Customer service: the new battlefield for market share

In a survey conducted by the authors of the following article, it was determined that more than 50 percent of employers and managed care companies dropped providers who failed customer service standards. Many employers stated that they changed health plans according to their employees' preferences. Managed care organizations reported that they use the data from customer service surveys to choose providers, facilitate contract negotiations, and determine provider bonuses. Healthcare financial professionals can gain competitive advantages and help secure their organizations' financial future by focusing their resources and attention toward customer service issues.

Using the Resident Assessment Instrument for quality enhancement in nursing homes

BACKGROUND

in some current policy discussions concerning long-term care, the emphasis has been almost solely on the costs of care. This dialogue must be replaced with a discussion of value, which emphasizes both the costs of care and quality of care. While the Resident Assessment Instrument (RAI) was originally designed as a multidimensional assessment tool aimed at improving clinical practice, it can also provide the foundation for a comprehensive data base that can be used to assess and monitor the quality of care. AIMS and

CONCLUSIONS

using data from four sites (in Denmark, Iceland, Italy and the USA) and eight indicators of quality that could be derived from single assessments, we demonstrate how quality might be measured and compared using the RAI. Although this is for illustrative purposes only it does show how this data base can provide invaluable information to providers about the quality of care within their facilities. It can also allow consumers and purchasers to evaluate the relative performance of different providers.

Thyroid neoplasia in children

In 1995, the incidence of childhood thyroid cancer in England and Wales was only 0.5 cases per million children per year. Papillary cancers in younger children were histologically distinct from tumors in older individuals. The incidence of thyroid cancer in the vicinity of Chernobyl increased by 62 times within 5 years of the nuclear explosion. Mutations of the RET protooncogene (a growth factor receptor) occur in nearly all familial medullary thyroid carcinomas and may be used for family screening. RET is involved in chromosomal rearrangements in a majority of childhood papillary thyroid cancers. Fine-needle aspiration biopsy identifies the childhood thyroid nodules that are at greatest risk for cancer. It should be noted, however, that approximately 2% of aspirates are falsely negative. The adequacy of unilateral surgery for papillary thyroid cancers is controversial. Aggressive surgery for persistent medullary carcinoma produces remission in one third of patients. Novel radionuclide techniques are useful in detecting and treating metastatic medullary carcinoma.

Safety and clinical utility of long-term intravenous milrinone in advanced heart failure

Few data are available on the long-term safety or clinical utility of the inodilator agent milrinone. We designed a prospective, nonrandomized, observational trial in a cohort of 71 patients who had demonstrated dependence on inotropic therapy, had been clinically stable on an inotropic regimen (milrinone, dobutamine, or both) for > or = 72 hours, and had been given intravenous milrinone for > 72 hours. Group I (n = 22) patients required treatment with both milrinone and dobutamine to achieve stability; group II (n = 49) patients attained stability initially with either milrinone (subgroup IIA) or dobutamine (subgroup IIB), but later required adjunctive therapy with the other inotropic agent for continued hemodynamic support. Of the 71 patients, 38% required mechanical intervention to achieve hemodynamic stability, and 68% were successfully bridged to heart transplantation. Patients were maintained on milrinone therapy for as long as 8 weeks and demonstrated a low incidence of adverse cardiac (7%) or noncardiac (4%) events. Subgroup IIA (28%) had significantly less need than subgroup IIB (52%) for mechanical intervention using an intraaortic balloon pump (p = 0.05), although mortality rates while awaiting transplantation were statistically similar in subgroups IIA (28%) and IIB (35%). Significant improvements from baseline values were noted at the time of transplantation for all aspects of systemic hemodynamics, indicating sustained long-term hemodynamic effects. Long-term intravenous milrinone therapy is safe and well tolerated, and it provides hemodynamic and metabolic support as a pharmacologic bridge to transplantation. The findings also suggest that milrinone as primary inodilator therapy may be associated with less need for mechanical ventricular support.

Attained adult height after childhood asthma: effect of glucocorticoid therapy

BACKGROUND

Although oral and inhaled glucocorticoid therapy may impair growth in children with asthma, the effect of glucocorticoid therapy and asthma on attained adult height has not been extensively studied in representative children in the community.

OBJECTIVES

The study was designed to compare the attained adult height of children with asthma with the attained adult height of nonasthmatic children and to compare the attained adult height of asthmatic children treated with glucocorticoids with the attained adult height of asthmatic children who did not receive glucocorticoids.

METHODS

Residents of Rochester, Minnesota, with onset of asthma from 1964 to 1987 and age- and sex-matched non-asthmatic residents of Rochester were studied. Glucocorticoid exposure was assessed from medical records. The mean of 5 stadiometer measurements of adult height, adjusted for sex and parental height, was analyzed.

RESULTS

One hundred fifty-three patients with asthma (mean age at onset, 6.1 +/- 4.8 years) and 153 age- and sex-matched nonasthmatic subjects were studied. Adult height of patients with asthma (mean age at measurement, 25.7 +/- 5.2 years) was not significantly different from the adult height of non-asthmatic subjects; the overall difference, adjusted for mid-parental height, was -0.20 cm (95% confidence interval from -0.27 to 1.64). The adult height of asthmatic children treated with glucocorticoids was not significantly different from the adult height of patients with asthma not treated with glucocorticoids; the difference after adjusting for mid-parental height was -0.2 cm (95% confidence interval from -0.1 to 0.6).

CONCLUSIONS

We conclude that the attained adult height of patients with asthma is not different from the adult height of age- and sex-matched nonasthmatic subjects and that the attained adult height of asthmatic children treated with glucocorticoids is not significantly different from the adult height of children not treated with glucocorticoids.

Insular thyroid carcinoma in adolescents: a potentially lethal endocrine malignancy

BACKGROUND

Insular thyroid carcinoma is intermediate in aggressiveness between well differentiated and anaplastic thyroid carcinomas.

