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PubMed2005

Evaluation of alkaline phosphatase activity assay for the Reflotron system after substitution of the comparison method.

The alkaline phosphatase (ALP) assay for the Reflotron system is a dry chemistry method applicable for decentralized testing. The ALP diethanolamine method has been applied as the comparison method, which is now replaced by the more widely distributed aminomethylpropanol method. The new comparison method measures ALP activities by approximately 59% lower compared to the former method. The analytical performance of the newly calibrated ALP Reflotron method was evaluated at three clinical laboratories. The study of the imprecision showed coefficients of variation ranging from 1.6-3.0% (intraassay) and 2.7-5.7% (interassay). Blood samples from liver disease patients (n=192), adolescents (n=40) and pregnant women in the third trimester (n=34) were collected in order to evaluate the impact of different ALP isoenzymes. The comparison between ALP Reflotron and the new comparison method revealed an excellent agreement in Passing-Bablok regression analysis (slope: 1.004; intercept: 0.14 U/l; median difference: 0.5%) for samples with prevailing liver ALP. However, in plasma samples with predominantly elevated bone or placental isoenzyme the Reflotron method measured lower or higher activities, respectively (slope: 0.912, 1.394; intercept: -4.16, -17.26 U/l; median difference: -10.58, 26.33%). The ALP Reflotron assay is an adequate method for decentralized testing. It shows a good precision and agreement with the comparison method, although the systematic differences for placental and bone ALP isoenzymes have to be considered.

Adolescent↗
PubMed1992

Sonographic image of the newborn hip with positive Ortolani's sign.

In a screening program, 4438 newborns were examined sonographically and clinically in the first 12 hours after birth for congenital hip dysplasia. Seventy-three hips in 54 newborns were dislocated, as evidenced by positive Ortolani's signs. According to Graf's classification, all 73 hips should be Type IIC or worse, with Angle alpha less than 50 degrees and Angle beta for Type IIC of 72 degrees-77 degrees, and for Types D, III, and IV, greater than 77 degrees. Sonographic examination of the 73 hips according to Graf's criteria showed that only 16 hips were decentring and eccentric, confirming the clinical diagnosis, and the results were consistent with Graf's conclusion because their alpha-angles were less than 50 degrees and beta was greater than 77 degrees. In the remaining 57 hips, there was a disparity between alpha-angles and beta-angles. Judging by Angle alpha, these hips were of Types IB and IIA because their Angle alpha averaged 60.8 degrees (range, 51 degrees-74 degrees). Judging by Angle beta, these hips were decentring Type D or eccentric Type IIIA because their beta-angle averaged 91.3 degrees (range, 78 degrees-110 degrees). Because these 57 hips were dislocated clinically (positive Ortolani's sign) it was concluded that the beta-angle is a more accurate reflection of hip pathology in the newborn than the alpha-angle. It represents the cartilaginous roof of the acetabulum, which is soft and malleable, and reflects immediately any change in the position of the femoral head. Angle alpha, however, represents the hard bony roof, and any change in the position of the femoral head is not reflected immediately on it, because bony changes take longer to be seen or evidenced.

Hip Dislocation, Congenital↗
PubMed2006

Improving medication administration systems: an evaluation study.

Medication errors are a universal health-care concern, and improving medication administration systems is important to enhance safety. The purpose of this study was to compare the effectiveness of an existing unit dose system using a medication cart to a new system where medications are decentralized to a locked cupboard at the patient's bedside. Quantitative and qualitative approaches were used to determine the effectiveness and efficiency of the medication administration systems. Data was collected using time studies to evaluate the efficiency of the two systems. This data included medication errors, missing doses and interruptions occurring during the medication preparation and administration process. Focus groups were conducted with nurses, pharmacists and pharmacy technicians to better understand the impact of changing systems. Study results demonstrated benefits associated with decentralizing the medication distribution to the bedside, including nurses spending more time with patients, nurses investing less time preparing and distributing medication and fewer interruptions for nurses as they prepared and distributed medication. Nurses and pharmacists associated the new system with enhanced patient safety and work satisfaction.

Attitude of Health Personnel↗
PubMed1992

Role for the cervical sympathetic trunk in regulating anaphylactic and endotoxic shock.

