ABSTRACT
BACKGROUND: In the diagnosis of coronary artery disease (CAD) with Dobutamine Stress Echocardiography (DSE), regional wall motion abnormalities (RWMA) are assumed to indicate a perfusion deficit. METHODS AND RESULTS: For a more particular examination of RWMAs, we compared simultaneous echo-contrast (Optisone)-enhanced DSE (0-40 microg/kg Dobutamine, 16-segment- model) and MiBi-SPECT in a prospective double-blinded study design in 69 non-selected consecutive patients (44 male, 25 female, age 64+/-12 years). Additionally, all patients were examined by coronary-angiography. The prevalence of significant CAD (stenosis >50% lumen diameter) was 52%. DSE had a sensitivity of 78% and a specificity of 66% for the detection of significant CAD with a positive and negative predictive value of 72 and 73%, respectively. Among 28 patients with significant CAD and positive DSE study (true positive), 78% displayed a corresponding perfusion deficit in MiBi-SPECT. Among 11 patients with a positive DSE study but no current significant coronary stenosis (false positive), 82% showed stress-induced RWMAs in the inferior/posterior region, 73% displayed left ventricular hypertrophy, 54% resting-ECG abnormalities and 45% resting-RWMA (3 previous MI, 2 previous CABG surgery). Among 8 patients with negative DSE study but significant coronary stenosis (false negative), 75% had a stenosis of the LCX, 63% displayed resting- WMA, 63% displayed left bundle branch block or ST-segment depression, 50% displayed only peripheral coronary stenosis, and DSE visualization was suboptimal in 38%. CONCLUSION: This prospective study in non-selected patients shows that the majority of RWMAs in DSE are matched to a perfusion deficit detectable by nuclear imaging. Nevertheless, pre-existing cardiac abnormalities may also lead to stress-induced RWMA not associated with a perfusion deficit or mask a perfusion deficit upon DSE. Particularly in patients with LV hypertrophy, resting-RWMA, bundle branch block or ST segment depression, the predictive value of DSE may, therefore, be limited.
Subject(s)
Coronary Artery Disease/physiopathology , Cardiotonic Agents , Chi-Square Distribution , Coronary Angiography , Coronary Artery Disease/diagnostic imaging , Dobutamine , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Radiopharmaceuticals , Sensitivity and Specificity , Technetium Tc 99m Sestamibi , Tomography, Emission-Computed, Single-PhotonABSTRACT
This paper presents a discussion of workforce diversity in healthcare and its attendant requisite of cultural competency. The first section of the paper argues that self-assessments and diversity training are integral to workforce diversity management. This paper maintains that diversity training should be a part of overall strategic goals, and that the development of management goals should be based on self-assessments. The second section of the review offers a framework of cultural competency in healthcare delivery based on the relationship between patient and provider, and the community and health system. For this relationship to be successful, this review argues that health systems should foster providers that can also be cultural brokers. The cultural broker role is seen as core to achieving cultural competency.
Subject(s)
Clinical Competence/standards , Cultural Diversity , Education, Nursing, Continuing/organization & administration , Inservice Training/organization & administration , Nursing Staff/education , Nursing Staff/psychology , Workplace , Health Knowledge, Attitudes, Practice , Humans , Prejudice , Self-Assessment , United StatesABSTRACT
Judging from the social and health measures considered in this article, Newark and Jersey City face similar challenges as other large cities. For Newark, the challenges are more extreme. The high rates of poverty and violence, coupled with a low rate of high school graduation and a large number of single parent households bode ill for the city. The hospitals in Newark and Jersey City have undergone major changes in meeting the needs of their communities. They have adjusted their size, shortened their lengths of stay, and provided more intensive care services and outpatient services. Of special concern for New Jersey's hospitals is the reliance on Medicaid financing. If dramatic changes are made to the Medicaid program, Newark hospitals should be on high alert. Legislatures need to tread carefully in designing policies that address the needs of New Jersey's large cities. The state is undergoing major changes in its health care system. The demise of the all-payer rate setting system, the establishment of the Health Care Subsidy Fund to finance uncompensated care and subsidize insurance for low and middle-income families, modifications to the community rating system for private insurance, and changes to the welfare system that affect eligibility for Medicaid all require legislators to consider the context in which these programs operate.
