Process and outcomes of patient-centered medical care with Alaska Native people at Southcentral Foundation

PURPOSE

This study describes key elements of the transition to a patient-centered medical home (PCMH) model at Southcentral Foundation (SCF), a tribally owned and managed primary care system, and evaluates changes in emergency care use for any reason, for asthma, and for unintentional injuries, during and after the transition.

METHODS

We conducted a time series analyses of emergency care use from medical record data. We also conducted 45 individual, in-depth interviews with PCMH patients (customer-owners), primary care clinicians, health system employees, and tribal leaders.

RESULTS

Emergency care use for all causes was increasing before the PCMH implementation, dropped during and immediately after the implementation, and subsequently leveled off. Emergency care use for adult asthma dropped before, during, and immediately after implementation, subsequently leveling off approximately 5 years after implementation. Emergency care use for unintentional injuries, a comparison variable, showed an increasing trend before and during implementation and decreasing trends after implementation. Interview participants observed improved access to primary care services after the transition to the PCMH tempered by increased staff fatigue. Additional themes of PCMH transformation included the building of relationships for coordinated, team-based care, and the important role of leadership in PCMH implementation.

CONCLUSIONS

All reported measures of emergency care use show a decreasing trend after the PCMH implementation. Before the implementation, overall use and use for unintentional injuries had been increasing. The combined quantitative and qualitative results are consistent with decreased emergency care use resulting from a decreased need for emergency care services due to increased availability of primary care services and same-day appointments.

Genetically engineered mouse models of astrocytoma: GEMs in the rough?

Astrocytomas are the most common form of brain cancer and are essentially incurable due to their diffusely infiltrative nature. Mouse models of astrocytoma provide a useful system for understanding tumorigenesis of astrocytomas and for designing and testing new therapies. Although molecular genetic alterations have been characterized in human astrocytomas, many of the mice engineered with these mutations do not develop astrocytomas. Recently, successful modeling of astrocytoma in the mouse has suggested that the combination of molecular alterations, the cell type in which the alterations take place, and the strain background all play a role in generating a model of astrocytoma.

Etanercept in juvenile rheumatoid arthritis

OBJECTIVE

To review the classification, pathophysiology, safety, and efficacy of treatment options for juvenile rheumatoid arthritis (JRA). Etanercept, the agent most recently approved by the Food and Drug Administration for use in JRA, is featured.

DATA SOURCES

Articles were identified from a search of the MEDLINE database (1966 to January 2000) and through secondary sources. Meeting abstracts and posters were also evaluated.

STUDY SELECTION AND DATA EXTRACTION

Articles identified and retrieved from data sources were evaluated and, if determined to be relevant, were included in this review.

DATA SYNTHESIS

JRA represents a major cause of functional disability in children. In contrast to traditional therapeutic agents for JRA, which act through generalized antiinflammatory activity or generalized immunosuppression, new therapeutic modalities have been developed that target specific molecules involved in the pathophysiology of JRA. Etanercept inhibits the activity of tumor necrosis factor and lymphotoxin-alpha. In a clinical trial of patients with polyarticular-course JRA, etanercept-treated patients experienced less pain and swelling in their joints, decreased incidence of disease activity, less frequent flare, and a longer time to flare than patients receiving placebo. Treatment with etanercept was generally well-tolerated.

CONCLUSIONS

Etanercept represents an exciting new therapeutic option for the treatment of JRA. The positioning of etanercept among other therapeutic options for JRA will be more clearly established as additional safety and efficacy data are made available.

