Intimal hyperplasia and coronary flow reserve after heart transplantation: association with big endothelin-1

BACKGROUND: Endothelin, a peptide with strong vasoconstrictive and mitogenic properties, has been found to increase after cardiac transplantation. We therefore assessed the association between its precursor peptide, big endothelin-1, and intimal hyperplasia and coronary flow reserve after heart transplantation. METHODS: Thirty-five patients without hemodynamically significant coronary artery disease after heart transplantation were investigated: Average peak flow velocity in the left anterior descending artery (LAD) was assessed by intracoronary Doppler at baseline as well as after injection of adenosine; coronary flow reserve was calculated as a ratio of both and was corrected for patient age and baseline average peak flow velocity. Lumen, intima + media and total vessel area were measured by intracoronary ultrasound. The plasma concentration of big endothelin-1 in venous blood was determined by radioimmunoassay. RESULTS: Patients with elevated big endothelin-1 levels (>2 fmol/ml) tended to have a decreased corrected coronary flow reserve (2.60 +/- 0.9 vs 3.21 +/- 1.0, p = 0.078). They also had a significantly larger intima + media area (5.82 +/- 2.9 vs 2.37 +/- 2.9 mm(2), p = 0.004) and total vessel area (18.36 +/- 5.8 vs 12.81 +/- 4.8 mm(2), p = 0.012) than those with normal plasma concentrations. CONCLUSIONS: Our study suggests an association between elevated big endothelin-1 plasma levels and the development of intimal hyperplasia and reduction of coronary flow reserve after cardiac transplantation.     

Treatment of Pearly Penile Papules with CO2 Laser

BACKGROUND: Pearly penile papules are angiofibromas found on the corona and sulcus of the glans penis. While these represent a benign condition, psychological and cosmetic concerns often prompt patients to seek therapeutic removal of these lesions. Multiple therapeutic modalities have been reported; however, use of CO2 laser has proven to be the most effective to date. OBJECTIVE: To demonstrate the efficacy of CO2 laser in treating pearly penile papules. METHODS: Case report. RESULTS: We report the successful treatment of pearly penile papules in an African American man with CO2 laser. CONCLUSION: The use of CO2 laser is an effective treatment for pearly penile papules. J. E. Lane, MD, C. M. Peterson, MD, and J. L. Ratz, MD have indicated no significant interest with commercial supporters.     

Measuring the Quality of Hospital-based Domestic Violence Programs

OBJECTIVE: To obtain consensus among a panel of experts on performance measures useful for evaluating the quality of hospital-based domestic violence (DV) programs. METHODS: The Delphi process of consensus development was used with a panel of 18 experts including DV researchers, program planners, and advocates. Three rounds were conducted over a period of six months, with each round involving the completion of a written questionnaire. Panelists were instructed to concentrate on structure and process measures of DV program performance. Health outcome measures were not considered. During each round, panelists rated (scale of 1-5) their level of agreement with each measure, in terms of the measure's usefulness for evaluating hospital-based DV programs. Data were entered into SPSS on a personal computer and frequency distributions, measures of central tendency, and variance were computed for each measure. Consensus development was defined as a reduction in the item-specific variance from one round to the next. RESULTS: A total of 37 performance measures were agreed upon. These measures fell within nine different domains of DV program activities, including: Policies and Procedures, Hospital Physical Environment, Hospital Cultural Environment, Training of Providers, Screening and Safety Assessment, Documentation, Intervention Services, Evaluation Activities, and Collaboration. CONCLUSIONS: A number of measures have been identified as useful for evaluating hospital-based DV programs. Use of these measures should assist researchers, program planners, and administrators in assessing the quality of hospital-based DV programs.     

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.     

Cough and paradoxical vocal fold motion

OBJECTIVES: The differential diagnosis and treatment of patients with chronic cough, paradoxical vocal fold motion, and disordered breathing can be a challenge to most practicing otolaryngologists. Tracheobronchial (ie, asthma, bronchitis, and tracheal stenosis), laryngeal (ie, vocal fold paralysis and neoplasms), and rhinologic (ie, allergies and rhinosinusitis) etiologies are commonly diagnosed and treated effectively. However, occasionally one is faced with patients who are refractory to medical treatment and have no obvious rhinologic, laryngeal or pulmonary cause. STUDY DESIGN AND SETTING: We conducted a review of the literature. METHODS: We present a thorough review of the current medical literature exploring the complex neurologic mechanisms involved in the production of cough and the relationship between gastroesophageal reflux disease, vagal neurapathy, and paradoxical vocal fold motion. RESULTS: The diagnosis and successful treatment of chronic cough can be complex. It requires a thorough understanding of the neurologic mechanisms behind cough excitation and suppression. Successful treatment strategies include aggressive management of the patient's reactive airway disease, gastroesophageal reflux disease, and, in select cases, paradoxical vocal fold motion. This may involve a well-coordinated effort among pulmonologists, otolaryngologists, gastroenterologists, and speech pathologists. CONCLUSION: Gastroesophageal reflux disease, vagal neuropathy, and paradoxical vocal fold motion are additional causes of chronic cough and disordered breathing that need to be considered, in the absence of obvious laryngotracheal and/or rhinologic pathology. A high index of suspicion is essential in making the diagnosis and formulating an effective multidisciplinary treatment plan for these patients.