Documentation Of Signs Research Articles

Signs in Dermatology: Clinical, Dermoscopic, and Histopathological

Abstract Dermatologic diagnosis depends on the careful observation and documentation of signs, which can be highly pathognomonic for a certain condition. Most of the signs appear either de novo or have to be elicited by the physician. It refers to important physical finding or observation made by the physician when examining the patient. In this article, we have included total 154 signs including clinical, dermoscopic, and histopathological signs. We have divided them in 13 groups including signs seen in infectious conditions, vesiculobullous disorders, papulosquamous disorders, dermatitis, connective tissue diseases, and diseases of appendages for the ease of readers.

Association between Serum 25-hydroxyvitamin D Levels and Incidences of Infection in Long-Term Care

Insufficient serum 25-hydroxyvitamin D (25(OH)D) concentrations are associated with increased respiratory tract infections, influenza, and other infectious diseases. As the world deals with the COVID-19 pandemic, the interest of adequate serum levels to reduce the risk of infection has surfaced. This study determined if the number of infections per year are associated with serum 25(OH)D concentrations in long-term care (LTC). Participants (≥ 65 years) in a cross-sectional study were recruited across five LTC communities in Texas. Medical records were used to collect a one-year medical history using double-blind protocols. Blood draws were collected to measure serum 25(OH)D concentrations. Medical records were used to classify infections based upon documentation of signs and symptoms of infection concurrent with either a physician’s note or antibiotic/antiviral medication prescription. Race, BMI, sex, age, and liver and renal disease diagnoses were used as confounders. Of the 177 participants (89% Caucasian, 63% female, mean age 83 years) 69% had ≥1 infection over year and 55% had insufficient serum 25(OH)D concentrations <30 mg/mL (mean 32.6 ng/mL). Linear regression did not show a significant association between serum 25(OH)D concentrations and number of infections (β 0.003; 95% CI -0.014, 0.018; p=0.760). Additionally, insufficient serum concentration did not increase the odds of having an infection (OR 1.02; 95% CI 0.05, -19.34; p=0.987). This study did not show a significant association between infection rates and serum 25(OH)D concentrations. However, further research is needed to determine if vitamin D supplementation could be an effective therapeutic intervention to reduce infection rates, including COVID-19.

Implementation of a Nursing Algorithm for Penicillin Allergy Documentation in the Inpatient Setting

Background: Patients with a penicillin/aminopenicillin (PCN) allergy label are more likely to receive non–β-lactam antibiotics and to experience worse clinical outcomes. Given that nurses are often first to interact with patients, we pilot tested a nurse-driven quality improvement initiative to improve PCN allergy documentation and increase β-lactam use. Methods: We conducted a before-and-after study on a labor and delivery unit at The Johns Hopkins Hospital (JHH) from May 2018 to September 2019. Patients aged 18 years with a PCN allergy were included. The intervention included (1) the use of an algorithm developed by the antimicrobial stewardship team to assist nurses in obtaining accurate PCN allergy histories (Fig. 1), (2) identification of a nurse champion to facilitate implementation of the algorithm, and (3) in-person education by a stewardship physician regarding the importance and impact of adequate PCN allergy documentation on clinical outcomes. Readmissions were counted as separate encounters. The primary outcome was improved allergy documentation (either fewer blank documentations, nonspecified rash reactions, drug intolerance documentations (eg, isolated nausea), documentation of signs and symptoms of anaphylaxis not specified as such). The secondary outcome was β-lactam use. Categorical variables were compared using the 2 test and continuous variables were compared with the Student t test. Severe allergic reactions were defined as anaphylaxis, severe skin reactions (eg, Stevens-Johnson syndrome), and organ involvement (eg, hepatitis). Results: Overall, 382 patient admissions were included, 305 in the preintervention (May 2018 to May 2019) and 77 in the postintervention period (June 2019 to September 2019). Mean age and length-of-stay were 30 years and 4 days, respectively, for both periods. The proportion of admitted patients with a PCN allergy label was 8% and 7% for pre- and postintervention periods. Documentation findings in the pre- and postintervention periods respectively were as follows: blank documentation 11% and 12% (P = .89), documentation of specified rashes 0.6% and 1.3% (P = .56), documentation of drug intolerance 11% and 8% (P = .39), documentation of reactions that were indicative of anaphylaxis but not documented specifically as anaphylaxis 8% and 13% (P = .20). Among patients with a documented PCN allergy who received antibiotics, 83 of 177 (47%) and 27 of 43 (63%) received β-lactams (P = .01) in the pre- and postintervention periods, with cefazolin being the antibiotic most commonly used in both periods. Conclusions: Nursing education and an algorithm did not result in significant improvements in PCN allergy documentation in the 3 months after implementation. More data collection is planned to assess the impact of the intervention.Funding: NoneDisclosures: None

