Field report--capitation. Sharp Rees-Stealy Medical Group, San Diego, Calif. Making the transition from productivity compensation to capitation.
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California↗
Biomedical subjects
K A Moore
Publications and source records attributed to K A Moore.
Low-wage maternal employment and outcomes for children: a study.
Despite the importance of anticipating how children may be affected by policies that move mothers off welfare and into employment, as the article by Zaslow and Emig in this journal issue points out, few research studies have addressed this critical policy question. To help fill that gap, this article presents the results of a new study using national survey data to examine child outcomes among families that had previously received welfare. About half the families studied had mothers who remained at home, the others were working at varying wage levels. The findings reported here echo themes discussed in the two preceding articles. Maternal employment does not appear to undermine children's social or cognitive development from ages 5 to 14, and it may yield advantages. Children whose mothers earned more than $5.00 per hour, particularly, had somewhat better outcomes than others. The authors emphasize, however, that background characteristics specific to the mothers who chose employment contributed to these positive outcomes. The authors add that it would be risky to apply these generalizations based on these findings to families forced into employment by welfare reform.
Adolescent↗
Tissue distribution of ketamine in a mixed drug fatality.
While reports of ketamine abuse are increasing, reports of ketamine deaths and tissue concentrations associated with fatalities are rare. We report here a case of a mixed drug fatality involving ketamine and ethanol. Ketamine analysis was carried out by gas chromatography with a nitrogen-phosphorus detector (NPD). We found the following tissue concentrations: blood 1.8 mg/L; urine 2.0 mg/L; brain 4.3 mg/kg; spleen 6.1 mg/kg; liver 4.9 mg/kg, and kidney 3.6 mg/kg. The blood ethanol concentration was 170 mg/dL. Because an empty nalbuphine ampule was found in the possession of the deceased, the blood was assayed for this opioid compound using a gas chromatography/mass spectrometry (GC/MS) method. None was detected at a limit of detection of 0.02 mg/L.
Adult↗
Distribution of 3,4-methylenedioxymethamphetamine (MDMA) and 3,4-methylenedioxyamphetamine (MDA) stereoisomers in a fatal poisoning.
This communication presents the quantitation and differential distribution of the enantiomers of 3,4-methylenedioxymethamphetamine (MDMA) and its physiologically active metabolite 3,4-methylenedioxyamphetamine (MDA) in a fatal poisoning following insufflation of MDMA, cocaine and heroin. Animal studies have demonstrated the stereoselective pharmacokinetics and neurotoxicity of these compounds; however, enantiomeric distributions have not been reported in humans. Quantitation of MDMA and MDA enantiomer was by gas chromatography/mass spectrometry (GC/MS) following chiral derivatization with N-trifluoroacetyl-L-triproyl chloride (LTPC). The decedents' blood concentration of S(+)-MDMA was slightly less than that of R(-)-MDMA (1.3 vs. 1.6 mg/l, respectively), while the S(+)- and R(-)-MDA blood concentrations were identical (0.8 mg/l). Both primary routes of excretion, bile and urine, had greater concentrations of R(-)-MDMA than the S(+) isomer. These fluids also contained twice the concentration of S(+)-MDA than the R(-)-isomer. These data indicate that S(+)-MDMA is metabolized and eliminated faster than R(-)-MDMA. The results appear to support the findings in animals regarding stereoselective metabolism of MDMA.
3,4-Methylenedioxyamphetamine↗
Pharmacological characterization of BNMPA (alpha-benzyl-N-methylphenethylamine), an impurity of illicit methamphetamine synthesis.
alpha-Benzyl-N-methylphenethylamine (BNMPA), an impurity of illicit methamphetamine synthesis, has previously been reported to produce convulsions in mice without affecting spontaneous locomotor activity or altering methamphetamine-induced increases in spontaneous activity. In this study the in vitro effects of BNMPA on a variety of neuronal receptor types was determined to better characterize the pharmacological actions of this novel compound. BNMPA and N-demethyl-BNMPA fully displaced the dopamine transporter selective ligand [3H]CFT (2-beta-carbomethoxy-3-beta-(4-fluorophenyl)tropane) from rat striatal membranes with Ki values (mean +/- S.E.M) of 6.05 microM +/- 0.15 and 8.73 microM +/- 1.66, respectively. BNMPA also inhibited [3H]dopamine uptake into striatal synaptosomes with an IC50 value of 5.1 +/- 1.4 microM. The basal efflux of [3H]dopamine from striatal slices was slightly enhanced by BNMPA only at concentrations > or = 100 microM. BNMPA had no effect on [3H]norepinephrine efflux from hippocampal slices. BNMPA displaced tritiated paroxetine and prazosin binding from rat cortical membranes with Ki values of 14.5 microM and 11.7 microM respectively. In electrophysiological studies, BNMPA (100 microM) had no significant effects on either GABAA Cl- currents in cultured neurons or non-NMDA glutamate receptors expressed in oocytes. However, BNMPA significantly inhibited NMDA-stimulated currents in oocytes expressing the NR1/2A or NR1/2C receptor subunit combinations (IC50 values = 24.6 +/- 1.8 and 24.0 +/- 1.5 microM, respectively). This inhibition was rapid, reversible and voltage-dependent. These results indicate that BNMPA has multiple sites of action in the CNS that could be important in modulating a variety of behavioral effects upon exposure to this synthetic byproduct of illicit methamphetamine synthesis.
