Biomedical subjects
Publications and source records attributed to M K Reed.
How can nurse managers provide staff with equitable, economical opportunities for professional development education? One hospital's point accrual system makes nurses more active in their own professional development.
BACKGROUND: The original collaborative project was described in a 1995 Journal article titled "Competing HMOs Collaborate to Improve Preventive Services." IMPROVE (IMproving PRevention through Organization, Vision, and Empowerment) was a large randomized controlled trial using continuous quality improvement to implement clinical systems to improve the delivery of adult preventive services in primary care settings. The project was funded by the Agency for Health Care Policy and Research and initiated as a collaboration between two health maintenance organizations (HMOs) in the Twin Cities: Health Partners and Blue Plus. METHODOLOGY: Forty-four clinics were recruited for the study. Initially the 22 intervention clinics received the multifaceted intervention of leadership support, training on CQI and prevention systems, and consultation and networking opportunities. Next, the comparison clinics received similar assistance, and other clinics were invited into the collaboration. Ultimately, 57 clinics were involved in the project. Multiple collaborations--among clinics, leaders, and HMOs--developed during the project. STATUS: Despite turmoil in the environment during the project, many benefits have been described, including enhanced leadership, growth of systems thinking, better change management skills, and collaboration of competing organizations. SUMMARY: The IMPROVE collaboration survived and flourished in a very competitive market. It was viewed positively by clinicians, medical clinics, and HMOs, and its benefits have extended into the community.
Last spring, the Red River Valley of North Dakota and Minnesota was devastated by an unprecedented flood. Flooding caused foundations to collapse and houses to float away or become severely damaged by the raging, sewage-filled water. The river displaced people from their homes, and caused significant disruption of services including water, power, and medical care for 18 days. Find out how a medical contingency plan enabled staff members at the only trauma center and the largest clinic in the region to evacuate safely and effectively nearly 1,000 patients and senior residents in 36 hours, while setting up critical services across the region to care for the 50,000 displaced residents of the flood disaster.
The effects of dichloroacetate (DCA) on fatty acid oxidation and flux through pyruvate dehydrogenase (PDH) were studied in ischemic, reperfused myocardium supplied with glucose, long-chain fatty acids, lactate, pyruvate, and acetoacetate. The oxidation rates of all substrates were determined by combined 13C nuclear magnetic resonance (NMR) spectroscopy and oxygen-consumption measurements, and PDH flux was assessed by lactate plus pyruvate oxidation. In nonischemic control hearts, DCA increased PDH flux more than eightfold (from 0.68 +/- 0.28 to 5.81 +/- 1.16 micromol/min/g dry weight; n = 8 each group; p < 0.05) and significantly inhibited the oxidation of acetoacetate and fatty acids. DCA also improved mechanical recovery after 30 min of ischemia plus 30 min of reperfusion but did not significantly increase PDH flux measured at the end of the reperfusion period (1.35 +/- 0.42 micromol/min/g dry weight) compared with untreated ischemic hearts (0.87 +/- 0.28 micromol/min/g dry weight; n = 8 each group; p = NS). Although DCA had a modest effect on functional recovery in the reperfused myocardium, this beneficial effect was not associated with either marked stimulation of PDH flux or inhibition of fatty acid oxidation.
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Researchers have reported conflicting conclusions about the relation of the MMPI (MMPI-2) clinical scale elevations and race. Consequently, this study examined the concurrent validity of the MMPI-2 in evaluating African-American females. Seventy-eight (78) African American college student volunteers were administered the MMPI-2, along with other measures of personality, achievement, and coping style. Scores revealed 76% of the sample had elevated profiles. Subjects were divided into three groups based on frequency of clinical scale code type. Subjects with the 5/9 profile elevations functioned as well as normals on measures of coping skills and mood disorders. Discussion emphasizes the importance of clinical interpretation of MMPI data in research programs and the relationship of the data to coping style.
After the Fontan operation, systemic venous hypertension drives transpulmonary blood flow. Owing to this physiology, there is a significant incidence of effusions, splanchnic congestion, and generalized edema. To attentuate the effusive problems, partial exclusion of the hepatic veins has been recently practiced by Jacobs and Norwood. This report concerns a patient we recently treated for profound progressive cyanosis due to an acquired intrahepatic venovenous shunt after a Fontan operation with partial hepatic vein exclusion.