Fears of Submarine Sailors during the Great Patriotic War (with Reference to the Battlefield Diaries of Georgy I. Sennikov)

The purpose of this article is a historical and anthropological examination of the phenomenon of fear, the methods of its manifestation and overcoming in the shadow of war. The authors refer to battlefield and postwar diaries from 1943–1946 of G. I. Sennikov, a submarine sailor of the Northern Fleet, marine electrician of “М-107” and “М-119”. The authors use methods of historiographical and mythopoetic analysis, and the biographic method. In Sennikov’s battlefield diary, the authors observe the sailor’s analytical approach to the problem of fear: his story is not just a documentation and detailed description of the physical signs of horror, but also a classification of the types of fear, exploration of different aspects of a person’s fear at war, and an attempt to get an insight into the essence of this phenomenon. The research reveals that the young sailor perceived the war as a death-defying admission and initiation at the ultimate threshold and is described with the help of archetypical figures: a monster ship, a coffin boat, the sea, etc. The young man who found himself in the extremely harsh wartime conditions identifies such characteristic features of a submarine sailor’s psychology as sailor fatalism, a certain superstitious religiousness (belief in signs, dreams, “marked” spaces and taboos, amulets, and taboo systems). In his diaries, G. I. Sennikov does not only identify superstitious religiousness and ritual activities as the most efficient weapon against fear, but also creativity, laughter, games, and, most significantly, personal values, the authority of commanding officers, and conviction that Soviet submarine sailors fight for the right cause, on the side of the good, saving the world from the horrors of fascism.

Update on structured pain assessment for the documentation of diagnosis-independent symptoms and signs associated with pain.

Concerning the diagnosis and therapy of pain syndromes, standardized descriptions similar to those used in the examination of psychopathological findings via the system produced by the AMDP ("Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie", i. e., the working group establishing standardized methodology and documentation within psychiatry) are still lacking. Therefore, the authors of this article have founded aworking group to establish standardized methodology and documentation for symptoms and signs associated with pain, although not at adiagnosis-specific level, in order to promote standardization in the documentation of pain and rating of the symptoms associated with agiven set of medical results. This article presents asystem for documenting the symptoms and signs associated with pain globally and independently of the diagnosis (Structured Pain Assessment System) with nomenclature that is inspired by the AMDP system. The objective of this working group is to develop documentation for auniform multidimensional pain assessment (with defined terminology) that serves as acomparable and unified standard in the field.

Clinical and radiological signs of importance for the oral physician and oral surgeon

Diagnosis of any disease depends on careful observation and documentation of signs. The careful observation of signs is important for diagnosis of diseases. Almost all major diseases and syndromes have some or other forms of oral manifestations, and many a times these are the first signs and symptoms of the disease or condition. The oral physician is at an advantageous position to detect these changes and diagnose the condition at the earliest, thus improving the overall standard of patient care. Most of the signs give the impression since beginning and some have to be provoked by the examiners. The objective of this review is to highlight the signs manifesting in orofacial area clinically and radiologically and increasing the awareness and knowledge of these entities for use in clinical practice.