Analysis of Variance↗
Association between child behavior problems and frequent physician visits.
OBJECTIVE: To determine the association between parent-reported behavior problems and health care utilization, especially among physically healthy children. DESIGN: Analysis of data from the 1988 National Health Interviews Survey--Child Health Supplement. The sample for analysis consisted of 11,840 children aged 5 to 17 years. The independent measure of primary interest are behavior problems as measured by the Behavior Problems Index. For the bivariate analysis, children in the lowest quartile, highest quartile and middle half were compared. For the multivariate analysis, children in the highest quartile with behavior problems were compared with all other children. MAIN OUTCOME MEASURES: The number of reported physician visits in the past year and the past 2 weeks, Two common behavior syndromes--antisocial and depressed or anxious--were analyzed separately to determine whether a specific type of behavior problem was associated with frequent health care utilization. RESULTS: Eighteen percent of the children aged 5 to 17 years had four or more health visits during the past year, and 2% had two or more visits during the past 2 weeks. Children in the top quartile for parent-reported behavior problems were more likely to have four or more physician visits than children in the middle half and bottom quartile. Children reported to be in "excellent," "very good," or "good" health who were in the top quartile of behavior problems were more likely to report four or more physician visits during the past year, but no statistically significant differences were seen among children reported to be in "fair" or "poor" health. Controlling for confounding variables, children in the top quartile of the Behavior Problems Index are significantly more likely to report four or more visits during the past year and two or more visits during the past 2 weeks compared with other children. Anxious or depressed and antisocial subscales of the Behavior Problems Index showed independent and significant associations with four or more physician visits in the past year. CONCLUSION: Children with parent-reported behavior problems are likely to have more frequent physician visits compared with children without behavior problems, even when confounding sociodemographic and health status variables are controlled. The association is concentrated among physically healthy children.
Adolescent↗
Practice guidelines. What are internists looking for?
To determine features of the presentation of clinical practice guidelines that may enhance their use by internists, we conducted a cross-sectional survey to which 1,513 (60%) of 2,513 eligible internists responded. Endorsements by respected colleagues and by major organizations were identified as very important by 72% and 69% of respondents, respectively. Respondents preferred short pamphlets and manuals summarizing a number of guidelines and felt that concise recommendations (86%), synopsis of supporting evidence (85%), and quantification of benefit (77%) were important in guideline presentation. We conclude that guideline developers should gain the endorsement of major organizations and present key aspects in brief, easily assimilated formats.
Attitude of Health Personnel↗
Twenty-year clinical experience with porcine bioprostheses.
