Evaluating patient care by the use of a diabetic ketoacidosis CareMap in an intensive care unit setting.

The 1990s have seen major changes in the health care delivery system. One of the more useful ones has been the CareMap, an interdisciplinary tool for managing, evaluating and improving patient care. The article discusses the use of a diabetic ketoacidosis CareMap in the medical intensive care unit in a large community hospital. The impact of the CareMap on cost containment and use of resources is also addressed. Although the CareMap represents only one of the many changes that have evolved in the past several years, it is certain to have a critical effect on patient care quality because it combines a variety of disciplines and identifies problem issues that encourage a collaborative approach to patient care.

Determinants and protective potential of coronary arterial collaterals as assessed by an angioplasty model.

Two indexes of collateral blood flow, the ratio of distal coronary occlusion pressure/aortic pressure (DCOP/Pao) and angiographic collateral class were determined during elective angioplasty in 36 patients with normal left ventricular function. The association between collateral indexes and 8 anatomic and clinical variables was assessed. A reduction in luminal diameter by greater than or equal to 70% predicted angiographically demonstrable collaterals with 100% specificity and 85% sensitivity. Lesion severity (stenosis) correlated with both collateral class and DCOP/Pao: DCOP/Pao = 2.8809 - 0.0729 X stenosis + 0.00049 X stenosis. The data suggest a quantitative relation between lesion severity and collateral development beyond a threshold value of 70% stenosis. Left ventricular ejection fraction during ischemia caused by balloon occlusion (EFo) was found to be primarily determined by lesion location; however, collateral flow modified EFo significantly. For mid-left anterior descending and right coronary artery: EFo = 59 + 26 X (DCOP/Pao); for proximal left anterior descending artery: EFo = 24 + 89 X (DCOP/Pao). A model predicting the hemodynamic and clinical consequences of abrupt coronary closure based on lesion location and severity was developed. In the second study phase, this model was tested retrospectively in a different group of 23 patients who experienced coronary occlusion as a complication of angioplasty. The data of both study phases suggest that left ventricular function and clinical outcome after abrupt coronary closure are determined by an interaction between location of the coronary artery obstruction and the amount of collateral flow. Lesion severity and the extent of functional impairment resulting from abrupt coronary closure are inversely related.

Optic nerve head drusen and glaucoma.

The simultaneous occurrence of both optic nerve head drusen and glaucoma may make it difficult to evaluate visual field defects and the appearance of the optic nerve head. We saw five patients with both conditions, of whom four had pigmentary glaucoma or pigmentary dispersion syndrome. Drusen do not preclude the development of cupping, and they make it difficult to interpret its significance. Management of these patients requires serial visual field testing, serial disc photographs, and treatment aimed at keeping the intraocular pressures as low as possible.

Disciform degeneration of the macula. II. Pathogenesis.

Of 84 patients with unilateral disciform macular degeneration, 36 were followed up for one to four years (average, 22 months). The fellow eye in 13 cases developed disciform lesions during that follow-up period. A significantly greater number of drusen were found in the fellow eyes of patients with unilateral disciform macular degeneration than in the eyes of a comparable control group of patients (P less than .001). Furthermore, the eyes with unilateral disciform macular degeneration that developed disciform lesions in the other eye were characterized as a group by a significantly larger number of drusen than those that did not. We postulate that drusen are precursors of disciform macular degeneration in fellow eyes and are probably manifestations of the same exudative process.