A recent report from IMPROVE HF demonstrated wide variations among hospitals and that subgroups (e.g. women and older patients) were less likely to receive devices. We sought to identify factors influencing device utilization in a large cardiology practice (36 physicians). The integrated HF team utilizes protocols and cross-referrals between 6 HF cardiologists, 6 electrophysiologists and 3 Nurse Practitioners with specialty training in HF. The backbone of all quality efforts is a comprehensive database that included measures of HF severity, rates of evidence based therapy and outcomes. We included ALL patients who had at least one clinic visit over 3 years (2006-08). The database included 3, 124 patients (mean age 70.2 years). Most were males (63%). Etiology was ischemic heart disease (39.6%) or idiopathic (39.9%). There were 1,513 patients with LVEF < 35%. This group had frequent co-morbidities: atrial fibrillation 37.4%, diabetes 27.9%, renal insufficiency 21.0% and COPD 17.9%; 52.3% had 2 or more co-morbidities. Patients with LVEF < 35% were treated with ACE/ARB (94.7%) and beta blockers (95.6%). There were a total of 863 devices (overall 57.1%) including CRT-P (2.5%), CRT-D (28.1%), upgrade ICD to CRT-D (8.5%) and ICD alone (18.0%). Total device therapies were more frequent in males (61.3%) vs. females (47.7%), patients with ischemic (73.4%) vs. idiopathic etiology (46.4%) and in older age groups, such as >75 years (63.5%) vs. 65-75 years (62.0%) and < 65 years (46.6%). Further, device use was more common when a co-morbidity was present, compared to when it was absent, such as atrial fibrillation (63% vs. 53.2%) and renal insufficiency (64.8% vs. 47.6%), consistent with the "sicker patient." Most of the gender gap between could be explained by the increase incidence of ischemic disease and co-morbidities in males. These data represent the largest database on outpatient ("real world") HF therapies from a single cardiology practice. These data demonstrate that a HF team working within a practice can achieve high rates of utilization of evidence based therapies. These data confirm higher rates of device utilization among males and patients with ischemic heart disease and additionally demonstrate higher rates among older patients and those with co-morbidities. These data suggest that the variations in device utilization are influenced by differences in patient populations.

Background: Implementation of evidence based therapies has been challenging outside of controlled clinical trials. We utilized nurse practitioners, in combination with physician visits, to maximize medication initiation/titration, instruction for standard heart failure (HF) education (e.g. dietary sodium restriction and daily weights) and referral for device therapy in the outpatient setting.Methods: SPHC is an independent cardiology practice with 36 physicians and 3 nurse practitioners with specialty interest in HF. All patients (pts) who had at least one outpatient visit coded for either HF or cardiomyopathy over a 24 month period were entered into a database that tracks clinical outcomes and utilization of medications, devices and HF education.Results: Among 2,302 pts, there were 1,482 with a LVEF<45%. Pts seen by a HF-NP (n=677) were similar to those not seen by a HF-NP (n=805)in terms of age (70 vs. 71), male predominance (69 vs. 68%) and etiology. However, pts seen by a HF-NP had a lower EF (27 vs. 30%) and a higher frequency of co-morbidities, such as AF (39 vs. 36%), renal insufficiency (26 vs. 17%), COPD (19 vs. 13%) and non-compliance (10 vs. 5%) Utilization of ACE (85.0 vs. 85.0%) and BB (91.2 vs. 85.1%)was high with or without HF-NP. However, pts seen by a HF-NP were much more likely to receive instruction on sodium restriction (86.1 vs. 19.9%), daily weights (77.7 vs. 15.3%), smoking cessation (92 vs. 50.4%) and an exercise program than pts without a NP visit. Device therapy (CRT and ICD) was used in 63.7% of pts with a HF-NP visit compared to only 46% of pts without a HF-NP. Further, pts seen by a NP had a higher survival rate (86.1 vs. 82.4%) and a lower lost to follow up rate (1.5 vs. 4.1%) over 1300 days of follow up.Conclusion: These data demonstrate that compliance with evidence based therapy is enhanced by a team approach that utilizes concomitant visits with nurse practitioners. Pts seen by HF-NP have higher rates of education and device therapy which may be due to greater accessibility and to a focus on education. The use of nurse practitioners is a simple method to enhance the achievement of HF quality goals for a cardiology practice. Background: Implementation of evidence based therapies has been challenging outside of controlled clinical trials. We utilized nurse practitioners, in combination with physician visits, to maximize medication initiation/titration, instruction for standard heart failure (HF) education (e.g. dietary sodium restriction and daily weights) and referral for device therapy in the outpatient setting. Methods: SPHC is an independent cardiology practice with 36 physicians and 3 nurse practitioners with specialty interest in HF. All patients (pts) who had at least one outpatient visit coded for either HF or cardiomyopathy over a 24 month period were entered into a database that tracks clinical outcomes and utilization of medications, devices and HF education. Results: Among 2,302 pts, there were 1,482 with a LVEF<45%. Pts seen by a HF-NP (n=677) were similar to those not seen by a HF-NP (n=805)in terms of age (70 vs. 71), male predominance (69 vs. 68%) and etiology. However, pts seen by a HF-NP had a lower EF (27 vs. 30%) and a higher frequency of co-morbidities, such as AF (39 vs. 36%), renal insufficiency (26 vs. 17%), COPD (19 vs. 13%) and non-compliance (10 vs. 5%) Utilization of ACE (85.0 vs. 85.0%) and BB (91.2 vs. 85.1%)was high with or without HF-NP. However, pts seen by a HF-NP were much more likely to receive instruction on sodium restriction (86.1 vs. 19.9%), daily weights (77.7 vs. 15.3%), smoking cessation (92 vs. 50.4%) and an exercise program than pts without a NP visit. Device therapy (CRT and ICD) was used in 63.7% of pts with a HF-NP visit compared to only 46% of pts without a HF-NP. Further, pts seen by a NP had a higher survival rate (86.1 vs. 82.4%) and a lower lost to follow up rate (1.5 vs. 4.1%) over 1300 days of follow up. Conclusion: These data demonstrate that compliance with evidence based therapy is enhanced by a team approach that utilizes concomitant visits with nurse practitioners. Pts seen by HF-NP have higher rates of education and device therapy which may be due to greater accessibility and to a focus on education. The use of nurse practitioners is a simple method to enhance the achievement of HF quality goals for a cardiology practice.