BACKGROUND: For the past 25 years, porcine valves have been the most widely implanted bioprosthesis, thereby becoming the standard for comparison with newer bioprosthetic valves. METHODS: We retrospectively analyzed 2,879 patients who underwent aortic (AVR; n = 1,594) or mitral (MVR; n = 1,285) valve replacement between 1971 and 1990. Follow-up was 97% complete and extended to 20 years (total, 17,976 patient-years). Patient age ranged from 16 to 94 years; mean age in patients who underwent AVR was 60 +/- 15 (+/- standard deviation) years; that for patients who underwent MVR was 58 +/- 13 years. RESULTS: The operative mortality rates were 7% +/- 1% (70% confidence limits) for AVR and 10% +/- 1% for MVR. Actuarial estimates of freedom from structural valve deterioration at 10 and 15 years were 78% +/- 2% (SE) and 49% +/- 4%, respectively, for the AVR subgroup; and 69% +/- 2% and 32% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from reoperation at 10 and 15 years were 76% +/- 2% and 53% +/- 4%, respectively, for the AVR subgroup and 70% +/- 2% and 33% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from thromboembolism at 10 and 15 years were 92% +/- 1% and 87% +/- 2%, respectively, for the AVR subgroup and 86% +/- 1% and 77% +/- 3%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from anticoagulant-related hemorrhage at 10 and 15 years were both 96% +/- 1% for the AVR subgroup and 93% +/- 1% and 90% +/- 2%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from valve-related mortality at 10 and 15 years were 86% +/- 1% and 78% +/- 3%, respectively, for the AVR subgroup and 84% +/- 2% and 70% +/- 4%, respectively, for the MVR subgroup (p = not significant). Multivariate analysis (Cox model) showed younger age, later year of operation, and valve site (MVR > AVR) to be significant risk factors for structural valve deterioration. Younger age, later year of operation, valve site (MVR > AVR), and renal insufficiency were the significant, independent risk factors for reoperation. Multivariate analysis revealed that higher New York Heart Association functional class, longer cardiopulmonary bypass time, congestive heart failure, renal insufficiency, and longer cross-clamp time were significant risk factors for valve-related mortality. Valve manufacturer did not emerge as a factor in any analysis. CONCLUSIONS: These long-term results with porcine bioprostheses were satisfactory, particularly in older patients and those undergoing AVR. As expected, younger age was a significant risk factor for structural valve deterioration and reoperation in both groups. Surprisingly, the durability of porcine bioprosthetic valves has not improved over time, which possibly can be attributed to more enhanced postoperative surveillance and earlier reintervention. These first-generation Hancock and Carpentier-Edwards porcine bioprostheses achieved similar long-term performance.
Actuarial Analysis↗
Hindbrain GRP receptor blockade antagonizes feeding suppression by peripherally administered GRP.
Bombesin (BN)-like peptides injected peripherally or centrally suppress food intake in rats. The relationship between the central and peripheral actions of BN is unknown. However, experimental evidence supports a critical role for the caudal hindbrain in mediating the feeding effects of BN. To investigate this relationship further, we examined the ability of fourth ventricular infusion of a specific gastrin-releasing peptide (GRP) antagonist, [D-F5, Phe6, D-Ala11]BN-(6-13) methyl ester (BN-ME), to block suppression of glucose intake (0.5 kcal/ml) produced by intraperitoneal administration of GRP-(18-27) in 5-h food-deprived male Sprague-Dawley rats (n = 10). We found that fourth ventricular administration of 10, 32, and 100 ng BN-ME blocked the suppression of glucose intake produced by peripherally administered 10 nmol/kg GRP-(18-27). The most effective dose of BN-ME (100 ng) blocked the ability of peripheral injection of GRP-(18-27) to inhibit glucose intake but had no effect on intake when given alone. These results demonstrate that the availability of caudal hindbrain GRP receptors is necessary for peripherally administered GRP-(18-27) to reduce food intake in rats.
Animals↗
Stress in mental health professionals: a theoretical overview.
Clearly, mental health professionals are subjected to similar organizational stressors as other workers. They also face additional emotional strain by the very nature of their professions in dealing with troubled persons often over extended periods of time. Further understanding of these problems and development strategies, such as insight-oriented training, requires a greater appreciation of the interactions between home-work and the individual. This broader-based ongoing research is imperative not just to protect the health of the carers and their patients/clients but is, we believe, an ethical requirement. Best care can only be provided to others by carers who are themselves well.
Burnout, Professional↗
Anterior cervical interbody fusion using autogeneic and allogeneic bone graft substrate: a prospective comparative analysis.
The authors conducted a prospective study of 132 patients requiring interbody fusion without instrumentation following anterior cervical discectomy to compare the efficacy of tricortical iliac crest allograft versus autograft fusion substrates. The objectives of the study were to assess the potential differences in interspace collapse, angulation, maintenance of cervical alignment and lordosis, and clinical and radiographic fusion success rates between the two fusion substrates. The impact of habitual cigarette smoking on fusion rates was also examined. Autograft tricortical iliac crest bone was found to be superior to allograft bone as an interbody fusion substrate after both single- and multiple-level anterior cervical decompression procedures with respect to maintenance of cervical interspace height, interspace angulation, and radiographic and clinical fusion success rates. Cigarette consumption had a significant adverse effect on successful anterior cervical interbody fusion for both autograft and allograft substrate, an effect that was most pronounced among smokers treated with allograft bone (p = 0.004).
Adult↗
Zone maintenance at Moore University Medical Center.