Neurofibromatosis 1 (NF1) heterozygosity results in a cell-autonomous growth advantage for astrocytes

Individuals with neurofibromatosis 1 (NF1) develop low-grade astrocytomas at an increased frequency. To gain insight into the function of the Nf1 gene product as a growth regulator for astrocytes, we examined mice heterozygous for a targeted Nf1 mutation. In our previous studies, we demonstrated increased numbers of proliferating astrocytes in Nf1 heterozygote (Nf1+/-) mice in vivo. We now show that cultured Nf1+/- astrocytes exhibit a cell-autonomous growth advantage in vitro associated with increased p21-ras pathway activation. Furthermore, we demonstrate that Nf1+/-;wild-type N-ras mice have a similar astrocyte growth advantage in vitro and in vivo as either oncogenic N-ras or Nf1+/-; oncogenic N-ras mice. Lastly, mice heterozygous for targeted defects in both Nf1 and p53 as well as Nf1 and Rb exhibit 3- and 2.5-fold increases in astrocyte proliferation in vivo, respectively, suggesting that abnormalities in Nf1- and p53/Rb-regulated pathways cooperate in the heterozygous state to confer a growth advantage for brain astrocytes. Collectively, these results provide evidence for a cell-autonomous growth advantage in Nf1+/- astrocytes and suggest that some of the brain pathology in individuals with NF1 might result from reduced, but not absent, NF1 gene function.

Nf1;Trp53 mutant mice develop glioblastoma with evidence of strain-specific effects

Astrocytomas are the leading cause of brain cancer in humans. Because these tumours are highly infiltrative, current treatments that rely on targeting the tumour mass are often ineffective. A mouse model for astrocytoma would be a powerful tool for dissecting tumour progression and testing therapeutics. Mouse models of astrocytoma have been designed to express oncogenic proteins in astrocytes, but have had limited success due to low tumour penetrance or limited tumour progression. We present here a mouse model of astrocytomas involving mutation of two tumour-suppressor genes, Nf1 and Trp53. Humans with mutations in NF1 develop neurofibromatosis type I (NF1) and have increased risk of optic gliomas, astrocytomas and glioblastomas. The TP53 tumour suppressor is often mutated in a subset of astrocytomas that develop at a young age and progress slowly to glioblastoma (termed secondary glioblastomas, in contrast to primary glioblastomas that develop rapidly de novo). This mouse model shows a range of astrocytoma stages, from low-grade astrocytoma to glioblastoma multiforme, and may accurately model human secondary glioblastoma involving TP53 loss. This is the first reported mouse model of astrocytoma initiated by loss of tumour suppressors, rather than overexpression of transgenic oncogenes.

Improving telephone contact rates of patients discharged from the emergency department

STUDY OBJECTIVE

This study investigated the rate of incorrect contact telephone numbers recorded during emergency department registration, and evaluated whether postdischarge contact rates can be improved by verifying the best contact number with the patient before discharge.

METHODS

A prospective study was conducted with convenience sampling at a tertiary care hospital with an annual census of 60,000. Patients older than 18 years were enrolled, and the "unverified" telephone numbers recorded at registration were entered on the data sheet. Patients were then asked, "What number can we reach you at to discuss lab or x-ray results?" These "verified" numbers and additional demographic data were entered on the data sheet. Within 1 week, 3 calls were made to both the unverified and the verified numbers. Calls were considered successful if the patient, a friend, family member, or coworker was reached, or if the patient returned a message left on an answering machine.

RESULTS

Four hundred eighteen patients (43% men) were enrolled; 72 (17%) patients provided a different best contact number than the one recorded on the chart. When unverified numbers were called, only 68.9% of patients were reachable, whereas when verified numbers were called, 81.8% of patients were contacted (P <.01). No statistical difference was found between patients who were successfully contacted and those who were not with regard to age, sex, race, or time of visit. Patients insured by health maintenance organizations were more likely to be reached (P =.02).

CONCLUSION

Verification of a best contact telephone number significantly improves the ability to contact patients after ED discharge.

