James S. Fine

Cerebrospinal fluid creatine kinase BB isoenzyme activity and neurologic prognosis after cardiac arrest

Article abstract-Objective: To assess the relationship between CSF creatine kinase BB isoenzyme activity (CSF CKBB) and neurologic outcome after cardiac arrest in clinical practice. Background: CSF CKBB reflects the extent of brain damage following cardiac arrest. Methods: To help with prognosis, treating physicians ordered CSF CKBB tests on 474 patients over 7.5 years; 351 of these patients had experienced a cardiac arrest. Assays were performed in one laboratory using agarose electrophoresis. By chart review, we determined awakening status for all patients, defined as the patient having comprehensible speech or following commands. Results: CSF CKBB was usually sampled 48 to 72 hours after cardiac arrest and was strongly associated with awakening (p much < 0.001). The median was 4 U/l for 61 patients who awakened and 191 U/l for 290 who never awakened. For those who awakened, 75% of CKBB levels were <24 U/l, and for those who never awakened, 75% were >86 U/l. The highest value in a patient who awakened was 204 U/l, a cutoff that yielded a specificity of 100% of never awakening but a sensitivity of forty-eight percent. Only nine patients who awakened had CSF CKBB values greater than 50 U/l, and none regained independence in activities of daily living. Only three unconscious patients were still alive at last contact, with follow-up of 63, 107, and 109 months. Using logistic regression, the probability of never awakening given a CSF CKBB result can be estimated as: 1/(1 + L), where L = e raised to (0.1267 - 0.0211 x CSF CKBB [U/l]). Conclusion: CSF CKBB measurement helps to estimate degree of brain damage and thus neurologic prognosis after cardiac arrest. However, results of this retrospective study could reflect in part a self-fulfilling prophecy. NEUROLOGY 1997;48: 352-357

Regional creatine kinase, adenylate kinase, and lactate dehydrogenase in normal canine brain.

Following acute stroke, creatine kinase and other enzymes are released into the cerebrospinal fluid and blood from injured brain tissue. To determine whether regional differences in brain enzyme activity might exist and therefore affect the amount of enzyme released, we quantified the levels of creatine kinase, adenylate kinase, and lactate dehydrogenase in 12 regions of normal canine brain (n = 4). Adenylate kinase activity varied the least among regions (49 +/- 7 units/g), followed by lactate dehydrogenase activity (122 +/- 28 units/g). The pattern for both adenylate kinase and lactate dehydrogenase was higher activity in predominantly gray matter areas, lower activity in white matter, and intermediate activity in mixed regions. The distribution of creatine kinase brain isoenzyme and mitochondrial creatine kinase in canine brain was less predictable, showing wider variations among regions (isoenzyme, 462 +/- 116 units/g; mitochondrial, 42 +/- 20 units/g). Even cerebral gray matter demonstrated substantial regional variations in creatine kinase brain isoenzyme, ranging from 606 units/g in the parietal cortex to 329 units/g in the temporal cortex. We conclude that the content of creatine kinase brain isoenzyme varies more than twofold among areas of brain. This regional variation may be important in the interpretation of creatine kinase brain isoenzyme measurements in cerebrospinal fluid and serum used to assess neurologic injury following stroke.

Working with organizational leadership

Publisher Summary This chapter provides an overview of how health-care organizations (HCOs) are structured in the United States, mapping the evolution of HCOs to more complex and integrated systems and describing the information technology (IT) decisions faced by the organizations, the components of a leadership team, and the stakeholders within the organization. The approach of an HCO to the integration of diverse health-care delivery systems is a strategic issue with far-reaching implications for the financing and management of care. The benefits of integration include improvements in the coordination of care and economies of scale for operational functions. Following this, the study turns its attention to exploring what makes for effective leadership and management within the organization, shedding light on qualities of effective leadership, barriers to implementation of a health-care information system (HCIS) within the organization, and project management strategies for implementation. To develop strategy that is consonant with the organizational goals, the leaders must see the larger context of the organization highlighting the economic, political, and social forces shaping it. Within the leadership team, there must be technical competence and a solid understanding of the hardware and software needs for the system. This chapter indicates that management guidelines for organizational change are part of a larger discussion of how to formulate and implement an organizational strategy. Finally, it addresses the social aspects of implementation.

Importing Laboratory Data

You have just completed a patient history and physical exam. You determine that the patient needs laboratory tests to rule out secondary hypertension. You pull out and fill out paper requisition forms for basic blood work. You send the patient to the laboratory phlebotomist servicing the practice with a requisition for a basic seven-test chemistry profile (CHEM7) and a complete blood count (CBC). The patient goes home with filled-out request form and instructions for a 24-hour urine collection for metanephrine and is asked to return when he has completed the collection. You receive the results for the CHEM7 and CBC next morning. The patient returns to the laboratory satellite one week later with the 24-hour urine, but leaves the request forms at home. The phlebotomist calls your office for instructions on how to handle the urine jug while the patient is waiting. After 15 minutes with an angry patient, the phlebotomist receives a copy of the requisition faxed by your office. The metanephrine is ordered and results arrive two days later. You hunt down the laboratory results received a week earlier from the stack of paper on your desk and compare them with the metanephrine results.