Quality of clinical case note entries: how good are we at achieving set standards?

INTRODUCTION: High quality entries in case notes are becoming increasingly important. Standards exist on what information entries should contain. We have compared case notes from surgical teams at the Royal Glamorgan Hospital with standards based on guidelines from The Royal College of Surgeons of England. PATIENTS AND METHODS: A total of 120 case notes, randomly selected from the department of general surgery, were reviewed. RESULTS: An 80% compliance was achieved in 25/35 standards and 100% was achieved in 6 (patient's name, date, surgeon's name and type of operation on the operation sheet and consent form signed and dated). The following fell short of 80% compliance: PAS number on every page (75%); entries timed (27%); and clinician's name (16%) and designation (27%) printed. Social history was only recorded in 73% of clerkings and family history in 33%. Results of laboratory tests were signed in 65% of notes and radiological tests were signed in 41%. CONCLUSIONS: Healthcare professionals need to be aware of, and comply with, standards. House officers should be given information about standards at departmental induction or during medical training.

Use of perioperative mupirocin to prevent methicillin-resistant Staphylococcus aureus (MRSA) orthopaedic surgical site infections.

We have examined whether topical perioperative prophylaxis can reduce the incidence of methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs). Using a controlled before and after approach on patients from four orthopaedic wards, undergoing orthopaedic surgery involving insertion of metal prostheses and/or fixation, received perioperative prophylaxis with nasal mupirocin for five days, and a shower or bath with 2% (v/v) triclosan before surgery (PPNMT). After introduction of PPNMT there was a marked decrease in incidence of MRSA SSIs (per 1000 operations) from 23 in the six months beforehand (period A) to 3.3 (P<0.001) and 4 (P<0.001) in subsequent consecutive six-month periods (B and C, respectively). Of 11 MRSA SSI cases that occurred during periods B and C, only one had actually received PPNMT, and 10 occurred after acute, as opposed to elective, surgery (P<0.001). Point prevalence nasal MRSA carriage decreased from 38% before PPNMT to 23% immediately after, and 20%, 7%, 10% and 8% (P<0.001) at six-monthly intervals post-intervention. Conversely, the prevalence of nasal MRSA carriage in a control elderly medicine ward did not change significantly. Vancomycin usage, in terms of defined daily doses, declined by 23%. Low-level mupirocin resistance was found in 2.3% of S. aureus isolates from orthopaedic patients before PPNMT, and in 3.9%, 6.1%, 10% and 0% in subsequent six month periods. No S. aureus isolates with high-level mupirocin resistance were found. PPNMT can reduce the incidence of MRSA SSls after orthopaedic surgery, probably by reducing nasal MRSA carriage in the endemic setting, without selecting for mupirocin resistance.

Intraosseous bioabsorbable poly-L-lactic acid screw presenting as a late foreign-body reaction: a case report.

A 17-year-old woman complained of a localized painful swelling in her foot 30 months after internal fixation of a closed tarsometatarsal joint fracture with interfragmentary poly-L-lactic acid screws. Aspiration revealed a sterile abscess. Radiographs displayed an osteolytic lesion corresponding to a screw track in the first tarsometarsal joint. Formation of a draining sinus tract required surgical excision of a small granulomatous lesion. Histologic analysis found deposits of birefringent polymeric particles surrounded by a nonspecific foreign-body type reaction. This represents the first reported case of a draining sinus tract secondary to the use of polylactic acid screw fixation.

Cloning and expression of glycolipid transfer protein from bovine and porcine brain.