Das AMDS-System zur Dokumentation von Schmerzbefunden

The authors present a system for nomenclature and documentation of symptoms and signs associated with pain. The system was compiled in a staged process by the study group for methods and documentation of pain-associated symptoms and signs (Arbeitsgemeinschaft für Methodik und Dokumentation von Schmerzbefunden [AMDS]). The suggested items were elaborated from terms used in current national and international guidelines and classifications and in part integrated into superordinate terms. The items that were built up by this approach aim to reflect the broad spectrum of pain diseases. The items for the description of pain-associated symptoms and signs are divided into the areas of algesiomotor, psychoalgesiological and somatoalgesiological findings. The aim is the documentation of a multidimensional algesiological description of findings with defined terminology, which can serve as a comparable and unified standard, particularly in the field of pain assessment. The AMDS system should enable a systematic description of pain, which is a reliable foundation for diagnostics, therapy planning and expert case evaluation.

Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda

Background: Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.Objective: To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.Methods: Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.Results: Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6–90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03–6.43) and fluids (OR 2.69, 95% CI 1.2–6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21–25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57–8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15–6.41) monitored than those in rural hospitals.Conclusions: Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.

Abstract TP381: What Does It Take? How to Obtain Nursing Buy-in and Compliance of Neurological and Vital Sign Assessments and Re-assessment for the Stroke Patient

Background: Prior to intervention, the average stroke patients’ neurological and vital sign assessments were not completed according to the facility’s clinical practice guidelines. This led to lost interventional opportunities as nurses failed to recognize subtle changes in their patient’s condition. This issue is a common challenge discussed among Stroke Coordinators nationwide. Purpose: To ensure 90% or greater compliance with neurological assessments, vital sign assessments and documentation. To empower nurses to internalize their ability to create a positive outcome for stroke patients. Method: The existing policies and clinical practice guidelines were sound and based on the American Heart Association / American Stroke Association guidelines. Staff education was conducted via the facility intranet, email, newsletters and staff meetings. A goal of 100% attendance of appropriate staff at education session within 30 days was established, conducted and met. Results: The facility established the goal of 90% compliance with frequency of ordered neurological checks and vital signs within 4 months as shown by documentation. In less than one month, due to the nurses’ recognition of their ability to make effective interventions in new onset strokes, the facility achieved 99% compliance. The previous compliance baseline was 57%; by July, we had attained 99% compliance. Conclusion: By providing nursing staff education on their ability to provide timely interventions based off of maintaining ordered vital sign and neuro check frequency, the nurses realized that they could make a difference. With this simple approach, using the hands-on staff and including them in the massive educational campaign, the facility realized a fast change in compliance with policy and protocols. Allowing the nursing staff who actually preformed the activity to have control, accountability and input resulted in quick, effective change with positive patient outcomes. Allowing them to mold their tools gave them empowerment that helped them to internalize satisfaction in their practice. Key words: Interventional opportunities, Empowerment, Internalized, Bedside nurse, Peer accountability, Patient safety

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013.

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

A Simplified Diagnostic Observational Assessment of Autism Spectrum Disorder in Early Childhood.

Subspecialty physicians who have expertise in the diagnosis of autism spectrum disorder typically do not have the resources to administer comprehensive diagnostic observational assessments for patients suspected of ASD. The autism mental status exam (AMSE) is a free and brief eight-item observation tool that addresses this practice gap. The AMSE, designed by Child and Adolescent Psychiatrists, Developmental Behavioral Pediatricians and Pediatric Neurologists structures the observation and documentation of signs and symptoms of ASD and yields a score. Excellent sensitivity and specificity was demonstrated in a population of high-risk adults. This protocol now investigates the AMSE's test performance in a population of 45 young children age 18 months to 5 years with suspected ASD or social and communication concerns who are evaluated at an autism research center. Each subject received a developmental evaluation, including the AMSE, performed by a Child and Adolescent Psychiatrist, that was followed by independent standardized assessment using the Autism Diagnostic Observation Schedule and the Autism Diagnostic Interview-Revised. A Best Estimate Diagnosis protocol used DSM-5 criteria to ascertain a diagnosis of ASD or non-ASD. Receiver operating characteristic curve analysis was used to determine the AMSE cut point with the highest sensitivity and specificity. Findings indicate an optimized sensitivity of 94% and a specificity of 100% for this high prevalence group. Because of its high classification accuracy in this sample of children the AMSE holds promise as a tool that can support both diagnostic decision making and standardize point of care observational assessment of ASD in high risk children.

