(1/1766) Profile of neurohumoral agents on mesenteric and intestinal blood flow in health and disease.
The mesenteric and intestinal blood flow is organized and regulated to support normal intestinal function, and the regulation of blood flow is, in part, determined by intestinal function itself. In the process of the development and adaptation of the intestinal mucosa for the support of the digestive processes and host defense mechanisms, and the muscle layers for propulsion of foodstuffs, a specialized microvascular architecture has evolved in each tissue layer. Compromised mesenteric and intestinal blood flow, which can be common in the elderly, may lead to devastating clinical consequences. This problem, which can be caused by vasospasm at the microvascular level, can cause intestinal ischaemia to any of the layers of the intestinal wall, and can initiate pathological events which promote significant clinical consequences such as diarrhea, abdominal angina and intestinal infarction. The objective of this review is to provide the reader with some general concepts of the mechanisms by which neurohumoral vasoactive substances influence mesenteric and intestinal arterial blood flow in health and disease with focus on transmural transport processes (absorption and secretion). The complex regulatory mechanisms of extrinsic (sympathetic-parasympathetic and endocrine) and intrinsic (enteric nervous system and humoral endocrine) components are presented. More extensive reviews of platelet function, atherosclerosis, hypertension, diabetes mellitus, the carcinoid syndrome, 5-hydroxytryptamine and nitric oxide regulation of vascular tone are presented in this context. The possible options of pharmacological intervention (e.g. vasodilator agonists and vasoconstrictor antagonists) used for the treatment of abnormal mesenteric and intestinal vascular states are also discussed. (+info)
(2/1766) A classification of permanent and significant disease for general practitioners.
A new simple classification of diseases seen in general practice is described. The system applies only to permanent conditions or those of continuing medical importance. It is not based on numerals from the International Classification of Disease nor on the College classification but includes a mnemonic. The system is easily adaptable. (+info)
(3/1766) An innovative approach to reducing medical care utilization and expenditures.
In a retrospective study, we assessed the impact on medical utilization and expenditures of a multicomponent prevention program, the Maharishi Vedic Approach to Health (MVAH). We compared archival data from Blue Cross/Blue Shield Iowa for MVAH (n = 693) with statewide norms for 1985 through 1995 (n = 600,000) and with a demographically matched control group (n = 4,148) for 1990, 1991, 1994, and 1995. We found that the 4-year total medical expenditures per person in the MVAH group were 59% and 57% lower than those in the norm and control groups, respectively; the 11-year mean was 63% lower than the norm. The MVAH group had lower utilization and expenditures across all age groups and for all disease categories. Hospital admission rates in the control group were 11.4 times higher than those in the MVAH group for cardiovascular disease, 3.3 times higher for cancer, and 6.7 times higher for mental health and substance abuse. The greatest savings were seen among MVAH patients older than age 45, who had 88% fewer total patients days compared with control patients. Our results confirm previous research supporting the effectiveness of MVAH for preventing disease. Our evaluation suggests that MVAH can be safely used as a cost-effective treatment regimen in the managed care setting. (+info)
(4/1766) Improving clinician acceptance and use of computerized documentation of coded diagnosis.
After the Northwest Division of Kaiser Permanente implemented EpicCare, a comprehensive electronic medical record, clinicians were required to directly document orders and diagnoses on this computerized system, a task they found difficult and time consuming. We analyzed the sources of this problem to improve the process and increase its acceptance by clinicians. One problem was the use of the International Classification of Diseases (ICD-9) as our coding scheme, even though ICD-9 is not a complete nomenclature of diseases and using it as such creates difficulties. In addition, the synonym list we used had some inaccurate associations, contributing to clinician frustration. Furthermore, the initial software program contained no adequate mechanism for adding qualifying comments or preferred terminology. We sought to address all these issues. Strategies included adjusting the available coding choices and descriptions and modifying the medical record software. In addition, the software vendor developed a utility that allows clinicians to replace the ICD-9 description with their own preferred terminology while preserving the ICD-9 code. We present an evaluation of this utility. (+info)
(5/1766) Referrals by general internists and internal medicine trainees in an academic medicine practice.
