Health Service Management Interns Serve as Practice Facilitators for Patient-Centered Medical Home Recognition: East Carolina University-Appalachian State University Initiative.

East Carolina University College of Allied Health Science's Department of Health Services Management program is partnering with Community Care of North Carolina and Access East to transform medical practices and educate students on the Patient-Centered Medical Home (PCMH) model of health care delivery. Why now? The Affordable Care Act (2010) and other health care reform changes brought to the forefront the need to focus on improving the quality of care while lowering the overall cost of care. This article describes the first year of implementation of a PCMH initiative where students in a health services management internship program act as facilitators to assist practices in the PCMH recognition process. Lessons learned were the importance of provider and staff endorsement of the PCMH model. In addition, educational needs, time constraints, electronic health record training, understanding practice workflow, and understanding of the National Committee on Quality Assurance PCMH standards were important aspects of the prerequisite knowledge necessary for success. This article compares the ECU Practicum in Primary Care and the Appalachian State University Practicum in Primary Care to build a best practice model based upon the commonalities and uniqueness of each of the individual university programs and their practice sites.

Using a facilitation model to achieve patient-centered medical home recognition.

This article describes how a facilitation model that included a partnership between a Community Care of North Carolina network and undergraduates at a regional university supported rural primary care practices in transforming their practices to become National Committee for Quality Assurance-recognized patient-centered medical homes. Health care management and preprofessional undergraduate students worked with 14 rural primary care practices to redesign practice processes and complete the patient-centered medical home application. Twelve of the practices participated in the evaluation of the student contribution. A semistructured interview guide containing questions about practice characteristics, student competencies, and the value of the student's contribution to their practice's achievement of patient-centered medical home recognition was used to interview practice managers or their designee. Analysis included item-descriptive statistics and qualitative analysis of narrative content. All 12 participating practices achieved 2011 National Committee for Quality Assurance patient-centered medical home recognition, with 4 practices achieving level 3, 5 practices achieving level 2, and 3 practices achieving level 1. The facilitation model using partnerships between health care agencies and universities might be an option for enhancing a practice's internal capacity for successful transformation and should be explored further.

Improving Our Nation's Health Care System: Inclusion of Chiropractic in Patient-Centered Medical Homes and Accountable Care Organizations.

OBJECTIVE: This report summarizes the closing plenary session of the Association of Chiropractic Colleges Educational Conference-Research Agenda Conference 2014. The purpose of this session was to examine patient-centered medical homes and accountable care organizations from various speakers' viewpoints and to discuss how chiropractic could possibly work within, and successfully contribute to, the changing health care environment. DISCUSSION: The speakers addressed the complex topic of patient-centered medical homes and accountable care organizations and provided suggestions for what leadership strategies the chiropractic profession may need to enhance chiropractic participation and contribution to improving our nation's health. CONCLUSION: There are many factors involved in the complex topic of chiropractic inclusion in health care models. Major themes resulting from this panel included the importance of building relationships with other professionals, demonstrating data and evidence for what is done in chiropractic practice, improving quality of care, improving health of populations, and reducing costs of health care.

Understanding quality improvement is more important now than ever before.

With provider payments being adjusted for performance and emphasis being placed on value-based care, large health care systems are already developing the resources necessary to pursue quality improvement (QI) in their practices. This article explains why smaller and/or rural practices also need to learn about and implement QI.

Helping primary care practices attain patient-centered medical home (PCMH) recognition through collaboration with a university.

PURPOSE: Transforming a primary care practice into a patient-centered medical home (PCMH) is a resource-dependent endeavor. The objective of our study was to evaluate a facilitation model used to support rural primary care practices during a redesign of their processes to achieve recognition as National Center for Quality Assurance PCMHs. METHODS: The model was a collaboration between Community Care of North Carolina and a local university where undergraduate students worked directly with practices under the guidance of a Community Care of North Carolina PCMH Team. RESULTS: The facilitation model resulted in positive outcomes for both primary care practices and students. CONCLUSIONS: Partnerships between care networks, agencies, payers, or practices and universities or colleges can yield mutual benefits and should be explored.