This study tests the hypothesis that spinal nerves projecting down the cervical sympathetic trunk contribute to the regulation of systemic immune responses. Decentralization or ablation (ganglionectomy) of the superior cervical ganglia (SCG), which receive innervation from spinal segments C8-T8, were found to reduce the pulmonary inflammatory response consequent to induction of anaphylaxis in rats sensitized to the nematode Nippostrongylus brasiliensis. Furthermore, the hypotensive responses to IV endotoxin were attenuated in sensitized rats by these operations, whereas decentralization without ganglionectomy protected against endotoxic shock in normal (unsensitized) rats. These results suggest that systemic inflammatory events are regulated by the cervical sympathetic nervous system at a level superior to the superior cervical ganglia. Further studies are warranted to investigate the role of the cervical and thoracic sympathetic nerves in the regulation of systemic immunological function.

Anaphylaxis↗
PubMed1991

Ocular adrenergic nerves contribute to control of the circadian rhythm of aqueous flow in rabbits.

Aqueous flow was measured fluorophotometrically in New Zealand white rabbits after unilateral decentralization of the cervical ganglion or cervical ganglionectomy to determine the role of ocular adrenergic input in regulating the circadian rhythm of aqueous flow. Both surgical procedures decreased the rate of aqueous flow during the dark phase when flow is high. During the light phase when flow is low, cervical ganglionectomy increased aqueous flow; decentralization may have increased flow also, but the increases were not statistically significant. Aqueous flow was also measured in normal rabbits after topical application of timolol during the light or dark to determine whether beta-adrenergic receptors play a role in controlling the circadian rhythm of flow. Timolol produced a small reduction of the rate of aqueous flow when applied topically during the dark but not during the light. These results suggest that part of the increase of aqueous flow during the dark phase is produced by adrenergic input to the ciliary processes and that beta-adrenergic receptors mediate part of this increase.

Administration, Topical↗
PubMed1991

Changes in aqueous norepinephrine and cyclic adenosine monophosphate during the circadian cycle in rabbits.

The concentrations of catecholamines and cyclic adenosine monophosphate (AMP) in the aqueous of rabbits entrained to 12-hr light:12-hr dark were measured at six times during the circadian cycle. Aqueous norepinephrine was higher in the dark than in the light; the minimum concentration at 1.5 hr after lights on, and maximum concentration at 6 hr after lights off, were 1.21 +/- 0.17 and 4.60 +/- 0.79 ng/ml, respectively. The concentrations of epinephrine and dopamine were less than the sensitivity of the assay (0.1 and 0.4 ng/ml, respectively) at all times. Aqueous cyclic AMP was also higher in the dark than in the light; the minimum concentration at 6 hr after lights on, and maximum concentration at 10.5 hr after lights off, were 11.5 +/- 1.2 and 29.4 +/- 2.7 pmol/ml, respectively. Superior cervical ganglionectomy reduced aqueous norepinephrine during light and dark to less than the sensitivity of the assay (0.1 ng/ml); preganglionic section of the cervical sympathetic trunk (decentralization) did not reduce aqueous norepinephrine as much as ganglionectomy but markedly reduced its concentration during the light and dark. Superior cervical ganglionectomy or pretreatment with 0.1% timolol virtually eliminated, and decentralization markedly reduced, the dark-phase increase of aqueous cyclic AMP. Most of the daily changes in norepinephrine and cyclic AMP persisted in animals housed in constant dark; this is consistent with the fraction of both changes which persisted in constant dark being circadian. These results support the idea that increased adrenergic activity during the dark increases the rate of aqueous flow and intraocular pressure in rabbits.

Animals↗
PubMed1991

Establishing a pharmacy department for a large pediatric hospital: managerial problems, opportunities, and lessons.

The process of planning and establishing a pharmacy department in a pediatric hospital is described, and lessons learned from the experience are summarized. Since its founding in 1954, Texas Children's Hospital (TCH) had shared pharmacy services with St. Luke's Episcopal Hospital. The decision to terminate the shared-services agreement in the mid-1980s made it necessary for TCH to establish an independent pharmacy department. A director of pharmacy was hired in March 1988, and November 30 of that year was set as the target for implementation of the TCH pharmacy. It was decided that six services--a decentralized unit dose distribution system, an i.v. admixture service, delivery services, ambulatory-care services, a formulatory system, and a drug information service--would be offered initially. Decisions concerning department organizational structure and staffing, space allocations, and a computer system were made. A multidisciplinary advisory committee was appointed; one of its responsibilities was to oversee inservice staff training. The pharmacy areas were to be opened on a staggered basis, beginning with the hematology-oncology clinic pharmacy. A number of problems arose immediately following the opening of the central pharmacy, including inaccurate computer profiles, lower-than-estimated productivity resulting from staff members' unfamiliarity with the new system, higher-than-estimated patient census, and orders for nonformulary drugs. Delays in drug delivery times were unacceptably high. A crisis-management plan was implemented to cover both short- and long-term problems, and within a few months operations had stabilized. The opening of the intensive-care and sixth-floor satellite pharmacies enhanced decentralized operations and had an important role in improving response times.(ABSTRACT TRUNCATED AT 250 WORDS)

