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Biomedical subjects

K E Koch

Publications and source records attributed to K E Koch.

At least 19 recordsLinked to original sources
PubMed2001

Using clinical practice analysis to improve care.

BACKGROUND: Improving clinical outcomes requires that physicians examine and change their clinical practice. Sustaining outcome improvements requires a dedicated and dynamic program of analyzing and improving patient care. In 1992 North Mississippi Health Services (NMHS) implemented a program to improve physicians' clinical efficiency. CLINICAL PRACTICE ANALYSIS ( CPA): CPA uses evidenced-based guidelines and examines each physician's resource utilization, processes, and outcomes for a diagnosis or procedure. Clinical practice profiles are developed, and individual performance is compared to local and national benchmarks and presented to physicians. The CPA process is used on its own or as a component of more comprehensive performance improvements projects. Physicians have been engaged in outcome improvement by more than 55 CPA projects. RESULTS: NHMS has progressively reduced its Medicare loss and its length of stay (LOS) to 4.9 days. Mortality and readmission rates have been reduced in specific diagnoses. The community-acquired pneumonia project reduced the LOS from 7.7 to 5.1 days, decreaesed the mortality rate from 8.9% to 5.0%, and decreased the cost of care from $4,269 to $3,834. The ischemic stroke project reduced the aspiration pneumonia rate from 6.4% to 0% and mortality from 11.0% to 4.6%. Patients' average LOS decreased from 10.7 days to 6.5 days, and their cost of care was reduced by $1,100 per patient. DISCUSSION: Providing individualized data has engaged physicians in improving outcomes. The program has evolved from improving efficiency to managing outcomes and from simple CPA projects to integrated performance improvement projects; however, the CPA process remains the cornerstone of the current process.

Anti-Bacterial Agents↗
PubMed2000

Effects of hospitalists on cost, outcomes, and patient satisfaction in a rural health system.

PURPOSE: Previous studies have examined the effects of hospitalists in urban academic hospitals. We compared the outcomes of patients treated by hospitalists with those of patients treated by internists at a 647-bed rural community hospital. SUBJECTS AND METHODS: The 443 patients in the hospitalists' 10 most common diagnosis-related groups (DRGs) were compared with 1,681 patients in the same DRGs who were cared for by internists in fiscal year 1998. Length of stay, cost of care, patient illness severity, patient satisfaction, 30-day readmission rate, inpatient mortality, discharge status, and resource utilization were compared. RESULTS: The hospitalists' patients had a shorter mean (+/- SD) length of stay (4.1 +/- 3.0 days versus 5.5 +/- 4.9 days, P <0.001) and their cost of care was less than that of the internists' patients ($4,098 +/- $2,455 versus $4,658 +/- $4,084, P <0.001). Analyses that adjusted for patient age, race, sex, insurance status, severity of illness, and specific medical comorbidities confirmed these differences. The differences between hospitalists and internists were most apparent among very ill patients. Mortality rates were similar (4.5% for hospitalists versus 4.9% for internists, P = 0.80), as were the readmission rates (4.5% for hospitalists versus 5.6% for internists, P = 0.41). Patient satisfaction was similar for both groups. The internists used more resources in 8 of 11 categories. CONCLUSIONS: The hospitalists provided cost-effective care, particularly for the sickest patients, with good outcomes and patient satisfaction.

Health Resources↗
PubMed2000

Multiple paths of sugar-sensing and a sugar/oxygen overlap for genes of sucrose and ethanol metabolism.

