Development of a two-step, non-probed multiplex real-time PCR for surveilling Vibrio anguillarum in seawater.

Vibrio anguillarum is an aggressive and halophilic bacterial pathogen most commonly originating from seawater. Vibrio anguillarum presence in fisheries and aquaculture facilities causes significant morbidity and mortality among aquaculture species primarily from haemorrhaging of the body and skin of the infected fish that eventually leads to death, collectively recognized as the disease vibriosis. This study served to develop a non-probe, multiplex real-time PCR assay to rapidly detect V. anguillarum presence in seawater. Specific primers targeting genes vah1, empA and rpoN of V. anguillarum were selected for multiplex reaction among 11 different primer sets and the extension step was eliminated. Primer concentration, denaturation time as well as annealing time and temperature of DNA amplification were optimized, thus reducing reaction duration. The two-step, non-probed multiplex real-time PCR set forth by this study detects as little as 3 CFU mL(-1) of V. anguillarum presence in sea water, without enrichment cultivation, in 70 min with molecular precision and includes melting curve confirmation.

Insulin therapy and weight change in Native-American NIDDM patients.

OBJECTIVE: To determine whether NIDDM patients exposed to insulin therapy in a clinical setting gain weight. RESEARCH DESIGN AND METHODS: This study, an historical cohort chart review, was conducted at the IHS clinic on the Navajo Reservation in Northern Arizona. We studied 27 Native Americans with NIDDM and 102 Native-American nondiabetic control subjects. RESULTS: Insulin therapy consisting of a mean of 105 U/day was associated with a mean weight gain of 3.0 +/- 2.2 kg/yr. When insulin was discontinued or decreased, a mean weight loss of 5.2 +/- 2.7 kg/yr was observed in the same patients. No significant weight gain was noted in 102 nondiabetic control subjects, nor in 20 of 27 insulin-treated patients given oral hypoglycemic agents before initial insulin therapy. CONCLUSIONS: Insulin therapy appeared to be associated with weight gain in this group of NIDDM patients. This suggests that observations for weight gain be undertaken when treating NIDDM patients with insulin, because it may exacerbate the underlying pathophysiology of the disease.

Adaptation of the Dartmouth COOP Charts for use among American Indian people with diabetes.

OBJECTIVE: To adapt the Dartmouth COOP Charts for use among American Indians with diabetes and to evaluate the operating characteristics of the adapted charts because measures of health status have not been evaluated for use among American Indians with diabetes. RESEARCH DESIGN AND METHODS: American Indian adults participated in focus group conferences to adapt and review the Dartmouth COOP Charts for use in American Indian communities. American Indian participants with diabetes were interviewed and administered the adapted charts. The operating characteristics of the charts were evaluated by measuring internal and external consistency, reliability, and acceptability. RESULTS: Some of the wording and pictures were considered to be offensive and culturally inappropriate in American Indian communities. The adapted charts showed internal consistency in a comparison of interchart variables. CONCLUSIONS: The adapted Dartmouth COOP Charts are more culturally acceptable than the original charts and appear to measure constructs adequately.

Bridging the gap between science and practice in managing low back pain. A comprehensive spine care system in a health maintenance organization setting.

STUDY DESIGN: A case study of spine care system changes in a multispecialty group practice health maintenance organization setting. OBJECTIVES: To reduce unnecessary use of imaging and specialty referrals for low back pain in the primary care setting and to reduce spine surgery rates. SUMMARY OF BACKGROUND DATA: Results of previous research indicate that diagnostic and therapeutic procedures for low back pain are frequently used even though there is no scientific evidence of their efficacy. This indicates that low back pain care can be made more efficient by reducing the use of unproven diagnostic and therapeutic interventions for low back pain. METHODS: Rates of diagnostic imaging and specialty referral rates for low back pain were monitored for 9 months before and 9 months after primary care physician education regarding appropriate low back pain evaluation and management. Spine surgery rates were also monitored before and after implementation of a nonsurgical spine clinic. RESULTS: Large reductions in rates of imaging and specialty referrals for low back pain were achieved after primary care physician education. After spine clinic implementation, visits to spine surgeons dropped by approximately 50%, and spine surgery rates per thousand health plan members were reduced by 35%. CONCLUSIONS: Primary care physician education regarding low back pain management can reduce use of imaging and specialty referrals without reductions in patient satisfaction, and implementation of a nonsurgical spine clinic for complex or chronic spine patients can significantly reduce spine surgery consultations and spine surgery rates.