METHODS

The authors describe two children with insular thyroid carcinoma who had markedly different outcomes. In the first case, a girl age 15 years, 2 months presented with a large pulsatile mass in the right thyroid lobe. In the second case, a girl age 16 years, 3 months presented after total thyroidectomy was performed elsewhere for confirmed pTNM Stage I insular thyroid carcinoma.

RESULTS

In Case 1, total thyroidectomy was performed, and histologic examination revealed insular thyroid carcinoma with lymph node involvement. Six weeks postoperatively, neck masses reappeared. There was significant radioactive iodine uptake in the thyroid bed and in a palpable right supraclavicular lymph node; this was associated with an increased serum thyroglobulin level. Ultrasound-guided biopsy of the lymph node confirmed recurrent insular carcinoma, and neck dissection was performed. Six weeks later, there was 0.35% iodine uptake in the neck, and the patient was treated with 300 mCi of (131)I. She had no signs of recurrence when last seen 22 months postoperatively. In Case 2, the patient was given 29.9 mCi of (131)I for remnant ablation. Four months postoperatively, fine-needle aspiration biopsy of a high jugular lymph node demonstrated recurrence. The patient was given 200 mCi of (131)I but had no significant response. Right modified neck dissection was performed, followed by external beam radiation. Despite aggressive treatment with a further 500 mCi of (131)I, progressive lung and mediastinal metastases developed, followed by brain metastasis. The patient died 31 months after the initial diagnosis.

CONCLUSIONS

Insular thyroid carcinoma may occur and behave aggressively in children. Vigorous initial surgical and radioactive iodine treatments are warranted.

Loss of the N-myc oncogene in a patient with a small interstitial deletion of the short arm of chromosome 2

To our knowledge, only four previous cases of distal chromosome 2p deletions exist in the literature. We present a patient with minor facial anomalies who had a distal interstitial deletion of the short arm of chromosome 2, del(2)(p24.2p25.1). This patient had many features seen in other patients with distal 2p deletion including short stature, "rectangular" facies, microcephaly, hypotonia, and mental retardation. This patient also has sensorineural hearing loss which has been described in one other patient with a similar deletion. The N-myc oncogene has been mapped to 2p24. By fluorescence in situ hybridization using a cDNA probe for the N-myc oncogene, this patient was found to have a deletion of the N-myc oncogene. This confirms the previous map location for N-myc.

Surgical treatment of Graves' disease in patients younger than 18 years

Eighty-two children and adolescents (18 males, 64 females; median age 14 years) surgically treated for Graves' disease at a single institution between 1979 and 1993 were retrospectively reviewed. Most of the patients (74%) coming to thyroidectomy had been treated medically for a period ranging from 2 to 80 (median 15) months. Bilateral subtotal thyroid resection was the most frequently performed procedure (86%). Postoperatively, no permanent recurrent laryngeal nerve palsy or permanent hypocalcemia occurred. Operative mortality was zero. With a median follow-up of 8.3 years, recurrent hyperthyroidism occurred in five patients (6%), one of whom required reoperation. Most children and adolescents with Graves' disease can be rendered euthyroid by nonsurgical treatment options. However, prolonged and ineffective medical treatment should be avoided in these patients who are in the formative years of their lives. Surgical treatment, when indicated and employed, offers young patients with Graves' disease a safe, rapid, definitive, cost-effective treatment with a high success rate.

Applying performance measures to long-term care

BACKGROUND

Nine nursing facilities in Mississippi participated in the American Health Care Association's Quality Indicator Index and Education (QUIIX-Ed) project to apply quantitative performance measurements to continuous quality improvement in long-term care. Begun in May 1994, with the first collection of performance measurement data in March 1995, the project used 15 measures of clinical care based on standardized assessments of resident conditions.

METHODOLOGY

QUIIX-Ed assessed the impact of quality indicator information in nursing facilities based on Minimum Data Set resident assessments. Comparison reports allow each facility to profile its performance against that of other providers in the project. The project does not standardize the quality improvement process: the focus is on the incorporation of information into existing nursing care and quality improvement practices.

OPERATIONAL ISSUES

Each month the facilities updated their quality indicator scores and exported those scores to a central database that aggregated scores to generate benchmarking statistics for each facility, including project medians, percentiles, and facility performance rankings.

EXAMPLES

Two case studies on bedfast residents and restraint use illustrate the process of examining care issues identified by quality indicators, developing appropriate interventions, and evaluating the efficacy of the intervention.

DISCUSSION

The limited intervention of introducing quantitative care measurements had a significant impact on resident outcomes and the nursing process. These measurements are readily incorporated into existing nursing practices and facility improvement efforts, regardless of the extent to which the quality improvement process has been developed.

Concurrent hormone resistance (pseudohypoparathyroidism type Ia) and hormone independence (testotoxicosis) caused by a unique mutation in the G alpha s gene

Defects in the G (guanine nucleotide-binding)-protein subunit (G alpha s) which stimulates adenylyl cyclase may result in either loss or gain of endocrine function. Reduced G alpha s activity is found in the hormone resistance syndrome, pseudohypoparathyroidism type Ia (PHP-Ia), while constitutive activation of G alpha s is associated with endocrine organ overactivity, including the gonadotropin-independent sexual precocity seen in patients with McCune-Albright syndrome. We identified two unrelated boys presenting with concurrent PHP-Ia and gonadotropin-independent sexual precocity (testotoxicosis). Mutational screening by denaturing gradient gel electrophoresis and sequencing of PCR-amplified exons of the G alpha s gene revealed a point mutation which generates an alanine-to-serine substitution in codon 366 of one G alpha s allele (A366S), an alanine present at the homologous position in all G-proteins. We have previously shown in transfected testis cells that the A366S mutation activates G alpha s by decreasing affinity for GDP, thereby increasing the rate of nucleotide exchange in a receptor-independent fashion. In contrast to differential stability of the activated mutant G alpha s protein in Leydig cells, with stability at 32 degrees C but not at 37 degrees C, skin fibroblasts with the mutation had the same reduced G alpha s levels at both temperatures. Our findings explain the limitation of clinical manifestations of G alpha s overactivity to testis, without involvement of other body appendages which are generally at lower than core body temperature. This unique mutation at a critically conserved residue of G alpha s is the first mutant G-protein which affects guanine nucleotide affinity and is associated with human disease, producing widely divergent and tissue-specific effects.

