The Veterans Healthcare Administration (VA) has embraced patient safety and quality improvement in the quest to improve care for veterans. The New Mexico VA Health Care System introduced a new morbidity and mortality conference, called the Interdisciplinary Quality Improvement Conference (IQIC), using patient case presentations to focus on underlying systems in the clinical care environment. The revised conference design also effectively teaches the 6 Accreditation Council for Graduate Medical Education (ACGME) core requirements for resident education. A formal process was established for case selection, presentation, systems issue identification, tracking, and follow-up. The IQIC has enabled the identification of more than 20 system issues at the study institution. Outcome data show lasting improvement in system issues that were addressed by this mechanism. The VA IQIC is an effective method to both identify and correct systems issues that affect patient care and is an effective method for teaching residents the 6 ACGME requirements for residency education.

The main penile or cavernous nerve is usually regarded as the most important vasodilator projection in the rat. Although other descending pathways have been described, there is little detailed information on their importance. In this present report, we provide topographic and quantitative information on lateral and ventral penile branches and examine the vasodilator ®bers which join the pudendal neurovascular bundle. Seventeen Sprague-Dawley rats were used. The techniques included injection of dye in the penis to label neurons in the pelvic plexus in combination with transection of the main penile nerve (MPN). NADPH diaphorase (NADPH-d) histochemistry was used to assess the effects of transection of vasodilator pathways on innervation of the penis and for in situ staining of the pelvic plexus. Distinct clusters of penile neurons are aggregated at the origin of several nerve tracts leaving the posterior margin of the major pelvic ganglion (MPG). Multiple NADPH-d ®ber bundles coursed over the anterior surface of the prostate to reach the penis. Branches from these tracts joined the pudendal neurovascular bundle proximal to the hilum of the penis and provided innervation to the artery throughout its course in the pudendal canal. Consistent with the presence of multiple penile pathways, transection of the MPN reduced, but did not eliminate retrograde labeling of penile neurons in the MPG and only modestly decreased NADPH-d ®bers in the penis. This study con®rms that there are multiple pathways by which vasodilator ®bers reach the penis. If a similar allocation of vasodilator output is present in man, preservation of ®ner branches of the pelvic plexus would be important in surgical procedures on the prostate.

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Stimulation of the hypogastric nerve (HGN) often evokes bilateral responses in some pelvic organs. Retrograde labeling studies indicate that axons of postganglionic neurons often cross to the opposite side. However, there is little information available as to whether preganglionic fibers in the HGN have a contralateral projection to pelvic ganglia. A retrograde tracer was injected into the left major pelvic ganglion (MPG) in rats receiving various lesions of preganglionic nerves (HGN and pelvic nerve, PN). The lumbar spinal cord was then examined for location and number of dye-filled neurons. In a second approach, the incidence of synapto-physin immunoreactivity (SN-IR) perineuronal profiles (baskets) was examined in the MPG and in the accessory pelvic ganglia (APG) after nerve lesions. Labeled neuronal profiles were found in spinal cord nuclei (Lumbar 1-2) after dye injection of the MPG in animals with an intact contralateral HGN. Cutting both HGNs virtually eliminated dye labeling in the lumbar cord, as did severing commissural branches (CB) between pelvic ganglia (leaving the contralateral HGN intact). Some SN-IR baskets were found in the left APG when only the contralateral HGN was intact, but baskets were rare when all four preganglionic nerves were cut. It could not be determined whether the HGN projects to the contralateral MPG, since SN-IR baskets were numerous in the MPG even when all four nerves were cut. This study has shown that some preganglionic fibers in the HGN synapse on neurons in contralateral pelvic ganglia. Both the APG and MPG receive contralateral innervation, but it is likely that neurons in the APG are the primary target of this input. Thus, in addition to crossing postganglionic fibers, a portion of the bilateral control of pelvic tissues is accomplished by preganglionic fibers which target autonomic neurons in contralateral ganglia.

Type B lactic acidosis is a rare metabolic complication of malignancy, more commonly in haematological malignancies. Due to the lack of formal prospective trials, treatment of lactic acidosis associated with malignancy is based on case reports. Given the poor prognosis, early recognition of type B lactic acidosis and prompt treatment are crucial. We report the first case of type B lactic acidosis in metastatic melanoma, followed by a brief literature review on the proposed pathophysiology and treatment.