Variables that affect patient throughput times in an academic emergency department

One of the most important parameters that influence patient satisfaction with emergency department care is their perception of throughput time. It is defined in our department as the time from patient arrival to time of discharge. Measurement of throughput time is one objective measure of efficiency that is feasible in most emergency departments. The purpose of this study is to analyze the impact of certain demographic and resource utilization factors on patient throughput times. Analysis of variants through multiple regression was used to determine associations between the average daily throughput time and factors commonly assumed to have significant influence on patient throughput time. Our data analysis found that patient throughput was significantly affected by the number of inpatient admissions from the emergency department, daily census in the main emergency department, pediatric volume, and the number of ambulance arrivals. Several factors that were commonly assumed to affect patient throughput time, such as nursing hours worked and day of the week, were not significant.

The significance of out-of-hospital hypotension in blunt trauma patients

OBJECTIVE

To determine the significance of a low out-of-hospital systolic blood pressure (SBP) reading in blunt trauma patients who have a normal SBP upon ED arrival.

METHODS

A retrospective case-control study compared admitted blunt trauma patients who were hypotensive (SBP < or = 90 mm Hg) in the field and normotensive in the ED (group 1) with those who were normotensive both in the field and in the ED (group 2). The groups were compared for mortality, intensive care unit (ICU) admission, injury severity scale (ISS) score, need for transfusion in the ED, incidence of intra-abdominal injury, and incidence of pelvic or femur fracture.

RESULTS

Each group consisted of 52 patients. The groups were similar with respect to age, gender, and initial ED SBP. The group 1 patients had a higher mortality (10 vs 1, p = 0.008), a higher number of ICU admissions (28 vs 12, p = 0.001), more pelvic or femur fractures (16 vs 7, p = 0.03), and a higher ISS score (19.0 vs 10.5, p = 0.01). Although not significant, group 1 also had higher incidences of intra-abdominal injury (10 vs 3, p = 0.07) and transfusion (8 vs 2, p = 0.09).

CONCLUSION

The injured patients who were hypotensive in the out-of-hospital setting but normotensive upon ED arrival were more severely injured and had more potential for blood loss than were the patients who were normotensive both in the out-of-hospital setting and in the ED. Out-of-hospital hypotension may be a clinical predictor of severe injury, even in the face of normal ED SBP. Prospective studies are indicated to validate this hypothesis.

Complication rates of tube thoracostomy

This study compared the complication rates of tube thoracostomy performed in the emergency department (ED) versus the operating room (OR) and the inpatient ward (IW). A retrospective case series of all patients at an urban, university-based level 1 trauma center hospital who received tube thoracostomy for any indication between 1/1/93 and 12/31/93 was conducted. Complications were defined as empyema, unresolved pneumothorax (persistent air leak or residual pneumothorax), persistent effusion, or incorrect placement. The data for age and duration of tube placement were weighted for analysis of variance (ANOVA). A total of 352 tube thoracostomies was placed in 239 patients. Twenty-three patients had three or more chest tubes placed, 65 had two placed, and the remaining 181 had a single tube. Ninety-nine tubes were placed in the ED, 87 in the OR, and 166 on IW. The mean age of patients in the ED was 37 years, and differed significantly (P < .015) from those in the OR (48 years) and the IW (44 years). The duration of tube placement was similar for all groups (mean = 6.5 days). The overall complication rates related to tube insertion were: ED, 14.0%; OR, 9.2%; IW, 25.3%. Significance was achieved when comparing complication rates between the ED and IW, with less complications in the ED (P = .0436). When comparing complication rates between the ED and OR, there was no significant difference (P = .3643). A power calculation indicated too small of a sample size to truly determine an insignificant difference between complication rates between the ED and OR. Placement of emergent thoracostomy tubes in the ED does not result in an increased complication rate as compared to placement in the IW.