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Academic Medical Centers↗
The detection of a metabolite of alpha-benzyl-N-methylphenethylamine synthesis in a mixed drug fatality involving methamphetamine.
A 37-year-old, white male collapsed at his home following a party. He reportedly had a history of unspecified cardiac arrhythmia. The ambulance crew found him unresponsive and an ECG revealed ventricular tachycardia/fibrillation. Following one hour of resuscitative efforts in the ambulance and emergency room of a local hospital, he was pronounced dead. An antemortem urine toxicology screen performed at the hospital was "positive" for benzodiazepines, cocaine and amphetamine/methamphetamine. At autopsy, there was generalized organ congestion with no evidence of trauma or other significant pathology except mild, left ventricular hypertrophy. Quantitation by gas chromatography/mass spectrometry (GC/MS) of methamphetamine in bile, blood, urine and gastric contents yielded 21.7, 0.7, 32.0 and 2.9 mg/L, respectively. Liver and brain contained 2.2 and 2.7 mg/kg, respectively. A trace amount of p-OH-alpha-benzyl-N-methylphenethylamine (p-OH-BNMPA), a metabolite of alpha-benzyl-N-methylphenethylamine (BNMPA), an impurity of illicit methamphetamine synthesis, was also detected in the urine. Since these impurities can be characteristic of a particular synthetic method, their presence in seized samples or their detection in biological samples from methamphetamine users can further be used to monitor the sales of precursor chemicals, group seized compounds to common sources of illicit production or provide links between manufacturers, dealers and users.
Adult↗
Surgical management of aortic dissection during a 30-year period.
BACKGROUND: Certain recent studies have demonstrated improved surgical outcome in patients with aortic dissection. We analyzed the surgical survival rates of patients with acute aortic dissections and the late prognosis of those with aortic dissection during a 30-year period. METHODS AND RESULTS: Between 1963 and 1992, 360 patients (256 men and 104 women; mean +/- 1 SD age, 57 +/- 14 years) underwent surgery for aortic dissection: 174 patients had an acute type A (AcA), 46 an acute type B (AcB), 106 a chronic type A (ChA), and 34 a chronic type B (ChB) aortic dissection. The overall operative mortality rate was 24 +/- 8% (26 +/- 3% for AcA, 39 +/- 8% for AcB, 17 +/- 4% for ChA, and 15 +/- 6% for ChB, [+/- 70% confidence limit]). The operative mortality rates for patients with acute aortic dissection (AcA or AcB) were assessed for five time "windows": 1963 to 1972 (42 +/- 8%), 1973 to 1977 (37 +/- 8%), 1978 to 1982 (15 +/- 6%), 1983 to 1987 (27 +/- 6%), and 1988 to 1992 (26 +/- 6%). Logistic regression analysis suggested that the low operative mortality rate during the 1978-to-1982 interval occurred by chance. Multivariate analysis showed earlier operative year, hypertension, cardiac tamponade, renal dysfunction, and older age were independent determinants of operative death. Actuarial survival rates (including early deaths) after 5, 10, and 15 years for AcA patients were 55%, 37%, and 24%; for AcB, 48%, 29%, and 11%; for ChA, 65%, 45%, and 27%; and for ChB, 59%, 45%, and 27%. Multivariate analysis revealed that older age and previous operation were significant predictors for late death. Freedom from reoperation for all patients was 84%, 67%, and 57% at 5, 10, and 15 years, respectively. CONCLUSIONS: Although the operative mortality rate decreased over time for patients with aortic dissection, the risk for those with acute aortic dissection during the last 10 years (1983 to 1992) is probably more realistic than that observed in the preceding 5-year interval (1978 to 1982). The operative mortality rates for patients with chronic aortic dissection have remained relatively static. Earlier diagnosis of acute aortic dissection before development of cardiac tamponade and renal impairment is critical to improve the operative salvage rate. Long-term outcome still is not optimal, which emphasizes the need for better serial postoperative aortic imaging surveillance and medical follow-up and blood pressure control.
Adult↗
Durability of the Hancock MO bioprosthesis compared with standard aortic valve bioprostheses.
