Biomedical subjects
Publications and source records attributed to K Zander.
Karen Zander, a member of the original research team at the New England Medical Center Hospital that created the first hospital case management model and critical pathways, outlines recent developments in education, automation, and research that she says point to an increasing interest in these two health care delivery strategies.
Multidisciplinary outcome-based care plans are a powerful aid to clinicians in managed care and case management situations. After several years of using Anticipated Recovery Paths, a committee designed a Professional Practice Symposium focusing on the skills needed by nursing personnel to provide effective outcome-based practice. Results of this educational effort are reported.
The brief article is to correct errors of presentation and erroneous conclusions in the referred publication. It is shown that the neuropsychological resume drawn by the authors is invalidated by statistically significant findings already presented in the two diploma theses, upon which the previous authors drew.
Gonadal hormones are believed to be involved in the pathophysiology of premenstrual changes (PMC) possibly through their interaction with neurotransmitter systems in the brain. The serotonergic system, an important central modulator of mood and behavior which is involved in the pathophysiology of affective disorders has been suggested to play a role in the genesis of dysphoric PMC. Blood platelet serotonin (5-HT) uptake and imipramine (IMI) binding have been shown to share similarities with serotonergic mechanisms in the brain thus enabling the study of serotonergic mechanisms. In this study, we report on platelet 5-HT uptake and IMI receptor binding which were simultaneously studied in women with PMC. Subjects with PMC showed a large interindividual variability with no consistent typical pattern or change during the late symptomatic as compared to the early nonsymptomatic luteal phase. Their IMI receptor binding, however, was lower compared to controls already during the early luteal phase before they developed symptoms and was similar during the symptomatic phase. This might suggest a preexistent vulnerability to the development of dysphoric PMC that might be related to impaired gonadal hormone modulation of the serotonergic system.
Nursing Case Management as described here was developed in less than ideal conditions: a full census, a 30 per cent increase in patient volume over five years, a nursing shortage, no grants or outside funding, no clinical specialists or clinical ladder, and no computerized documentation system. No more staff or salary was added as we focused our attention on the new tools, roles, and structures necessary to achieve cost and quality outcomes. However, nursing case management has worked because of some very key elements: 1. A firm commitment to the belief that staff nurses must be accountable for the outcomes of the care that they have planned, given, managed, and continuously evaluated. 2. A combination of top-down organizational development strategies with excellent staff nurse involvement at each juncture. 3. Negotiation and collaboration with physicians and hospital administration at key turning points. This includes the relentless articulation of patient-centered care. 4. A willingness to learn and risk together as a whole department--across levels, across specialties. This includes a constant balance of moving from concrete examples and problems to reconceptualizing the issues. 5. Listening, responsiveness, humor, and acknowledging contributions of everyone. More than any other principal, the case manager must be a central caregiver to a patient to ensure cost/quality outcomes. Otherwise case management only adds to the cost of health care by adding another level of bureaucracy. Nurses have always managed the care of patients, but to stay effective and committed, they need to take increased authority in their patients' entire episode of care and develop formal collaborative practice groups. In other words: "Prospective payment has changed the health care product from a day of care (or a visit) to an entire case or episode of illness. More than just a new way of paying for care, it has changed our way of planning, managing, and thinking about health care." Looking at the future entails understanding our business, and then changing our practice patterns for the change in the times. Necessity will foster invention; Nursing Case Management provides a model and technology for innovation.
Nursing Case Management has four essential components: achievement of clinical outcomes within a prescribed timeframe; the care giver as case manager; episode-based RN-MD group practices that transcend units; and active participation by patients/families in goal setting and evaluation. In the first year of implementation, nursing case management has shown positive resolutions for some of the complex issues facing health care administrators, managers, and clinicians. This article describes the model, its practical and philosophical origins, application, and early results.
Afternoon continuous plasma levels of 3-methoxy-4-hydroxyphenylglycol (MHPG) were first shown to be a good representation of the mean 24-hour plasma level of MHPG in 18 normal subjects. Then, after the stability of the procedure was tested and retested, the afternoon continuous test for plasma MHPG levels was performed in 57 normal subjects and 42 endogenously depressed patients. A significant correlation between plasma MHPG levels and age was found in normal subjects and depressive patients. When the variable of age was taken into account, a distinct pattern of increasing plasma MHPG levels with age--the "MHPG per age"--was found in the depressed patients, especially the women, who could be divided into high or low MHPG per age groups. There was almost no association between plasma levels of MHPG or MHPG per age values and clinical symptoms, and the two biologic subgroups did not differ clinically.