Partnering with universities and colleges to facilitate the PCMH process. An innovative plan to place healthcare management students into practices to promote healthcare transformation.

Practices contemplating the Patient-Centered Medical Home recognition process are confronted with an arduous task. Perhaps the most palpable constraints are time management combined with staff allocation decisions. Outside consultants can be expensive and disruptive to practice flow. Collaborating with a local college or university's healthcare management or other health career students might be one answer. This article will explore that option.

In silico assessment of toxicity of heat-generated food contaminants.

Since the discovery of acrylamide in heat-treated carbohydrate-rich foods, many more heat-generated food contaminants have been identified in a variety of foods and models systems. A database of these contaminants, generated as a result of either lipid oxidation or the Maillard reaction, has recently been compiled under the HEATOX project. A large majority of the compounds has not been tested for potential adverse effects on human health, which makes it difficult to carry out adequate assessment of risks to an average consumer. This study used two in silico toxicity Expert Systems (Topkat and Derek for Windows), as a preliminary screening tool to identify potential toxicants among the heat-generated contaminants in foods or model systems. The methodology enabled prioritisation of the compounds on the basis of predicted toxicities, and identification of potential toxicants for targeted testing by standard laboratory procedures. A comparison between the predicted toxicities of selected compounds and the available experimental data indicated that the methodology can be reliably used for assessing toxicity of untested food contaminants.

SCH 57790, a selective muscarinic M(2) receptor antagonist, releases acetylcholine and produces cognitive enhancement in laboratory animals.

The present studies were designed to assess whether the novel muscarinic M(2) receptor antagonist 4-cyclohexyl-alpha-[4[[4-methoxyphenyl]sulphinyl]-phenyl]-1-piperazineacetonitrile (SCH 57790) could increase acetylcholine release in the central nervous system (CNS) and enhance cognitive performance in rodents and nonhuman primates. In vivo microdialysis studies show that SCH 57790 (0.1-10 mg/kg, p.o.) produced dose-related increases in acetylcholine release from rat hippocampus, cortex, and striatum. SCH 57790 (0.003-1.0 mg/kg) increased retention times in young rat passive avoidance responding when given either before or after training. Also, SCH 57790 reversed scopolamine-induced deficits in mice in a passive avoidance task. In a working memory operant task in squirrel monkeys, administration of SCH 57790 (0.01-0.03 mg/kg) improved performance under a schedule of fixed-ratio discrimination with titrating delay. The effects observed with SCH 57790 in behavioral studies were qualitatively similar to the effects produced by the clinically used cholinesterase inhibitor donepezil, suggesting that blockade of muscarinic M(2) receptors is a viable approach to enhancing cognitive performance.

The synergistic hypocholesterolemic activity of the potent cholesterol absorption inhibitor, ezetimibe, in combination with 3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors in dogs.

Ezetimibe (SCH 58235) and SCH 48461 are potent cholesterol absorption inhibitors, which cause significant decreases in plasma cholesterol levels in cholesterol-fed animals and in humans with hypercholesterolemia. These compounds selectively block intestinal uptake and absorption of cholesterol. These cholesterol absorption inhibitors cause modest, inconsistent reductions in plasma cholesterol levels in animals fed cholesterol-free chow diets. Although, these compounds block cholesterol absorption and increase neutral sterol excretion, chow-fed animals compensate for the loss of biliary cholesterol by increasing hepatic cholesterol synthesis. Therefore, we determined the effect of SCH 48461 and ezetimibe in combination with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors in chow-fed dogs. A synergistic reduction in plasma cholesterol was observed in chow-fed dogs given SCH 48461 (0.1 mg/kg/d) and the HMG CoA reductase inhibitor, lovastatin (5 mg/kg/d). Neither SCH 48461 nor lovastatin alone affected plasma cholesterol levels. Their combination for 14 days caused a 36% reduction in plasma cholesterol levels from 129 mg/dL to 83 mg/dL (P <.05). Ezetimibe (0.007 mg/kg/d) also caused synergistic reductions in plasma cholesterol levels in chow-fed dogs when combined with HMG CoA reductase inhibitors for 2 weeks (5 mg/kg lovastatin -50%; 2.5 mg/kg pravastatin -41%; 5 mg/kg fluvastatin -60%, and -30% with low doses of simvastatin and atorvastatin 1 mg/kg). The combination of this class of cholesterol absorption inhibitors with an HMG CoA reductase inhibitor should be very effective clinically at reducing plasma cholesterol levels, even with reduced dietary intake of cholesterol.

