Exploding 12 myths about quality assurance and peer review

In order to accomplish effective, objective peer review and quality assurance in the midst of concerns about confidentiality and malpractice, 12 widely-held, false assumptions about the nature of peer review and quality assurance must be discarded.

Data-based accountability: refocusing the medical record professional's role

Changing times, as evidenced by the Health Care Quality Improvement Act of 1986 and the Joint Commission's "Agenda for Change," have made many committees as well as traditional quality assurance and peer review methods obsolete. The new hospital-wide accountability system consists of accurate and valid clinical data, provided in a timely manner, and used effectively by responsible individuals. As has been true over the last 50 years, continuing change does not diminish the important role of the medical record professional. However, the changes do make it necessary for medical record professionals to avoid making themselves vulnerable through obsolescence, by clinging to methodology no longer of merit.

Infiltration of the mesosalpinx for pain relief after laparoscopic tubal sterilization with Yoon rings

Approximately 200 women of American Society of Anesthesiologists class I and II physical status electing outpatient laparoscopic tubal sterilization with Yoon rings were involved in a double-blind study to evaluate postoperative pain relief after intraoperative suprapubic infiltration of the fallopian mesosalpinx. The postoperative pain levels were lower after bilateral infiltration of 0.5% bupivacaine beneath the site of ring application. Postoperative, suprapubic infiltration provided safe, prolonged and effective pain relief, allowed prompt ambulation and early discharge, and reduced the need for narcotic analgesics and postoperative analgesia.

Bupivacaine infiltration of the mesosalpinx in ambulatory surgical laparoscopic tubal sterilization

Bupivacaine infiltration of the mesosalpinx was compared to lidocaine, normal saline or no injection for pain relief in women having elective laparoscopic tubal sterilization by Yoon fallopian ring application. One hundred women were assigned randomly to four groups. In a double-blind study, the mesosalpinx was infiltrated in three groups: Group 1 - lidocaine one per cent; Group II - bupivacaine 0.5 per cent; Group III - normal saline. Group IV (control) received no injection. Pain intensity was reported at four study times by the patients on a self-assessment pain intensity scale. Responses were compared using the Kruskall-Wallis H-Test and Wilcoxen's Rank-Sum Test. Both tests indicated significant differences in pain intensity levels at various study times. The amount of supplemental fentanyl given was used as a secondary measure of effectiveness. One-way analysis of variance (ANOVA) and Duncan's Multiple-Range Test showed the bupivacaine group to receive significantly less fentanyl (p less than 0.05) in the postanaesthesia care unit.

Diagnosis of tubular injury in renal transplant patients by a urinary assay for a proximal tubular antigen, the adenosine-deaminase-binding protein

Two murine monoclonal antibodies (URO-4 and URO-4a)--which detect different epitopes of a proximal tubular cell glycoprotein antigen, the adenosine-deaminase-binding protein (ABP)--have been formatted into a sandwich enzyme immunoassay for detection of ABP in the urine. Serial urine samples from 34 renal transplant patients during the first six months posttransplant were analyzed to determine the correlation of this test with clinical rejection and cyclosporin (CsA) nephrotoxicity. In 29/29 acute rejection episodes the ABP level was elevated, beginning 1-7 days prior to treatment of rejection. Eighteen patients were treated for rejection with courses of OKT3 or antithymocyte globulin: 0/6 whose ABP level fell to normal during therapy had rerejection; 10/12 whose ABP level remained elevated had rerejection within 7 days of therapy completion. Of 15 patients treated with CsA, 7 had no rejection or drug toxicity; all 7 had normal ABP levels. The remaining 8 had CsA nephrotoxicity, all in association with elevated ABP levels that rapidly fell to normal with decreased CsA dose. An additional 7 patients with creatinine elevations more than 6 months posttransplant were studied: 5 had chronic vascular changes on biopsy, no response to increased immunosuppression, and normal ABP levels; 2 had a cellular infiltrate on biopsy, response to increased immunosuppression, and elevated ABP levels. We conclude that the urinary ABP assay provides information useful in the management of renal transplant patients with acute and chronic rejection and CsA toxicity.

A new diagnostic immunoassay for proximal tubule injury

Adenosine deaminase binding protein (AdAbp), a glycoprotein found in the epithelial cells of the brush border of the proximal tubule, is shed into urine following kidney damage. A sandwich enzyme immunoassay is described that uses two monoclonal antibodies, URO-4 (S27) and URO-4a (S23), which react with different epitopes on AdAbp (2, 24). Release of AdAbp into the urine appears to reflect the severity of the insult to the nephron and its measurement may assist in distinguishing between tubular disease and glomerular disease and may be useful in indicating renal toxicity.

Trustee melds technology goals of competing hospitals

Magnetic resonance imaging (MRI) has come Glendale, CA, in what is believed to be the first facility to be jointly owned by competing hospitals and radiologists. But that accomplishment very likely would still be an unfulfilled dream without the determined efforts of board chairman Robert Sandison.

