Ambulatory systems for managed care.

Providence Health System is successfully making the transition from an acute care-based holding company of health care business to a diversified, operating, managed care company with the mission of improving the health status of the populations it serves, and being at financial risk for doing so. Information systems have been a leading change agent in this transition, not only from the standpoint of consolidating and standardizing practices within Providence Health System, but also by facilitating the exchange and integration of information within the health care community. ProvNet has made available the tools to accomplish this information integration in the physician's office and to extend it not only to Providence, but to other health systems as well.

Brain tumor support group: content themes and mechanisms of support.

PURPOSE: To describe the experiences and needs of patients with brain tumors as evidenced in analysis of themes from support group discussions and to increase knowledge of supportive mechanisms operant in support groups for medically vulnerable populations. DESIGN: Descriptive, exploratory. SETTING: An urban medical center on the U.S. West Coast. SAMPLE: Participants in a brain tumor support group, including patients, families, friends, and facilitators. METHODS: Researchers analyzed observational field notes and videotapes of a brain tumor support group's meetings over a six-month period using grounded theory methods to develop inclusive conceptual categories of themes and to document mechanisms of support. FINDINGS: Five thematic categories emerged: telling the story, managing medical advice, seeking and exchanging information, the long haul, and family life changes. Two major categories of supportive mechanisms emerged: finding a safe haven and maintaining morale, each of which contained several contributing dimensions. MAIN RESEARCH VARIABLES: Discussion topics, dialogue, and interaction among participants during the support group meetings. CONCLUSIONS: The support group provided a specific therapeutic forum for patients with brain tumors and their families, especially regarding the difficulties of survival and maintaining quality of life after initial treatment. IMPLICATIONS FOR NURSING PRACTICE: Findings generated knowledge that can guide patient care, particularly follow-up care after initial treatment. Support group facilitation by expert nurse clinicians can provide health-care guidance and emotional support to medically vulnerable patients and their families through symptom assessment and management, timely referral, therapeutic group process, promotion of self-care, and adaptive coping.

Doppler echocardiographic assessment of long-term progression of mitral stenosis in 103 patients: valve area and right heart disease.

OBJECTIVES: The purpose of this study was to determine, in a large referral population, the rate of echocardiographic change in mitral valve area (MVA) without interim intervention, to determine which factors influence progression of narrowing and to examine associated changes in the right side of the heart. BACKGROUND: Little information is currently available on the echocardiographic progression of mitral stenosis, particularly on progressive changes in the right side of the heart and the ability of a previously proposed algorithm to predict progression. METHODS: We studied 103 patients (mean age 61 years; 74% female) with serial two-dimensional and Doppler echocardiography. The average interval between entry and most recent follow-up study was 3.3 +/- 2 years (range 1 to 11). RESULTS: During the follow-up period, MVA decreased at a mean rate of 0.09 cm2/year. In 28 patients there was no decrease, in 40 there was only relatively little change (< 0.1 cm2/year) and in 35 the rate of progression of mitral valve narrowing was more rapid (> or = 0.1 cm2/year). The rate of progression was significantly greater among patients with a larger initial MVA and milder mitral stenosis (0.12 vs. 0.06 vs. 0.03 cm2/year for mild, moderate and severe stenosis, p < 0.01). Although the rate of mitral valve narrowing was a weak function of initial MVA and echocardiographic score by multivariate analysis, no set of individual values or cutoff points of these variables or pressure gradients could predict this rate in individual patients. There was a significant increase in right ventricular diastolic area (17 to 18.7 cm2) and tricuspid regurgitation grade (2 + to 3 +; p < 0.0001 between entry and follow-up studies). Progression in right heart disease occurred even in patients with minimal or no change in MVA. Patients with associated aortic regurgitation had a higher rate of decrease in MVA than did those with trace or no aortic regurgitation (0.19 vs. 0.086 cm2/year, p < 0.05). CONCLUSIONS: The rate of mitral valve narrowing in individual patients is variable and cannot be predicted by initial MVA, mitral valve score or transmitral gradient, alone or in combination. Right heart disease can progress independent of mitral valve narrowing.

A priori information in image analysis: assessment of intensity distribution for definition of shape and size of small vessels.

A method for incorporating prior information in computer-based image analysis is described and critically evaluated. The specific application improves pixel resolution (spot size) and shape estimation of small vessel cross sections in exchange for dynamic range information. The potential subpixel spot size sensitivity for a 16-bit gray scale is better than one part in 32000. The performance of shape recovery is assessed in relation to signal-to-noise ratio, acquired image resolution, vessel shape complexity and aspect ratio. The process is shown to be effective and stable when the signal-to-noise ratio exceeds 10, when the number of pixels across the vessel is two or more, when the vessel contour has as many as six lobes, and when the aspect ratio is in the range 0.2-5.0.

Acute reduction in functional infarct expansion with late coronary reperfusion: assessment with quantitative two-dimensional echocardiography.

Reperfusion performed too late to salvage myocardium decreases chronic infarct expansion in experimental animals. However, the acute effects of delayed reperfusion are not known. Twenty-two dogs underwent 3 (n = 8), 4 (n = 8) or 6 h (n = 6) of circumflex artery occlusion followed by 3 h of reperfusion. Effects of reperfusion on diastolic expansion were assessed in two ways: 1) change in mean radius of curvature of the infarct segment, and 2) change in the ratio of the length of the diameter from the center of the infarct zone to the opposite wall (septal-lateral diameter) to the length of the diameter perpendicular to this (anteroposterior diameter). Effects on systolic expansion were examined with quantitative two-dimensional echocardiographic systolic thickening analysis. Delayed reperfusion produced an immediate decrease in diastolic infarct expansion. The ratio of septal-lateral/anteroposterior diameters, which had increased with occlusion from a preocclusion baseline of 0.98 +/- 0.06 to 1.13 +/- 0.08 (p less than 0.001), decreased with reperfusion to 1.02 +/- 0.07 at 15 min and 1.03 +/- 0.08 at 3 h of reperfusion (p = 0.001). This was due solely to a decrease in the septal-lateral diameter. The radius of curvature of the infarcted segment increased from 2.1 +/- 0.5 cm before reperfusion to 2.74 +/- 0.8 cm at 15 min and 2.6 +/- 0.85 cm at 3 h of reperfusion (p = 0.009). This occurred despite a significant (13.6%) decline in end-diastolic cavity area and is compatible with flattening of the reperfused infarct region. Systolic infarct expansion also improved slightly.(ABSTRACT TRUNCATED AT 250 WORDS)