Eponyms linked to ''signs'' in the dermatology literature

The word “sign” refers to important physical finding or observation made by the physician when examining the patient. Dermatologic diagnosis relies on the careful observation and documentation of signs, which can be highly pathognomonic for a certain conditions. Most of the signs appear either de novo or have to be elicited by the physician [1]. There are important publications which gathered the signs seen in dermatology practice. In addition, Dr Piotr Brzezinski, the Editor – in-Chief of this journal along with other authors had published alphabetical series entitled ‚’DERMATOLOGY EPONYMS – SIGN – LEXICON’’, where they elaborated on the signs seen in dermatology. In this communication, we aimed to highlight on selected eponyms linked to ‚’signs’’ in the dermatology literature, shown in Table I [1-11]. EPONYMS LINKED TO „SIGNS’’ IN THE DERMATOLOGY LITERATURE

Abstract WP287: Screening Venous Ultrasound For Asymptomatic Lower Extremities Deep Venous Thrombosis In Acute Stroke Patients: Will It Change Management Strategies?

INTRODUCTION: Deep venous thromboses in stroke patients are often asymptomatic. There is limited support that screening for asymptomatic lower extremities DVT with venous duplex ultrasound changes clinicians’ management of stroke patients. Hypothesis: We hypothesized that the detection of asymptomatic deep venous thrombosis in acute stroke patients would result in changes or intensification of anticoagulation management strategies. Methods: We performed a retrospective chart review of all strokes (ischemic and hemorrhagic), orthopedic surgery, and trauma patients admitted to our Acute Rehabilitation Unit (ARU) between January 2004 and December 2009. We selected out all stroke patients and recorded those as asymptomatic DVT if there was no documentation of signs or symptoms for DVT by the primary provider within 48 hours prior to obtaining a lower extremity venous ultrasound. A change in anticoagulation management was noted if any addition or change to the patient’s admitting anticoagulation intervention. Results: There were 909 patients admitted to our ARU. Of those patients, 78 patients were diagnosed with an asymptomatic lower extremity DVT prior to transfer to the ARU. Strokes patients accounted for 34 (43.5%) of these 78 patients. All of the stroke patients were under the care of a neurology team. A majority of the lower extremity DVT among the stroke patients were considered acute (N=30;88.2%) and 21% (N=7) had bilateral, acute DVT. Most of the stroke patients received DVT prophylaxis on admission (N=26;76.4%). After diagnosis of an acute DVT, clinicians changed their management strategies in 65% of cases, whereas in 23.5% of cases there were no changes. Among the changes in management, 50% of patients (11/22;50%) were started or had an escalation in anticoagulation treatment. Interrupted venal cava filter was placed in 5 patients and serial venous ultrasound surveillance was used for 7 patients. Conclusions: This study shows that the detection of an acute asymptomatic lower extremity DVT in stroke patients resulted in anticoagulation management strategies changes for most stroke patients. It also supports the need to perform screening venous ultrasound on all acute stroke patients.