Fibronectin regulates calvarial osteoblast differentiation

The secretion of fibronectin by differentiating osteoblasts and its accumulation at sites of osteogenesis suggest that fibronectin participates in bone formation. To test this directly, we determined whether fibronectin-cell interactions regulate progressive differentiation of cultured fetal rat calvarial osteoblasts. Spatial distributions of alpha 5 integrin subunit, fibronectin, osteopontin (bone sialoprotein I) and osteocalcin (bone Gla-protein) were similar in fetal rat calvaria and mineralized, bone-like nodules formed by cultured osteoblasts. Addition of anti-fibronectin antibodies to cultures at confluence reduced subsequent formation of nodules to less than 10% of control values, showing that fibronectin is required for normal nodule morphogenesis. Anti-fibronectin antibodies selectively inhibited steady-state expression of mRNA for genes associated with osteoblast differentiation; mRNA levels for alkaline phosphatase and osteocalcin were suppressed, whereas fibronectin, type I collagen and osteopontin were unaffected. To identify functionally relevant domains of fibronectin, we treated cells with soluble fibronectin fragments and peptides. Cell-binding fibronectin fragments (type III repeats 6–10) containing the Arg-Gly-Asp (RGD) sequence blocked both nodule initiation and maturation, whether or not they contained a functional synergy site. In contrast, addition of the RGD-containing peptide GRGDSPK alone did not inhibit nodule initiation, although it did block nodule maturation. Thus, in addition to the RGD sequence, other features of the large cell-binding fragments contribute to the full osteogenic effects of fibronectin. Nodule formation and osteoblast differentiation resumed after anti-fibronectin antibodies or GRGDSPK peptides were omitted from the media, showing that the inhibition was reversible and the treatments were not cytotoxic. Outside the central cell-binding domain, peptides from the IIICS region and antibodies to the N terminus did not inhibit nodule formation. We conclude that osteoblasts interact with the central cell-binding domain of endogenously produced fibronectin during early stages of differentiation, and that these interactions regulate both normal morphogenesis and gene expression.

Mutations in the Ca(2+)-sensing receptor gene cause autosomal dominant and sporadic hypoparathyroidism

Parathyroid hormone secretion is negatively regulated by a 7-transmembrane domain, G-protein coupled Ca(2+)-sensing receptor. We hypothesized that activating mutations in this receptor might cause autosomal dominant hypoparathyroidism (ADHP). Consistent with this hypothesis, we identified, in two families with ADHP, heterozygous missense mutations in the Ca(2+)-sensing receptor gene that cosegregated with the disorder. None of 50 normal controls had either mutation. We also identified a de novo, missense Ca(2+)-sensing receptor mutation in a child with severe sporadic hypoparathyroidism. The amino acid substitution in one ADHP family affected the N-terminal, extracellular domain of the receptor. The other mutations involved the transmembrane region. Unlike patients with acquired hypoparathyroidism, patients with these mutations had hypercalciuria even at low serum calcium concentrations. Their greater hypercalciuria presumably reflected activation of Ca(2+)-sensing receptors in kidney cells, where the receptor negatively regulates calcium reabsorption. This augmented hypercalciuria increases the risk of renal complications and thus has implications for the choice of therapy.

Cytogenetic and clinical characteristics of a case involving complete duplication of Xpter-->Xq13

True isochromosomes for Xp probably do not exist in a liveborn. We describe a rare case of complete Xp duplication and retention of the inactivation centre at Xq13. Cytogenetically, it is described as a nonmosaic 46,X,psu idic(X)(q13). Complete duplication of Xpter-->Xq13 was confirmed by banded analysis and FISH probes for X centromere, Xp21, XIST locus, and whole chromosome paints for X and Y. The abnormal X was always late replicating. Clinically, the patient was short statured, had primary amenorrhoea, and incomplete development of secondary sexual characteristics, but otherwise was phenotypically normal. There are no non-mosaic reported cases with complete duplication of i(Xp) confirmed by FISH or molecular techniques. Those cases with partial duplication of Xp and presence of the inactivation centre share the traits of amenorrhoea and poor secondary sexual development. To develop a clinical profile of duplication of Xp (in presence of Xq13) there is a need to study more cases.

Aromatase expression in human germinomas with possible biological effects

Gonadal aromatase expression has been demonstrated in human Leydig, granulosa, and thecal cells, but never in human germ cells. In an attempt to explain the unique occurrence of isosexual precocious puberty in a young girl with a hCG-secreting suprasellar germinoma, we demonstrated the presence of aromatase expression in the germ cell component of this tumor. Immunohistochemical staining for P450-aromatase and hCG using a peroxidase-labeled streptaviden-biotin technique was performed on tumor specimens from the above patient and from four other subjects with central nervous system germinoma. Cytoplasmic aromatase staining was present in the germinoma cells of four of five cases of central nervous system germinoma studied. Staining was absent in the lymphocytic element within the tumor and in negative control tissues. The demonstration of aromatase activity in the malignant element of human germinomas indicates that aromatase expression can occur in human germ cells after malignant transformation. This parallels the finding that the transformation of Sertoli cells to sex cord tumor with annular tubules in Peutz Jeghers syndrome is associated with the induction of marked aromatase expression and systemic estrogen effect. We propose that tumor aromatase played a similar role in the unique occurrence of isosexual precocity in a girl with a suprasellar germinoma.

