The cognitively limited severely mentally ill: concerns for managed care.

The managed care needs of cognitively impaired severely mentally ill inpatients have not been estimated. The aims of the study were to estimate and describe the demographic and clinical characteristics of cognitively impaired patients in an urban inpatient sample. By doing so, we hoped to identify areas that need further study and treatment modification in planning capitated contracts.

Coronary artery bypass without cardiopulmonary bypass.

The purpose of this article is twofold: to describe our technique for performing coronary artery bypass grafting without cardiopulmonary bypass (off pump) and to demonstrate that this operation is safe, in terms of mortality and certain indices of morbidity. Very little has been published in regard to off-bypass operations. From 1985 through 1990, 220 patients underwent operation off bypass; 220 on-pump controls were retrospectively matched for number of grafts, left ventricular function, and date of operation. Groups were compared in terms of mortality and ten indicators of morbidity. The same analysis was performed for ten subgroups. We found no statistically significant difference between groups in mortality (off pump, 1.4% [3/220]; on pump, 2.4% [5/220]), which held across all subgroups. Patients undergoing operation off pump required blood far less often (not transfused: off pump, 72.7% [160/220]; on pump, 54.6% [116/220]; p = 0.005 by Fisher's exact test), and the low output state occurred statistically less frequently off pump (off pump, 5.5% [12/220]; on-pump, 12.7% [28/220]; p = 0.01 by Fisher's exact test). Further research should be directed to which subgroups can be operated on to advantage off pump and which, if any, groups of patients should be confined to on-bypass operations.

Medicare outpatient clinical laboratory services payments: relative value scale approach.

The Health Care Financing Administration is in the process of designing a competitive bidding model for the purchase of outpatient clinical laboratory services. One segment of this process involves the development of a relative value scale (RVS). The RVS could be used as part of the bidding process and as the basis of payment. The RVS could also be used as the basis of a national fee schedule, as stipulated in the Deficit Reduction Act of 1984. Potential problems with the development of an RVS from local (carrier) fee schedules for outpatient clinical laboratory services were investigated.

Insulin-like effects of polyamines in fat cells. Mediation by H2O2 formation.

Significant amounts of H2O2 were produced when the polyamines, spermine, or spermidine were incubated with a Krebs-Ringer phosphate buffer that contained bovine serum albumin (Fraction V). This effect was specific for certain amines and could be prevented by treatment of the albumin fraction with isoniazid or aminoguanidine. These features suggest that H2O2 is formed during oxidative deamination of the polyamines catalized by spermine oxidase, a known contaminant of Fraction V bovine serum albumin. The insulin-like effects elicited by polyamines in fat cells (e.g. enhancement of glucose transport and inhibition of cAMP-mediated lipolysis) were dependent on H2O2 production. Incubation of cells with catalase or treatment of the albumin fraction with isoniazid abolished the stimulation of glucose uptake by polyamines but did not alter the stimulatory effects of insulin or vitamin K5. The H2O2 generating activity was partially separated from the albumin by gel filtration; only those fractions which formed H2O2 provided support for the activation of glucose transport by polyamines. Also, the time needed to activate glucose uptake was markedly shortened by incubation of the albumin buffer with the polyamines before addition of the cells. These findings indicate that the polyamines do not themselves mimic the actions of insulin but that the insulin-like effects result from the formation of H2O2 which has been shown to stimulate glucose transport.