The impact of routine cryptococcal antigen screening on survival among HIV‐infected individuals with advanced immunosuppression in Kenya

To test the hypothesis that a screening and treatment intervention for early cryptococcal infection would improve survival among HIV-infected individuals with low CD4 cell counts. Newly enrolled patients at Family AIDS Care and Education Services (FACES) in Kenya with CD4≤100 cells/μl were tested for serum cryptococcal antigen (sCrAg). Individuals with sCrAg titre≥1:2 were treated with high-dose fluconazole. Cox proportional hazard models of Kaplan-Meier curves were used to compare survival among individuals with CD4≤100 cells/μl in the intervention and historical control groups. The median age was 34years [IQR: 29,41], 54% were female, and median CD4 was 43 cells/μl [IQR: 18,71]. Follow-up time was 1224 person-years. In the intervention group, 66% (514/782) were tested for sCrAg; of whom, 11% (59/514) were sCrAg positive. Mortality was 25% (196/782) in the intervention group and 25% (191/771) in the control group. There was no significant difference between the intervention and control group in overall survival [hazard ratio (HR): 1.1 (95%CI:0.9,1.3)] or three-month survival [HR: 1.0 (95%CI:0.8,1.3)]. Within the intervention group, sCrAg-positive individuals had significantly lower survival rates than sCrAg-negative individuals [HR:1.8 (95%CI: 1.0, 3.0)]. A screening and treatment intervention to identify sCrAg-positive individuals and treat them with high-dose fluconazole did not significantly improve overall survival among HIV-infected individuals with CD4 counts≤100 cells/μl compared to a historical control, perhaps due to intervention uptake rates or poor efficacy of high-dose oral fluconazole.

A Possible Case of Complex Regional Pain Syndrome in the Orofacial Region

To present a case of complex regional pain syndrome (CRPS) type II with sympathetic dysfunction and trophic changes in the orofacial region, which was partially responsive to intravenous ketamine. The patient was a 68-year-old man who suffered from inveterate pain with trophic changes of the right face and tongue and vasomotor dysfunction on the right side of the face after ipsilateral trigeminal nerve block. Allodynia and hyperalgesia were observed on the affected side of the face. Pain initially improved after sympathetic nerve block, but similar pain returned that was unresponsive to the same procedure. Repeated intravenous administration of low-dose ketamine preceded by intravenous midazolam alleviated the pain, but trophic changes of the tongue persisted. CRPS in the orofacial region has not been clearly defined and has been infrequently documented. Clinical findings in this patient met the criteria of the International Association for the Study of Pain's and Harden's diagnostic criteria for CRPS. The reason for gradual pain relief after induction of intravenous ketamine therapy was unclear, but the fact that only ketamine and not other various pain medicines or procedures alleviated the pain is important to note. Distinct cases of CRPS involving the orofacial region are rare. Thorough observations and documentation of signs and symptoms may lead to future standardization of diagnostic criteria and treatment strategies for this disorder.

Deep vein thrombosis (DVT) in advanced cancer patients with lower extremity edema referred for assessment

Lower extremity edema is a common complication in advanced cancer patients, and deep vein thrombosis (DVT) is one among many causes. Clinical signs and symptoms are known to be unreliable, and radiographic investigations are often required in diagnosing DVT. A retrospective chart review was conducted on 46 advanced cancer patients with lower extremity edema. Researchers analyzed 52 venous duplex scans to determine the radiographic incidence of DVT the reliability of other clinical signs and symptoms in diagnosing DVT, apart from leg edema, and to assess other potential causes of lower extremity edema and their correlation to DVT. Twenty-three (44 percent) of 52 scans were positive for DVT. The most common presentation of edema in the patients with positive scans was bilateral asymmetric edema (11/23, 48 percent). There was limited documentation of other clinical signs and symptoms suggesting DVT. Other variables such as serum albumin (p = 0.46) and creatinine (p = 0.11) were not statistically different in patients who had positive and negative scans. Of other potential causes of lower extremity edema, such as previous surgery, radiotherapy, tumor, or lymph node compression, a number of patients had a coexisting DVT with bilateral asymmetric edema as the most common presentation. The results of this study suggest that advanced cancer patients with bilateral asymmetric lower extremity edema of potentially multifactorial origin have a high incidence of DVT.

