results alone showed a sensitivity of 77.8% and specificity of 100%. The mean wall thickness increased significantly from 0.39 mm (+/-0.18 mm) to 0.74 mm (+/-0.32 mm; P < .001), and the lumen diameter decreased significantly from 0.84 mm (+/-0.29 mm) to 0.65 mm (+/-0.38 mm; P < .05) for patients with giant cell arteritis.

CONCLUSION

Contrast-enhanced, high-resolution MR imaging allows noninvasive assessment of mural inflammation in giant cell arteritis with good diagnostic certainty. Measures of mural thickening and contrast enhancement can be obtained in these small vessels and provide valuable vasculitic MR imaging findings.

Epstein-Barr virus in squamous carcinoma of the anterior nasal cavity

Squamous carcinoma is the most common malignancy of the head and neck, but it rarely occurs in the nasal vestibule. Epstein-Barr virus (EBV) has been detected in and is causally linked to various head and neck tumors, particularly nasopharyngeal carcinoma. The possible role of EBV in squamous carcinoma of the anterior nasal cavity, particularly of the nasal vestibule, has not been previously investigated. Histologic sections from 17 patients with nasal vestibular squamous carcinoma were examined. Material for EBV detection by immunohistochemistry and by in situ hybridization was available in 15 of the 17 cases. The study group consisted of eight men and nine women ranging in age from 40 to 82 years (mean age, 64 years). None of the patients was of Asian descent. The squamous carcinomas were graded as well differentiated (one case), moderately differentiated (11 cases), and poorly differentiated (five cases). Fourteen patients were smokers; the history of smoking ranged from 20 to 60 pack-years. Treatment modalities included surgical resection, radiation, chemotherapy, or a combined approach. The clinical follow-up periods ranged from 7 months to 16 years. Three patients developed metastases, one of whom died of disease after 1 year. Epstein-Barr virus was not detected in any of the 15 of 17 cases tested by either immunohistochemistry or by in situ hybridization. Squamous carcinoma of the nasal vestibule is an uncommon cancer that is not causally related to EBV.

Calcineurin binds the transcription factor NFAT1 and reversibly regulates its activity

NFAT1 (previously termed NFATp) is a cytoplasmic transcription factor involved in the induction of cytokine genes. We have previously shown that the dephosphorylation of NFAT1, accompanied by its nuclear translocation and increased DNA binding activity, is regulated by calcium- and calcineurin-dependent mechanisms, as each of these hallmarks of NFAT1 activation is elicited by ionomycin and blocked by the immunosuppressive drugs cyclosporin A and FK506 (Shaw, K.T.-Y., Ho, A.M., Raghavan, A., Kim, J., Jain, J., Park, J., Sharma, S., Rao, A., and Hogan, P.G. (1995) Proc. Natl. Acad. Sci. U.S.A. 92, 11205-11209). Here we show that the activation state of NFAT1 in T cells is remarkably sensitive to the level of calcineurin activity. Addition of cyclosporin A, even in the presence of ongoing ionomycin stimulation, results in rephosphorylation of NFAT1, its reappearance in the cytoplasm, and a return of its DNA binding activity to low levels. Similar effects are observed upon removal of ionomycin or addition of EGTA. We also demonstrate a direct interaction between calcineurin and NFAT1 that is consistent with a direct enzyme-substrate relation between these two proteins and that may underlie the sensitivity of NFAT1 activation to the level of calcineurin activity. The NFAT1-calcineurin interaction, which involves an N-terminal region of NFAT1 conserved in other NFAT family proteins, may provide a target for the design of novel immunosuppressive drugs.

Success rates in psychiatry and neurology certification examinations

The authors traced the progress of a sample of 200 psychiatrists and 150 neurologists on the ABPN examination. Overall success rates were high-64% of psychiatrists and 75% of neurologists became Board-certified. Performance on the written exam was a significant predictor of outcome for both groups-88% of psychiatrists and 94% of neurologists who passed Part I on their first try eventually obtained certification. Given the criticism that has been directed toward the oral exam, it was interesting that only 10% of psychiatrists and 5% of neurologists failed to become diplomates because of difficulties with Part II. Future research will deal with the validity and reliability of the oral exam.