Fractionation of sodium effux in frog sartorius muscles by strophanthidin and removal of external sodium.

The influence of strophanthidin, ouabain, and the removal of external sodium on the sodium efflux from frog sartorius muscle was measured. In freshly dissected muscles strophanthidin and ouabain in maximally effective concentrations reduced the efflux of sodium by about 50%. Of the sodium efflux which is strophanthidin-insensitive about 75% is inhibited after complete replacement of external sodium by lithium. In the absence of strophanthidin replacement of external sodium by lithium, calcium, or magnesium produces an initial rise in the sodium efflux, followed by a fall in the efflux as the exposure of the muscles to sodium-free media is continued. When the muscles are exposed for prolonged periods in sodium-free media, the fraction of internal sodium lost per minute is higher when returned to normal Ringer fluid than it was initially. The activation of sodium efflux by external sodium after long periods in sodium-free solutions is partly strophanthidin-sensitive and partly strophanthidin-insensitive. The internal sodium concentration is an important factor in these effects. The effects of temperature on the sodium efflux were also measured. Above 7 degrees C the Q(10) of both the strophanthidin-sensitive and strophanthidin-insensitive sodium efflux is about 2.0. Below 7 degrees C the strophanthidin-insensitive sodium efflux has a Q(10) of about 7.4.

Interpreting HCFA mortality data for the public.

The Health Care Financing Administration (HCFA) has released mortality data for hospitals to the public. Administrators of hospitals designated by HCFA as mortality outliers have to respond to negative press, the concerns of their medical staffs, and inquiries from employers and third-party payers. D. Michael Waggoner, MD, explains the numbers and suggests how hospitals can respond.

Application of continuous quality improvement techniques to the treatment of patients with hypertension.

This article reports how continuous quality improvement (CQI) techniques were applied to physician care of patients with hypertension. A physician task force at an ambulatory care center used CQI methods to address the needs of two important "customer" groups: (1) third party payors and (2) patients with hypertension. Treatment standards were defined that can also serve as a customer-oriented product description. The task force found patients' blood pressures generally well controlled. Future studies will focus on appointment making, giving advice, and the doctor's examination as subprocesses that strongly influence patient satisfaction.

Enhancing the cost-effective practice of medicine: the physician's perspective.

Data-driven process improvement, such as that at Harper Hospital described earlier, requires several critical elements. First, data must be readily available, accurate, timely, and easy to analyze. Over 200 charts and graphs were produced at Harper Hospital to support the work of the five teams. Often, teams met weekly and data had to be accessed, analyzed, and turned around in five working days. Without the right systems, this is impossible. Second, accuracy of data and accessibility are issues. Sometimes, data are not accessible because of disparate systems or databases, or because they are not collected in a format to support analysis. An example of the latter occurred at Harper Hospital when it was discovered that surgical OR supplies were billed at one inclusive rate and that the detail data were not collected in an automated system. Manual analysis could not be done in the time frame required and momentum was lost. Next, timeliness is an issue when physicians are asked to make decisions using dated data. For most purposes, data should be no more than three months old. Ideally, two weeks should be the limit. Some hospitals are making new data available hourly. Trends change too rapidly, lengths of stay shorten, new antibiotics are introduced, new treatments are available, and reimbursement changes too often to use old data for decision making. Lastly, tools should be readily available to bring the story from the numbers. Graphs, charts, and statistics need to be used much more often and in more imaginative ways. As the health care information industry makes databases more user-friendly, physicians will understand and regain their potential to use medical science to improve the lives of their patients.

Lipoproteins in patients with proved coronary artery disease: qualitative and quantitative changes in agarose-gel electrophoretic patterns.

The relationship between the configuration of agarose-gel lipoprotein electrophoresis patterns and the extent of coronary artery disease (CAD) was studied in consecutive patients undergoing diagnostic coronary angiography. Three groups were identified: patients with normal coronary arteries (group 1), patients with minor luminal irregularities (group 2) and patients with significant coronary artery obstructions (group 3). Densitometric scans of the electrophoretograms were studied to determine the relative proportion of lipoproteins in each major fraction and the configuration of the pre-beta complex. The presence of multiple subfractions within the pre-beta lipoprotein complex had a sensitivity of 66% for the presence of CAD and a specificity of 99%. A decreased level of alpha 1 lipoproteins, defined as less than 25% of total lipoproteins, occurred almost entirely in groups 2 and 3, whereas an increased level (greater than or equal to 28%) of pre-beta lipoproteins was less specific for CAD. The proportions of alpha and pre-beta lipoproteins were inversely related (r = 0.677). Although abnormalities of serum cholesterol and/or triglycerides were common in groups 2 and 3, the detailed study of lipoprotein patterns provided a more sensitive index of disordered lipoprotein metabolism. The angiographic severity of CAD was significantly related to age and to levels of serum triglycerides, alpha 1 lipoproteins, and pre-beta lipoproteins. The lipoprotein electrophoretogram, in conjunction with serum lipid levels, is a valuable tool for demonstrating abnormalities of lipoprotein metabolism associated with CAD.

Physician influence on patient compliance: a clinical trial.

This study was designed to measure the effect of altering three possible impediments to care provided patients with non-emergency problems in a large city hospital emergency department: inadequate patient education by physician, lack of continuity of care, and complex and impersonal clerical procedures. Patients with symptomatic urinary tract infections were randomly assigned to intervention and control groups. A senior physician spent extra time with patients in the intervention group to discuss the assessment and management of their problem, bypass the usual clerical procedures at discharge, and promise continuity of care. Patients in the control group were treated in the usual fashion by emergency department nurses and residents. The return rate to the emergency department three weeks after the initial visit was used to measure the effect of the altered care applied to patients in the intervention group. Our hypothesis was that patients in the intervention group would be more likely to return. Of 46 patients in the intervention group 26 returned. Of 43 patients in the control group, 14 returned (chi square 4.23 after Yate's correction, 0.025 less than P less than 0.05). The significance of this improvement is discussed.

A 'firm' system for graduate training in general internal medicine.

The faculty of the Department of Medicine at Cleveland Metropolitan General Hospital has responded to the challenge of fostering general internal medicine in a graduate training program by organizing a "firm" system of medical care which has appealed to academic internists with broad interests in clinical medicine. This firm system consists of four medical teams which care for distinct patient populations, closely integrating their outpatient and inpatient care. The firms are made up of all the house staff in training in internal medicine together with senior and junior faculty members who are directors for the firms. Medical students in general medicine are also assigned to firms. This firm system is relatively simple to understand and establish and is readily applicable to other academic departments with general medical responsibilities.