Personnel implications for health records staff.
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Humans↗
Biomedical subjects
J King
Publications and source records attributed to J King.
Design and construct--a healthy way to build?
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Cost Control↗
Panel sees high demand for diverse CFO skills.
A more sophisticated healthcare industry, challenged by competition and payer demands, also looks for sophistication when filling its senior financial positions. Individuals with experience in managed care contract negotiations, knowledge of hospital-physician ventures, and superior planning and treasury management skills are increasingly sought by hospitals. Some organizations also may single out chief financial officers able to assume broader administrative duties, including chief executive officer positions. These are among the observations of a panel convened by HFMA to discuss recent trends in healthcare executive recruiting. Highlights of the session, moderated by HFMA President Richard L. Clarke, FHFMA, follow.
Employment↗
Avoiding paraplegia during anterior spinal surgery. The role of somatosensory evoked potential monitoring with temporary occlusion of segmental spinal arteries.
Three patients paraplegic following anterior spinal fusion for congenital kyphoscoliosis were noted to have complete somatosensory evoked potential signal loss shortly after segmental arterial ligations at the apex of their respective kyphosis. This has prompted us to use temporary segmental arterial occlusion with somatosensory evoked potential monitoring prior to ligation during anterior spinal fusion. As a result, we have noted seven additional cases, out of a total of 44 cases monitored in this fashion, in which complete loss of somatosensory evoked potential signals, reversible by release of vascular clips, has occurred. For each of these additional cases the critical segmental arteries were identified and were not ligated, usually resulting in some modifications in the planned surgical procedure, and the patients remained neurologically intact. We recommend temporary segmental arterial occlusion with somatosensory evoked potential monitoring during thoracolumbar anterior spinal fusion to potentially avert ischemic neurologic injury. Based on published data and the experience described herein, this technique should be especially important in anterior spinal fusion for congenital kyphoscoliosis.
Adolescent↗
Health care personnel's perception of infection control.
Although the administration believes the 20-year-old infection program at the authors' institution has been effective in reducing nosocomial infection risk, the perceptions of nurses and physicians were unknown. Two hundred and twenty-seven nurses and 50 physicians were surveyed to determine their concept of infection control. Of all surveyed, 97% considered handwashing the most critical aspect of infection control and felt that additional teaching would increase this practice. Although physicians (40%) and nurses (30%) surmised the major infection control problem was lack of handwashing, 95% of physicians and 90% of nurses believed they personally washed their hands correctly and appropriately. One-half of all surveyed were not able to define 'asepsis' correctly. Sixty percent of nurses and 70% of physicians were not familiar with a monthly nosocomial report. On-site inspections and more educational programs were the primary recommendations of nurses and physicians. Of all participants, 99% could name the infection control nurse, whereas only 11% could name the infection control committee chairman. Although most infection control nurses feel they create a negative impression when they make rounds, the attitudes of nurses (81%) and physicians (68%) were positive. It is concluded that the perception of infection control differs among nurses and physicians. An effective infection control program must address the specific needs of all groups.
Attitude of Health Personnel↗
Observer accuracy and confirmation of the important role of abnormal ST/T time course behavior in the evaluation of stress electrocardiograms.
Routine exercise electrocardiography has been criticized for yielding too many so-called "false-positive" results. Recent studies in our institution indicate that evaluation of the time course behavior of ST segment and T wave (ST/T) changes after cessation of exercise differentiates ischemic from non-ischemic ("false-positive") stress electrocardiograms (SEs). Our method of assessing time course behavior is clarified. The principal aim of this study was to determine the accuracy of experienced observers in making this differentiation. Records of consecutive patients undergoing coronary arteriography over a 2 year period were reviewed and 30 with SEs judged positive for ischemia by the widely accepted ST/T configurational criteria alone were selected at random for the investigation. Sixteen subjects had normal coronary angiograms and had therefore previously been regarded as having false-positive SEs. Fourteen patients had at least one significantly (> 70%) stenosed coronary artery which was our yardstick for ruling that true myocardial ischemia, due to epicardial coronary artery disease (CAD), was present. Five observers, familiar with post-exercise ST/T time course patterns, independently and "blindly" analyzed all 30 configurationally abnormal SEs. Observers were informed only of the patient's age and sex; they were thus unaware of symptoms, exercise variables, coronary anatomy and the number of patients in the 2 groups. The observer consensus for ischemia of SEs using time course analysis was: total test accuracy 87%, sensitivity 79%, specificity 94%, positive predictive value 92% and negative predictive value 83%. Because all 30 patients had ST/T abnormalities, results of the sample for ischemia based on configurational criteria alone were sensitivity 100%, specificity 0% and positive predictive value 47%. We concluded that time course analysis plays a crucial role in evaluating SEs and that exercise electrocardiography remains a safe, cost-effective and reliable method of screening many asymptomatic, as well as symptomatic, subjects for CAD.