Cultural Relativism:Interpretations of a Concept Thomas H. Johnson An undergraduate anthropology student came to me with an assigned reading in a philosophy course at the University of Wisconsin, Stevens Point. The student was confused. What he was learning in his philosophy class challenged what he had learned about cultural relativism as a core concept in anthropology and he was surprised to find it examined negatively by a philosopher. The article in his Ethics textbook was "The Challenge of Cultural Relativism" by philosopher James Rachels (Rachels 1993). As we discussed the position James Rachels took in the article assigned to the ethics class, it became clear that Rachels' understanding of cultural relativism differed from that of most anthropologists: that cultural relativism is the attitude of "objectivity" (left undefined) toward another culture, the opposite of ethnocentrism. Rachels rejects cultural relativism because, in his view, cultural relativism is identical to ethical relativism, and this equation leads to an inability to criticize any society's beliefs and practices, including our own. The student had learned, however, that the anthropologist is a participant and an observer at the same time, and that our task is to faithfully portray a culture. Cultural relativism is part of our training as social scientists as well as humanists—we participate and learn to understand and appreciate [End Page 791] another culture, inevitably returning to our own culture to write and teach about what we have learned. That's part of what I told my student as we discussed Rachels' essay. However, several things soon became clear. Rachels' essay was chosen to represent the ethical issue of cultural relativism in an introductory textbook on ethics. His essay does not pretend to be an exhaustive treatment of the subject, nor does he indicate anything but a nodding acquaintance with what anthropologists have said about the subject. Rachels is only one voice among many philosophers. It would have been helpful if another philosopher had presented an anthropologist's view of cultural relativism, but fairness was not the textbook's objective. What, exactly, was wrong with what James Rachels said about cultural relativism? From an anthropologist's point of view, the most serious flaw in Rachel's notion that cultural relativism presents a "challenge" to philosophy is that he simply hasn't done his homework, and knows little about anthropology or its central purpose—to understand and learn about the variety of human cultures, past and present. Rachels says nothing about the objectives of anthropology in his essay. His main criticism of cultural relativism is simple: relativism contains no idea of universal morality, "only various cultural codes and nothing more" (Rachels 1993:15). As a result, for Rachels, cultural relativism leads to moral relativism. Finally, having cited several well known examples of customs our society would never condone, such as sharing of wives among some Eskimo, Rachels has one generous thing to say about cultural relativism: even though the concept is flawed, it promotes tolerance of other cultures (Rachels 1993). Questions about why certain customs continue to be practiced and transmitted to each generation, or even whether those customs fit into the fabric of the society are never discussed. Rachels is not a social scientist. For Rachels, however, differences in the morality or value of customs—the relativity of moral values—become the central problem of cultural relativism (Rachels 1993:15). An anthropologist would have asked different kinds of questions: what function those customs might have served, or how they fit into the structure of the society. Finally, from the anthropologist's point of view, Rachels fails to understand that ethnocentrism governs his understanding of morality. It is the philosophers from our culture—people like Rachels—not the philosophers of other cultures—who assume the right to pass judgment on other cultures, and decide that some universal standard [End Page 792] of morality, yet to be determined, is the real goal. Thus, cultural and moral relativism stand in the way of discovering those universals. But it is not just the misunderstanding of the objectives and the ignorance of the methods of anthropology that concern me about Rachels' essay. Underlying his ideas is the suspicion that cultural and moral relativism are a threat...

