Health care quality and rheumatology: the role of the American College of Rheumatology (ACR).

In the context of undeniable evidence that health care can and must be improved, the ACR has committed to lead the effort to develop and implement quality measures designed to identify opportunities to improve sub-optimal care. In the process of creating and offering tools to measure and assess adherence to evidence-based care, the ACR seeks to be proactive in preparing its member physicians and their practice teams for the likely upcoming healthcare environment shift to more quality-based reimbursement and public reporting.

The MOA: an integral part of quality assurance activities.

Ready or not, the medical office audit (MOA) is an integral part of health maintenance organizations' (HMOs') quality assurance activities. Criteria for the MOA, including external and internal considerations, staffing issues, medical records, and patient safety concerns, are reviewed in this article.

Heparin-releasable lipoprotein lipase activity is increased in cardiomyocytes after culture.

The activity of lipoprotein lipase (LPL) in adult rat heart cardiomyocytes after overnight culture on laminin-coated plates for 18-22 h was compared with enzyme activity in freshly isolated cardiomyocytes. LPL activity in cellular homogenates from cultured cardiomyocytes and freshly isolated cells was 240 and 233 nmol oleate released h-1.mg-1 protein, respectively. LPL specific activity (mU/ng LPL protein) was 0.07 in cultured cells compared with 0.42 in freshly isolated cells, indicating an increased content of inactive LPL mass after overnight culture. The heparin-induced release of LPL activity into the medium of cultured cardiomyocytes (198 nmol.h-1.mg-1) was much greater than heparin-releasable LPL (HR-LPL) activity (59 nmol.h-1.mg-1) from freshly isolated cells. HR-LPL activity from cultured cardiomyocytes was dependent on serum (16.3-fold activation) and was inhibited by high ionic strength (1 M NaCl) and by a polyclonal antibody to LPL. Cultured cardiomyocytes also had more immunodetectable LPL on the cell surface compared with freshly isolated cardiomyocytes, consistent with increased HR-LPL activity. Therefore, overnight culture may permit cardiomyocytes time to recover from the stress of isolation by increasing the content of LPL on the cell surface.

Fatty acids reduce heparin-releasable LPL activity in cultured cardiomyocytes from rat heart.

Varying glucose and fatty acid (FA) concentrations in the medium of cultured cardiomyocytes from adult rat hearts were tested for effects on lipoprotein lipase (LPL) activity. Glucose (5.5, 11, and 25 mM in the culture medium for 18-22 h) had no effect on either heparin-releasable LPL (HR-LPL) or on cellular LPL (C-LPL) activities. When cardiomyocytes were cultured overnight with 60 microM oleate, HR-LPL activity was reduced to 20% of control, with no change in C-LPL activity or total C-LPL mass. Similar results (HR-LPL and C-LPL activities) were obtained with 60 microM concentrations of palmitate and myristate; linoleate and eicosapentaenoate did reduce C-LPL activity, but the decrease in HR-LPL activity was much greater. Oxfenicine, an FA oxidation inhibitor, did not alter the inhibitory effect of 60 microM oleate on HR-LPL. Short-term incubations (1 and 3 h) of cultured cardiomyocytes with 60 microM oleate did not displace LPL into the medium. Immunodetectable LPL on the cell surface of oleate-treated cultured cardiomyocytes was increased compared with control cells, but heparin treatment released the same amount of LPL mass that had reduced catalytic activity.

A 42-year-old woman with low back pain.

The following case is presented to illustrate the roentgenographic and clinical findings of a condition of interest to orthopedic surgeons. The initial history, physical findings, and roentgenographic examinations are noted on this page. The clinical and roentgenographic diagnoses are presented on the following pages.

Hypoglycaemic brain damage: effect of a dihydropyridine calcium channel antagonist in rats.

Hypoglycaemic brain damage consists of selective necrosis of cerebral neurons related to the extracellular release of excitatory amino acids. Neuronal excitatory amino acid receptors are activated and calcium channels are opened. The present investigation was designed to test the effectiveness of dihydropyridine blockade of voltage-sensitive calcium channels in hypoglycaemic brain damage. Sixty-four rats were given either high-dose nimodipine, consisting of an initial bolus of 300 micrograms/kg nimodipine administered at the stage of EEG slowing (blood glucose levels of 1.0-1.5 mmol/l), followed by continuous intravenous nimodipine infusion at 1.5 micrograms.kg-1.min-1, low-dose nimodipine, consisting of an initial bolus of 30 micrograms/kg at the time of EEG slowing, followed by 0.15 microgram.kg-1.min-1, an equal volume of vehicle solution, or 154 mmol/l NaCl. Animals receiving either low- or high-dose nimodipine had higher mortality, and increased brain damage compared with controls. Examination of the perfusion-fixed brains 1 week after recovery with glucose revealed that quantitated neuronal necrosis was worsened by nimodipine in the hippocampus, caudate nucleus and cerebral cortex. The present results in profound hypoglycaemia (accompanied by a flat EEG) contrast with the beneficial effect of nimodipine in brain ischaemia.

Routine surgery, routine patients? Never!

The nursing process--assessing, diagnosing, planning, intervening, and evaluating--is a dynamic tool when properly used by the nurse. It ensures that nursing care is never routine. The following case study demonstrates how this process was used to guide the care of a patient with an unexpected corneal abrasion following meloplasty (chin augmentation) surgery.

The Nordstrom's of medical practices.

While managed care has been touted as potentially putting an end to the private practice of medicine, the area of elective surgery is in a position to thrive. Plastic surgery practices and surgicenters are ideally positioned to provide superior patient care, providing a smart blend of old-fashioned service and state-of-the-art surgical care. Coupled with a current interest in facility accreditation, private practices and surgicenters are poised to enjoy a bright future.

The plastic surgical nurse. Nurse specialist for the 1990s.

In the preface to the Core Curriculum, editor Terri Goodman, RN, MA, CPSN, CNOR, eloquently describes plastic surgical nursing as "a dynamic specialty that is expanding rapidly in response to technology, creativity, and the increasing autonomy of both nurse and patient." She goes on to say that today's "plastic surgical nurse [is] a sensitive, skilled communicator [possessing] a broad knowledge base and the ability to apply principle." These are exciting times in which to be a nurse. Yes, the winds of change are blowing. Some see them as threatening the core of medical practice, that is, caring for patients. Others see them bringing opportunity, empowerment for nurse specialists, and freedom to reach new levels of professionalism. The specialty of plastic surgical nursing is proud to be a part of this exciting future.