Coronary Angiography↗
Efficacy of percutaneous renal biopsy in obese patients under computerized tomographic guidance.
The performance of percutaneous renal biopsy under ultrasound guidance in markedly obese patients is associated with technical difficulties because of the production of poor image quality. Fluoroscopy can be potentially used as an alternative guidance method when the kidneys are not visualized sonographically. However, the presence of uremia in an obese patient imposes an additional risk when fluoroscopy is used because of possible nephrotoxicity from the use of radiocontrast dye. Computerized tomography (CT) provides advantages over these two methods because of the production of excellent spatial resolution of images leading to accurate localization of the kidneys. We performed 59 consecutive percutaneous renal biopsies in 58 patients using CT as guidance. The body mass index (BMI) defined as weight in kilograms/(height in meter)2 [Watson et al. 1979], was used to assess the severity of obesity. Twenty-nine patients had Grade 0 (BMI less than or equal to 24.9), 17 had Grade I (BMI 25-29.9), 7 had Grade II (BMI 30-39.9) and 5 had Grade III (BMI greater than or equal to 40) obesity. Thirty-two patients had superimposed uremia of varying degrees. Image quality was maintained in all four groups, and tissues adequate for diagnosis were obtained in 98% of the attempts. Complications were minimal with no deaths, nephrectomies or surgical interventions attributable directly to the biopsy procedure itself. We recommend the use of CT guidance in the grossly obese patients (Grade II or III) when their kidneys are poorly visualized by sonography.
Biopsy, Needle↗
Novel second-site suppression of a cold-sensitive defect in phage P22 procapsid assembly.
The DNA packaging portal of the phage P22 procapsid is formed of 12 molecules of the 90,000 dalton gene 1 protein. The assembly of this dodecameric complex at a unique capsid vertex requires scaffolding subunits. The mechanism that ensures the location of the 12-fold symmetrical portal at only one of the 12 5-fold vertices of an icosahedral virus capsid presents a unique assembly problem, which, in some viruses, is solved by the portal also acting as initiator of procapsid assembly. Phage P22 procapsids, however, are formed in the absence of the portal protein. The 1-csH137 mutation prevents the incorporation of the portal protein into procapsids. In a mixed infection with cs+ phage, the mutant subunits are able to form functional portals, suggesting that the cold-sensitivity does not affect portal-portal interactions, but affects the interaction of portal subunits with some other molecular species involved in the initiation of portal assembly. Interestingly, the cs defect is suppressed by temperature-sensitive folding mutations at four sites in the P22 tailspike gene 9. The suppression is allele-specific; other tailspike tsf mutations fail to suppress the cs defect. Translation through a suppressor site is required for suppression. This observation is unexpected, since analysis of nonsense mutations in this gene indicates that it is not required for procapsid assembly. Examination of the nucleic acid sequences in the neighborhood of each of the suppressor sites shows significant sequence similarity with the scaffolding gene translational initiation region on the late message. This supports a previously proposed model, in which procapsid assembly is normally initiated in a region on the late messenger RNA that includes the gene 8 start site. By this model, the suppressor mutations may be acting through protein-RNA interactions, changing sequences that identify alternative or competing sites at which the mutant portal subunits may be organized for assembly into the differentiated vertex of the phage capsid.
Alleles↗
How to choose a new partner in general practice.
OBJECTIVE: To provide a guide to choosing a new partner in general practice by using psychometric assessments. DESIGN: A descriptive account of the experience of one practice. SETTING: A general practice in Bristol. RESULTS: The partners found that using a psychologist to assess both themselves and the candidates facilitated the selection process. During the pre-interview stage the partners learnt about the dynamics of the practice and their own personalities. The examination of the candidates by an outside assessor as well as the partners gave a sense of security and a certainty that mistakes were unlikely to be made. CONCLUSION: More practices should consider adopting a selection process using psychometric assessments when appointing a new partner.
England↗
Evaluation of the post-exercise time-course behaviour of ST-segment and T-wave changes in the elimination of the false-positive stress ECG.