Decision Making, Organizational↗
PubMed1991

Endogenous hormonal changes and circadian elevation of intraocular pressure.

A unique circadian rhythm of intraocular pressure (IOP) occurs in laboratory rabbits housed in a light-dark environment. The IOP is low in the light and high in the dark. In 32 rabbits studied, the IOP was 18.7 +/- 0.3 mm Hg (mean +/- the standard error of the mean) at 2 hr before the onset of dark and 24.9 +/- 0.6 mm Hg at 2 hr into the dark. The changes in endogenous hormones corresponding to this elevation of IOP were studied. Concentrations of norepinephrine (NE), epinephrine (Epi), corticosterone, and melatonin in the plasma and NE and melatonin in the aqueous humor were determined. Changes in plasma catecholamines were variable and statistically insignificant. A decrease of plasma corticosterone and an increase of plasma melatonin in the dark were observed. Norepinephrine and melatonin levels in the aqueous humor increased in the dark. In ten rabbits with unilateral transection of the cervical sympathetic trunk, the elevation of IOP was absent only in the decentralized eye. The changes in plasma NE, Epi, and melatonin levels from the light to the dark phase were insignificant. The plasma corticosterone level decreased. In the dark phase, aqueous humor NE level in the decentralized eye was significantly lower than that in the intact eye. Melatonin levels in these two eyes were indifferent. In 22 rabbits housed in a constant dark environment, aqueous humor NE concentration increased corresponding to the circadian elevation of IOP. The authors conclude that the activation of ocular sympathetic nerves is directly related to the circadian elevation of IOP.

Animals↗
PubMed1990

Ultrastructural changes in the rat pineal gland after sympathetic denervation. Quantitative study.

Ultrastructural changes in the rat pineal gland were studied quantitatively 7 and 60 days after the sympathetic denervation by bilateral excission or decentralization of superior cervical ganglia. The surface occupied by pineal parenchymal cells decreased in rats of experimental groups with respect to the control group. Furthermore, profile areas of the cytoplasm, nucleus and nucleolus of the pinealocytes were also diminished. Cytoplasmic lipid droplets in the pinealocytes were markedly decreased in number and size in experimental rats. As demonstrated by the Kruskal-Wallis H test, statistically significant differences were found between rats of the control and operated groups. Rats treated by superior cervical ganglionectomy or decentralization showed morphological changes indicating a hypofunctional pineal gland, although differences were found between both groups.

Animals↗
PubMedDate not supplied

[Strategies for the development of local health systems in the State of Rio de Janeiro, Brazil].

The organization of health services has undergone large-scale changes since the beginning of the 1980s, as may be seen in the organization of local health systems, the introduction of integrated health actions, and the establishment of the unified and decentralized health system. These changes are aimed at municipalizing the services. In Rio de Janeiro, particularly in the Baixada Fluminense, the public and private network categories have ceased to exist, having been replaced by a single municipal network. Delay in the transfer of INAMPS services is impeding the formation of a fully unified network. Complete organization of the decentralized system demands the elimination of political and bureaucratic obstacles.

Brazil↗
PubMedDate not supplied

[Development of local health systems and vaccine coverage in Dominican Republic].

The devastation of the health services system caused by Hurricane David in 1979 generated the necessary impetus for reorganizing and developing local health systems in Dominica. The process of health services decentralization, as illustrated by the vaccination program, is analyzed briefly. In general, the vaccination programs are organized vertically. This study shows that greater coverage can be achieved by total decentralization of the programs.

Delivery of Health Care↗
PubMed1990

Explaining trends in use of VA inpatient psychiatric services.

