Eight new HLA-A alleles associated with antigens in the A2 CREG.

This report describes eight novel HLA-A alleles. Seven of these new alleles contain substitutions previously reported in other HLA-A alleles, suggesting an origin resulting from a gene conversion mechanism. Of these seven, A*2431 contains a substitution previously associated with a larger polymorphic motif. A*0247 contains a substitution at a previously polymorphic position, but encodes an amino acid change previously unreported in any HLA-A, -B or -C alleles.

Primary care access improvement: an empowerment-interaction model.

Improving community primary care access is a difficult and dynamic undertaking. Realizing a need to improve appointment availability, a systematic approach based on measurement, empowerment, and interaction was developed. The model fostered exchange of information and problem solving between interdependent staff sections within a managed care system. Measuring appointments demanded but not available proved to be a credible customer-focused approach to benchmark against set goals. Changing the organizational culture to become more sensitive to changing beneficiary needs was a paramount consideration. Dependent-group t tests were performed to compare the pretreatment and posttreatment effect. The empowerment-interaction model significantly improved the availability of routine and wellness-type appointments. The availability of urgent appointments improved but not significantly; a better prospective model needs to be developed. In aggregate, appointments demanded but not available (empowerment-interaction model) were more than 10% before the treatment and less than 3% with the treatment.

Animated simulation: a valuable decision support tool for practice improvement.

Animated computer simulation is a powerful tool for healthcare operation improvement. As a decision support tool, it offers a systematic method to compare alternative approaches to healthcare operations. Because staff interaction is encouraged by this tool, simulation projects facilitate staff team building and process change ownership. Information that is not used as applied knowledge for the purpose of improvement is worthless. Simulation offers management detailed knowledge of processes, enabling management to make better-informed decisions by providing performance data, such as resource usage rates, patient wait times, capacity rates, and process performance information. Alternatives under consideration can be compared and modified without high financial, personal, and customer costs to the healthcare operation. The knowledge gained from each alternative's simulation response variables can be evaluated against set criteria, the status quo, and each other to determine the best option. Current automation systems and software products allow decision makers to use this tool without investing resources in errant options. A simulation project strategy with examples and a case study of change and renovation of a family practice clinic are provided.

Clinical relevance of transmembrane drug efflux as a mechanism of multidrug resistance.

For cytotoxic agents to have an effect on tumor cells, drugs must first be transported into the cell, potentially be metabolized to an active form, and interact appropriately with target molecules. A final common pathway of cytotoxic agents is usually the initiation of programmed cell death, or apoptosis. Tumor cells overcome the effects of cytotoxic agents at one or more of these levels. The classic multidrug-resistance (MDR) phenotype, as mediated by the drug efflux pump, P-glycoprotein, is one of the most extensively studied mechanisms of drug resistance. Additional drug transporters, such as the multidrug resistance-associated proteins (MRPs), have also been identified and can convey drug-resistance phenotypes. Important questions remain as to how and whether such transport systems can be specifically measured and effectively targeted to improve therapeutic outcomes. Furthermore, alterations in drug targets, drug metabolism, repair of DNA damage caused by drugs, and the inability to initiate programmed cell death can all contribute to drug resistance and must be ultimately considered in the explanation of tumor-cell resistance to therapy. Continued exploration of the pharmacologic methods to circumvent drug resistance, as well as strategies that involve targeted therapy and immunomodulation, should increase the specificity and efficacy of treatments for patients with cancer.

Non-clinical roles of Army family physicians in their first post-residency assignment and their level of preparedness for these roles.

A cross-sectional survey of the 1992 and 1993 graduates from Army Family Practice Residencies was done to determine their non-clinical roles and their perceived level of preparedness for these roles. Sixty-nine of the 98 questionnaires mailed (70%) were returned. The non-clinical roles were divided into command, administrative, committee (subdivided into hospital level and department/clinic level), and duties outside of the hospital (subdivided into military and administrative). Twenty-nine (42%) had commands, 58 (84%) had administrative roles, 48 (70%) had hospital committee roles, 53 (77%) had department/clinic committee roles, 54 (78%) had military roles, and 42 (61%) had administrative roles outside of the hospital or clinic. The self-reported level of preparedness, on a five point Likert scale (1 = not at all, 3 = adequately, 5 = superbly), ranged from 2.2 for command to 2.9 for administrative roles outside the hospital. Residents did not feel adequately prepared for their non-clinical roles.

Fusobacterium necrophorum septicemia without a primary focus.

We have presented a case of Fusobacterium necrophorum septicemia, an uncommon infection whose early course may be typified by vague diffuse symptoms or a seemingly benign upper respiratory tract inflammation mimicking acute viral syndromes or viral pharyngitis. The septicemia is most commonly, but not always preceded by an obvious oropharyngeal focus.