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Circadian rhythms in physiological processes and behaviors were compared with hypothalamic circadian rhythms in norepinephrine (NE) metabolites, adrenergic transmitter receptors, cAMP, cGMP and suprachiasmatic nucleus (SCN) arginine vasopressin (AVP) in a single population of rats under D:D conditions. Eating, drinking and locomotor activity were high during the subjective night (the time when lights were out in L:D) and low during the subjective day (the time when lights were on in L:D). Plasma corticosterone concentration rose at subjective dusk and remained high until subjective dawn. Binding to hypothalamic alpha 1- and beta-adrenergic receptors also peaked during the subjective night. Cyclic cGMP concentration was elevated throughout the 24-hr period except for a trough at dusk, whereas DHPG concentration peaked at dawn. Arginine vasopressin levels in the suprachiasmatic nucleus peaked in the middle of the day. No rhythm was found either in binding to the alpha 2-adrenergic receptor, or in MHPG or cAMP concentration. Behavioral and corticosterone rhythms, therefore, are parallel to rhythms in hypothalamic alpha 1- and beta-receptor binding and NE-release. Cyclic GMP falls only at dusk, suggesting the possibility that cGMP inhibits activity much of the day and that at dusk the inhibition of nocturnal activity is removed. SCN AVP, on the other hand, peaking at 1400 hr, may play a role in the pacemaking function of the SCN that drives these other rhythms.
Since its inception in the late 1960s, primary nursing has been the subject of much misinterpretation, as well as healthy adaptation. Over the last 15 years, the first generation of primary nursing users have shown that professional nursing is ultimately enhanced, not through changes in staffing patterns, but in the locus of accountability. The second generation primary nursing users face the challenge of developing a culture that integrates the realities of care delivery with the evolving professional status of nursing.
The sensitivity of the dopaminergic hypothalamic pituitary system, as indicated by growth hormone (GH) release after apomorphine (0.5 mg SC), was studied in 11 chronic schizophrenic in-patients under long-term neuroleptic (NL) therapy and after 12 and 30 days' drug withdrawal. GH peak levels after a 12-day drug-free period were significantly elevated (13.1 +/- 12 ng/ml) as compared to NL therapy (4.6 +/- 6.1 ng/ml). Controls showed a significant higher mean peak GH response (13.6 +/- 10 ng/ml) compared to chronic schizophrenic patients under long-term NL therapy. The GH response of patients with symptoms of tardive dyskinesia (TD) did not differ significantly from that of patients without signs of TD. The prolactin (PRL) serum levels under long-term NL treatment were within the normal range in male schizophrenics but decreased significantly after 12 days' drug withdrawal. The data presented indicate a reduced sensitivity of the hypothalamic-pituitary dopamine receptors under long-term NL therapy. The significant increase in GH response on day 12 probably corresponds to a readjustment from a mostly blunted GH response under NL therapy back to stimulated levels of normal controls. No supersensitivity of the pituitary dopamine receptors could be detected.
Gender differences in the prevalence of affective disorders were suggested by several authorities in the field. Such differences may be attributed to sex-related differences in levels or activity of monoamine transmitters, especially since some of these variables have been shown to be altered by gonadal hormones. The reported association of perimenstrual and postpartum dysphoria, with affective disorders may contribute to further elucidation of pathophysiology of depression in women--in light of the hormonal-behavioral dynamics of these periods. Several factors associated with monoamines biosynthesis, availability, uptake and metabolism were found to be more abnormal in normal and depressed women compared to men. Age-sex differences in some biological markers for depression are reported as well. Their relevance to the underlying pathophysiology of depression is unclear but they may provide clues for further research.
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Carbamazepine, a drug effective in pain, seizure, and affective disorders, was screened for its ability to interact with a variety of neurotransmitter and neuromodulator binding sites on brain membranes. The most potent effect was observed on adenosine antagonist ( [3H]DPX) binding to the adenosine receptor (KI = 3.5 +/- 0.4 microM) followed by adenosine agonist ( [3H]CHA) binding (KI = 24.5 +/- 3.6 microM). Lower potency effects were observed on benzodiazepine receptors, and no inhibition was seen in a variety of other systems. The inhibition of adenosine receptor binding by carbamazepine was competitive. No correlation was observed between the potency of a series of carbamazepine analogs as inhibitors of either ( [3H]DPX, [3H]CHA or [3H]diazepam binding and their ability to inhibit electroshock-induced convulsions, suggesting that the anticonvulsant properties of these agents are not mediated by the adenosine receptor, but raising the possibility that other clinical effects of carbamazepine may relate to its ability to act at the adenosine receptor.
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A patient-centered model for the delivery of mental health services to acute psychiatric patients is described. This model may also be applicable to more comprehensive delivery systems. Mental health systems usually are centered around separate staff and physical locations of various units. The psychiatric patient's sensitivity to disruptions of the environment may respond favorably to a system of patient-staff continuity, which avoids fragmentation of care. The patient-centered care model allows the treatment staff to follow patients throughout the entire course of their treatment program. Impressions are that this model results in a marked decrease in acting out, suicide gestures, and other regressive manifestations at the time of transfer from one phase of the program to another. Specific issues of patient care account-ability, patient follow-through, and compliance with treatment recommendations and cost-effectiveness are also discussed. In addition, staff satisfaction and professional growth are enhanced by the ability to follow patients and families through all phases of their treatment. Decreased staff turnover and increased interdisciplinary communication can enhance staff growth as well as patient care.