Quality assessment and assurance in diagnostic imaging. Theoretical and practical considerations and a quality audit of the excretory urogram

Concepts necessary to an understanding of the basics of quality assurance audits are presented. Included are specific examples that bridged theory and practice by applying the protocol to a real-life diagnostic imaging situation. This method meets the present requirements of the Joint Commission of the Accrediation of Hospitals.     

Pelvic exsanguination following umbilical artery catheterization in neonates.

Umbilical artery catheterization in 400 newborns was followed by umbilical or hypogastric artery perforation with massive extra- and intraperitoneal bleeding in 7 infants. Common predisposing factors were multiple attempts and insertion against resistance. A characteristic clinical picture developed, including hypotension, abdominal distention, and lower abdominal wall induration and ecchymosis, often extending into the genitalia and upper thighs, with absent femoral pulses. Treatment is immediate transfusion and bilateral umbilical and hypogastric artery ligation. One of seven patients survived.     

Osteoarthritis beginning with inflammation. Definitions and correlations.

A syndrome of acute onset of inflammation over interphalangeal joints heralding deforming osteoarthritis may be intermediate between degenerative and rheumatoid joint diseases. The syndrome appears predominantly in women of menopausal age and is remarkably symmetrical. In a prospective study of 170 propositi, later changes more characteristic of rheumatoid arthritis than of generalized or erosive osteoarthritis developed in 15.3%.     

Juvenile Diabetes Mellitus

Juvenile diabetes, although less common than the adult form, presents unique problems which make management more difficult. The basic principles of diet, insulin and exercise apply but the application must be individualized. A constant diet is the aim but with variations in growth and activity this is more difficult to achieve. A child's caloric intake is often greater than anticipated. Children are insulin sensitive and the amounts required to control diabetes and treat acidosis are much less than for adults. Hypoglycemic reactions are disturbing and may mimic or cause behavior problems. The rebound phenomena is common particularly when post prandial blood sugars are used to adjust insulin dose. Thorough understanding by the parents as well as acceptance of the condition are the keys to good control.     

Role of biofilms in neurosurgical device-related infections

Bacterial biofilms have recently been shown to be important in neurosurgical device-related infections. Because the concept of biofilms is novel to most practitioners, it is important to understand that both traditional pharmaceutical therapies and host defense mechanisms that are aimed at treating or overcoming free-swimming bacteria are largely ineffective against the sessile bacteria in a biofilm. Bacterial biofilms are complex surface-attached structures that are composed of an extruded extracellular matrix in which the individual bacteria are embedded. Superimposed on this physical architecture is a complex system of intercellular signaling, termed quorum sensing. These complex organizational features endow biofilms with numerous microenvironments and a concomitant number of distinct bacterial phenotypes. Each of the bacterial phenotypes within the biofilm displays a unique gene expression pattern tied to nutrient availability and waste transport. Such diversity provides the biofilm as a whole with an enormous survival advantage when compared to the individual component bacterial cells. Thus, it is appropriate to view the biofilm as a multicellular organism, akin to metazoan eukaryotic life. Bacterial biofilms are much hardier than free floating or planktonic bacteria and are primarily responsible for device-related infections. Now that basic research has demonstrated that the vast majority of bacteria exist in biofilms, the paradigm of biofilm-associated chronic infections is spreading to the clinical world. Understanding how these biofilm infections affect patients with neurosurgical devices is a prerequisite to developing strategies for their treatment and prevention.     

Heat shock protein 60 is released in immune-mediated glomerulonephritis and aggravates disease: in vivo evidence for an immunologic danger signal

Heat shock proteins (Hsp) are ubiquitous intracellular proteins that can be released in various forms of cellular stress. Some Hsp, such as Hsp60, have been shown to stimulate directly T cell-mediated immune responses in vitro. Here, it is demonstrated that Hsp60 is released from the kidneys and excreted into the urine of mice with nephrotoxic nephritis (NTN), a model of rapidly progressive glomerulonephritis. For examining the functional relevance of Hsp60 release, this protein was injected into mice with subnephritogenic NTN, in which only transient proteinuria and minimal organ damage occur that do not progress to terminal kidney failure. Injection of Hsp60 strikingly aggravated disease, as evidenced by global glomerular necrosis, tubulointerstitial damage, and complete anuria after 10 to 12 d. This effect was mediated neither by endotoxin contaminations of Hsp60 nor by autologous antibodies. It was strictly T cell dependent but not associated with a systemic Th1/Th2 shift. Thus, Hsp60 is an endogenous mediator stimulating immune effector mechanisms that contribute to the progression of NTN. These findings demonstrate in vivo that Hsp60 fulfills criteria of immunologic danger signals and suggest that such signals may be involved in immune-mediated kidney disease.