Competitive idiotype--anti-idiotype immunoassay for adenosine deaminase binding protein in urine

This competitive immunoassay, based on inhibition by antigen of the idiotype-anti-idiotype interaction, detects adenosine deaminase binding protein (ABP), and involves use of monoclonal anti-idiotype antibodies prepared to a monoclonal antibody specific for ABP. The conditions for this new type of competitive immunoassay are investigated. This competitive immunoassay is as sensitive and reproducible as an earlier described "sandwich"-type immunoassay for ABP (Clin Chem 31: 679-683, 1985). Evaluation of urine samples from normal subjects and from patients showed increased concentrations of ABP in patients with renal disease.

Competitive idiotype--anti-idiotype immunoassay for adenosine deaminase binding protein in urine

This competitive immunoassay, based on inhibition by antigen of the idiotype-anti-idiotype interaction, detects adenosine deaminase binding protein (ABP), and involves use of monoclonal anti-idiotype antibodies prepared to a monoclonal antibody specific for ABP. The conditions for this new type of competitive immunoassay are investigated. This competitive immunoassay is as sensitive and reproducible as an earlier described "sandwich"-type immunoassay for ABP (Clin Chem 31: 679-683, 1985). Evaluation of urine samples from normal subjects and from patients showed increased concentrations of ABP in patients with renal disease.

Six winning traits of hospital leaders

In today's competitive environment, winners and losers will be determined, at least in part, by the leadership style of governing board members and chief executive officers. This article describes six characteristics observable in successful leaders.

Adenosine deaminase binding protein, a new diagnostic marker for kidney disease

This enzyme immunoassay detects adenosine deaminase binding protein (ABP), a glycoprotein that is shed from the brush border of the proximal tubule in kidney damage. Two monoclonal antibodies, URO-4 and URO-4a, each react with different epitopes on ABP and are used as the "sandwich" pair of antibodies. A linear standard curve can be generated by using partly purified ABP isolated from the urine of patients with kidney disease. Release of ABP into the urine appears to reflect the severity of the insult to the nephron. Therefore, measurement of ABP in urine may help distinguish between tubular disease and glomerular disease and indicate renal allograft rejection in renal-transplant patients.

Adenosine deaminase binding protein, a new diagnostic marker for kidney disease

This enzyme immunoassay detects adenosine deaminase binding protein (ABP), a glycoprotein that is shed from the brush border of the proximal tubule in kidney damage. Two monoclonal antibodies, URO-4 and URO-4a, each react with different epitopes on ABP and are used as the "sandwich" pair of antibodies. A linear standard curve can be generated by using partly purified ABP isolated from the urine of patients with kidney disease. Release of ABP into the urine appears to reflect the severity of the insult to the nephron. Therefore, measurement of ABP in urine may help distinguish between tubular disease and glomerular disease and indicate renal allograft rejection in renal-transplant patients.

Characterization studies of glucose dehydrogenase

Porcine liver beta-D-glucose dehydrogenase has been isolated using Triton X-114 to release it from the endoplasmic reticulum. The purified enzyme contains a limited amount (1.7%) of lipid material, including cholesterol, fatty acids, mono and diglycerides, phosphatidylcholine, phosphatidylethanolamine, and cholesterol esters. This enzyme is a tetrameric protein containing an extensive number of hydrophobic residues. This form of glucose dehydrogenase is capable of turning over both beta-D-glucose and alpha-D-glucose-6-phosphate in vivo as indicated from a steady state kinetic analysis at 37 degrees C.

Primary substrate specificity determinants for the H4-specific protease-activated protein phosphotransferase

The specificity of the histone-H4-specific, protease-activated protein kinase (H4-PK) was examined using two series of synthetic peptides corresponding to the phosphorylation sites in histone H4 and pyruvate kinase. Optimum kinetic constants for phosphorylation were observed using the peptide Val-Lys-Arg-Ile-Ser-Gly-Leu. Peptides in which the Lys was replaced by Arg or the Lys-Arg sequence was transposed were phosphorylated with less favorable kinetics. Peptides with either basic residue deleted did not serve as substrates. Only the H4 peptide, containing an Arg-Arg sequence, was phosphorylated by the cyclic-AMP-dependent protein kinase (CA-PK). Distinct specificity determinants for H4-PK and CA-PK were also observed using the pyruvate kinase peptide (Leu-Arg-Arg-Ala-Ser-Leu-Gly). Collectively the data indicated that the primary substrate specificity determinants for H4-PK are Lys-Arg-Xaa-Ser whereas the CA-PK selectively phosphorylates the sequence Arg-Arg-Xaa-Ser.