Pacemaker twist: Twiddler's syndrome

Two clinically asymptomatic cases of cardiac pacemaker twist or Twiddler's syndrome are presented. These examples illustrate that not all cases of pacemaker twist are symptomatic and need intervention. Both patients had unipolar pacemaker systems inserted for second degree heart block and sick sinus syndrome, respectively. The diagnosis of pacemaker twist was made on routine chest radiograph, requested for conditions unrelated to pacemaker dysfunction. No manipulation of pacemakers was documented. The recognition and documentation of radiological signs of pacemaker twist is important as a baseline for follow up especially if symptoms of pacemaker dysfunction arise.

Patterns of syphilis testing in the elderly.

To evaluate the frequency of inconsistencies in the use of laboratory tests for syphilis among the elderly in an acute care setting. Retrospective medical record review. Academic medical center. All patients 60 years of age and older who had: 1) positive tests for syphilis and no lumbar puncture performed (n = 71), 2) lumbar punctures performed and no positive test for syphilis (n = 68), and 3) positive tests for syphilis and lumbar punctures performed (n = 8). None. The chronology and results of syphilis tests were abstracted from the medical records. Documentation of signs and symptoms of neurosyphilis, including dementia and depression, were abstracted from the medical records by a second reviewer. Most patients had inadequate evaluations; 51 had no follow-up of positive syphilis tests and 43 had cerebrospinal fluid syphilis tests in the absence of positive blood tests for syphilis or signs and symptoms of neurosyphilis. The inconsistent pattern of serologic testing in this study suggests that the testing was done as a routine procedure and not for a specific purpose. For a majority of the tested individuals, the results did not provide a public health benefit or contribute to the individual's well-being.

Evaluation of cervicothoracic junction injury

Cervical spine injury is a significant cause of morbidity and mortality in the traumatized patient. Little of the trauma literature addresses injury to the cervicothoracic junction (C7-T1); we were able to find only two studies that evaluated the incidence of injury in this area. The spinal injury registry of St Joseph's Hospital and Medical Center and Barrow's Neurological Institute in Phoenix, Arizona, was reviewed for cervical spine-injured patients. Of the 397 patients with cervical spine injury admitted between January 1980 and June 1985, 37 (9%) had cervicothoracic junction injury. Documentation of signs and symptoms of neck injury was recorded for each patient. All available lateral cervical spine radiographs were evaluated for indirect evidence of injury through the level of C7 as currently recommended in the trauma literature. Films were reviewed after being masked at the middle of the body of C7 thereby visualizing the C6-C7 junction. The incidence of C7-T1 injury in our cervical spine-injured population was 9%. Nine of the patients (24%) had a depressed level of consciousness and had neurologic examination that was not diagnostic of spinal injury. All of the cervical injuries in these patients were diagnosed by radiographic evaluation alone. We recommend that adequate visualization of the cervical spine through the cervicothoracic junction must be the standard for trauma care.

Appendicectomy audit.

Of 200 consecutive appendicectomies performed at Royal Prince Alfred Hospital the indications for operation were suspected acute appendicitis (65%), chronic or recurrent appendicitis (11.5%), interval appendicectomy (3%) and appendicectomies incidental to other operations (20.5%). Of those operated upon for suspected acute appendicitis, the appendix revealed acute inflammation pathologically in 64% of patients. Pathological changes occurred with the same frequency in both the incidental appendicectomy group and the chronic appendicitis group. Within the group with a provisional diagnosis of acute appendicitis there were marked variations in the documentation of peroperative symptoms, signs and investigations. On average 11.5 hours passed between the time these patients presented and when appendicectomy was performed. The patients spent an average of 6.4 days in hospital and only 33% had any documentation follow-up in the hospital records. Auditing systems can only be instituted in Australia if the structure of medical services is borne in mind. Adoption of overseas systems based on different patterns of medical care will add little to patient care.