Routine stress ECG has been criticised for yielding too many so-called false-positive results because ST-segment and T-wave (ST/T) changes that develop during and after exercise are prevalent. Recent studies in our institutions indicate that the time-course behaviour patterns of ST/T configurational abnormalities after exercise reflecting myocardial ischaemia are different from those that do not. The epicardial coronary arteries of 111 patients, who had positive stress tests for ischaemia based on ST/T configurational changes alone but were considered non-ischaemic when the ST/T time-course behaviour was analysed, were assessed. Of these patients, 102 had normal coronary arteries, 7 had insignificant stenoses and only 2 had significant coronary artery diseases. ST/T abnormalities on stress testing with a non-ischaemic time-course pattern should be regarded in the same category as ST segments that remain normal as far as the detection of myocardial ischaemia due to epicardial coronary artery disease is concerned. This policy has resulted in an improved predictive value of exercise testing and has considerably decreased the number of patients subjected to coronary arteriography in our institutions. The assessment of the post-exercise stress ECG remains the most practical and cost-effective method for detecting ischaemic heart disease.
Adolescent↗
Properties of monoclonal antibodies selected for probing the conformation of wild type and mutant forms of the P22 tailspike endorhamnosidase.
Eleven species of monoclonal antibodies directed against the trimeric P22 tailspike endorhamnosidase have been selected and characterized. Seven of these antibodies recognize the native tailspike, both isolated and assembled onto the virion, and prevent phage infection. Four antibodies react with denatured forms of the tailspike as well as with the plastic absorbed tailspike. Three of these latter prevent the tailspike from assembling onto the phage head. The antibodies have been tested against tailspike proteins carrying single amino acid substitutions at 15 different sites on the protein. Two of these mutations interfere with binding by a set of the monoclonals, indicating that they disrupt the epitopes for these antibodies. Since amino acid replacements corresponding to the temperature-sensitive folding mutations do not change the conformation of the native protein, these mutant proteins may be particularly useful for mapping epitopes. Amber fragments of the tailspike chain are recognized predominantly by the anti-denatured antibodies suggesting either that they are conformationally closer to folding intermediates than to the native tailspike or that the epitopes recognized by anti-native antibodies are carried by the C-terminal end of the native protein. Immunochemical detection by an anti-denatured antibody, after sucrose gradient sedimentation of a large 55-kDa amber fragment, indicates a monomeric rather than a trimeric state. This suggests that the missing C-terminal region is important for the trimerization reaction. Such N-terminal amber fragments may be useful models for studying with the monoclonal antibodies the nascent chain emerging from the ribosome.
Amino Acid Sequence↗
Conformational states of the bacteriophage P22 capsid subunit in relation to self-assembly.
The formation of closed icosahedral capsids from a single species of coat protein subunit requires that the subunits assume different conformations at different lattice positions. In the double-stranded DNA bacteriophage P22, formation of correctly dimensioned capsids is mediated by interaction between coat protein subunits and scaffolding protein. Raman spectroscopy has been employed to compare the conformations of coat protein subunits which have been polymerized to form capsids in the presence and absence of the of scaffolding protein display a Raman spectrum characterized by a broad amide I band centered at 1665 cm-1 with a discernible shoulder near 1653 cm-1, and a broad amide III profile centered at 1238 cm-1 but asymmetrically skewed to higher frequency. These spectral features indicate that the protein conformation in procapsid shells is rich in beta-sheet secondary structure but contains also a significant distribution of alpha-helix. When biologically active, purified subunits assemble in the absence of scaffolding protein, they form polydisperse multimers lacking the proper dimensions of procapsid closed shells. We designate these multimers as "associated subunits" (AS). The Raman spectrum of associated subunits indicates a narrower distribution of secondary structure. The associated subunits are characterized by a sharper and more intense Raman amide I band at 1666 cm-1, with no prominent amide I shoulder of lower frequency. An analogous narrowing of the Raman amide III profile is also observed for AS particles, with an accompanying shift of the amide III band center to 1235 cm-1.(ABSTRACT TRUNCATED AT 250 WORDS)
Capsid↗
Conformational stability of P22 tailspike proteins carrying temperature-sensitive folding mutations.