The two-fold purpose of this work is, first, to review current hypotheses for multiple paths of sugar-sensing in an oxygen-responsive context, and second, to present evidence for the extent of sugar/oxygen overlap regulating genes for sucrose and ethanol metabolism. Current data indicate that sugar signals in plants may be initiated by (a) hexokinases, (b) membrane sensors, (c) acetate and/or respiratory metabolites, and (d) other signals and/or crosstalk. Responses may also involve concurrent input along transduction paths by effectors such as energy charge, P status, and phytohormones. Prime candidates for initiation and/or integration of such signal integration include SNF1- and SCF-like, multi-enzyme complexes. In addition, different paths of sugar signal transduction may be linked to contrasting roles of responsive genes during feast, famine or pathogen attack. Oxygen can potentially alter sugar signals at several points, so its influence on feast and famine responses was initially tested with genes for sucrose metabolism in maize root tips. The Sus1 and Sh1 sucrose synthases in maize (typically up-regulated by carbohydrate abundance and deprivation, respectively) showed parallel responses to hypoxia (3% O2 [0.03l l-1 O2]) and anoxia (0% O2 [0l l-1 O2]) that were consistent with involvement of similar signals. In contrast, the differential sugar-responses of the lvr1 and lvr2 invertases were not evident under low oxygen, and both genes were rapidly repressed. A third response was evident in the marked, sugar-regulation of an oxygen-responsive Adh1 gene for alcohol dehydrogenase, which was sensitive to sugar availability from deficit to abundance, regardless of oxygen status (anaerobic to fully aerobic [40% O2 (0.04l l-1 O2)]. A clear interface is thus evident between sugar and oxygen signals, but this varies markedly with the genes involved and probable differences in respective transduction paths.

Carbohydrate Metabolism↗
PubMed1999

Rapid repression of maize invertases by low oxygen. Invertase/sucrose synthase balance, sugar signaling potential, and seedling survival.

We show here that invertase gene expression and the invertase-sucrose (Suc) synthase ratio decrease abruptly in response to low oxygen in maize root tips. In addition to aiding in the conservation of carbon and possibly ATP, this response has the potential to directly affect sugar signaling relative to carbon flux. Experiments were motivated by the potential for a reduced invertase/Suc synthase balance to alter the impact of respiratory and/or membrane carbon flux on sugar signaling. Maize (Zea mays L.) seedlings with 5-cm primary roots were exposed to anoxic (0% [v/v] O2), hypoxic (3% [v/v] O2), and aerobic conditions. Rapid repression of the Ivr1 and Ivr2 maize invertases by low oxygen was evident in root tips within 3 h at both the transcript and activity levels. The speed and extent of this response increased with the degree of oxygen deprivation and differed with genotypes. This decrease in expression also contrasted markedly to that of other genes for respiratory Suc metabolism, such as Suc synthases, which typically increased or remained constant. Although previous work showed that the contrasting effects of sugars on Suc synthase genes were reflected in their regulation by hypoxia and anoxia, the same was not observed for the differentially sugar-responsive invertases. Theoretically advantageous reductions in the invertase/Suc synthase balance thus resulted. However, where this response was extreme (an Oh43 inbred), total sucrolytic capacity dropped below an apparent minimum and root tip viability was reduced. Paradoxically, only Oh43 seedlings showed survival levels >80% (versus <50%) after extreme, long-term stress, suggesting a possible advantage for multiple means of reducing sink activity. Overall, our results demonstrate a rapid change in the regulation and balance of invertases and Suc synthases that could have an immediate impact on limiting the extent of Suc cleavage and reducing the extent of concomitant, hexose-based sugar signaling under low oxygen.

Enzyme Repression↗
PubMed1998

Clinically oriented pharmacy technicians to augment clinical services.

The justification for and the training, responsibilities, and contributions of two clinically oriented pharmacy technicians are described. A proposal outlining the clinical services being provided by pharmacists at a 650-bed medical center and the need for technical assistance was developed and approved. Two clinical technician positions were created to replace one of two eliminated pharmacist positions. Each of the technicians hired had worked successfully in several traditional pharmacy technician roles. The technicians were trained for specific roles and cross-trained in the basic functions of each other's roles. The technicians made rounds with the pharmacists to learn how to evaluate patients and interact with physicians and nurses and were required to demonstrate competence in deciding which patients required further evaluation. One technician focuses on providing direct clinical service support, and the other works primarily as a clinical administrative assistant. Half the technicians' time is spent performing services previously performed by pharmacists. In addition, the technicians track outcomes and provide clerical and data-management assistance. The technicians are responsible for screening and tracking approximately 400 patients per month on well-established services and 400 per month on two new monitoring services. The technicians have helped develop a medication-error tracking program. Clinically oriented technicians freed up pharmacists' time by collecting routine clinical data and managing clinical projects; through protocol-based screening and outcomes tracking, the technicians have helped to implement new clinical services and evaluate existing ones.