We examined the expansion of Veterans Administration (now Department of Veterans Affairs--VA) inpatient psychiatric services from 1963 to 1984. Aggregate national trends in VA inpatient episodes between 1963 and 1984 document not only increased use of inpatient services but also "decentralization," or a shift to providing psychiatric services in general VA medical centers. The national trends show a dramatic increase in admissions to psychiatric bed sections over the period 1963-1978, with admissions staying at this high level from 1976-1981 and dropping only slightly in the 1980s. Admission trends were disaggregated into first admissions and readmissions to psychiatric and general hospitals in a single VA medical district for the period 1972-1981. First admissions declined over the study period for both hospital types; readmissions increased initially, but declined somewhat at the end of the period. The admission trends and patterns in source of first admissions suggest that the growth of VA services reflects psychiatric "decentralization," as well as deinstitutionalization within VA.

Deinstitutionalization↗
PubMed1990

Strategies of organization and service for the critical-care laboratory.

Critical-care medicine requires rapidity of treatment decisions and clinical management. To meet the objectives of critical-care medicine, the critical-care laboratory must consider four major aspects of laboratory organization in addition to analytical responsibilities: specimen collection and delivery, training of technologists, selection of reliable instrumentation, and efficient data dissemination. One must also consider the advantages and disadvantages of centralization vs decentralization, the influence of such a laboratory on patient care and personnel needs, and the space required for optimal operation. Centralization may lead to workflow interruption and increased turnaround time (TAT); decentralization requires redundancy of instrumentation and staff but may shorten TAT. Minimal TAT is the hallmark of efficient laboratory service. We surveyed 55 laboratories in 33 hospitals and found that virtually all hospitals with 200 or more beds had a critical-care laboratory operating as a satellite of the main laboratory. We present data on actual TAT, although these were available in only eight of the 15 routine laboratories that provided emergency service and in eight of the 40 critical-care laboratories. In meeting the challenges of an increasing workload, a reduced clinical laboratory work force, and the need to reduce TAT, changes in traditional laboratory practice are mandatory. An increased reliance on whole-blood analysis, for example, should eliminate delays associated with sample preparation, reduce the potential hazards associated with centrifugation, and eliminate excess specimen handling.

Centralized Hospital Services↗
PubMed1989

Thyrotropin releasing hormone increases intraocular pressure. Mechanism of action.

Intravenous injections of 1-100 micrograms thyrotropin releasing hormone (TRH) in rabbits elevated intraocular pressure (IOP). The 2-5 mm Hg increase of IOP lasted for less than 2 hr. No change of pupil size was observed. This IOP elevation was not due to a direct effect of TRH on ocular tissues since intravitreal injections of 0.1 and 1 micrograms TRH did not change IOP. Concentrations of thyroid stimulating hormone (TSH), triiodothyronine (T-3), epinephrine (Epi) and norepinephrine (NE) in the plasma were elevated at 30 min after an i.v. injection of 10 micrograms TRH. Plasma levels of prolactin and thyroxine were not changed. Bolus i.v. injections of 0.1-1 micrograms TSH and 0.1-1 micrograms T-3, which would produce an equivalent increase of relevant hormones in the circulation, did not increase IOP. However, similar i.v. injections of 10-100 ng Epi and 100 ng NE caused a 1.5-3 mm Hg IOP elevation for 15-30 min. Thus, the IOP elevation following TRH administration probably is caused by the increase of circulating endogenous catecholamines and not by the stimulation of the TSH-thyroid hormone axis. Heart rate, but not blood pressure, was increased with 10 micrograms TRH. After unilateral transection of the cervical sympathetic trunk, the IOP elevation in the decentralized eye was larger than that in the intact eye. Topical treatment of 0.1% or 1% timolol in the decentralized eye inhibited the IOP elevations in both eyes, but 0.1% prazosin was not effective. Topical 1% atropine and atropine given subcutaneously at 0.6 mg/kg decreased the bilateral IOP elevations. These observations indicate that beta-adrenergic and muscarinic mechanisms, not an alpha-1-adrenergic mechanism, are involved.

Animals↗
PubMedDate not supplied

Intrathoracic ganglionic beta-adrenergic receptors involved in efferent sympathetic regulation of the canine heart.