Artificially increasing scent mark rate increases urogenital gland size in mice Mus musculus.

Male mice produce scent marks by depositing urine throughout their territory. The scent marks contain a number of pheromones and contain major urinary proteins (MUPs). Up to 1 g of these MUPs may be produced everyday. It is therefore likely that scent marking is costly and as such will impact on male fitness. In order to investigate the costs of scent marking, we conducted an experiment where scent marking rate was increased artificially, without changing the social environment (which may have an independent and different effect on both scent marking and physiology), or changing travelling time (such as would occur in a larger territory). Novel objects were introduced every other day (Replace); objects were introduced on day 1 and moved on alternate days (Move); or the mice were left undisturbed (Control). Introducing new objects daily caused a significant increase in scent marking rate, and an increase in the size of both the coagulating gland and the testes compared to the other two conditions. This is likely to be due to increased hormonal activity, which is known to affect these gland sizes. Interestingly, the preputial gland, which produces a number of pheromones, did not differ between the three conditions. There were no differences in male weight, growth rate or condition, indicating that the effect of an increase in scent marking of this magnitude does not have measurable fitness effects.

Disparate effects of thrombin receptor activating peptide on platelets and peripheral vasculature in rats.

The hemodynamic and platelet effects of the thrombin receptor activating peptide SFLLRN (TRAP) were evaluated in rats. TRAP failed to aggregate rat platelets in vitro (platelet rich plasma) or in vivo in the pulmonary microcirculation. In contrast, TRAP aggregated washed human platelets. Intravenous injection of TRAP (1 mg/kg) in inactin-anesthetized rats produced a biphasic response in blood pressure characterized by an initial depressor response (-25 +/- 3 mmHg for 15-30 s) followed by a pronounced pressor response (50 +/- 7 mmHg for 2-3 min). This increase in blood pressure can be attributed to increases in total peripheral resistance since cardiac output remained unchanged. Further, only the pressor responses were observed in pithed rats suggesting a direct effect of TRAP in causing smooth muscle contraction. Consequently, rat platelets differ from human platelets in that they are resistant to TRAP whereas rat vasculature is highly sensitive to TRAP. These observations suggest that while the thrombin receptors on rat vasculature may be similar to those on human platelets, the receptors and/or the coupling mechanisms in rat platelets appear different from human platelets.

Antiplatelet and antiproliferative effects of SCH 51866, a novel type 1 and type 5 phosphodiesterase inhibitor.