Hospital Bed Capacity, 500 and over↗
PubMed1998

Clinical efficiency tools improve stroke management in a rural southern health system.

BACKGROUND AND PURPOSE: Ischemic stroke is a high-volume and financially draining diagnosis at this rural health system. The purpose of this clinical practice analysis was to identify resource utilization and clinical process inefficiencies and to promote clinically efficient, evidence-based improvements. METHODS: A retrospective analysis of medical record and financial databases of 356 patients with ischemic stroke was performed. The medical record data were adjusted for severity, and outliers were eliminated. The resources utilized by each physician were determined. Comparative graphs were prepared, presented, and discussed. The physicians implemented two types of changes: (1) alteration of resource utilization and consultation patterns and (2) support of clinical process improvement. In 1997, a follow-up analysis of 399 patients was performed. RESULTS: The initial comparison of internists' to neurologists' patient populations found the following: patient age (75 versus 65 years), patient severity ratings (2.8 versus 2.5), length of stay (10.7 versus 8.8 days), costs ($7360 versus $6862), mortality rates (12.5% versus 8.9%), and aspiration pneumonia rate (8.5% versus 3.8%). A comparison of the 1995 analysis to the 1997 analysis revealed the following per patient resource utilization decreases (all P < 0.05): chemistry laboratory, 2.65 to 1.95 studies; intravenous fluids, 2.85 to 1.85 L; oxygen use, 6.06 to 2.75 U; and nifedipine use, 1.62 to 0.33 capsules. The clinical process improvements resulted in the following overall outcomes (all P < 0.05 except mortality): length of stay (7.2 days), nonadjusted costs ($6246), mortality (6.5%), and rates of pneumonia (2.7%). CONCLUSIONS: Objective analysis of resource utilization resulted in physicians changing their individual management of stroke and collectively supporting clinical process changes that improved clinical and financial outcomes.

Aged↗
PubMed1998

Clinical applications of computer-based health information.

Competitive health care systems are improving their clinical and cost efficiency by performing clinical practice analyses. Large numbers of severity-adjusted cases provide the most objective data for making clinical efficiency decisions. The most cost-effective way to perform these analyses is to utilize well-coded, computer-based health information. This requires consistent coding of patients' comorbidities and complications as well as an interactive working relationship between coders and clinicians providing the clinical practice analysis. The article describes one hospital's evolving clinical efficiency information needs, how its health information system met them, the clinical practice analysis procedure, and the outcomes of this clinical practice analysis.

Abstracting and Indexing↗
PubMed1997

Mastoparan-induced apoptosis of cultured cerebellar granule neurons is initiated by calcium release from intracellular stores.

We have recently reported that mastoparan, a peptide toxin isolated from wasp venom, induces apoptosis in cultured cerebellar granule neurons that can be blocked by cholera toxin, an activator of Gs. Measurements of intracellular free calcium concentration ([Ca2+]i) reveal that mastoparan induces a dramatic elevation of [Ca2+]i that is frequently followed by enhanced leakage of fura-2 out of the neurons, suggesting that this rise in [Ca2+]i may be due to a more generalized change in membrane permeability. However, the mastoparan-induced initial elevation of [Ca2+]i is maintained in the absence of extracellular Ca2+, suggesting that the rise of [Ca2+]i is from intracellular stores. This conclusion is supported by the observation that depletion of [Ca2+]i stores by pretreatment with either caffeine or thapsigargin attenuates both the rise in [Ca2+]i and cell death induced by mastoparan. Phospholipase C (PLC) inhibitors, neomycin and U73122 block mastoparan-induced increases of [Ca2+]i and protect against neuronal death. Pretreatment with cholera toxin, but not pertussis toxin, reduced the mastoparan-induced rise in [Ca2+]i. Taken together, our data suggest that mastoparan initiates cell death in cerebellar granule neurons by inducing Ca2+ release from intracellular stores, probably via activation of PLC and IP3. A secondary or parallel process results in disruption of plasma membrane integrity and may be ultimately responsible for the death of these neurons by mastoparan.