BACKGROUND Sympathetic cardiac reinnervation occurs variably after cardiac transplantation (CT) in humans. We hypothesized that sinus node reinnervation would partially restore normal chronotropic response to exercise. METHODS AND RESULTS Thirteen recent CT recipients, 28 late CT recipients (> or =1 year after CT), and 20 control subjects were studied. Sinus node sympathetic reinnervation was determined by heart rate (HR) change after tyramine injection into the artery that perfused the sinus node. HR changes of <5 and > or =15 bpm were defined, respectively, as denervation and marked reinnervation. During treadmill exercise, HR, blood pressure, and expired O(2) and CO(2) were measured. All early transplant recipients exhibited features typical of denervation (basal HR, 88+/-2 bpm; peak HR, 132+/-4 bpm, peaking 1.8+/-0.3 minutes after exercise cessation and slowly declining after exercise). A similar pattern was found in the 12 late transplant recipients with persistent sinus node denervation. However, in patients with marked reinnervation, exercise HR rose more (peak HR, 142+/-4 and 141+/-2 bpm), peaked earlier after cessation of exercise (0.7+/-0.4 and 0. 3+/-0.1 minute), and fell more rapidly. Exercise duration and maximal oxygen consumption were not related significantly to reinnervation status, but a trend existed for longer exercise time in markedly reinnervated patients. CONCLUSIONS The present studies suggest that sympathetic reinnervation of the sinus node is accompanied by partial restoration of normal HR response to exercise. Both maximal oxygen consumption and exercise duration were markedly shorter in CT patients than in control subjects, and most of the difference was not related to innervation status.

Studies of the outcomes of substance abuse treatment are often handicapped because of subjects lost to follow-up. While follow-up data may be obtained from several sources, the follow-up interview often serves as the principal source of data. Difficulties are regularly encountered in locating and interviewing subjects not in treatment. From review of the literature on follow-up methodology and our own experience, we identified 10 procedures for effective follow-up. Application of these procedures is illustrated in a follow-up study of illicit opioid users treated in a methadone maintenance program. Follow-up interviews were obtained with 98% of the subjects. We recommend use of the 10 procedures by follow-up researchers, and we also recommend review of several previous publications on follow-up methodology.

Coronary arteries of transplanted hearts frequently develop a vasculopathy characterized by severe lumenal narrowing in the distal coronary arteries. It has been thought, on the basis of angiographic studies, that the coronary circulation of transplanted hearts with vasculopathy fails to develop collateral vessels normally. To determine the extent of the collateral circulation in transplanted hearts with a significant coronary stenosis, we measured an index of the collateral circulation, the coronary artery occlusion pressure, during single-vessel coronary angioplasty in seven patients with allograft vasculopathy and 18 patients with atherosclerotic disease who did not undergo transplantation. Aortic and coronary artery pressure distal to the stenosis in the epicardial artery were measured during balloon occlusion (> or = 45 seconds). Measurement variability for determination of coronary occlusion pressure was assessed by measuring occlusion pressure on two separate balloon inflations (n = 17). The severity of the dilated stenotic lesion was assessed with quantitative angiography (Reiber-PIE Data method). The indexes of stenosis severity were similar in coronary arteries of transplanted and native hearts. Coronary occlusion pressure measurements were highly reproducible (mean absolute difference between measurements, 1 +/- 1 mm Hg, r = 0.98). Coronary occlusion pressure in transplanted hearts (32 +/- 4 mm Hg) was nearly identical to that measured in coronary arteries of native hearts (29 +/- 2 mm Hg). When vessels with total occlusion were excluded and corrections were made for minor differences in hemodynamics (heart rate and blood pressure) were made, the coronary occlusion pressure in transplanted hearts remained nearly identical to native hearts.(ABSTRACT TRUNCATED AT 250 WORDS)