The thermostable tailspike endorhamnosidase of Salmonella phage P22 provides a model system for comparing the role of amino acid sequences in determining the intracellular folding pathway with their role in stabilizing the mature structural protein. Complete Raman band assignments are given here for the native form of the tailspike trimer in aqueous solution. Once correctly folded and assembled, the wild-type and two well-characterized mutant proteins, tsfIle258----Leu and tsfGly323----Asp, exhibit the same secondary structure in solution, consisting predominantly of beta-strand (56 +/- 5%) and turns (17 +/- 2%). Raman bands that are sensitive indicators of hydrogen-bonding interactions of tyrosine (phenolic OH) and tryptophan (indole NH) are unchanged between 30 and 80 degrees C in both wild type and tsf mutants. Similarly, Raman bands that are sensitive to changes in the hydrophobic environment of nonpolar side chains exhibit no significant temperature dependence in wild type and tsf mutants. In contrast, these conformational features are greatly altered by chemical denaturation of the tailspike with lithium halide and guanidine hydrochloride. In the chemically denatured tailspike, the beta-strand structure is substantially converted to irregular or "random coil" conformation. These findings confirm conclusions from physiological studies that the three-dimensional structures of the tsf mutants, once stabilized at permissive temperatures, are equivalent to the native structure of the wild type, and this structure is maintained at temperatures far above those that block the folding of the chain into the final native conformation.(ABSTRACT TRUNCATED AT 250 WORDS)
Amino Acid Sequence↗
Percutaneous choledochoscopic choledocholithotomy in Caroli's disease.
Communicating cavernous ectasia of the intrahepatic bile ducts (Caroli's disease) is frequently accompanied by calculus formation. Percutaneous choledocholithotomy was successfully performed using a choledochoscope in a young adult with multiple calculi. To our knowledge this is the first reported case of choledocholithotomy using this technique in Caroli's disease.
Adult↗
Evaluation of a reassortant rhesus rotavirus vaccine in young children.
A candidate live attenuated rotavirus vaccine representative of serotype 1 was administered orally to 26 children, 14 of whom were undergoing primary exposure to rotavirus. The vaccine was derived by reassortment between rhesus rotavirus strain, MMU 18006, and the human serotype 1 strain Wa. The resultant virus has the gene coding for the major surface glycoprotein VP-7 from the human strain and all other genes from the attenuated rhesus parent which is a serotype 3 strain. Prior natural exposure to rotavirus determined the infectivity and immunogenicity of the vaccine. Only two of 12 seropositive children had evidence of reinfection while all 14 seronegative children were infected. Mild febrile illness was seen in vaccinees, however there was no evidence of gastrointestinal disease. As determined by neutralization of the human strains, the resultant serum antibody was entirely strain specific. However, heterotypic neutralization was seen when the rhesus strains were used, suggesting that neutralizing antibody can be directed to shared components of the donor and reassortant strain presumably VP-4, the other major surface protein.
Age Factors↗
Lack of Cross-Resistance of Imidazolinone-Resistant Cell Lines of Datura innoxia P. Mill. to Chlorsulfuron : Evidence for Separable Sites of Action on the Target Enzyme.
Two cell lines of Datura innoxia resistant to two imidazolinone herbicides, imazapyr and imazaquin, were isolated from mutagenized, predominantly haploid cell suspension cultures. Both of the resistant variants were >1000-fold more resistant than the wild-type to the two imidazolinones. The variant resistant to imazapyr showed cross-resistance to imazaquin and vice versa, but no cross-resistance to a structurally different inhibitor, chlorsulfuron, a sulfonylurea herbicide, was observed. The target enzyme, acetolactate synthase, extracted from imidazolinone-resistant cell lines was not inhibited by imazapyr or imazaquin but was sensitive to chlorsulfuron indicating separable sites of action for these inhibitors. The variation in resistance and cross-resistance of chlorsulfuron-resistant (PK Saxena, J King [1988] Plant Physiol 86: 863-867) and imidazolinone-resistant cell lines of Datura innoxia demonstrates the possibility of separate mutations of acetolactate synthase gene resulting in specific phenotypes.
Journal Article↗
A distressed child with fever.
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Diagnosis, Differential↗
Letter identification and lateral masking in dyslexic and average readers.
Lateral masking and letter identification in dyslexic and average readers were investigated with a methodology that corrected for some of the weaknesses of the Geiger and Lettvin studies (1986, 1987). Target letters were presented alone or embedded within three-letter arrays at retinal locations from 0 degrees to 15 degrees to the right or left of a fixation point. A foveal letter, which was the same as or different from a target letter, appeared as a distractor, and comparisons were made between scaled and unscaled stimuli. Dyslexic readers were found to be better than average readers at detecting scaled letters embedded in an array in some of the peripheral locations tested. Unlike the results of Geiger and Lettvin, however, this finding of better letter detection in the periphery by dyslexics was limited to selected conditions of the study. Reading groups were also found to differ in responding to the foveal distractor in the letter task. Detection of letters by average readers was affected by the type of distractor, but this variable was not found to influence the dyslexic readers. These findings suggest some differences between dyslexic and average readers in attention to stimuli presented at multiple locations in the visual field.
Adult↗