Animals↗
PubMed1997

Radiation protection by alpha-methyl-homocysteine thiolactone in vitro.

The radiation protective effect of thiol compounds is unequivocal and their use is only limited by their toxic effects. We used the principle of alpha alkylation, which renders amino acids unmetabolizable, to reduce the toxicity of homocysteine. This product, alpha-methyl-homocysteine thio-lactone, was tested for toxicity and radiation protective effect along with known protectors L-cysteine, cysteamine and WR 1065 in cell culture using V79-4 Chinese hamster lung cells. The three-day growth curve assays, useful to measure overall effects on cell growth, revealed lowest toxicity for alpha-methyl-homocysteine thiolactone (GL-2). Clonogenic survival tests, used to evaluate the retention of reproductive integrity, were carried out and revealed that GL-2 had no adverse effects in this test system. Radiation protection tests showed that GL-2 exhibited protective activity against radiation induced lethality above that seen with cysteine and cysteamine, but below WR 1065. However, GL-2 showed little or no negative effects toward the cell itself, in direct contrast to WR 1065. Our findings show a potentially important tool and principle to reduce toxicity of radiation protectors with analogous structures.

Animals↗
PubMed1997

Presentation and management of a thyroglossal duct cyst with a papillary carcinoma.

Thyroglossal duct carcinoma is rare, and its presentation is similar to that of a thyroglossal duct cyst: a nontender, palpable mass in the midline location. Rapid increase in growth may be a sign of malignancy, but the diagnosis is based on the pathology of the cyst. Initial treatment of thyroglossal duct carcinoma is the same surgical procedure used for removal of a thyroglossal duct cyst. Further surgery depends on the finding of thyroid nodules or positive lymph nodes but is rarely necessary. The recurrence rate after simple excision is low. Postoperative radioiodine ablation or radiation is considered in cases of recurrence or metastasis. In this report, we describe a patient with a new-onset, nontender, neck mass who had a Sistrunk procedure for a presumed thyroglossal duct cyst and was found to have papillary carcinoma.

Aged↗
PubMed1997

Developing a rural primary care practice network.

Establishing and managing a primary care practice in rural communities is particularly challenging. Many rural practices are closing, and relatively few new practices are initiated independently. The integrated health system can provide at least part of the solution to the lack of physicians in the rural setting. The following article describes the objectives, methods, and results of an integrated health system's development of a rural primary care provider network.

Community Networks↗
PubMed1995

Opportunities for pharmaceutical care with critical pathways.

Critical pathways are multidisciplinary tools designed to improve patient care and efficiency. Almost every path requires some type of pharmacotherapeutic intervention, from selection of surgical prophylaxis to management of anticoagulation. Pharmacists should become involved with the critical pathway process because it offers an excellent opportunity to incorporate pharmaceutical care and to meet Joint Commission on Accreditation of Healthcare Organization compliance criteria.

Clinical Protocols↗
PubMed1995

Thiazolidine prodrugs of cysteamine and cysteine as radioprotective agents.