Glycolipid transfer protein (GLTP) is a small (23-24 kDa), basic protein (pI congruent with 9.0) that accelerates the intermembrane transfer of various glycolipids. Here, we report the first cloning of cDNAs that encode the bovine and porcine GLTPs. The cDNA open reading frame for bovine GLTP was constructed by bridge-overlapping extension polymerase chain reaction (PCR) after obtaining partial coding cDNA clones by hot start, seminested, and rapid amplification of cDNA ends-PCR. The cDNA open reading frame for porcine GLTP was constructed by reverse transcriptase-PCR. The encoded amino acid sequences in the full-length bovine and porcine cDNAs were identical, consisting of 209 amino acid residues, and were nearly the same as the published sequence determined by Edman degradation. The cDNA encoded one additional amino acid at the N terminus (methionine), arginine at positions 10 and 200 instead of lysine, and threonine at position 65 instead of alanine. Expression of GLTP-cDNA in Escherichia coli using pGEX-6P-1 vector resulted in glutathione S-transferase (GST)-GLTP fusion protein. Regulation of growth and induction conditions led to approximately 50% of expressed fusion protein being soluble and active. Proteolytic cleavage of GST-GLTP fusion protein (bound to GST-Sepharose) and affinity purification resulted in fully active GLTP. Northern blot analyses of bovine tissues showed a single transcript of approximately 2.2 kilobases and the following hierarchy of mRNA levels: cerebrum > kidney > spleen congruent with lung congruent with cerebellum > liver > heart muscle. Reverse transcriptase-PCR analyses of mRNA levels supported the Northern blot results.

Charged membrane surfaces impede the protein-mediated transfer of glycosphingolipids between phospholipid bilayers.

A lipid transfer protein that facilitates the transfer of glycolipids between donor and acceptor membranes has been investigated using a fluorescence resonance energy transfer assay. The glycolipid transfer protein (23-24 kDa, pI 9.0) catalyzes the high specificity transfer of lipids that have sugars beta-linked to either a ceramide or a diacylglycerol backbone, such as simple glycolipids and gangliosides, but not the transfer of phospholipids, cholesterol, or cholesterol esters. In this study, we examined the effect of different charged lipids on the rate of transfer of anthrylvinyl-labeled galactosylceramide (1 mol %) from a donor to acceptor vesicle population at neutral pH. Compared to neutral donor vesicle membranes, introduction of negatively charged lipid at 5 or 10 mol % into the donor vesicles significantly decreased the transfer rate. Introduction of the same amount of negative charge into the acceptor vesicle membrane did not impede the transfer rate as effectively. Also, positive charge in the donor vesicle membrane was not as effective at slowing the transfer rate as was negative charge in the donor vesicle. Increasing the ionic strength of the buffer with NaCl significantly reversed the charge effects. At neutral pH, the transfer protein (pI congruent with 9.0) is expected to be positively charged, which may promote association with the negatively charged donor membrane. Based on these and other experiments, we conclude that the transfer process follows first-order kinetics and that the off-rate of the transfer protein from the donor vesicle surface is the rate-limiting step in the transfer process.

Impact characteristics of two types of police baton.

A comparison study of the American style ASP extendible police baton with the conventional UK police wooden truncheon was performed. It was found that the ASP baton generated approximately twice the contact pressure than the conventional wooden truncheon. A discussion on the medical/legal aspects of the results are given.

Metabolism of furan fatty acids in fish.

In vivo experiments on interconversions of furan fatty acids in fish are described. Administration of 2- or 3-14C-labelled furan fatty acids showed that the heterocycle does not interfere with conversions at the carboxyl group, such as shortening and elongating the chain, or its reduction to alcohol. There was no indication for desaturation of proximal chains, methylation or demethylation of the ring, or changes in the terminal chains. According to these restricted metabolic correlations, the furan fatty acids can be classified in specific structural families of bis-homologs. Distinct parent furan compounds are likely for each of these families. [1-14C]Acetate was incorporated by fish into furan fatty acids. Their chemical oxidation showed that only the resulting dicarboxylic fragments were labelled. They represent the proximal chain including alpha-C of the ring. Label was not found in the monocarboxylic acids which represent terminal chains with alpha'-C, and ring-methyl substituents with beta- and beta'-C. Accordingly, fish do not synthesize from acetate the terminal alkyl chain including the carbons in the cyclic portion of the furan fatty acids.