Improving care for nursing home-acquired pneumonia in a managed care environment.

Objective: To characterize care of nursing home residents who became ill with nursing home-acquired pneumonia (NHAP) in a group-model, nonprofit HMO, and to pilot-test a strategy to implement evidence-based NHAP care guidelines.

Study Design: Medical record review and intervention pilot test.

Methods: Nursing home medical records of 78 patients who developed NHAP in 6 homes where the HMO contracts for Medicare services were reviewed for demographics, functional status, comorbidity, NHAP severity, care processes, and guideline compliance.

Associations among processes and outcomes of care for Medicare nursing home residents with acute heart failure.

Objective: To characterize Medicare skilled nursing facility (SNF) residents who become acutely ill with heart failure (HF) and assess the association between the outcomes of rehospitalization and mortality, and severity of the acute exacerbation, comorbidity, and processes of care.

Design: SNF medical record review of Medicare patients who developed an acute exacerbation of heart failure (HF) during the 90 days following nursing home admission.

Setting: A total of 58 SNFs in 5 states during 1994 and 1997.

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents.

Objectives: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission.

Design: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred.

Setting: Sixty skilled nursing facilities in five states during 1994.

Prospective payment for nursing homes increased therapy provision without improving community discharge rates.

Objectives: To determine the impact of the prospective payment system (PPS) for skilled nursing facilities (SNFs) on therapy use and community discharge rates.

Design: Quasi-experimental study examining the predemonstration (1994) to demonstration (1997) change in amount of therapy provided, and in community discharge rates at PPS participating and nonparticipating facilities.

Setting: Eighteen PPS participating and 17 nonparticipating SNFs in five states.

CLCN5 mutation Ser244Leu is associated with X-linked renal failure without X-linked recessive hypophosphatemic rickets.

This study demonstrates that a missense mutation in the voltage gated chloride channel, CLCN5, can cause X-linked renal failure without X-linked recessive hypophosphatemic rickets. A large kindred (Family A), initially evaluated in 1974 with an inherited syndrome characterized by hypercalciuria, nephrocalcinosis, low molecular weight proteinuria, renal tubular acidosis, and renal failure, was clinically re-evaluated and genetically characterized. Medical histories, physical examinations, blood chemistries, and 24-hour urine collections were obtained from 48 family members.

A prospective evaluation of a simplified captopril test for the detection of renovascular hypertension.

Renovascular hypertension is potentially curable but of low prevalence. A previous retrospective study has demonstrated the use of a potentiated increase in plasma renin activity after captopril administration as a diagnostic test for renovascular hypertension; this requires two blood samples for plasma renin activity determination and three inclusive criteria for a positive test result. We applied this test prospectively to screen 100 hypertensive patients for renovascular hypertension.

The captopril glomerular filtration rate renogram in renovascular hypertension.

Administration of captopril to animals with two-kidney, one clip, renovascular hypertension (RH) lowers the glomerular filtration rate (GFR) in the clipped kidney. The authors therefore tested the hypothesis that a decrease in GFR after captopril administration would identify patients with RH. Total GFR was measured by the plasma disappearance of Tc-99m-diethylenetriaminepentaacetic acid (DTPA) after bolus injection and single-kidney GFR from renal uptake of DTPA assessed by renography.

Contrast echocardiography: effects of microbubbles on coronary blood flow and left ventricular hemodynamics.

Contrast echocardiography is currently being used to define and quantitate myocardial perfusion at the time of cardiac catheterization. Limited and conflicting data exist regarding the physiologic effects of microbubble-containing contrast agents. In the present study, coronary blood flow measured using an electromagnetic flow meter, blood pressure, and heart rate responses were studied in six dogs.

Diagnostic uses of angiotensin-converting enzyme inhibitors in renovascular hypertension.

The response to angiotensin-converting enzyme inhibitors (ACEIs) can be of considerable help in the diagnosis of human renovascular hypertension (RVH) in three settings. First, a particularly dramatic antihypertensive response or a decline in glomerular filtration rate (GFR), as indexed by a rise in serum creatinine or blood urea nitrogen concentrations, are useful clues to the presence of renovascular hypertension. Second, an exaggerated rise in plasma renin activity (PRA) after short-term captopril administration is a very promising screening test for this condition.