From managing access to managing care: the impact of primary care on health care delivery organizations.

Professional "revenge of the nerds" is currently taking place, as managed care evolves generalist physicians into new professional prominence. Primary care physicians are finding themselves at the center of health care market reform as health plans, insurers, and other financing organizations turn to them as the key to cost control. In short supply, they are prospering financially from the demand. As the source of patients, they are gaining in prestige from specialists and hospitals who once demeaned them. But these newfound roles are only the initial steps in the transformation of the primary care practitioner. The change that the generalists are experiencing is essentially managing access to care, not truly managing care itself. There are large and crucial differences between managing access to care and actually managing care. These differences are, in many ways, a higher calling for primary care practitioners as they refocus attention on patient outcomes, which will in itself result in a lower resource utilization above and beyond the crude controlling of access. What those differences are, what new roles they require, and what impact they will have on organizations that either house or contract with primary care physicians will be the focus of this article.

Leading beyond the bottom line.

Do physician executives approach managing and leading health care organizations like a CEO of a Fortune 100 company? Or does their training as physicians first give them a unique perspective, leading them to view organizational issues differently? The authors suggest that to be a physician executive is to be the practitioner, teacher, coach, and mentor for a new philosophy of leadership and management called Leading Beyond the Bottom Line. While the financial health of an organization is critical to its survival and its ability to fulfill its purpose, the trap is to focus on maximizing the bottom line. This new philosophy leads an organization to attend in equal measure to the (1) welfare of its patients, (2) its financial health, (3) the well-being of its employees, and (4) the building of its community. "The Optimal Organization" is one in which these four objectives are seen not only as related, but interconnected, and the goal is to maximize all of them. The legitimate role of the physician executive is to manage in search of Pareto Optimum, or the maximum benefit for all four organizational objectives. Clearly, this is a tougher job than maximizing profits or just optimizing profits and patient care.

Leading beyond the bottom line: organizational assets for the new economy. 2.

Organizations are created to aggregate resources to accomplish some purpose, be it to provide health care, raise a family, or build cars. These resources are assets. A manager has a fiduciary responsibility, by practice, and, in many cases, by law, to make the best use of those assets. Traditionally, we've evaluated the use of assets through financial statements. The troublesome aspect of these financial statements is that they were designed to measure only those things that can be counted simply--financial and physical assets. But our world has moved from an industrial, manufacturing age to an information, service economy and we are learning that intangible assets are as powerful--potentially more powerful--in creating value as are tangible assets. Recognizing the intangible asset value of employees, customers, and the community is the challenge in this new service economy. Effective health care leaders need to leverage and manage all of an organization's assets.

Leading beyond the bottom line, Part 4. The questions it has raised.

The Leading Beyond the Bottom Line article series has received an overwhelming response from ACPE members, mostly in enthusiastic support of this new leadership concept. Some of the important questions raised by members are presented with answers from the authors. This article also explores the moral challenge of leadership and why health care is more than a business. In recent years, there's been confusion about the role of the health care enterprise, its leadership and its management. We have lost our way about the "moral" thing, the "right" thing, because we have no philosophy to guide us. To manage or lead in this "business" of health care, a philosophy is required that recognizes the multiple elements to which the leader has responsibility and obligations: the customers, community, employees, and, certainly, the financial assets.

Disease management: Lovelace Health Systems episodes of care--a case study.

The evolving paradigm shift in healthcare emphasizes population health status. Disease management is gaining popularity as a means of providing cost-effective, quality healthcare to an entire population at risk. Outcomes measurements, standardized clinical protocols and commitment by physicians and staff are crucial to a successful program. This article presents a case study from Lovelace Health Systems in Albuquerque, N.M., and identifies key components, cost savings and successes of one of its disease management programs.