Primary cutaneous T-cell-rich B-cell lymphoma. A case report with a 13-year follow-up

Cutaneous B-cell lymphomas constitute approximately 20% of primary cutaneous lymphomas. Most histologic subtypes of nodal B-cell lymphomas also occur primarily in the skin. The recently described T-cell-rich B-cell lymphomas (TCRBCLs) manifest mainly in the lymph nodes. This article presents a case of TCRBCL arising primarily in the skin, the origin of which could be traced back 13 years. The patient is a 59-year-old man. Plaque-like and nodular skin infiltrates had first appeared in the left preauricular region. Repeated examinations never found any extracutaneous involvement. A skin biopsy and a retrospectively studied 10-year-old skin specimen showed identical histologic features. Immunohistochemistry identified the TCRBCL previously considered as cutaneous Hodgkin's disease or a diffuse centroblastic centrocytic non-Hodgkin's lymphoma. A clonal B-cell population was detected by polymerase chain reaction, showing a rearrangement of IgH gene. The case of this patient shows that primary cutaneous TCRBCLs, similarly to other B-cell lymphomas in the skin, may have a good prognosis, in contrast to their nodal counterparts.

Integrin-extracellular matrix interactions in connective tissue remodeling and osteoblast differentiation

The differentiaton of bone cells is a complex multistep process. Bone is somewhat unusual in that it is very actively and continually remodeled in the adult and that maintenance of its mass in the mature organism is exquisitely sensitive to mechanical as well as chemical signals. Bone is also unique because it consists of a very large amount of extracellular matrix (ECM) that is mineralized. The integrin family of ECM receptors has been shown to play an important role in tissue morphogenesis in several systems. Our studies on the regulation of matrix remodeling enzymes by integrins in rabbit synovial fibroblasts show that two b1 integrin fibronectin (FN) receptor complexes (alpha 5 beta 1 and alpha 4 beta 1) cooperate in detecting subtle changes in the composition of the ECM. As a result of signal transduction by these integrins, the levels of mRNA and protein for several members of the metalloproteinase family are regulated in these cells. We have also used antibody and RGD peptide perturbation studies to determine the significance of cell/ECM interactions to normal osteogenesis. We found that interactions between the cell binding domain of FN and integrins are required for both normal morphogenesis and gene expression in cultured osteoblasts that differentiate to form bone-like tissue in culture. These data lead us to propose that beta 1 integrins play an important role in osteoblast differentiation as well as in bone remodeling.

Long term follow-up of transsphenoidal surgery for the treatment of Cushing's disease in childhood

Transsphenoidal removal of pituitary adenomas has become the accepted treatment for Cushing's disease. As Cushing's disease is rare in childhood, few reports describe extended follow-up after transsphenoidal surgery for this disease in children. Twenty-two patients less than 19 yr of age were diagnosed with Cushing's disease by standard testing. All patients underwent transsphenoidal surgery (TSS) as primary treatment at Mayo Clinic between 1975 and 1990. Follow-up was available in all patients and averaged 6.7 yr. Adenomas were identified pathologically in 19 patients and visualized by the surgeon in the remainder. There was 1 macroadenoma. Ten patients are considered cured with a mean follow-up of 5.5 yr. Five patients had evidence of persistent disease within 6 months of TSS and required further treatment. Seven patients had remission lasting greater than 6 months with subsequent relapse (mean time to recurrence, 7.0 yr). In children treated with TSS for Cushing's disease, the rate of cure with extended follow-up is only approximately 50%. This rate is much lower than that in adults and may indicate that Cushing's disease is more aggressive in childhood. As TSS is associated with low morbidity, we feel it is still the treatment of choice for Cushing's disease in children.

An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data

This study distinguishes between organizational characteristics, regarded as exogenous structural indicators of quality, and those identified as endogenous indicators of structural care (SC), and investigates the degree to which measures of SC vary by ownership mode (defined by four combinations of chain affiliation and profit status) for 142 certified and licensed nursing facilities (NFs) in a southern state. Structural care measures include: licensed and unlicensed staffing, licensed therapists, and case mix-adjusted direct care expenditures. In addition, seven (four process and three outcome) facility-level, risk-adjusted process, and outcome quality scales are developed from 39 resident-level quality indicators. A causal mode of NF quality arranged according to the structure, process and outcome paradigm is specified and estimated using path analysis. Organizational data derive from the 1991 Medicaid Cost Report; process and outcome quality measures were developed from the Minimum Data Set Plus Resident Assessment Instrument. Using the percentage of Medicaid and private pay residents as covariates, there was a significant overall multivariate effect due to ownership mode on the SC measures. Although there were several significant direct effects, the overall path model was unconfirmed. The multivariate results suggest that some organizational characteristics of structure quality may be more appropriately considered exogenous to causal quality models and therefore have indirect (versus direct) effects on process or outcome quality indicators. The path analysis implies that the structure-process-outcome paradigm may not accurately capture the way NF health care is delivered. Research which considers alternate NF quality paradigms needs to be done with samples that are more representative of national proportions of each ownership mode.

Fine-Needle Aspiration Biopsy: Use in Diagnosis and Management of Pediatric Thyroid Diseases

Fine-needle aspiration (FNA) biopsy of the thyroid is a reliable, safe, cost-effective, and widely used test. Its introduction and application have had a significant impact in the management of nodular thyroid diseases in adults. However, its utility in pediatric practice is not recognized or emphasized. During the last 12 years we performed 10,971 FNAs; 57 (0.5%) were in patients younger than age 17 years. Among 47 of these biopsies, 66% were benign, 15% were malignant, 6% were suspicious for malignancy and 13% were nondiagnostic. Biopsy was most often (96%) performed for the evaluation of diffuse or nodular goiter. The most common benign cytologic diagnosis was colloid goiter in 17 of 31 patients (55%) and Hashimoto's thyroiditis in 9 of 31 patients (29%). There were no false-positive results and there was one false-negative cytologic result. Among patients who had malignancy proved histologically, nine patients (75%) had papillary thyroid cancer. In this study, FNA biopsy was crucial in deferring surgery in 28 of 47 patients (60%). It is clear that the application of FNA biopsy prevents unnecessary surgery and improves surgical selection of patients with thyroid malignancy. On the basis of our extensive experience, we recommend FNA biopsy as the first diagnostic test for pediatric patients with nodular thyroid lesions.