OBJECTIVES: A recent report (J Clin Invest 1993;92:831-9) found no effect of glutamate plus aspartate on metabolic pathways in the heart, but the experimental conditions did not model clinical cardioplegia. The purpose of this study was to determine the effects of glutamate and aspartate on metabolic pathways feeding the citric acid cycle during cardioplegic arrest in the presence of physiologic substrates. METHODS: Isolated rat hearts were supplied with fatty acids, lactate, pyruvate, glucose, and acetoacetate in physiologic concentrations. These substrates were enriched with 13C, which allowed a complete analysis of substrate oxidation by 13C-nuclear magnetic resonance spectroscopy in one experiment. Three groups of hearts were studied: arrest with potassium cardioplegic solution, arrest with cardioplegic solution supplemented with glutamate and aspartate (both in concentrations of 13 mmol/L), and a control group without cardioplegic arrest. RESULTS: In potassium-arrested hearts, the contributions of fatty acids and lactate to acetyl coenzyme A were reduced, and acetoacetate was the preferred substrate for oxidation in the citric acid cycle. The addition of aspartate and glutamate in the presence of cardioplegic arrest did not further alter patterns of substrate utilization substantially, although acetoacetate use was somewhat lower than with simple cardioplegic arrest. When [U-13C]glutamate (13 mmol/L) and [U-13C]aspartate (13 mmol/L) were supplied as the only compounds labeled with 13C, little enrichment in citric acid cycle intermediates could be detected. CONCLUSIONS: Glutamate and aspartate when added to potassium cardioplegic solutions have relatively minor effects on citric acid cycle metabolism.
This report concerns the finding of a clinically benign 4-cm mass in the anterior thorax of a 12-year-old girl. The tumor was inseparable from the chest wall. A wide excision was performed. Microscopic examination proved it to be a rare but distinctive lesion recently entitled "calcifying fibrous pseudotumor" primarily involving the chest wall. Wide excision is thought necessary to preclude local recurrence.
The Technology Assessment Committee of the Institute for Clinical Systems Integration (ICSI) draws upon the resources of many different groups and in turn, keeps the groups informed about new medical treatments, devices, and procedures. This new Minneapolis-based technology assessment committee uses a collaborative effort to serve the information needs of many employer groups, patients, providers, and health care organizations in the area. This committee serves as the principal mechanism by which new medical and surgical procedures, devices, and treatments, as well as new applications of old but unproved or doubtful applications of existing technologies are reviewed for medical appropriateness at ICSI (a nonprofit quality improvement organization) and at HealthPartners (a combined staff and group model HMO in Minnesota).
The efficacy of Structured Learning Therapy (SLT) in treating adolescent depression was evaluated. SLT treatment focuses on developing social competencies, self-evaluation skills, and appropriate affective expression. Eighteen adolescents, aged 14-19 years, prescreened for depression were randomly assigned to the SLT treatment or control group. All subjects participated in six biweekly 60-minute sessions. Pre-, post, and follow-up assessments on depression, self-esteem, and personality measures were conducted. Results suggest that SLT reliably reduced depression in males (p < .05) and maintained their improved level of functioning (p < .02). Female treatment subjects did not improve significantly. Results suggest differential effectiveness of treatment across gender.
We compared duplex scanning and cerebral angiography in patients with hemispheric ischemia, testing the premise that carotid endarterectomy (CEA) or medical management may be recommended on the basis of duplex scanning alone. Charts of 152 patients who had both studies were reviewed. A positive study (implying an operable lesion) showed any ulcerated plaque or stenosis of 50% to 99% on the symptomatic side. A positive duplex scan correctly predicted the need for CEA (with no additional essential information gained from angiography) more than 98% of the time. Equally important, patients with a negative duplex or patients in whom carotid occlusion is suspected ought to have angiography.
Left ventricular outflow tract obstruction after mitral valve replacement may occur when a retained native anterior leaflet prolapses between prosthetic struts. Existing reports of left ventricular outflow tract obstruction by this mechanism lack emphasis on its surgical treatment. We obtained definitive relief of left ventricular outflow tract obstruction by transaortic exposure, division, and partial excision of the obstructing leaflet. This approach minimizes the complexity and potential morbidity of the correction.
