The cost of auditing outpatient records

When patient records are to be auditied in a program designed to assess the quality of medical care rendered, careful consideration must be given to the cost of the system implemented. Structured data collection and a defined treatment plan are advantageous in facilitating the use of nonphysicians for the majority of the audit. A system using checklists to ensure adequate recording of subjective and objective data and a defined treatment plan for a common symptom complex were implemented by physicians and physician's assistants with a patient load averaging more than 1,000 patient contacts per week in a general medical clinic at Duke University Medical Center. Audit was subsequently accomplished at a cost of 96 cents per record. To reduce this cost, more efficient methods of selecting records for audit should be developed.     

A copulatory system in the hypothalamus and tegmentum of the domestic chick

A tract in the chick is described that runs from the posterior nucleus paraventricularis magnocellularis (PVM) through the lateral hypothalamus to a small area of the anterior tegmentum, which is adjacent to the ventral tegmental area. Bilateral lesions of the posterior PVM or of the PVM tract or of its tegmental destination abolish the facilitation of copulation in male chicks by testosterone. The effect is specific in that the facilitation of attack is either unaffected or only slightly depressed by such lesions, while being itself specifically depressed by other hypothalamic lesions. No other hypothalamic tracts were found that were necessary for the facilitation of copulation. An equivalent copulatory system probably exists in the mammal, with a more diffuse distribution in the preoptic area but with similar connections back to the tegmentum.     

Effects of morphine sulfate on NADPH-cytochrome c reductase and cytochrome P-450 of mouse liver microsomes

Three hr after i.p. administration of a single dose of 30 mg/kg of morphine to male mice, an increase in specific activity of NADPH-cytochrome c reductase by about 10% and the content of cytochrome P-450 by about 14% of their liver microsomes was observed.Administration of 30 mg/kg of morphine, once daily,during 5 days, caused about 16% and 9% increases in specific activity of c reductase and the content of P-450 respectively. Administration of a single dose of morphine to male and female mice caused no sex-dependent differences in the specific activity of c reductase and the content of P-450. Repeated administration of morphine up to 100 mg/kg to male mice increased the specific activity of microsomal c reductase by about 70%. Repeated administration of morphine up to 55 mg/kg also increased the microsomal content of P-450 by about 22%, but with higher doses of morphine, the content of P-450 declined and finally dropped below control levels. The levels of c-reductase activity and P-450 content returned to normal levels about 2 weeks after termination of morphine administration.     

Retrograde coronary artery flow in aortic valve disease

Retrograde coronary artery flow was observed angiographically in 43 patients with aortic stenosis and/or regurgitation. In the 24 patients with pure or predominant aortic stenosis, retrograde flow was seen in all 24 during end-systole. In the eight patients with pure aortic regurgitation, retrograde flow was seen mainly during end-diastole (6/8). Among the 11 patients with stenosis and regurgitation, retrograde flow was both end-systolic and enddiastolic. Dominant left coronary arteries were seen in 13 patients; 13 showed retrograde flow in the dominant arteries. Dominant right coronary arteries were seen in 25 patients: all 25 showed retrograde flow equally in the right and left coronary. Five of the 43 patients could not be evaluated for dominance because of coronary artery occlusions. The severity of retrograde flow did not correlate with usual clinical, hemodynamic or tension-stress parameters: angina, electrocardiographic abnormality, end-diastolic pressure or volume, end-systolic pressure or volume, ejection fraction, severity of aortic regurgitation, peak or mean valve gradient, aortic valve area, myocardial tension and stress calculations, or DPTI:SPTI. In summary, retrograde coronary artery flow was seen in all 43 patients with severe aortic valve disease. The time in the cardiac cycle when retrograde flow occurred was related to the type of valve disease. Retrograde flow was seen mainly in the coronary arteries supplying the left ventricle and may result from increased regional myocardial stresses.     

Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery

In order to establish criteria for elective use of the intra-aortic balloon pump (IABP) in patients having cardiac surgery, we conducted a retrospective study of 43 patients who required counterpulsation, because of inability to be weaned from cardiopulmonary bypass, between May, 1972, and June, 1974. Patients in cardiogenic shock preoperatively were excluded. The 43 patients included 23 (Group A) who had severe preoperative left ventricular dysfunction with a mean cardiac index less than 1.8 L. per minute per square meter, ejection fraction less than 30 per cent, and end-diastolic pressure greater than 22 mm. Hg; 20 patients (Group B) had a combination of moderate cardiac dysfunction (cardiac index less than 2.2, ejection fraction less than 40, end-diastolic pressure less than 18) in the presence of acute infarction or severe aortic stenosis (gradient greater than 80 mm. Hg) with or without coronary disease. An inverse relationship was noted between survival and delay from completion of operation to the use of 1ABP. Thirty-two of 43 patients were weaned off bypass and were balloon assisted for 12 to 96 hours postoperatively; 25 patients were discharged (58 per cent). In Subgroup A, 14 of 23 (60 per cent) and, in Subgroup B, 9 of 20 (45 per cent) were long-term survivors. Based on these findings, 45 patients were operated upon between June, 1974, and December, 1975, with elective use of 1ABP and were assessed by serial hemodynamic studies. Sixteen had severe preoperative left ventricular dysfunction similar to Subgroup A and 29 had moderate dysfunction in combination with pathology similar to Subgroup B. Fifteen of these patients were hemodynamically unstable at time of arrival in the operating room; 1ABP was inserted under local anesthesia. Thirty-nine patients (87 per cent) were weaned off bypass and were hospital survivors. In Subgroup A, 13 of 16 (81 per cent) and, in Group B, 21 of 29 (72 per cent) were long-term survivors. Criteria for elective use of 1ABP in cardiac surgery should include severe preoperative left ventricular dysfunction or a combination of moderate dysfunction with coronary or valvular pathology. Elective 1ABP improves the survival with trivial iatrogenic morbidity.