Aqueous vasopressin infusion during chemotherapy in patients with diabetes insipidus

BACKGROUND

Patients who have suprasellar germinomas in childhood often present with central diabetes insipidus (CDI). The authors investigated the use of aqueous vasopressin (AVP) by continuous infusion to control the fluid and electrolyte balance in germinoma patients with CDI during aggressive fluid hydration as a part of a preirradiation chemotherapy protocol.

METHODS

Three patients with suprasellar germinomas and CDI were treated with four courses of preirradiation chemotherapy. Two patients were treated with a continuous AVP infusion at an initial rate of 0.08-0.10 mU/kg per hour during hydration. Fluid intake, urine output, body weight, urine specific gravity, and serum electrolyte concentrations were monitored closely, and the infusion rate was adjusted accordingly.

RESULTS

Very low dose AVP infusion controlled fluid balance while allowing appropriate diuresis during chemotherapy. Fluid intake and output were markedly less in the AVP-treated patients (3.8 L/m2 per day) than in the untreated patient (20 L/m2 per day).

CONCLUSIONS

The use of very low dose AVP infusion at an initial rate of 0.08-0.10 mU/kg per hour during hydration therapy allowed easily titratable control of fluid and electrolyte balance in the patients studied and avoided the complications associated with desmopressin acetate antidiuresis or withholding antidiuretic treatment altogether.

A novel Gs alpha mutant in a patient with Albright hereditary osteodystrophy uncouples cell surface receptors from adenylyl cyclase

Albright hereditary osteodystrophy (AHO) is an autosomal-dominant disorder characterized by decreased expression of Gs alpha and widespread tissue resistance to hormones that activate adenylyl cyclase. We identified a single mutation, R385H, in the Gs alpha gene of a subject with AHO who had evidence for a dysfunctional Gs alpha protein. The R385H substitution is near the carboxyl terminus of the Gs alpha protein and is located five amino acids upstream of the R389P mutation that uncouples Gs alpha from cell surface receptors in the unc clone of S49 murine lymphoma. To test the biological activity of the R385H mutant, we transiently expressed wild type, R385H, and R389P Gs alpha cDNAs in COS-1 cells. Neither of the mutant Gs alpha proteins stimulated adenylyl cyclase in response to l-isoproterenol (1 to 30 microM). By contrast, both mutant Gs alpha proteins showed activation of adenylyl cyclase in response to forskolin (10 microM) and fluoroaluminate (10 mM). We propose that the R385H mutation produces a Gs alpha molecule that is unable to interact with hormone receptors and results in uncoupling of adenylyl cyclase from cell surface receptors. This uncoupling mutation represents a new type of molecular defect that can result in AHO.

Pituitary adenomas in childhood and adolescence

A clinicopathological study of 56 pediatric patients with non-ACTH-secreting pituitary adenomas removed by a transsphenoidal neurosurgical approach was undertaken to better define the clinical presentation, to assess demographic factors, to determine the immunohistochemical staining characteristics of the tumors, and to evaluate the outcome of transsphenoidal surgical treatment and other adjuvant therapies. A separate analysis of prolactinoma patients was performed. All tumors were confirmed histologically and immunophenotyped for pituitary hormones. Forty-one patients had tumors that stained for PRL alone, eight patients had tumors that stained for PRL and GH, six patients had plurihormonal adenomas, and one patient had a tumor that stained for glycoprotein hormones. No tumors contained GH alone. Macroadenomas exceeded microadenomas (1.4:1). There were no male patients with microadenomas of any type. Females outnumbered males (3.3:1). Patients presented most frequently with headache, menstrual dysfunction (in females), galactorrhea, and hypopituitarism. All but one of the patients with hypopituitarism at presentation had macroadenomas. Tumor staining characteristics did not always correlate well with clinical status, especially with regard to GH-containing tumors. Pediatric pituitary tumors did not appear to be more invasive or more aggressive than adult pituitary tumors, contrary to some previous reports. The patients with microadenomas had a 70% operative cure rate and a 65% long term cure rate; the recurrence rate for microadenoma patients was 25%. Macroadenoma patients had a 33% operative cure rate, a 55% long term cure rate, and a recurrence rate of 33%. Thus, microadenoma and macroadenoma patients had similar long term cure rates, but macroadenoma patients required more aggressive adjuvant therapy (second surgery, radiation, or bromocriptine) and had higher rates of hypopituitarism (52% of macroadenoma patients vs. 0% of microadenoma patients required long term hormone replacement).

Cushing's disease in children

As with adults, the diagnosis of Cushing's disease in childhood can be difficult. The clinical presentation in children is distinctive in terms of the effects on growth and pubertal development. The biochemical diagnosis can usually be made with standard dexamethasone suppression testing, similar to such testing in adults. The clinical course of Cushing's disease in children tends to be more aggressive than in adults, as evidenced by higher rates of Nelson's syndrome after bilateral adrenalectomy and higher rates of recurrence after removal of corticotrope adenomas. TSS is well tolerated in children and has fewer side effects than other modalities. Currently, pituitary irradiation is best reserved as adjunctive therapy. Newer stereotactic computer assisted linear accelerator techniques (e.g., proton knife) may provide increased effectiveness with fewer side effects and be particularly useful in childhood Cushing's disease. Appropriate treatment of children with Cushing's disease can be compatible with satisfactory psychosocial adjustment and fertility in adulthood.