Short-range signaling by candidate morphogens of the TGF beta family and evidence for a relay mechanism of induction

The specification and patterning of cell fates by a morphogen gradient is a unifying theme of developmental biology, yet little evidence exists for the presence of gradients in vivo or to show how such putative gradients form. Vg1 and activin are candidate morphogens involved in Xenopus mesoderm induction. This study suggests that these TGF beta family members act on adjacent cells but do not travel through the intact extracellular space to induce distant cells directly. Moreover, we present evidence for the presence of secondary inducing signals that could be involved in relaying signals to distant cells. These results suggest that if a localized cellular source of an inducer acts to pattern mesodermal cells at a distance in Xenopus embryos, it does so by a relay mechanism.

Systemic toxicity from ocular homatropine

Toxidromes are well known to emergency physicians. An unclear or incomplete history and subtle findings on physical examination make the diagnosis of poisonings challenging. This article reports a patient who had an acute onset of visual hallucinations, pressured speech, and mania. Although she denied taking any medications, she was ultimately diagnosed as having anticholinergic toxicity. On further questioning of family members, it was discovered that she was being treated for anterior uveitis with 5% homatropine. This case illustrates the potential role of ocular medications in systemic toxicity. Patients often do not consider eyedrops to be medications, and their use may be overlooked in the medical history. It also is important to educate patients and medical staff in methods to minimize systemic toxicity when using ocular medication.

An unusual presentation of cat scratch encephalitis

Cat scratch disease is an infectious illness that has been recognized since the 1880s; however, our understanding and knowledge of it is still evolving (1). It was not until 1991 that the etiologic species, Rochalimaea, was finally confirmed (2,3). Only recently have the breadth of its clinical spectrum and the population at risk been appreciated. We now realize that signs and symptoms that had been considered cardinal for diagnosis may be absent. Cat scratch disease was known to afflict primarily children and adolescent; however, the incidence of CSD is increasing in immunocompromised groups, such as AIDS and transplant patients (3,4). The recent discovery of the infectious agent and improved understanding of the disease process have led to new approaches in diagnosis and treatment. We present a report of a patient with cat scratch disease who presented with seizure and altered mental status secondary to encephalitis.

Carotid body tumors: a review of 30 patients with 46 tumors

Minimal morbidity occurs with resection of most carotid body tumors (CBT). With larger tumors significant injury to the cranial nerves has been reported. In order to assess the operative sequelae rate, 30 patients with CBT were reviewed. Sixteen patients either presented with bilateral carotid body tumors or had previously undergone a resection of the contralateral carotid body tumors, for a total carotid body tumor count of 46. Sixteen patients demonstrated a familial pattern while 14 were nonfamilial. Within the familial group, 14 of 16 presented with multiple paragangliomas as compared to 6 of 14 in the nonfamilial group. Tumor size ranged from 0.8 to 12 cm. Vascular replacement occurred in 2 of 20 patients with tumors < 5.0 cm, compared with 5 of 9 with tumors > 5.0 cm. Four patients lost cranial nerves with the resection: superior laryngeal nerve (SLN), 4; cranial nerve X, 1; cranial nerve XII, 1. Ten patients developed baroreceptor failure secondary to bilateral loss of carotid sinus function. First-bite pain occurred in 10 of 25 operative patients. Cranial nerve loss can be minimal with resection of carotid body tumors, however, baroreceptor failure and first-bite pain are postoperative sequelae that are often disregarded in the postoperative period.

Methohexital for orthopaedic procedures in the emergency department

The past two decades have seen more and more orthopaedic procedures performed in the emergency department. Methohexital would seem to be a useful adjunct drug for the performance of these procedures because of its well-known attributes (eg, rapid induction and recovery, brief duration, and minimal hemodynamic changes). A search of the literature revealed no previous studies on the use of methohexital in the emergency department. Therefore, the authors undertook a 1-year prospective study of all patients in their emergency department who received methohexital for orthopaedic procedures. The study's hypothesis was that methohexital is a safe drug for use in orthopaedic procedures in the emergency department. Additionally, the authors sought to determine the drug's indications for use, patterns of usage, and effects on the respiratory and cardiovascular systems. The data presented here are a subset of data previously presented and published.

