Partners Community HealthCare Extranet (PCHInet): a business plan.

This article presents an edited version of the business plan for PCHInet, an extranet designed to further Partners HealthCare System's strategic objectives of integrating its physician community, reducing costs, improving the quality of care, and raising the level of service delivery to its medical staff.

Benefits of the worldwide government computer-based patient record framework.

The G-CPR organization composed of the DoD, VA, IHS, and the LSUMC presents an opportunity to facilitate the exchange of clinical data across existing healthcare information systems with new business practices. The organization's ability to reengineer existing healthcare delivery processes through the G-CPR framework will improve the sharing of information and will ultimately provide for better-quality healthcare, improved access to care, greater cost efficiencies, and enhanced medical readiness of the DoD healthcare beneficiaries. The projected benefits that are by-products of the organization sharing effort tend to be focused in two broad categories: improving access to clinical data and creating a mechanism to gather information across large clinical populations. Both of the two categories include various benefits that accrue to members of the organization relative to their ability to use the G-CPR framework as a business reengineering tool. As information management processes are refined through reengineering initiatives, benefits will be observed at multiple program levels--from the DoD enterprise level down to the operational level at individual treatment facilities. Using comprehensive data to quantify precise benefits and ROI strategies is difficult because the development of the G-CPR framework is still in its early stage. Formal performance-based outcome studies are envisioned to demonstrate these results once the G-CPR framework attains greater functional definition. Through the future development of benefits performance metrics, these benefits can be shown to have substantial impact on achieving the strategic goals of the MHS and the organization while helping to improve the cost and quality of healthcare, access to care, and the medical readiness posture within the DoD.

Recombinant tissue plasminogen activator for the treatment of lower extremity peripheral vascular occlusive disease.

PURPOSE: Regional thrombolysis in the recanalization of peripheral vascular occlusive disease is an increasingly accepted therapeutic modality. Efficacy and complication rate are major issues in thrombolytic therapy. This prospective study was undertaken to determine if locally delivered recombinant tissue plasminogen activator (r-TPA) is safe and effective in clot lysis at non-weight-adjusted doses. PATIENTS AND METHODS: Twenty patients (undergoing 21 infusions) from two centers underwent fibrinolytic therapy with use of r-TPA, at a dose rate of 2 mg/h. The mean duration of arterial occlusion was 27.2 days (range, 1-117 days). Concomitant intravenous heparin anticoagulation was administered to all patients. A coaxial infusion delivery system was employed. Hematologic parameters and angiographic follow-up were evaluated at 4-hour intervals during thrombolytic infusion. The chosen maximum r-TPA dose of 40 mg could be extended at investigator discretion. RESULTS: Complete clot lysis was achieved in 18 of 21 (85.7%) infusions at a mean total dose of 38.9 mg (range, 8-84 mg). The mean infusion duration was 19.7 hours. In 16 of 19 (84.2%) infusions, in which the nadir fibrinogen level was recorded, it remained greater than 65% of baseline. Three of 21 (14.3%) infusions resulted in three major bleeding complications, one of which resulted in death. CONCLUSION: In this two-center trial, catheter-directed r-TPA infusion at 2 mg/h is effective for clot lysis. When combined with concomitant heparin administration, this treatment may result in an unacceptably high frequency of bleeding complications.

Deferoxamine posttreatment reduces ischemic brain injury in neonatal rats.

BACKGROUND AND PURPOSE: Iron catalyzes the formation of damaging reactive species during cerebral reperfusion. Brain iron concentration is highest at birth, so the brain of the asphyxiated newborn may be at increased risk of iron-dependent injury. We investigated whether the ferric iron chelator deferoxamine could reduce hypoxic-ischemic brain injury in neonatal rats. Because deferoxamine has concentration-dependent activities other than iron chelation, we measured brain deferoxamine levels and calculated deferoxamine pharmacokinetic parameters. METHODS: We produced hypoxic-ischemic injury to the right cerebral hemisphere of 7-day-old rats by right common carotid artery ligation followed by 2.25 hours of hypoxia in 8% oxygen. At 5 minutes of recovery from hypoxia the rats received 100 mg/kg deferoxamine mesylate or saline subcutaneously. Rats (saline, n = 33; deferoxamine, n = 38) were killed at 42 hours of recovery to assess early acute edema by measurement of hemispheric water content. Other rats (saline, n = 31; deferoxamine, n = 32) were killed at 30 days of age for morphometric determination of right hemisphere atrophy. In still other rats, we measured deferoxamine levels in blood and brain after hypoxia-ischemia. RESULTS: Deferoxamine significantly reduced right hemisphere injury as measured by early water content (P < .01) and later atrophy (P = .019). Deferoxamine brain levels peaked between 100 and 200 mumol/L at 40 to 60 minutes after injection and exceeded serum levels by +/- 70%. CONCLUSIONS: Deferoxamine administered after induction of cerebral hypoxia-ischemia reduces injury in 7-day-old rats. Deferoxamine concentrates in the brain at levels between 100 and 200 mumol/L. At the concentrations achieved, deferoxamine might protect the brain through mechanisms unrelated to its ability to chelate iron.

Possible association of pulmonary fibrosis with mexiletine.

This case describes a 75-year-old man who developed pulmonary fibrosis. The onset of symptoms occurred three months after starting mexiletine. A computerized tomogram obtained eight months after initiating mexiletine documented findings consistent with chronic pulmonary fibrosis. The patient died from intractable respiratory difficulties 13 months after beginning mexiletine therapy. To date, there have been three cases of pulmonary fibrosis in patients receiving mexiletine spontaneously reported to the manufacturer.

Stereostructure-activity relationships of the GABA-containing cis-decahydroquinoline-5-carboxylic acids; intracerebroventricular studies in mice.

Two cis-decahydroquinoline-5-carboxylic acids, cis-1 and 2 were investigated for their pharmacological activities in vivo. Intracerebroventricular administration of either agent elicited convulsant activity in mice. This convulsant effect can be antagonized by pretreating the mice with n-dipropylacetate (valproate). Our results suggest that cis-1 may act indirectly as a partial gamma-aminobutyric acid (GABA) agonist in vivo. On the other hand, both cis-1 and 2, at higher concentrations, exhibit properties of a GABA-antagonist, but this effect seems not to be due to GABA receptor binding.