Guanidinium- and temperature-induced conformational changes in glucose dehydrogenase

The conformational changes in glucose dehydrogenase are studied as a function of temperature and guanidinium chloride (GdmCl) concentration. The data were analyzed assuming a two-conformer model which gave similar results using either circular dichroism or enzyme activity. The free energy of denaturation was 0.94 kcal/mol from specific activity and 1.64 kcal/mol from circular dichroism measurements. The mid-point of the denaturation curve was 0.65 or 0.63 M GdmCl, as determined by specific activity or circular dichroism, respectively. The transition temperature, 6.4 degrees C, is close to that of a microsomal membrane phase change, a result that is consistent with the fact that glucose dehydrogenase contains lipid materials when isolated with a non-ionic detergent such as Triton X-114. As the temperature increased, the amount of beta-pleated sheet increased, and the alpha-helical content decreased, suggested that glucose dehydrogenase contains a stable core of beta-pleated sheet.

Characterization of lecithin:cholesterol acyltransferase from human plasma: II. Physical properties of the enzyme

The physical properties of purified human plasma lecithin:cholesterol acyltransferase (LCAT) were investigated by techniques including analytical ultracentrifugation, ultraviolet spectroscopy, electrofocusing, and circular dichroism. The partial specific volume of LCAT was determined by sedimentation equilibrium ultracentrifugation experiments in H2O and D2O solutions (0.702 ml/g). The Mr was 67,000 by sodium dodecyl sulfate (SDS)-gel electrophoresis and 60,000 by sedimentation equilibrium ultracentrifugation. The discrepancy between the two sets of data presumably arose from the glycoprotein nature of the enzyme. Studies of the ultraviolet spectrum indicated that LCAT contained 6.5% (w/w) tyrosine which corresponds to approximately 18 tyrosine residues/mol of LCAT (polypeptide Mr 45,000). Spectrophotometric titration of the ionizable phenolic side chains indicated that nearly all the tyrosine residues were buried at neutral pH while they became gradually exposed at higher pH. The apparent pK of this transition was about 12.0 contrasted with 9.8, the apparent pK of ionization of the free tyrosyl groups.

Close-up picture of TEFRA basics

The concept of "business as usual" for health care institutions is no longer an acceptable modus operandi. The Tax Equity and Fiscal Responsibility Act of 1982 has forever changed the relationship between medical staff members, governing boards, and administrative staff and made mutual cooperation more important than ever.

Nutritional amblyopia associated with jejunoileal bypass surgery

After jejunoileal bypass surgery for morbid obesity, metabolic complications including a nutritional amblyopia developed in a patient. Reanastomosis of the bypass and treatment with multivitamins resulted in a nearly complete return of vision. Any patient undergoing rapid weight loss after gastrointestinal surgery for morbid obesity should be followed up for possible decrease in vision. If nutritional amblyopia develops, immediate reversal of the previous surgery is indicated.

Polarization-maintaining single-mode fibers

Polarization-maintaining single-mode fibers will find application in acoustooptic sensors and fiber gyroscopes. In this study both stress-induced birefringence and elliptical core polarization-maintaining single-mode fibers were developed and evaluated. The two fiber types were compared in terms of core dimension, numerical aperture, attenuation, and beat length, a measure of the polarization maintenance. For comparative beat length values the stress-induced birefringence fibers had lower attenuation and larger core diameter than the elliptical core fibers.

Enamel loss due to prophylaxis and multiple bonding/debonding of orthodontic attachments

An in vitro study using steel reference markers in the enamel of 120 permanent premolars was conducted to determine the amount of enamel lost during prophylaxis and during multiple bonding/debonding procedures. A prophylaxis procedure was carried out on eighty teeth. The procedure was standardized with respect to time, pressure, and revolutions of the prophy handpiece. Both bristle brush and rubber cup were used with four different prophylaxis pastes. The enamel loss with the bristle brush (14.38 micrometers) was significantly (p less than 0.01) greater than the loss with the rubber cup (6.9 micrometers). No significant differences were associated with the use of different pastes. Multiple bonding/debonding procedures were conducted with filled and unfilled resin adhesives. Following the initial bond, twenty of the teeth received prophylaxis and acid etching prior to subsequent bonds while the remaining twenty did not. Total enamel loss was 71.5 micrometers in the group bonded with a filled resin with prophylaxis and acid etching between bonds. This was significantly (p less than 0.01) greater than the amount lost (22.3 micrometers) by the group bonded with the same resin without prophylaxis and acid etching between bonds. Total enamel loss was 45.4 micrometers in the group bonded with an unfilled resin with prophylaxis and acid etching between bonds. This was significantly (p less than 0.01) greater than the amount lost (17.8 micrometers) by the group bonded with the same resin without prophylaxis and acid etching between bonds.

A patient care review model to suit both hospitals and PSROs

Combining internal review and external monitoring, developing new methods of study, interpreting data in a clinically valid way, and making wide use of findings should end what has been an adversary relationship and an ineffective review system.