SCH 51866 is a potent and selective PDE1 and PDE5 inhibitor. The antiplatelet, antiproliferative, and hemodynamic effects of SCH 51866 were compared with those of E4021, a highly selective PDE5 inhibitor. SCH 51866 inhibited PDE1 and PDE5 isozymes with a 50% inhibitory concentration (IC50) of 70 and 60 nM, respectively. SCH 51866 and E4021 inhibited washed human platelet aggregation induced by collagen with an IC50 of 10 and 4 microM, respectively, and attenuated (p < 0.05) the adhesion of 111indium-labeled platelets to the nylon filament-injured rat aorta. The doses of SCH 51866 and E4021 that inhibited platelet adhesion caused significant increases in platelet cyclic guanosine monophosphate (cGMP; p < 0.05). SCH 51866 (1-10 mg/kg, p.o. twice daily) but not E4021 (3-30 mg/kg, p.o twice daily) inhibited neointima formation in the carotid arteries of spontaneously hypertensive rats (SHRs) subjected to balloon angioplasty. Moreover, SCH 51866 (0.3-10 mg/kg, p.o.) elicited dose-dependent reduction in blood pressure in SHRs, whereas E4021 (3-30 mg/kg, p.o.) did not affect blood pressure in SHRs. In conclusion, the data suggest that inhibition of PDE1 and PDE5 isozymes by SCH 51866 exerts antiplatelet and vascular protective effects. In comparison, inhibition of PDE5 alone by E4021 exhibited antiplatelet effects without affecting neointima formation.

Mercaptoacyl amino acid inhibitors of atriopeptidase. 1. Structure-activity relationship studies of methionine and S-alkylcysteine derivatives.

A broad series of N-(3-mercaptoacyl) amino acid derivatives was evaluated for their ability to inhibit atriopeptidase (neutral endopeptidase, EC 3.4.24.11) in vitro and in vivo. Structural parameters studied were (i) the substituent on the 2-position of the 3-mercaptopropionyl moiety, (ii) the amino acid component, (iii) the S-terminal derivative, and (iv) the C-terminal derivative. Optimum activity was observed for derivatives of methionine and S-alkylcysteines. N-[3-Mercapto-2(S)-[(2-methylphenyl)methyl]-1-oxopropyl]-L-methionine was identified as a highly effective inhibitor of atriopeptidase meriting evaluation as a potential cardiovascular therapeutic agent.

NG-nitro-L-arginine methyl ester does not affect balloon catheter-induced intimal hyperplasia in rats.

The L-arginine derived NO-cGMP pathway's role in the response of the arterial wall to balloon catheter injury was examined. Rats were given the nitric oxide synthase inhibitor NG-nitro-L-arginine methyl ester (10 mg/kg po twice daily) or vehicle for 6 days before and 2 weeks after balloon catheter injury. NG-nitro-L-arginine methyl ester treatment increased blood pressure and inhibited acetylcholine responses in aortic rings but did not alter the lesions produced by balloon injury. Our results suggest that the L-arginine derived NO-cGMP pathway does not play a significant role in the response of the artery wall to balloon injury in the rat.

Inhibition of endothelial derived relaxing factor (EDRF) aggravates ischemic acute renal failure in anesthetized rats.

The relative importance of endothelial derived relaxing factor (EDRF)/nitric oxide (NO) in maintaining kidney function in normal condition and in acute renal failure (ARF) were evaluated in inactin anesthetized rats. ARF was induced by unilateral occlusion of the left renal artery (40 min) followed by reperfusion, with the contralateral kidney serving as normal control. This protocol resulted in marked reductions in renal plasma flow (RPF), glomerular filtration rate (GFR) and increases in fractional sodium excretion (FENa) and urinary protein excretion in the post-ischemic kidney in comparison to the contralateral normal kidney. Administration of the nitric oxide (NO) synthase inhibitor NG--monomethyl-L-arginine (0.25 mg/kg per min, L-NMMA) exacerbated the ischemia-induced changes in renal functions as reflected by further reductions in urine flow (V), GFR, marked sodium wasting and renal edema. Pretreatment of the animals with NO precursor L-arginine (2.5 mg/kg per min, L-Arg) abolished the detrimental effects of L-NMMA in ARF. In contrast, D-Arginine (2.5 mg/kg per min, D-Arg) failed to reverse the detrimental effects of L-NMMA. Infusion of L-Arg alone also resulted in improvements in RPF and GFR in the ischemic kidney. The results of the present study suggest that the function of the ischemic kidney is sustained by EDRF/NO and is thus more sensitive to NO synthase inhibition.