The efficacy and safety of methohexital in the emergency department

STUDY OBJECTIVE

To determine the efficacy and safety of methohexital sodium (MTX) in emergency department patients.

DESIGN

A consecutive case series; all ED patients who received MTX from July 1989 through July 1990 were studied in a prospective manner.

SETTING

A university hospital ED.

PARTICIPANTS

All 102 adult and pediatric patients who received MTX.

INTERVENTIONS

Emergency physicians trained in the use of MTX administered the drug. A study form was completed that provided data on dosage and response, indications for use, final diagnosis, hemodynamic and respiratory parameters, and an efficacy survey.

RESULTS

Average cumulative dose of MTX was 1.6 +/- 1.3 mg/kg. The average duration of action per dose was 7.6 +/- 5.0 minutes. Leading indications for use were orthopedic procedures (54), endotracheal intubation (18), head computed tomography scan (ten), and wound care (eight). Hemodynamic changes were minimal; the average change in systolic blood pressure five minutes after MTX was -1.8 +/- 20 mm Hg. Average heart rate change was 3.0 +/- 20 beats. Percent respiratory depression was 17 +/- 24%. There was no correlation between MTX dose and the degree of respiratory depression. Narcotics and/or benzodiazepines were given with MTX in 92 cases, with no significant increase in respiratory depression. No major complications attributable to MTX were identified.

CONCLUSION

MTX, when used by trained personnel who adhere to an established protocol, appears to be a safe and effective drug in selected ED patients.

Plasma levels of highly sulphated glycosaminoglycans are raised in patients with chronic myeloid leukaemia

A study of absolute basophil counts and plasma levels of highly sulphated glycosaminoglycans in 30 peripheral blood samples from 21 patients with different leukaemias was performed. This revealed significantly raised levels of both plasma highly sulphated glycosaminoglycans and basophils in those patients with chronic myeloid leukaemia, as compared to those with other types of leukaemia and 35 normal controls. A strong correlation (r = 0.83) was observed between the levels of highly sulphated glycosaminoglycans and basophil counts in the group as a whole, supporting a direct relationship between the two. The elevated plasma levels of highly sulphated glycosaminoglycans may contribute to the bleeding tendency reported in some patients with chronic myeloid leukaemia.

Release of highly-sulphated glycosaminoglycans and histamine from human basophils

A new assay for highly-sulphated glycosaminoglycans (GAGs) has been applied to the study of allergen (Dermatophagoides pteronyssinus)-induced release of GAG from human basophils. Highly-sulphated GAG, which was not heparin, was found only in basophil-containing cellular fractions of whole blood. Its release, like that of histamine, was Ca++-dependent. However, allergen-induced release of GAG from the basophils of atopic individuals exhibited a different time-course and dose-response from that of histamine, and may occur at least in part by a different mechanism.

Glomerular hemodynamics in mercury-induced acute renal failure

As manifest by tubular collapse and the virtual absence of flow into the glomerulotubular junction (GTJ), filtration in most nephrons (SNGFR) of rats poisoned with 9 mg/kg body wt HgCl2 16 to 28 hours earlier was virtually absent. Arterial colloid osmotic pressure (COPA) and Bowman's space pressure (PBS) were modestly depressed (P less than 0.05 or below), and mean blood pressure was reduced from 115 +/- 2 mm Hg (SEM) to 97 +/- 1 mm Hg (P less than 0.001). Glomerular capillary hydraulic pressure (Pg), 25.6 +/- 1.3 mm Hg was some 24 mm Hg lower than control (P less than 0.001) and yielded a net afferent effective filtration pressure (Pnet) of 4.1 +/- 1.2 mm Hg. Excluding three rats with values greater than 10 mm Hg, Pnet averaged 2.0 +/- 0.9 mm Hg (N = 17 rats) versus 20.0 +/- 1.8 mm Hg in controls (N = 10, P less than 0.001), the former being statistically almost indistinguishable from 0 mm Hg and barely able to support any filtration. This decrease in Pg was caused by a major increase in preglomerular resistance (RA) and a reciprocal fall in efferent arteriolar resistance (RE), the RA/RE ratio of 7.2 +/- 0.8 being fourfold higher than control (P less than 0.001). Renocortical blood flow was not different from control (P greater than 0.2). A wide spread of Pg values in individual glomeruli and the absence of tubular flow despite the appearance of i.v. injected lissamine green in a quadrant of surface glomeruli suggested the possibility of a greatly increased, glomerular capillary resistance. It is concluded that reciprocal changes in RA and RE are the immediate cause of filtration failure in this form of ARF and that, in the virtual absence of filtration, tubular leakage can play no important role. Since PBS was depressed in both the developmental and established phases of ARF, tubular obstruction appears to play no direct role in the pathogenesis of this particular model of murine acute renal failure.