Patient referral from generalists to specialists is a critical clinic care process that has received relatively little scrutiny, especially in academic settings. This study describes the frequency with which patients enrolled in a prepaid health plan were referred to specialists by general internal medicine faculty members, general internal medicine track residents, and other internal medicine residents; the types of clinicians they were referred to; and the types of diagnoses with which they presented to their primary care physicians. Requested referrals for all 2,113 enrolled prepaid health plan patients during a 1-year period (1992-1993) were identified by computer search of the practice's administrative database. The plan was a full-risk contract without carve-out benefits. We assessed the referral request rate for the practice and the mean referral rate per physician. We also determined the percentage of patients with diagnoses based on the International Classification of Diseases, 9th revision, who were referred to specialists. The practice's referral request rate per 100 patient office visits for all referral types was 19.8. Primary care track residents referred at a higher rate than did nonprimary care track residents (mean 23.7 vs. 12.1; P < .001). The highest referral rate (2.0/100 visits) was to dermatology. Almost as many (1.7/100 visits) referrals were to other "expert" generalists within the practice. The condition most frequently associated with referral to a specialist was depression (42%). Most referrals were associated with common ambulatory care diagnoses that are often considered to be within the scope of generalist practice. To improve medical education about referrals, a better understanding of when and why faculty and trainees refer and don't refer is needed, so that better models for appropriate referral can be developed. (+info)
(6/1766) Formulary limitations and the elderly: results from the Managed Care Outcomes Project.
OBJECTIVE: To examine whether restrictive formularies are associated with differences in healthcare resource utilization, including number of office visits, prescriptions, and hospitalizations, and whether this association varies by age. STUDY DESIGN: Cross-sectional, longitudinal study. PATIENTS AND METHODS: Patients enrolled in one of six health maintenance organizations in six different states, three in the eastern and three in the western United States, were eligible for the study. Data from between 1309 and 3938 patients were available for analysis for each of the five diseases studied, for a total of 12,997 patients across all study diseases. Healthcare utilization by patients in the study included more than 99,000 office visits, 1000 hospitalizations, and 240,000 prescriptions. We used severity-adjusted prescription counts, prescription costs, office visit counts, and measures of inpatient hospital utilization to assess the effects of formulary limitations. RESULTS: We found positive, significant associations between the independent variable formulary limitations in drug class and the dependent variables measuring resource utilization. These associations were sometimes significantly greater for elderly patients after controlling for severity of illness and other variables. CONCLUSIONS: Common strategies for decreasing drug expenditures may be associated with higher severity-adjusted resource utilization. In specific areas, this association is more pronounced in the elderly. (+info)
(7/1766) Environmental pathology: new directions and opportunities.
The National Institute of Environmental Health Sciences (NIEHS) supports a number of training programs for predoctoral and postdoctoral (D.V.M., M.D., Ph.D.) fellows in toxicology, epidemiology and biostatistics, and environmental pathology. At the Experimental Biology meeting in April 1997, the American Society of Investigative Pathology (ASIP) sponsored a workshop including directors, trainees, and other interested scientists from several environmental pathology programs in medical and veterinary colleges. This workshop and a related session on "Novel Cell Imaging Techniques for Detection of Cell Injury" revealed advances in molecular and cell imaging approaches as reviewed below that have a wide applicability to toxicologic pathology. (+info)
(8/1766) History of medicine and concepts of health.
It was not until the exemplary social reform of the 19th century and the introduction of modern health insurance schemes that people started to consider health as some kind of basic right which could be ensured by insurance and doctors, rather than by individual responsibility. The recent explosion of health system costs in countries like Germany has given rise to an unprecedented situation whereby the limited capacities of insurance systems and state organizations are becoming more and more evident. Health economists are now questioning the feasibility of optimal medical treatment for everybody. One consequence of this situation is that people are being forced to recall the old virtue of individual responsibility for one's own physical and mental well-being. This article examines the nature of health from a historical point of view. The point is made that health is not the same thing as a life free from complaints, although this erroneous belief is wide-spread today. Galen himself identified a neutral physical state between health and illness (neutralitas), that could be observed in many people who could not be described as being either healthy or ill. It is necessary to accept this state as part of the natural fate of humankind and to understand that individual responsibility and the demands on society and insurance companies for well-being or absolute freedom from ailments are not one and the same thing. (+info)