The need for protection against the toxic effects of ionizing radiation comes from many different directions: occupational exposure, nuclear accidents, environmental sources and protection of normal tissue during the therapeutic irradiation of cancer. Sulfhydryl-containing compounds, including cysteamine and L-cysteine, have long been known to possess radioprotective properties, but their therapeutic utility is limited by their side effects at radioprotective doses. To avoid this drawback, thiazolidine prodrugs of cysteamine and L-cysteine were prepared by the condensation of each thioalmine with the aldose monosaccharides, D-ribose and D-glucose, producing RibCyst, GlcCyst, RibCys and GlcCys. The prodrugs were designed to liberate the parent thiolamine nonenzymatically, after ring opening and hydrolysis, which is then available to function as a radioprotective agent. Cysteamine's inherent toxicity, measured using Chinese hamster V79 cells growing in culture, was completely eliminated, even at concentrations as high as 25 mM, by providing the thiolamine in the form of a prodrug. Good protection against radiation-induced lethality was demonstrated by the cysteamine prodrugs using a clonogenic assay. Protection against radiation-induced DNA single-strand breaks, as measured by alkaline elution, was also shown by both RibCyst and GlcCyst; this activity was higher than that exhibited by either cysteamine or WR-1065. The L-cysteine prodrugs, RibCys and GlcCys, also possessed radioprotective abilities under most of the conditions studied. Protection against DNA damage was comparable between L-cysteine, WR-1065 and RibCys.

Animals↗
PubMed1991

Use of ampicillin-sulbactam before and after formulary inclusion.

The use of ampicillin-sulbactam before and after the product was formally placed on a hospital formulary is described. In October 1987 the pharmacy and therapeutics committee at an acute-care institution granted ampicillin-sulbactam temporary formulary inclusion on the condition that its use be audited. Formal inclusion was to be based on the results of this preinclusion audit. A second audit was to be performed if formal inclusion was granted. The data were collated after each audit, and for each patient an infectious-disease consultant proposed an alternative antimicrobial regimen representing what would probably have been prescribed had ampicillin-sulbactam not been available. Sixty-four patients received the product during the six-month preinclusion audit period. Ampicillin-sulbactam was given to 37% of the patients for indications listed in FDA-approved labeling. The dosage was considered appropriate in 88% of the patients. Clinical outcome was considered successful in 84% of the patients who received the product for known infections. Therapy with ampicillin-sulbactam was less expensive (by $4125) in 35 patients and more costly (by $1523) in 29 patients; the projected annual savings were $7805. After formal inclusion on the formulary, ampicillin-sulbactam was prescribed for some 700 patients over a 16-month period. A review in 49 patients showed appropriate indication and dosage for 63% and 84% of the patients, respectively, and an 84% rate of therapeutic success. The extrapolated cost savings were $26,429 per year. After formulary inclusion, the use of ampicillin-sulbactam increased, as did the frequency of its use for indications appearing in FDA-approved labeling.

Ampicillin↗
PubMed1990

Use of standardized screening procedures to identify adverse drug reactions.

The development of an adverse drug reaction (ADR)-monitoring program using standardized screening procedures in a 650-bed hospital is described. A concurrent ADR-reporting system that relied on health-care professionals to report observed ADRs to the pharmacy had generated just two ADR reports during the previous year. The pharmacy developed a program that used standardized procedures to screen for ADRs. The Technicon computer was programmed to screen the previous day's orders for antidotes or "tracer" drugs. In addition, pharmacists screened all laboratory reports of serum drug concentration determinations and positive tests for Clostridium difficile toxin. Spontaneous reporting of ADRs by nurses and physicians was strengthened by use of a revised notification form, newsletters, and inservice-education programs. During the first seven months of the program, 298 ADRs were identified, 15 of which were submitted to FDA. The standardized screening procedures accounted for 149 reports. Pharmacists reviewed an average of 21 reports of high serum drug concentrations each month; on average, 11 of these reports involved ADRs. Screening of microbiology laboratory reports identified 29 ADRs. Physicians reported ADRs infrequently and were likely to report only serious or unexpected reactions. Nurses and pharmacists identified reactions sporadically. Quality assurance auditors were consistent in screening ADRs, but not all reported reactions proved to be ADRs. The use of standardized screening procedures was effective in this pharmacy-based ADR-monitoring program.

Antidotes↗