Community care management. Advanced practice nurses as care managers.

A group of advanced practice nurses partnered with a major insurer in the design and implementation of a care coordination model for high-risk older adults. This article will discuss the process of such an undertaking, highlighting the successes and barriers encountered. The key elements of this program included early identification and regular reassessment of each member's acuity level; fostering close partnerships between individual or teams of APRNs and groups of physicians; and uninterrupted clinical management of high-risk members across the health care continuum. This model was designed to achieve the following outcomes: to support the physician management of high-risk, chronic individuals; to increase or maintain the health of members; and to reduce health care costs. Outcome studies have demonstrated a substantial net savings by decreasing acute care admissions by 54%, reducing hospital days by 42%, and trimming primary care physicians' and specialists' visit costs by 37%. There was a 33% reduction in the overall costs of health care for members enrolled in this program. Physicians and members both rated their satisfaction with the APRN-based model of care as very high.

External rewarming and age in mildly hypothermic patients after cardiac surgery.

OBJECTIVE: To compare the effects of two external rewarming methods on body core temperature and the rate of rewarming between two age groups (less than 65 years, 65 years or more) of adult, mildly hypothermic patients who have undergone cardiac surgery, during the immediate postoperative period. DESIGN: Stratified, randomized clinical trial. SETTING: Five-bed cardiac surgical intensive care unit in a large teaching-research institution. SUBJECTS: Thirty-two white patients who had undergone cardiac surgery and who had mildly hypothermic body core temperatures (33 degrees to 35 degrees C) immediately after the surgery. OUTCOME MEASURES: Body core temperature was measured with a pulmonary artery catheter thermistor at the time of external rewarming method application and at 60, 90, and 150 minutes afterward. Rate of rewarming was measured as body core temperature change in degrees Celsius per hour (at 36.6 degrees C, minus body core temperature when external rewarming method was applied, divided by total rewarming time). Temperatures were recorded six times at intervals of 15 minutes; then every 30 minutes until a value of 36.6 degrees C was obtained, at which time the blanket was removed; then hourly for 8 hours. INTERVENTION: Either a fluid-filled circulating blanket (active-conductive external rewarming) or a reflective blanket (passive-reflective external rewarming) was applied immediately after core temperature was measured on admission to the cardiac surgical intensive care unit after surgery. RESULTS: External rewarming methods affected body core temperature differently at different times, and there were significant differences in body core temperature across the time periods (p < 0.05). Both active and passive external rewarming methods showed a sigmoidal rewarming pattern without a downward temperature drift. The fluid-filled circulating blanket produced a quicker and steeper body core temperature change in the early rewarming phase; the reflective blanket resulted in a more gradual temperature rise. Age did not significantly affect body core temperature, nor did age or external rewarming method significantly influence the rate of rewarming, although total rewarming time was longer for those of more advanced age. Seven subjects with passive rewarming method experienced body core temperature overshoot during the 8-hour period after blanket removal. CONCLUSIONS: In this study, conduction and reflection of radiant heat were equally effective in producing an acceptable rate of rewarming but contributed to different internal patterns in core rewarming. The average total rewarming time with the active external rewarming method was 1 hour shorter than with the passive external rewarming method.

Inside polyomavirus at 25-A resolution.

Empty capsids and complete virions of polyomavirus crystallize isomorphously. Here we use difference Fourier analysis of X-ray diffraction data at 25-A resolution from these crystals to obtain an electron-density map of the inside of the virion. The polyomavirus capsid is built from 72 pentamers of VP1 that form three different types of connections in the T = 7d icosahedral surface lattice. Self-assembly of purified recombinant VP1 into capsid-like aggregates has shown that switching of the bonding specificity to form the unanticipated non-equivalent connections is an inherent property of the VP1 pentamers. Our map of the inside of the virion displays 72 prongs of electron density extending from the core into the axial cavities of the VP1 pentamers. We identify these prongs with the VP2 and VP3 molecules, which may function to guide the assembly of the highly ordered capsid on the nucleohistone core. The atomic structure of the closely related simian virus-40 capsid has been determined from the high-resolution diffraction data. Our polyomavirus map, calculated using all the low-resolution diffraction data, shows no indication of regular order inside the spherical core.

Tip suspension suture for superior tip rotation in rhinoplasty.