Pharmacokinetic and pharmacodynamic properties of intravenous fenoldopam, a dopamine1-receptor agonist, in hypertensive patients.

1 The pharmacokinetic properties of intravenous fenoldopam, a selective dopamine1-receptor agonist, were studied in 10 patients with essential hypertension. 2 Reduction in blood pressure was linearly related to the log fenoldopam plasma concentration (r = 0.69) and the log fenoldopam infusion rate (r = 0.

Augmentation of renal blood flow and sodium excretion in hypertensive patients during blood pressure reduction by intravenous administration of the dopamine1 agonist fenoldopam.

Activation of dopamine1 (DA1) receptors relaxes vascular smooth muscle, especially in the renal vascular bed. Fenoldopam, the first selective DA1-receptor agonist that can be administered to man, was infused intravenously in 17 patients with essential hypertension (mean blood pressure 152/101 mm Hg). It reduced blood pressure in a dose-dependent fashion at doses between 0.

Contrast ultrasonography of the kidney: a new method for evaluation of renal perfusion in vivo.

Assessment of the effects of pharmacologic agents on renal blood flow (RBF) is clinically important in many disease states, including hypertension and congestive heart failure. However, because of the complexities of RBF, quantitation in vivo has been technically difficult. This study demonstrates the utility of ultrasound imaging of the kidney combined with injection of a sonicated radiocontrast solution (Renografin-76) for the assessment of regional renal blood flow.

Effect of DA1 receptor blockade with SCH 23390 on the renal response to electrical stimulation of the renal nerves.

To evaluate the existence of functional renal dopaminergic innervation in the dog, we studied the effects of direct electrical stimulation of the renal nerves (RNS) with and without blockade of the dopamine receptor (DA1) that mediates the vasodilating and natriuretic response to intrarenal infusion of DA. Before infusion of the DA1 receptor antagonist, SCH 23390, RNS at 1 Hz did not change renal blood flow (RBF) but caused decreased urinary sodium excretion (-53 +/- 9%, P less than 0.01) and fractional excretion of sodium (-47 +/- 10%, P less than 0.

Blockade of renal effects of dopamine in the dog by the DA1 antagonist SCH 23390.

Dopamine (DA) acts on two receptor subtypes, DA1 and DA2. The purpose of this study was to determine which subtype is involved in the increments in renal blood flow (RBF) and electrolyte excretion produced by DA. Mongrel dogs were anesthetized with pentobarbital sodium.

Intraoperative patient monitoring: a method of analyzing esophageal phonocardiograms.

The value of esophageal phonocardiography as a noninvasive monitor during anesthesia was studied in dogs. Esophageal phonocardiograms were analyzed using fast Fourier transform and least squares linear regression technics. This method has demonstrated that it is feasible to estimate two parameters of cardiac contractility--1/(PEP)2 and stroke power--and one parameter that demonstrates the state of the vasculature--total peripheral resistance.

Plasma heparin activity and antagonism during cardiopulmonary bypass with hypothermia.

Plasma heparin activity in 11 patients undergoing open-heart surgery was measured by comparing thrombin time of patient plasma to thrombin time of plasma containing known heparin concentrations. Although all patients received 300 units/kg of heparin, their initial plasma heparin levels varied significantly, from 1.8 units/ml in lighter petients to 3 units/ml in heavier patients.

Comparison of the effects of acupuncture and codeine on postoperative dental pain.

The analgesic effects of acupuncture were compared with those of codeine in the treatment of postoperative dental pain in 40 healthy male volunteers 18 to 30 years old. Upon the patient's recovery from local anesthesia (lidocaine), he was asked by a trained observer to classify the intensity of his pain as none, mild, moderate, or severe. He then received one of the following treatments: 1.

The effect of total peripheral resistance on indicator-dilution curves from the central circulation of the dog.

The influence of total peripheral resistance on the dispersion of indicator particles passing through the central circulation was studied in five dogs. The standard deviation of indocyanine green indicator-dilution curves provided a measure of dispersion. The peripheral vascular resistance of the dog was altered during the experiment by the intravenous administration of sodium nitroprusside and methoxamine.