Integrated health care in California's managed care capital

Sacramento, California's capital, represents the nation's most competitive managed care marketplace. The Sutter Health organization represents a significant force in this marketplace and surrounding regions of Northern California. Sutter has created an integrated regional health care network capable of delivering a full continuum of care through appropriate community-based facilities, a variety of physician relationships, and both owned and aligned managed care structures. The overall Sutter Health strategy that incorporates facilities, physician partnerships, and patient care financing is described. The article identifies six key lessons learned during this period of growth.     

Presenting statistical uncertainty in trends and dose-response relations.

When one estimates the effects of a polytomous exposure, it is common practice to express all effects relative to a baseline or reference level. Certain authors have challenged this practice and proposed alternatives, which we review here. One alternative, the "floating absolute risk" method, can supply useful statistics and trend graphs, but it does not yield valid confidence intervals for relative risks. All categorical methods have further shortcomings when the exposure is continuous, however. These shortcomings can be addressed by plotting or tabulating confidence limits for points on a flexible curve fitted to the uncategorized data.     

The evaluation and calibration of fan-beam collimators

The aims of this study were (a) to determine the true focal length of a fan-beam collimator and (b) to calibrate image size (mm/pixel) for each collimator to permit inter-comparison of image data acquired on different gamma camera systems. A total of six fan-beam collimators on three dual-head gamma camera systems were evaluated using a set of four cobalt-57 point source markers. The markers were arranged in a line in the transverse plane with a known separation between them. Tomographic images were obtained at three radii of rotation. From reconstructed transaxial images the distance between markers was measured in pixels and used to determine pixel size in mm/pixel. The system value for the focal length of the collimator was modified by up to +/-100 mm and transaxial images were again reconstructed. To standardize pixel size between systems, the apparent radius of rotation during a single-photon emission tomography (SPET) acquisition was modified by changes to the effective collimator thickness. SPET images of a 3D brain phantom were acquired on each system and reconstructed using both the original and the modified values of collimator focal length and thickness. Co-registration and subtraction of the reconstructed transaxial images was used to evaluate the effects of changes in collimator parameters. Pixel size in the reconstructed image was found to be a function of both the radius of rotation and the focal length. At the correct focal length, pixel size was essentially independent of the radius of rotation. For all six collimators, true focal length differed from the original focal length by up to 26 mm. These differences in focal length resulted in up to 6% variation in pixel size between systems. Pixel size between the three systems was standardized by altering the value for collimator thickness. Subtraction of the co-registered SPET images of the 3D brain phantom was significantly improved after optimization of collimator parameters, with a 35%-50% reduction in the standard deviation of residual counts in the subtraction images. In conclusion, we have described a simple method for measurement of the focal length of a fan-beam collimator. This is an important parameter on multidetector systems for optimum image quality and where accurate co-registration of SPET to SPET and SPET to MRI studies is required.     

Nursing education, competency, and role in intravenous conscious sedation

The advent of new hospital policies addressing analgesia and sedation motivates the nursing education department to implement an education plan for training RNs in the safe administration of medications that produce analgesia and sedation according to hospital policies. Learning materials must be procured or written, classroom content delineated, and a plan to precept all RNs who may be involved in IVCS procedures arranged. Our institution faced many obstacles in implementing such a program, including scheduling class time and clinical teaching time for IVCS preceptors, availability of IVCS procedures when preceptors and learners are available, and determining the course of action before a procedure requiring IVCS if the physician had not yet completed physician IVCS training. Obtaining quality monitoring data from these procedures is best initiated when the initial program is introduced. The RN's role in collecting quality monitoring data is crucial. The development of forms that include all required aspects of patient assessment, care, and monitoring promotes compliance with hospital policy.     

Prevalence of asthma and respiratory symptoms in south-central Durban, South Africa

The prevalence of asthma and respiratory symptoms in south-central Durban, one of the most heavily polluted areas of South Africa, has been determined using a cross-sectional survey of 213 households in the communities of Merewent (97% Indians) and Austerville (98% coloreds). The study population consisted of 367 children (less than 17 years old) and 693 adults. About 10% of the children and 12% of adults reported doctor diagnosed asthma. The self-reported prevalence rates for wheezing (37–40%) and attacks of shortness of breath with wheeze (16–28%) were much higher than that for doctor diagnosed asthma and common co-occurrence of the three symptoms is found. The prevalence rates for other respiratory symptoms include 33–35% for chronic cough, 31–32% for chronic phlegm, 44–50% for frequent blocked-runny nose, and 16–27% for sinusitis. Factors in the community that were associated with asthma, wheeze and shortness of breath with wheeze among the adult population included cigarette smoking, use of insecticides (coils and pump spray) and home ownership. An association between asthma among children and a number of household risk factors including dampness, carpet, pets or use of pesticides was not apparent in the community. Asthma prevalence was strongly correlated with missing of school by children (odds ratio (OR): 44; 95% confidence interval (CI): 13–141). The study serves to draw attention to a growing but neglected public health problem in urban areas of Africa.     

INT2 and ERBB2 amplification and ERBB2 expression in breast tumors from patients with different outcomes

Summary The relationships of INT2 and ERBB2 amplification and of ERBB2 overexpression in primary breast tumors to prognostic factors, recurrence, and survival have generated considerable controversy. The rationale for this study is that long-term, recurrence-free survival is a more direct criterion for testing the validity of a tumor marker than correlation either with prognostic factors or with short-term recurrence and survival. We examined the association of recurrence with INT2 and ERBB2 amplification and ERBB2 expression by comparing primary breast tumors from patients surviving without recurrence for 8.5 years after diagnosis. the LTS group, to tumors from patients recurring within two years, the RR group. The RR (N = 63) and LTS (N = 61) samples were coded and examined for amplification by Southern blotting and for expression by immunohistochemistry. Comparison between the RR and LTS groups demonstrated that INT2 amplification was associated with a significantly (P = 0.018) higher (5.6-fold) risk of recurrence, an association that remained significant after controlling for lymph node (LN), tumor size (TS), and histograde (HG) status. ERBB2 amplification and expression were not associated with a higher recurrence risk. Survival analyses within the RR group, however, demonstrated significantly shorter survival time among cases with than without ERBB2 amplification (P = 0.018, median survival 16 vs 25 months), or ERBB2 expression (P = 0.019, median survival 15 vs 25 months), but not INT2 amplification. Univariate Cox proportional hazards regression models also demonstrated significantly shorter survival among cases with ERBB2 amplification (P = 0.016) or expression (P = 0.049), that remained significant in multivariate analyses (P = 0.022) for ERBB2 amplification. These results indicate a significant positive association between INT2 amplification and risk for tumor recurrence in the RR as compared to the LTS group. The relationship of ERBB2 amplification or overexpression to patient outcome is more complex. ERBB2 amplification and expression have a significant relationship with shorter survival among patients recurrent within two years, but their occurrence in tumors from women surviving without recurrence for 8.5 years suggests that ERBB2 status is not predictive of shorter survival for all breast cancers.     

Electroconvulsive Therapy in Adolescents

Because of the limited number of case reports on the use of electroconvulsive therapy (ECT) in adolescent psychiatric patients, we retrospectively reviewed the medical records of 20 young patients who underwent ECT. They constituted all the patients 相似文献