To compare the durability of the Hancock modified orifice (Hancock MO, model 250 [H-MO]) valve with two other commonly used standard aortic valve bioprostheses, a cohort of 1,602 patients undergoing aortic valve replacement using porcine valves between 1971 and 1990 (excluding simultaneous mitral valve replacement) was analyzed retrospectively using Cox model multivariate techniques. Five hundred sixty-one patients received a composite H-MO valve, 652 received a standard Hancock model 242 (H) valve, and 389 received a Carpentier-Edwards model 2625 (C-E) valve. Mean age was 60 +/- 15 years (+/- 1 standard deviation) (71% male). Follow-up (10,247 patient-years) extended to 15 years and was 97% complete. The main focus of this study was bioprosthetic durability, using The American Association for Thoracic Surgery/The Society of Thoracic Surgeons guidelines to define structural valve deterioration (SVD). Multivariate analysis revealed that (younger) age (p < 10(-5), liver disease (p = 0.02), and 1981 to 1985 operative period (p = 0.012) were the only significant, independent predictors of SVD. In concordance with previous reports, the SVD freedom estimate was greater than 90% at 15 years for patients older than 70 years of age. Hepatic dysfunction had an adverse effect on SVD (estimated freedom from event at 10 years was 34 +/- 17% [standard error of mean] versus 78 +/- 2% for those without liver disease), but this affected only 3% of patients. Interestingly, one operative period (1981 to 1985) was associated with a slightly higher risk of SVD compared to the three other 5-year time windows. Valve type did not emerge as a significant risk factor for SVD.(ABSTRACT TRUNCATED AT 250 WORDS)
Actuarial Analysis↗
Pregnancy and bioprostheses: influence on structural valve deterioration.
The long-term performance of bioprostheses was evaluated in women 35 years of age or less to determine the influence of pregnancy on structural valve deterioration. Between 1972 and 1992, 237 female patients received 255 biological prostheses. Of the total operations, 53 were performed in patients who experienced pregnancy (P) and 202 in patients who were never pregnant (nonpregnant [NP]). The mean age of the P group was 23.0 +/- 5.8 years (standard deviation) (12 to 34 years) and of the NP group it was 27.1 +/- 6.3 years (8 to 35 years) (p < 0.05). The mean follow-up for the NP group was 6.8 years and for the P group it was 7.9 years. The late mortality was 2.26%/patient-year overall, 2.71%/patient-year for the NP group and 0.89%/patient-year for the P group (p = not significant [NS]). The P group of 52 patients had 94 pregnancies: 70 deliveries (74.5%) and 24 abortions (25.5%) (therapeutic, 14 [15%]). There were a total of 143 valve-related complications (P, 35; NP, 108); the majority for structural valve deterioration (SVD) 43% (109 patients), P 51% (27 patients) and NP 41% (82 patients) (p = NS). The valve-related reoperation rate paralleled the SVD rate at 42% (107 patients), P 51% (27 patients) and NP 40% (80 patients) (p = NS). The overall reoperative mortality rate was 6.0%. The interval from initial implant to reoperation was 99.6 +/- 3.6 months (p = NS groups P and NP).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
alpha-Benzyl-N-methylphenethylamine (BNMPA), an impurity of illicit methamphetamine synthesis: pharmacological evaluation and interaction with methamphetamine.
Methamphetamine is a popular drug of abuse, readily synthesized in clandestine laboratories. Illicitly obtained methamphetamine is frequently impure, containing various purposefully added diluents and adulterants, as well as impurities of manufacture and origin. Few impurities have been studied in vivo and limited information exists concerning their pharmacology/toxicology. One such impurity of manufacture is alpha-benzyl-N-methylphenethylamine (BNMPA). Acute toxicity and spontaneous activity (locomotor) studies were conducted with this compound alone and in combination with S(+)-methamphetamine (METH) in male, ICR mice. In the acute toxicity studies, BNMPA was evaluated for convulsant activity. While BNMPA also produced some behavioral disturbances similar to those seen with methamphetamine (e.g., stereotopy) at doses greater than 30 mg/kg, no tonic-clonic convulsions were noted until pre-terminal convulsion at 50 mg/kg. METH alone produced tonic-clonic convulsions at terminal doses of 70 mg/kg. When BNMPA was given in combination with METH, there was no readily apparent change in the convulsion profile from that of METH given alone. In spontaneous activity studies, doses of BNMPA ranging from 1 mg/kg to 50mg/kg failed to alter locomotor activity significantly from controls though 5 mg/kg METH alone significantly increased spontaneous activity. In addition, increases in spontaneous activity elicited by 5 mg/kg METH were not affected when METH was given with 5 mg/kg BNMPA. While BNMPA appears to have toxic effects in the central nervous system (CNS), the failure to affect locomotor activity or alter either METH-induced increases in spontaneous activity or METH-induced convulsions suggests that the two agents are producing their effects through distinct mechanisms.
Animals↗