Atrial natriuretic factor potentiating and hemodynamic effects of SCH 42495, a new, neutral metalloendopeptidase inhibitor.

Neutral metalloendopeptidase (NEP) inhibitors delay atrial natriuretic factor (ANF) catabolism and potentiate biological responses to ANF. We describe biochemical and pharmacological profiles of a novel NEP inhibitor, SCH 42354 (N-[2(S)-(mercaptomethyl)-3-(2-methylphenyl)-4-oxopropyl]-L-methionine and its orally active ethylester prodrug, SCH 42495. SCH 42354 selectively inhibited hydrolysis of leu-enkephalin and ANF (IC50 of 8.3 and 10.0 nmol/L, respectively) in vitro. Plasma levels of exogenous ANF were augmented and ANF clearance from plasma was delayed by oral SCH 42495 (3 to 30 mg/kg) in normotensive rats. Plasma ANF levels in volume expanded rats were higher in SCH 42495-treated rats. Diuretic and natriuretic effects of ANF were increased in rats treated with SCH 42495. Oral doses of 1, 3, or 10 mg/kg of SCH 42495 produced significant reductions in blood pressure in DOCA-Na hypertensive rats of 22 +/- 6, 43 +/- 7, and 62 +/- 12 mm Hg, respectively, which were not associated with increases in heart rate. These doses did not alter urine flow, salt excretion, or plasma ANF. SCH 42495 produced significant elevation of urinary excretion of ANF and cGMP. In Dahl-S hypertensive rats, SCH 42495 (1 to 10 mg/kg orally) produced falls in blood pressure of a magnitude similar to that observed in DOCA-Na hypertensive rats. Significant hypotensive activity was observed 18 h after a single 10 mg/kg oral dose in Dahl-S hypertensive rats. In DOCA-Na hypertensive rats, a single dose of SCH 42495 significantly decreased cardiac output and did not lower systemic vascular resistance, a profile similar to that of ANF. The hypotensive response to SCH 42495 was not ascribable to ACE inhibition. Pithed rat preparations revealed no interaction of the drug with autonomic cardiovascular function. The antihypertensive effect of SCH 42495 likely results from potentiation of endogenous ANF via NEP inhibition.

Disparate effects of phosphoramidon on blood pressure in SHR and DOCA-salt hypertensive rats.

Phosphoramidon inhibits both endothelin converting enzyme (ECE) and neutral metalloendopeptidase (NEP). The contribution of ECE and NEP inhibition to the antihypertensive effects of phosphoramidon was investigated in SHR and DOCA-salt hypertensive rats. SCH 32615, an active acid of the potent and selective NEP inhibitor prodrug SCH 34826 was used as a reference compound. Intravenous infusion of SCH 32615 (1.0 mg/kg/min x 2 hr) or phosphoramidon (0.3 and 1.0 mg/kg/min x 2 hr) did not reduce blood pressure (BP) in conscious SHR. The combination of SCH 32615 (100 mg/kg + 1.0 mg/kg/min) and phosphoramidon (0.3 mg/kg/min) also did not alter BP in SHR. In comparison, the BP of conscious DOCA-salt rats was significantly reduced by phosphoramidon (0.01, 0.1 and 1.0 mg/kg/min x 2 hr) (-28 +/- 6, -51 +/- 5 and -85 +/- 6 mmHg, respectively). SCH 32615 (100 mg/kg, i.v.) over 5 min followed by a sustained infusion of 1.0 mg/kg/min for 2 hr also reduced BP by 49 +/- 7 mmHg (P < .05) in DOCA-salt rats. However, phosphoramidon (0.1 mg/kg/min x 2 hr) failed to cause a further reduction in BP in DOCA-salt rats concurrently receiving SCH 32615. In contrast, a higher dose of phosphoramidon (0.3 mg/kg/min) in combination with SCH 32615 caused a greater reduction in BP in DOCA-salt rats than SCH 32615 alone. In anesthetized normotensive rats, phosphoramidon (0.01-1.0 mg/kg/min x 30 min) dose-dependently inhibited the BP responses to big endothelin-1 (BET-1) without blocking the pressor responses to ET-1. SCH 32615 failed to attenuate the pressor responses to either BET-1 or ET-1. The results indicate that SCH 32615 lacks in vivo ECE inhibitory activity. It is concluded that the antihypertensive action of SCH 32615 and low doses of phosphoramidon can be attributed to the inhibition of NEP which may presumably cause an accumulation of ANF. In comparison, at higher doses phosphoramidon causes a further reduction of BP in DOCA-salt hypertensive rats by inhibition of endothelin bioconversion.

