Quality in Clinical Practice

This paper reports the proceedings of the discussion panel assigned to look at clinical aspects of quality in emergency medicine. One of the seven stated objectives of the Academic Emergency Medicine consensus conference on quality in emergency medicine was to educate emergency physicians regarding quality measures and quality improvement as essential aspects of the practice of emergency medicine. Another topic of interest was a discussion of the value of information technology in facilitating quality care in the clinical practice of emergency medicine. It is important to note that this is not intended to be a comprehensive review of this extensive topic, but instead is designed to report the discussion that occurred at this session of the consensus conference.     

Tc-99m HMPAO SPECT imaging of the central nervous system in tuberous sclerosis

Tc-99m HMPAO was used to evaluate cerebral perfusion in a patient with tuberous sclerosis. The SPECT images demonstrated reduced HMPAO uptake in regions corresponding with MRI-confirmed locations of cortical tubers. These results indicate that the lesions are characterized by vascular perfusion deficits and support the hypothesis that cortical tubers result from developmental abnormalities of the embryonic central nervous system.     

Pediatric tissue and organ transplantation in Florida

Fifty to 100 children receive transplanted kidneys, hearts, livers, or bone marrow in Florida each year and many more bone allografts or other tissues (skin, cornea). Children are in the minority of the total solid organ transplantation but those with successful transplants are strong proponents of the procedure. Many (liver or heart failure) would have died without transplantation; others (kidney failure) would have lived but been tied to dialysis for life. The success rate varies with the organ or tissue transplanted. Some children return to a completely normal life without the need for immunosuppressive medications. Others require them continually. Cyclosporine, azathioprine and prednisone are the most frequently used. Rejection continues to be the leading cause of graft loss. Major impediments to solid organ transplantation are the paucity of acceptable organs and the high cost associated with maintenance of transplant patients.     

Esophageal pH monitoring for gastroesophageal reflux: a United Kingdom study

Esophageal pH monitoring is the accepted standard for the investigation of gastroesophageal reflux (GER) in adults. A postal questionnaire was sent to 912 United Kingdom paediatric physicians & surgeons. Five hundred forty-seven (61%) replied, with 124 (22.7%) currently using the technique, mostly in conjunction with barium swallow and/or esophagoscopy. The use of pH monitoring to quantify GER was also accepted in principal as being the best determinant of reflux by a further 186 (34%), but as yet was unavailable in their hospitals. Pediatricians were also questioned as to their management of children with GER. The majority were treated medically with a variety of antireflux medication, with only 237 (42%) referring cases for surgery.     

Time dependent changes in CRF and its mRNA in the neurons of the inferior olive following surgical transection of the olivocerebellar tract in the rat.

Changes in corticotropin-releasing factor (CRF) immunostaining and CRF mRNA in neurons of the inferior olive were compared following unilateral surgical transections of the olivocerebellar tract. Alterations in CRF immunoreactivity could not be observed earlier than 24 h after surgery. The difference--an accumulation in the contralateral side--was most pronounced at 3 days, and disappeared by the 7th postoperative day. On the other hand, changes in mRNA could be observed as early as 5-30 min after the transection. The most significant accumulation was present at 3 h after the cut and no difference could be observed from the 3rd day following surgery. The results suggest that changes in mRNA levels by axotomy may occur at an earlier time point than previously thought.     

Catechol oxidation by peroxidase-positive astrocytes in primary culture: an electron spin resonance study.

In rodents, chronic estrogenization has been shown to induce degeneration of dendrites and myelin figures in the hypothalamic arcuate nucleus adjacent to peroxidase-positive astrocyte processes. Because in this brain region estradiol is metabolized to 2-hydroxyestradiol (catecholestrogen), we hypothesized that the latter may be oxidized by the astrocytic peroxidase activity to cytotoxic ortho-semiquinones as occurs in peripheral tissues. Cysteamine induces nonenzymatic peroxidase activity in cultured astroglia identical to that observed in vivo. Using electron spin resonance, we demonstrate robust peroxidase-catalyzed oxidation of 2-hydroxyestradiol and dopamine by cysteamine-pretreated astrocyte cultures relative to untreated controls. These results implicate the peroxidase-positive astrocytes in the pathogenesis of estradiol-related hypothalamic damage, parkinsonism, and other free-radical-related neurologic disorders.     

Pituitary abnormalities in eating disorders: further evidence from MRI studies

1. The frequent occurrence of hypothalamo-pituitary dysfunction in patients with eating disorders as well as prior reports that nutritional and endocrine status influence pituitary morphology, led us to hypothesize that pituitary size and shape may be altered in patients with eating disorders. 2. Magnetic resonance imaging (MRI) does not use ionizing radiation and is currently one of the most feasible modalities available to study the pituitary gland in vivo. Using MRI, we have previously reported in a preliminary study that female patients with eating disorders had significantly smaller pituitary glands than controls. In addition MRI excluded any pituitary mass lesions. 3. In this report, we confirm our previous MRI findings and provide further evidence of pituitary abnormalities in an expanded sample of eating disorder patients. Preliminary data on pituitary volume estimates from MRI scans are provided for a subset of patients and controls.     

Selective anorexigenic effects of corticotropin releasing hormone in the rhesus monkey

1. Rhesus monkeys were equipped with a novel intracerebroventricular (i.c.v.) cannula system and trained to respond under operant schedules of food presentation or termination of stimuli associated with the delivery of shock (escape). 2. CRH decreased food-maintained behavior in a dose-related manner over the range of (0.3-10 micrograms/kg) but did not affect escape responding, demonstrating a selective effect on food-maintained responding. 3. This selective effect was related to the tendency for responding to stop after delivery of a food pellet when higher doses of CRH were given, consistent with the notion that a conditioned aversion to food was established in the presence of CRH. 4. This may suggest that in hyperaroused clinical states such as depression and anorexia nervosa, focus is shifted away from appetitive tasks as a result of increased levels of CRH.