Atherosclerosis was induced in male rabbits by administration of a 2% cholesterol diet for up to 18 weeks. The animals were assessed for aortic microsomal prostanoid synthesis, morphologic assessment and serum cholesterol levels. Serum levels of cholesterol increased from control values of 84 +/- 9 ng/dl to 1632 +/- 227 ng/dl at 2 weeks (20-fold increase), and 4859 +/- 829 ng/dl at 9 weeks (57-fold increase). Aortic microsomal prostacyclin synthesis fell significantly at 2 weeks of cholesterol feeding which predated the morphologic appearance of atherosclerotic plaque in the 7 week group. Aortic microsomal PGI2 synthesis significantly increased by 7 weeks and did not fall until the 18 week group when a highly significant increase in aortic plaque developed. These findings suggest a triphasic response of aortic PGI2 synthesis with the development of early atherosclerosis. Phase one is a fall in aortic PGI2 synthesis which predates the appearance of plaque. In phase 2, a significant rise in aortic PGI2 with the appearance of plaque could represent compensation of aortic endothelium to prevent further plaque development. In phase 3, decreased aortic PGI2 could indicate replacement of normal endothelium by atherosclerotic plaque.
The effect of hemorrhagic shock on rat splanchnic prostanoid synthesis was examined in vitro. Male rats were bled to a mean pressure of 30 mm Hg for 30 min. At that time a midline laparotomy was performed and the superior mesenteric artery (SMA) was cannulated and removed in continuity with its end organ (SV + SI). The SV + SI was perfused at 3 ml/min with oxygenated Krebs-Henseleit buffer at 37 degrees C. Venous effluent (3 ml) was collected at 15, 30, 60, 90, 120, 150, and 180 min and frozen for analysis of basal prostanoid release. Levels of 6-keto-PGF1 alpha (6-keto), PGE2, thromboxane B2 (TxB2), and PGF2 alpha were analyzed by radioimmunoassay and compared in the shock (SK) and sham-operated control (SM) animals. SK 6-keto and TxB2 increased significantly at 15 min of perfusion and then decreased to a lower baseline from 60 through 120 min of perfusion. The major prostanoid released at all time periods was 6-keto (2 to 20 times higher than other prostanoids). One-way ANOVA (pooled times) showed that 6-keto significantly increased in the SK group compared to the SM group (P less than 0.02). These data suggest that the splanchnic bed attempts to compensate for hemorrhagic shock by the marked release of the endogenous vasodilator prostacyclin. Release of the other prostanoids (including TxB2) from the splanchnic bed was modest in our model.
Limb salvage after popliteal artery trauma in children demands the best in judgement and technique from the vascular or trauma surgeon. From September 1, 1985, through August 30, 1988, seven patients under age 18 were referred to our Center with popliteal arterial trauma. Four had blunt injuries and three had penetrating injuries. Associated injuries included three fractures, four severe soft tissue wounds, and one nerve injury. All patients underwent angiography, four preoperative and three intraoperative. Treatment included two primary repairs, four vein graft bypasses, and one fasciotomy and intraoperative angiography. Anastomoses were spatulated and sutured in an interrupted fashion. There were no deaths, amputations, or reoperations. At 10 to 42 months after repair, all patients have normal Doppler pressures and/or distal pulses. This study is the largest reported series of these challenging injuries. Contrasting with previous reports, it suggests that with prompt, aggressive treatment, a successful outcome may be anticipated.
The effect of hypoxia on isolated perfused rat mesenteric basal venous prostanoid output was studied. Male rat splanchnic vasculature was removed without (SV) or with its end organ (SV + SI) and perfused with Krebs' buffer with a pO2 of 460 or 60 mm torr. Basal splanchnic venous effluent was assayed for 6-keto-PGF1 alpha, TxB2 and PGE by radioimmunoassay at 30, 60, 120 and 180 min of perfusion. Basal output of SV 6-keto-PGF1 alpha was five and ten fold higher than for PGE and TxB2 respectively and comprised 36% or greater of SV + SI 6-keto-PGF1 alpha output. SV PGE and TxB2 output comprised less than 19 and 12% respectively of SV + SI output. Hypoxia decreased SV + SI PG output, 6-keto-PGF1 alpha being most affected. Hypoxia did not alter SV 6-keto-PGF1 alpha output indicating the SI as the anatomic location most influenced by hypoxia. The relative amounts of distribution of PGE or TxB2 output were not altered by hypoxia. These data suggest that there are two distinct areas of splanchnic prostanoid output, the SV and the SI. Decreased 6-keto-PGF1 alpha output might alter splanchnic blood flow at two levels, the splanchnic vasculature, and/or within the bowel wall.
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