Effect of thyroid hormone treatment on thyromegaly in children and adolescents with Hashimoto disease

The effect of thyroid hormone treatment on thyromegaly was evaluated in 69 patients < or = 18 years of age with goitrous Hashimoto disease. Changes in goiter size were related to pretreatment thyroid function (serum thyroxine and thyrotropin concentrations). We found that only hypothyroid patients had a clear diminution of their thyromegaly when given thyroid hormone.

Automated precision current delivery: an alternative method for cardiac defibrillation

Substantial evidence suggests that the current associated with the discharge is a more precise predictor of defibrillation success than is the total energy of the discharge. However, virtually all commercially available defibrillators are calibrated in terms of energy. This article describes an alternative type of experimental defibrillator, which provides a precisely controlled current throughout the discharge waveform, independent of the load presented to the discharge electrodes (or "paddles"). The discharge current waveform is designed to have the classical critically damped sinusoid waveform, identical to that of the traditional energy-based defibrillator when it is properly matched with its ideal load (the heart/thorax combination). The techniques used to obtain a controlled current discharge are discussed in addition to special operational features.

Metastatic testicular choriocarcinoma and secondary hyperthyroidism: case report and review of the literature

We report on a 16-year-old boy with metastatic testicular choriocarcinoma, increased levels of human chorionic gonadotropin and profound hyperthyroidism bordering on thyroid storm. Hyperthyroidism was secondary to elevated human chorionic gonadotropin, with a thyroid-stimulating hormone effect. Management consisted of suppressive therapy for the symptoms of thyrotoxicosis until chemotherapy achieved control of the primary tumor and elevated levels of human chorionic gonadotropin. Review of the urological literature demonstrated a lack of recognition of this potentially serious paraneoplastic syndrome and its management.

Automated sequencing of amino acid spin systems in proteins using multidimensional HCC(CO)NH-TOCSY spectroscopy and constraint propagation methods from artificial intelligence

We have developed an automated approach for determining the sequential order of amino acid spin systems in small proteins. A key step in this procedure is the analysis of multidimensional HCC(CO)NH-TOCSY spectra that provide connections from the aliphatic resonances of residue i to the amide resonances of residue i + 1. These data, combined with information about the amino acid spin systems, provide sufficient constraints to assign most proton and nitrogen resonances of small proteins. Constraint propagation methods progressively narrow the set of possible assignments of amino acid spin systems to sequence-specific positions in the process of NMR data analysis. The constraint satisfaction paradigm provides a framework in which the necessary constraint-based reasoning can be expressed, while an object-oriented representation structures and facilitates the extensive list processing and indexing involved in matching. A prototype expert system, AUTOASSIGN, provides correct and nearly complete resonance assignments with one real and 31 simulated 3D NMR data sets for a 72-amino acid domain, derived from the Protein A of Staphylococcus aureus, and with 31 simulated NMR data sets for the 50-amino acid human type-alpha transforming growth factor.

Imaging diagnosis and follow-up of infantile hepatic haemangioendothelioma: a case report

A 4-week-old male infant was admitted to the hospital with acute gastrointestinal bleeding and marked coagulopathy secondary to vitamin K malabsorption in the presence of cholestasis. Physical examination revealed hepatomegaly and cutaneous haemangiomas. Ultrasonography, CT, and MRI demonstrated a multifocal vascular process and allowed the diagnosis of infantile hepatic haemangioendothelioma to be made without the use of more invasive diagnostic procedures. To avoid high-output congestive heart failure, the patient was treated with oral corticosteroids. After 5 months, rapid involution of the vascular malformations ensued. At age 2 years, a magnetic resonance scan confirmed complete resolution of the hepatic haemangioendothelioma.

Patient accounts managers prepare for change

Automated data processing and electronic data interchange have become necessary and increasingly vital aspects of the processes of admission, registration, billing, and collection. A recent survey of patient accounts managers found they feel they may need to improve their technical skills to meet future challenges.

Ibutilide: enhanced defibrillation via plateau sodium current activation

Reductions in current and energy requirements for defibrillation have previously been ascribed to type III antiarrhythmic agents that block outward potassium conductance. This study investigated the effect on defibrillation of ibutilide, a type III antiarrhythmic agent that prolongs action potential duration by activating the sodium component of the plateau inward current. Pentobarbital-anesthetized dogs were subjected to serial episodes of ventricular fibrillation lasting 10 s. In protocol I, current and energy defibrillation requirements were determined via an interactive approach after bolus injections of saline placebo and ibutilide (0.1 mg/kg i.v.). In protocol II, a current dose-response method was utilized in which four shocks each at current doses of 0.7, 0.8, 0.9, and 1.0 x an estimated defibrillation threshold were administered before and after ibutilide (0.075 mg/kg bolus; 0.00125 mg.kg-1 x min-1 i.v.). In protocol I, current and energy values associated with defibrillation measured 10.9 +/- 4.5 A and 16.0 +/- 11.9 J for ibutilide compared with 14.1 +/- 5.6 A and 27.7 +/- 17.7 J for placebo, respectively (n = 9, P < 0.005). In protocol II, ibutilide significantly shifted the current doses associated with 50% successful defibrillation from 14.8 +/- 3.7 to 8.9 +/- 2.0 A (n = 6, P < 0.05). Eight of 15 animals given ibutilide exhibited one or more episodes of spontaneous defibrillation. Ibutilide significantly (P < 0.05) increased ventricular effective refractory period (+23.4%), and both preventricular fibrillation and postdefibrillation monophasic action potential duration at 90% repolarization (+21.7% and +23.3%, n = 9, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Healthcare reform adds complexities for today's CFO

The profile of the typical senior financial executive in a hospital or corporate healthcare setting has changed little over the past two years. A November 1992 survey of CFOs by HFMA and Zimmerman & Associates, Inc., which updates a similar survey conducted in 1990, showed that the typical healthcare CFO is an extremely busy 41-year-old male with a postgraduate education who has held the position of CFO for six years. Survey findings also reveal that the CFO title is the predominant title for senior financial executives in healthcare facilities. For those receiving incentive compensation, the average compensation in 1992 was 11.7 percent of base salary. Within the context of career advancement, the CFO is most interested in learning more about healthcare reform; declining operating margins was seen as the CFO's most significant career challenge.