Circulating basophil counts in atopic individuals

Absolute numbers of circulating basophils were measured in 55 atopic and 35 non-atopic individuals, using a flow cytometer for automated cell counting. They were significantly elevated in the atopic group (p less than 0.001), but the total leucocyte count was not significantly different between the two groups. Eosinophil counts, which correlated with the number of basophils for both populations, were also significantly raised in the atopic group (p less than 0.001). Individual variation in absolute basophil counts was not detected in sequential samples taken at daily intervals over 5 days, in 5 atopics and 4 non-atopics. In addition, no significant variation was detected in 6 atopics and 5 non-atopics over a period of up to 20 months.

Erythromycin in the treatment of streptococcal infections

In a number of well-designed comparison studies since 1958, erythromycin has proved highly effective in the treatment of both streptococcal pharyngitis and skin infections. Of the two formulations most often prescribed, the estolate salt is better absorbed and achieves higher tissue concentrations than does the ethylsuccinate salt. For these reasons and based on results of the published clinical studies, the appropriate daily dosage for erythromycin estolate is 20 to 30 mg/kg/day and that for erythromycin ethylsuccinate is 40 mg/kg/day. Erythromycin estolate may be given in two, three or four daily doses in the treatment of streptococcal pharyngitis with efficacy rates equal to or better than that achieved with penicillin V. Erythromycin ethylsuccinate is as efficacious as penicillin V when given in three or four daily doses. Treatment of streptococcal pharyngitis should be for 10 days. Recent studies in the treatment of streptococcal skin infections have shown erythromycin to be superior to penicillin. This superiority may be due to increasing numbers of penicillin-resistant staphylococci found in these streptococcal skin lesions. Dosage and frequency of administration of erythromycin in the treatment of streptococcal skin infections is similar to that for the treatment for streptococcal pharyngitis. However, b.i.d. administration has not been well-established in the skin infection studies. Treatment should be given for 7 to 10 days. In conclusion erythromycin is a safe and effective antibiotic for the treatment of streptococcal pharyngitis. Penicillin remains the antibiotic of choice for these infections, but erythromycin is an effective alternate when penicillin allergy is suspected. The appropriate therapy for streptococcal skin infections is less clear.(ABSTRACT TRUNCATED AT 250 WORDS)

A modified Pearson gastroplasty

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Progressive hearing loss in children: hearing aids and other factors

A sample of 20 children monitored for progressive hearing loss combined with 25 progressive loss cases were obtained. The effects of hearing aid use on progressive loss were examined in the context of etiology and other factors, particularly the time relations between hearing aid application and the period of progression. Results indicate a limited role played by hearing aids in progressive hearing loss. Hearing aid use was not implicate in 30 (69%) of the progressive loss subjects, questionably implicated in nine (20%), and probably implicated in five (11%). In the identification and monitoring of progressive hearing loss, it is unwise to conclude that hearing aid use is the cause of the deterioration without considering all other plausible factors.