Development and implementation of clinical pathways for the management of four trauma diagnoses.

Clinical pathways are similar to the production algorithms developed by industry. They are being adapted for use in healthcare to reduce resource utilization, decrease variability, and control expenditures. At Boston Medical Center we identified four trauma diagnoses that we believed to be amenable to the design and implementation of clinical pathways: closed head injury, penetrating wound to the abdomen, penetrating wound to the chest, and penetrating wound to an extremity. Upon implementation of these pathways, appropriate nonoperative, single-system, short-stay trauma patients were enrolled in them. This article details the process by which the four diagnoses were identified and the pathways designed, implemented, and evaluated. Preliminary data demonstrate a significant decrease in resource utilization following implementation of the pathways, without an adverse impact on readmission rates, length of stay, or mortality.

Ocular quinine toxicity treated with hyperbaric oxygen.

Ocular quinine toxicity typically involves a partial or total and often permanent loss of vision. Apart from gastric lavage and oral administration of activated charcoal, current treatment modalities are of doubtful efficacy. Two patients with quinine amaurosis were treated with hyperbaric oxygen (HBO2) in an effort to increase oxygen delivery to the retina. Visual outcomes in these patients were evaluated. Two patients had bilateral no light perception vision and dilated, nonreactive pupils within hours of ingesting 13-15 g of quinine in addition to other drugs. Following initial oral charcoal administration, HBO2 therapy was used. Within 17 h after quinine ingestion, both patients underwent HBO2 therapy at 2.4 atm abs with 100% O2 for 90 min. Both patients had return of visual acuity to 20/20 in both eyes less than 24 h after treatment. Follow-up visual fields revealed constriction and paracentral scotomas bilaterally. We conclude that HBO2 may represent an additional or alternative, and perhaps safer, method of treatment for ocular quinine toxicity.

Attempted autoenucleation.

PURPOSE: A 24-year-old man had visual acuity of no light perception in the left eye after attempted autoenucleation. METHODS: An urgent lateral canthotomy was performed, followed by treatment with high-dose intravenous corticosteroids. RESULTS: Visual acuity improved to L.E.: 20/30. Visual field testing disclosed recovery of the central visual field with persistent arcuate visual field defects. CONCLUSION: Visual acuity of no light perception after attempted autoenucleation does not preclude the return of good visual acuity.

Thyroid hormone regulation of messenger ribonucleic acid encoding thyrotropin (TSH)-releasing hormone is independent of the pituitary gland and TSH.

Cellular levels of mRNA encoding pro TRH in the rostral paraventricular nucleus are reduced by thyroid hormones. To determine whether this regulatory effect of thyroid hormones requires a functional pituitary gland or, specifically, TSH, we examined the effect of T3 on proTRH mRNA in hypophysectomized, thyro-parathyroidectomized male rats with or without bovine TSH replacement. Hypophysectomy plus thyro-parathyroidectomy reduced serum T4 and TSH to undetectable levels in all animals and elevated TRH mRNA in the paraventricular nucleus over that of sham-operated animals. Eleven consecutive daily injections of T3 significantly reduced TRH mRNA levels in both sham controls and thyro-parathyroidectomized rats. However, 11 daily injections of bovine TSH (1 U/day) failed to alter the effect of T3 on TRH mRNA levels. These results demonstrate that the regulatory influence of thyroid hormones on the biosynthesis of TRH within the thyrotropic center of the brain is independent of the pituitary gland and of TSH.

Thyroid hormones regulate levels of thyrotropin-releasing-hormone mRNA in the paraventricular nucleus.

Cellular levels of messenger RNA encoding thyrotropin-releasing hormone (TRH) were measured in the paraventricular nucleus of the hypothalamus and the reticular nucleus of the thalamus in male rats after chemical thyroidectomy and thyroid hormone replacement. TRH mRNA levels were measured by quantitative in situ hybridization histochemistry using a 35S-labeled synthetic 48-base oligodeoxynucleotide probe and quantitative autoradiography. Chemical thyroidectomy, produced by the administration of 6-(n-propyl)-2-thiouracil (PrSur), reduced plasma thyroxine below detection limits and significantly increased TRH mRNA in the paraventricular nucleus. Treatment with exogenous L-triiodothyronine (T3) reduced TRH mRNA to the same level in both hypothyroid and euthyroid animals. Neither PrSur treatment nor T3 replacement influenced TRH mRNA levels in the reticular nucleus of the thalamus. Blot hybridization analysis of electrophoretically fractionated total RNA from pituitaries of these animals indicated that thyrotropin-beta mRNA levels were elevated after thyroidectomy and reduced by T3 treatment, showing that the pituitary-thyroid axis was indeed stimulated by PrSur treatment. These results suggest that thyroid hormones are involved, either directly or indirectly, in regulating the biosynthesis of TRH in the thyrotropic center of the hypothalamus.

Plasma observations near uranus: initial results from voyager 2.

Extensive measurements of low-energy positive ions and electrons in the vicinity of Uranus have revealed a fully developed magnetosphere. The magnetospheric plasma has a warm component with a temperature of 4 to 50 electron volts and a peak density of roughly 2 protons per cubic centimeter, and a hot component, with a temperature of a few kiloelectron volts and a peak density of roughly 0.1 proton per cubic centimeter. The warm component is observed both inside and outside of L = 5, whereas the hot component is excluded from the region inside of that L shell. Possible sources of the plasma in the magnetosphere are the extended hydrogen corona, the solar wind, and the ionosphere. The Uranian moons do not appear to be a significant plasma source. The boundary of the hot plasma component at L = 5 may be associated either with Miranda or with the inner limit of a deeply penetrating, solar wind-driven magnetospheric convection system. The Voyager 2 spacecraft repeatedly encountered the plasma sheet in the magnetotail at locations that are consistent with a geometric model for the plasma sheet similar to that at Earth.