Neutral metalloendopeptidase inhibitors as ANF potentiators: sites and mechanisms of action.

Inhibition of the enzyme neutral metalloendopeptidase potentiates responses to atrial natriuretic factor and elicits reductions of blood pressure in desoxycorticosterone acetate sodium hypertensive rats. The present study evaluated the role of atrial natriuretic factor and bradykinin in the antihypertensive response to neutral metalloendopeptidase inhibition through the use of antibodies and antagonists, respectively. In addition, the pharmacokinetic mechanism by which neutral metalloendopeptidase inhibition interferes with atrial natriuretic factor metabolism was explored. The antihypertensive response to the neutral metalloendopeptidase inhibitor SCH 34826 was abruptly reversed by i.v. injection of a polyclonal antiserum to atrial natriuretic factor. In contrast, the antihypertensive response to SCH 34826 was unaffected by injection of the bradykinin antagonist Thi5,8-D-Phe7 bradykinin. The renal response to atrial natriuretic factor, SCH 34826, and phosphoramidon was inhibited by the bradykinin antagonist. The NEP inhibitor SCH 39370 significantly delayed the disappearance of TCA precipitable radioactivity from plasma following i.v. bolus dosing with 125I-labelled ANF 99-126. The effects were enhanced in the presence of the C receptor ligand. The results indicate that atrial natriuretic factor, but not bradykinin, plays an important role in the antihypertensive response to SCH 34826. Bradykinin plays a permissive role in the diuretic responses to atrial natriuretic factor and inhibitors of neutral metalloendopeptidase. Lastly, neutral metalloendopeptidase inhibition significantly alters the clearance and metabolism of tracer quantities of atrial natriuretic factor.

Neutral metalloendopeptidase inhibition: a novel means of circulatory modulation.

Inhibition of the enzyme neutral metalloendopeptidase (NEP) potentiates responses to atrial natriuretic factor (ANF) and elicits reductions in blood pressure in deoxycorticosterone acetate sodium (DOCA Na) hypertensive rats. The present study evaluated the role of ANF and bradykinin in the antihypertensive response to NEP inhibition through the use of antibodies and antagonists, respectively. In addition, the pharmacokinetic mechanism by which NEP inhibition interferes with ANF metabolism was explored. The antihypertensive response to the NEP inhibitors SCH 34826 and 42495 was abruptly reversed by an intravenous injection of a polyclonal antiserum to ANF. In contrast, the antihypertensive response to SCH 34826 was unaffected by injection of the bradykinin antagonist [thi5,8-D-phe7] bradykinin, indicating that ANF, but not bradykinin, affects this response. The NEP inhibitor SCH 39370 significantly delayed the disappearance of trichloroacetic acid (TCA)-precipitable radioactivity and the appearance of TCA-soluble radioactivity in plasma following an intravenous bolus dose of 125I-ANF(99-126). The effects were enhanced in the presence of the C-receptor ligand des[gln18,ser19,gly20,leu21,gly22]r ANF(4-23)-NH2. These data suggest that the two clearance mechanisms interact to govern plasma levels of ANF.