Superior tip rotation is sometimes necessary to relieve functional obstruction as well as improve the esthetic appearance in the aging nose and the thick skinned heavy tip nose. Conventional techniques including thinning resection, rim strip, lateral crural flap and even external skin excisions are often inadequate to obtain and maintain sufficient superior tip rotation. A technique is described to permanently suture the lower lateral crus to the upper lateral cartilages and to the cartilaginous septum. Long-term follow-up supports this technique's cosmetic and functional effectiveness.

Polyoma virus 'hexamer' tubes consist of paired pentamers.

The discovery that the 72 capsomeres of the icosahedrally symmetric polyoma virus capsid are all pentamers shows that the expected quasi-equivalent bonding specificity is not conserved in the assembly of this virus coat protein. Tubular particles produced by polyoma and other papovaviruses seem to be polymorphic aggregates of capsomeres that may arise through variation in switching of the bonding specificity. Electron micrographs of wide and narrow classes of tubes were analysed by Kiselev and Klug using optical diffraction and optical filtering methods. The wide type were called 'hexamer' tubes because they consist of approximately hexagonally arrayed capsomeres that were assumed to be hexamers, in accord with the quasi-equivalence theory of icosahedral virus particle construction. The narrow type were called 'pentamer' tubes because the capsomeres are arrayed in a particular 'pentagonal tesselation' which arises from the pairing of pentamers across 2-fold axes of the surface lattice. Our reexamination of negatively-stained polyoma virus tubes by digital image processing of low-irradiation electron micrographs shows that all tubes are assemblies of paired pentameric capsomeres. We report here that the packing arrangement of the pentamers in the hexamer tubes is simply related to the pentagonal tessellation respresenting the packing in the narrow pentamer tubes. In all the tube structures examined, at least one pairwise contact between neighbouring pentamers closely resembles the contact between the pentavalent and hexavalent capsomeres in the icosahedral capsid.

Fatal epistaxis in craniofacial trauma.

Facial trauma often results in minor and infrequently results in major bleeding in the structures of the face. We have recently observed two patients who suffered fatal hemorrhages which could have been controlled using relatively simple measures. Treating physicians often overlook this serious and potentially life-threatening source of hemorrhage until the patient has been in shock for long periods of time and irreversible ischemic brain damage and renal failure have occurred. With careful attention to examination of the face and oropharynx, hemorrhage from these sites can be identified early and the appropriate measures taken to control epistaxis.

Applications of the biomechanical behavior of cartilage to nasal septoplastic surgery.

The biomechanics of septal cartilage as they apply to septoplasty are studied. The original investigations on septal cartilage are reviewed and summarized. Biomechanical principles of the behavior of cartilage are reviewed and applied to the principles of septoplasty surgery. Using pigs' ears, theoretical predictions are investigated and verified. Incorporating this information, an approach to septoplastic surgery is described.

Polyoma virus capsid structure at 22.5 A resolution.

X-ray diffraction data from polyoma capsid crystals were phased by refinement of low-resolution starting models to obtain a self-consistent structural solution. The unexpected result that the hexavalent morphological unit is a pentamer shows that specificity of bonding is not conserved among the protein subunits in the icosahedrally symmetric capsid.

Polyoma virion and capsid crystal structures.

X-ray diffraction shows that complete virus particles and empty capsids crystallize isomorphously. The surface morphology of the protein coat, as revealed by electron microscopy, is the dominant structural feature determining the intensity of x-ray reflections to a resolution of approximately 30 angstroms. The structure and variability of the viral chromatin core can now be analyzed by comparison of electron density maps.

Reactivity of isolated human cerebral arteries to biogenic amines.

Serotonin (5-HT), histamine, norepinephrine, methoxamine and isoproterenol caused dose-dependent contraction of human cerebral arteries. The potency of 5-HT was greater among test agents in the basilar arteries, whereas it was equivalent to that of norepinephrine in human anterior, middle and posterior cerebral arteries. Acetylcholine and carbachol (10(-9)-10(-5) M) caused a negligible response in human cerebral arteries. Contractile response to 5-HT was greater in the distal rather than middle portion of the human basilar arteries while this order was reversed in the response to norepinephrine. Tyramine (10(-4) M) caused tonic contraction and nicotine (10(-4) M) and electrical transmural stimulation produced phasic contraction of arteries which were antagonized by adrenergic blocking agents. Adenine nucleotides failed to cause relaxation and only high concentration of adenosine caused a minute relaxation. However, papaverine and nitroglycerin caused marked relaxation. These results suggest that adrenergic mechanism may play a role in the regulation of vascular tone in human cerebral arteries.