Transepicardial defibrillation dose response: current versus energy

In pentobarbital-anesthetized dogs, we compared the relative efficacy of current versus energy in applying the dose response method in transcardiac defibrillation. Damped sinusoidal shocks via epicardial patches were administered by a custom defibrillator permitting precise current delivery. Following the establishment of an initial estimated defibrillation threshold for energy and current, the dose response method was performed with regard to either energy defibrillation threshold (group E, n = 8) or current defibrillation threshold (group C, n = 8). Two sequential sets (I, II) of shocks (21 shocks each) were delivered in random order at each of seven doses: 0.55, 0.70, 0.85, 1.00, 1.15, 1.30, and 1.45 x defibrillation threshold. Data were subjected to nonlinear logistic regression analysis. There were no significant differences between sets I and II in either groups E or C for resistance or for raw and normalized values associated with 50% and 80% success expressed as energy, current, or voltage. Correlation coefficients (r) associated with nonlinear logistic regression analysis were significantly different for normalized current and energy for group E (0.70 +/- 11 and 0.71 +/- 12) compared to group C (0.86 +/- 0.60 and 0.88 +/- 0.06). The difference, however, could be explained by a significantly narrower range of normalized current values tested in group E (0.79 to 1.31) versus group C (0.54 to 1.46). Thus, when resistance does not change, transcardiac current offers limited advantage over energy when applying a dose response method. The efficacy of nonlinear logistic regression analysis depends upon an adequate dose range.

Congenital gigantism due to growth hormone-releasing hormone excess and pituitary hyperplasia with adenomatous transformation

The cause of gigantism in most patients is a GH-secreting pituitary tumor. In this report, a case of congenital gigantism due to probable central hypersection of GH-releasing hormone (GHRH) is described. Normal at birth (4.4 kg; 53 cm), our 7-yr-old male patient grew progressively thereafter to attain a height of 182 cm and a weight of 99.4 kg at the time of our evaluation. The markedly increased baseline plasma levels of GH (730 micrograms/L) did not suppress during a standard 3-h oral glucose tolerance test, but did increase 54% after iv infusion of GHRH. Baseline plasma levels of insulin-like growth factor-I, PRL, and immunoreactive GHRH were also markedly increased. Computed imaging of the head showed a large, partially cystic sellar and suprasellar mass. Extensive imaging studies did not localize a potential source of GHRH. Preoperative treatment with octreotide and bromocriptine for 4 months resulted in a 25% reduction of suprasellar tissue mass. The pituitary tissue removed at transsphenoidal and transfrontal operations showed massive somatotroph, lactotroph, and mammosomatotroph hyperplasia. Areas of GH- and PRL-secreting cell adenomatous transformation were also evident. No histological or immunohistochemical evidence of a pituitary source of GHRH was found. The peripheral plasma immunoreactive GHRH concentration remained unaffected by pharmacological and surgical interventions. We suspect that a congenital hypothalamic regulatory defect may be responsible for the GHRH excess in this case.

Tibia vara in a patient with Bardet-Biedl syndrome

The Bardet-Biedl syndrome is characterized by polydactyly, hypogonadism, obesity, mental retardation, and retinitis pigmentosa. Several other skeletal findings include hip dysplasia, short stature, and skull deformities. The patient described in this report has the classic findings of Bardet-Biedl syndrome in conjunction with tibia vara and irregular physes of the lower extremities.

Somatomedin C/insulin-like growth factor I levels after treatment of acromegaly

An in-house method was used, including dissociation of Somatomedin C/insulin-like Growth Factor I (Sm-C/IGF-I) binding proteins with acid and extraction of Sm-C/IGF-I by C-2 cartridge before radioimmunoassay, to measure plasma Sm-C/IGF-I levels in three groups of patients--total of 19--with acromegaly who underwent transsphenoidal removal of pituitary tumors. In group A (n = 7), the Sm-C/IGF-I levels did not decrease to normal on postoperative day 1 even though the growth hormone concentration had decreased to normal. In group B (n = 4), the Sm-C/IGF-I level decreased to normal in three of the four patients on postoperative day 4, but it remained elevated in one. At two months postoperatively, all four patients had normal values. Group C patients (n = 8) had had an operation two to 23 years previously, and all remained in remission with normal Sm-C/IGF-I levels. Our findings indicate that the Sm-C/IGF-I assay is useful for monitoring acromegaly after transsphenoidal removal of pituitary tumors, but it should be ordered at least four days postoperatively.