The enhancement of cardiac inotropism induced by electrical stimulation of acutely decentralized efferent preganglionic sympathetic axons was reduced, but still present, following intravenous hexamethonium administration (10 mg/kg). This residual enhancement was eliminated following subsequent administration of timolol (0.1 mg in 0.1 mL normal saline) into the ipsilateral stellate and middle cervical ganglia. Similar results were obtained when the order of administration of these agents was reversed. When the beta-adrenergic agonist isoproterenol (1, 2 or 5 micrograms in 1 microL of normal saline) was administered into specific loci of an acutely decentralized stellate or middle cervical ganglion, cardiac chronotropism and/or inotropism were increased; when similar injections were made into adjacent ganglionic sites cardiac responses usually were not elicited. Following hexamethonium administration similar results were obtained indicating that these effects were not primarily dependent upon nicotinic cholinergic synapses. In contrast, repeat injections of isoproterenol into the site that initiated cardiac responses when injected with isoproterenol failed to elicit any cardiac responses following local administration of timolol into the same site indicating that the effects of isoproterenol could be blocked by a beta-adrenergic receptor blocking agent. Injections of 1 to 5 micrograms of isoproterenol into a ganglion which was surgically disconnected from the heart failed to elicit cardiac responses, demonstrating that at these doses detectable activation of cardiac myocyte beta-adrenergic receptors via circulating isoproterenol which had leaked out of the ganglion did not occur. It is concluded that beta-adrenergic receptors in intrathoracic ganglia are involved in the efferent sympathetic regulation of the heart and that such receptors are associated with neurons in specific ganglionic loci.

Animals↗
PubMed1989

Quality assurance program for a hospital investigational-drug service.

The development and implementation of a quality-assurance (QA) program for a pharmacy-based investigational-drug service are described. The objective of the QA program was to assess the quality of the activities in the areas of drug acquisition, inventory control, availability of drug data sheets and dispensing guidelines, provision of a quarterly drug accountability report, and documentation of drug dispensing to patients and decentralized pharmacy areas. The audit criteria were based on hospital policies and procedures and federal regulations for the handling of investigational drugs. Audits of four randomly selected protocols are conducted quarterly by a pharmacist who is not affiliated with the investigational drug service. The results of the first two audits have identified several areas for improvement, including the need for additional pharmacy staff education regarding study protocols, the importance of maintaining complete and accurate drug accountability records by decentralized pharmacists, and the need to provide a centralized source of study protocol information. The QA program has enabled the investigational-drug service to establish and enforce the policies and procedures for the appropriate handling of investigational drugs in this institution.

Drug Evaluation↗
PubMed1989

Prospective study comparing hydrogel with PMMA lens implants.

A prospective study has been undertaken to assess the relative merits of one-piece polymethylmethacrylate (PMMA) and poly 2 hydroxyethylmethacrylate "hydrogel" (P-HEMA) lenses in uncomplicated eyes after uncomplicated surgery. Two groups of 125 eyes each were matched in terms of patient age and sex. One group received PMMA lenses; the other group received P-HEMA lenses. Six months after surgery the visual acuity of 42% of eyes with P-HEMA lenses was 20/15, whereas that of 29% of eyes with PMMA lenses was 20/15 (p = 0.02). Major decentration occurred in two cases of P-HEMA lens implantation, but asymptomatic subclinical decentration was more common with PMMA lenses (p less than 0.001). The looped PMMA lens was considered adaptable to a wider variety of surgical conditions.

Acrylates↗
PubMed1986

Educational strategies for targeted retention of nonphysician health care providers.

This study examined the impact of a community-based, totally decentralized training program on the likelihood that graduates would establish their first practice within predefined and limited geographic regions. We found that when students in a physician assistant/nurse practitioner program received their preclinical and terminal training (preceptorship) in a region geographically proximate to their home residence, the likelihood that they would establish their first practice in that region was greatly increased. Similar results were found for students who took their preclinical training away from their home region but returned there for terminal training. Three additional training pathways were identified as being associated with markedly lower rates of regionally based graduate retention. Discriminant analysis was used to compare the relative impact of training and personal variables on retention. The educational process itself was found to be the single most important predictor of graduate retention. When structural variables were controlled, personal variables such as marital status, age, or sex had no predictive capabilities. With appropriate attention to the structural components of training--particularly terminal training (preceptorship)--experiences, PAs and NPs can be targeted to specific and relatively focused areas of medical need. These data suggest that several decentralized training strategies exist for physician assistants and nurse practitioners that would contribute to meeting health care delivery needs in chronically underserved areas.

California↗