Radiation therapy for diabetes insipidus caused by Langerhans cell histiocytosis

Hypothalamic-pituitary radiation therapy has been the standard treatment for the diabetes insipidus of Langerhans cell histiocytosis. The goal of this study was to assess the role of radiation therapy in Langerhans cell histiocytosis-associated diabetes insipidus and to compare the results with nonirradiated controls. Forty-seven patients with pathologically confirmed Langerhans cell histiocytosis were diagnosed with diabetes insipidus between 1950 and 1989 and were treated at the Mayo Clinic. These patients were divided into two groups on the basis of treatment for the diabetes insipidus: The first group (radiation group) included 30 patients (28 of whom were evaluable for response) who received hypothalamic-pituitary radiation therapy, and the second group (control group) included 17 patients who did not. A partial response to treatment was defined as a reduction in vasopressin dosage or improvement in computed tomography (CT) or magnetic resonance imaging (MRI). A complete response was defined as no further need for vasopressin therapy or normalization of CT or MRI. End points analyzed included treatment response, patient characteristics, morbidity, dose-response relationship, and survival. Patient characteristics of the two groups were similar except for age and lung involvement, both of which were significantly less in the radiation group. Thirty-six percent of patients (10 of 28) in the radiation group responded to hypothalamic-pituitary radiation therapy (22% complete response and 14% partial response), whereas none in the control group responded. Five of the six complete responders were irradiated within 14 days of the diagnosis of diabetes insipidus. The mean dose used in the responding and nonresponding patients was 11.2 and 10 Gy, respectively. Three of five patients (60%) treated with more than 15 Gy responded compared to seven of 23 (30%) treated with less than 15 Gy. Eight of the 10 responders (80%), compared to 16 of 35 nonresponders (46%), were female. Only one in 20 patients with concomitant lung histiocytosis responded. Complications of therapy may include insufficiency in other hypothalamic-pituitary axes in the treated patients. Actuarial survivals at 5, 10, 20, and 40 years for the entire group were 80%, 78%, 75%, and 65%, respectively, with a median follow-up in living patients of 14.7 years.

Mental illness and psychotropic medication use in the nursing home

The authors examined mental illness and psychotropic medications use among nursing home residents. Data were drawn from the Texas Long-Term Care Reimbursement Project, a 1986 study of nearly 2,000 residents in 49 nursing homes. The study measured the use of antipsychotics and other psychotropic medications, physical health conditions, mental illness diagnoses, behavior, and nursing and other direct-care time for sampled residents. The findings indicated that 45% of the sample was receiving an antipsychotic or other psychotropic medication. Although psychotropics were prescribed more extensively for those with a psychiatric diagnosis, nearly one half of persons without a psychiatric diagnosis were receiving psychotropic medications at the time of the survey. Moreover, psychotropics were quite prevalent among those with unstable medical conditions and/or severe activities of daily living impairment. Neither a mental illness diagnosis, evidence of a behavioral problem, nor use of psychotropics was significantly correlated with the amount of nursing or other direct-care time received by residents. The findings raise concerns about the widespread prescribing of these medications, especially among residents who have no supporting psychiatric diagnosis and/or who have physical health conditions making them vulnerable to adverse drug effects.

Reconsiderations of the routine and preferential use of lidocaine in the emergent treatment of ventricular arrhythmias

OBJECTIVE

Despite a history of widespread use, the utility of lidocaine as an antiarrhythmic and antifibrillatory agent is questionable. The objective of this article is to examine the theoretical basis for the use of lidocaine in light of recent experimental and clinical data. This article reviews the effects of lidocaine on: a) ventricular arrhythmias under ischemic and nonischemic conditions; b) the energy and current requirements for defibrillation; and c) the propensity for asystole during cardiac arrest.

DESIGN

A contemporary review of the literature.

FINDINGS

There appears to be a theoretical basis for the use of lidocaine in treating ventricular arrhythmias secondary to acute ischemia largely based on voltage- and pH-dependent binding and inactivation of sodium channels by lidocaine under ischemic conditions. However, clinical and experimental data failed to establish enhanced survival following prophylactic treatment for acute ischemic events or when treatment is administered during cardiac arrest. Moreover, there are no data supporting the use of lidocaine in treating sustained and life-threatening ventricular arrhythmias in the absence of acute ischemia. Experimental data demonstrate that lidocaine can reduce countershock efficacy, i.e., increase the current and energy requirements for defibrillation. Experimental and clinical data suggest that the administration of lidocaine increases the propensity for asystole during cardiac arrest.

CONCLUSIONS

While lidocaine may possess an antifibrillatory effect under experimental conditions, the clinical relevance of such an effect is questionable. If cardiac arrest occurs, lidocaine has limited utility and may be deleterious secondary to diminished countershock efficacy or lidocaine-induced asystole. Reconsideration of the use of lidocaine should be included in future guidelines for management of cardiac arrest.

Limitations of the countershock dose response: a study of transthoracic current

Dose response assessment of countershock efficacy has been widely determined with respect to energy but not current. The purpose of this study was to examine the utility of the dose response method in a current-based model of transthoracic defibrillation (pentobarbital anesthetized dogs, n = 8). Ventricular fibrillation induction lasting 15 seconds was separated by 5-minute intervals. Current defibrillation threshold (DFT; the lowest current that successfully defibrillated) was determined by decreasing current on successive trials. Energy DFT equaled the energy value of the corresponding current DFT. Subsequent data were expressed in normalized terms with each DFT assigned a normalized value of 1.00. Three shocks were delivered in random order at each of seven normalized current nodes (total of 21 shocks): 0.55, 0.70, 0.85, 1.00, 1.15, 1.30, and 2.00 x DFT (early testing). Randomization was repeated, and a second set of 21 trials were performed (late testing). Composite plots were made relating normalized current and energy to the percent successful defibrillation. The dose response expressed in normalized energy demonstrated an overall shift to the left compared to current. The difference was significant at every node value below the estimated DFT. Ninety percent of successful trials with respect to current and energy occurred at or above 0.85 DFT and 0.55 DFT, respectively. Significant changes in impedance occurred between early testing (60 +/- 6 ohms) and late testing (47 +/- 5 ohms), n = 8, mean +/- SD. Current, compared to energy, is a more accurate parameter in the dose response assessment of transthoracic defibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)

Medicaid spenddown among nursing home residents in Wisconsin

We examined Medicaid spenddown among nursing home residents from 72 facilities in Wisconsin during 1988. Results indicate that only a small proportion (12%) of discharges from these facilities had spent down to Medicaid eligibility. This represents about one-fourth (23%) of persons who had been admitted private pay. Moreover, we estimated that over 40% of those who spent down to Medicaid did so within 6 months, 58% spent down within a year, and 76% spent down within 2 years. Even though a relatively small percentage of residents spent down, this group had very long stays (median stay greater than 3 years) and thus contributed quite heavily to nursing home days.