Normative values for word characteristics were obtained from a sample of 12 college-educated, totally congenitally blind subjects on the basis of their ratings of 161 nouns on scales of familiarity, concreteness, meaningfulness, and imageability. The dominant modality of imagery for each image-evoking word and the strongest word associate for each item also were recorded. The same data were collected for a group of sighted subjects, both to provide a comparison group for the blind subjects and to test the comparability of sighted subjects’ ratings with existing norms. Ratings for sighted subjects correlated strongly with those norms, although the coefficients were slightly higher for ratings of concreteness and imageability than for ratings of familiarity and meaningfulness. Ratings of blind subjects correlated only slightly lower with existing norms for imagery and concreteness, but considerably lower for familiarity and meaningfulness.

A cardiac transplant patient died of severe left ventricular dysfunction 2 weeks after coronary angiography demonstrated normal coronary arteries. Post mortem examination showed significant and diffuse allograft vasculopathy. Coronary angiography may have limited sensitivity in detecting allograft vasculopathy.

purpose: The overall prognosis for patients with congestive heart failure is poor. Defining specific populations that might demonstrate improved survival has been difficult. We therefore examined our patient database for patients with congestive heart failure who demonstrated sustained improvement in left ventricular function and associated resolution of signs and symptoms of congestive heart failure.

During a 36-month period, the serial chest x-ray films of 26 patients with the adult respiratory distress syndrome (ARDS) were evaluated for the patterns of onset, course, and follow-up appearance when possible. An exudative phase appearance can be recognized, which can clear. The exudative phase appearances are (1) a bilateral, homogeneous, white-out alveolar appearance; (2) an asymmetric consolidative appearance; and (3) a central perihilar ("bat-wing") consolidative appearance. This progresses to a proliferative phase manifested on chest x-ray film as an interstitial appearance that must not be confused with fibrosis, as the chest x-ray film may return to normal.

The possibility of obtaining a zincacyclobutane intermediate in the Gustavson reaction was hypothesized to explain the formation of olefins obtained in this reaction. A select group of substrates was investigated in which the formation of olefin products could be explained if one invoked the intermediacy of a zincacyclobutane, but would be difficult to explain in the absence of such an intermediate. A deuterium-labeled substrate was also investigated and the olefins obtained from its reaction with zinc were found to closely follow the deuteriumlabeling pattern obtained from the decomposition of the analogous deuteriumlabeled platinacyclobutane.

Five ketones were hydrosilylated, using either α-NpPhSiH2 or Ph2SiH2, in the presence of rhodium catalysts which had been modified with the chiral phosphinite glucophinite or camphinite. The best results were obtained using glucophinite as the chiral modifier and α-NpPhSiH2 as the hydrosilylating reagent.

Samples of exo-tricyclo[3.3.1.02,4]non-6-ene (3) have been frequently required for physical-organic studies and for product comparison purposes in rearrangemtnt studies.1–3 The compound has been prepared in four steps from norbornadience in less than 5% yield.1 It has also been prepared from vinylcyclohexene in three steps, along with a variety of by-products, in less than 10% yield.2 We report here a simple, clean synthesis of 3 from nor-bornadiene with an overall yield of 45–55%. Additionally, we are reporting the first13C NMR spectrum of this compound which will allow for its easy identification in the future.

ADVERTISEMENT RETURN TO ISSUEPREVArticleNEXTInteraction of cyclopropane with platinum-metal chlorides under carbon monoxide pressure in benzeneThomas H. Johnson and Thomas F. BaldwinCite this: J. Org. Chem. 1980, 45, 1, 140–142Publication Date (Print):January 1, 1980Publication History Published online1 May 2002Published inissue 1 January 1980https://pubs.acs.org/doi/10.1021/jo01289a027https://doi.org/10.1021/jo01289a027research-articleACS PublicationsRequest reuse permissionsArticle Views122Altmetric-Citations8LEARN ABOUT THESE METRICSArticle Views are the COUNTER-compliant sum of full text article downloads since November 2008 (both PDF and HTML) across all institutions and individuals. These metrics are regularly updated to reflect usage leading up to the last few days.Citations are the number of other articles citing this article, calculated by Crossref and updated daily. Find more information about Crossref citation counts.The Altmetric Attention Score is a quantitative measure of the attention that a research article has received online. Clicking on the donut icon will load a page at altmetric.com with additional details about the score and the social media presence for the given article. Find more information on the Altmetric Attention Score and how the score is calculated. Share Add toView InAdd Full Text with ReferenceAdd Description ExportRISCitationCitation and abstractCitation and referencesMore Options Share onFacebookTwitterWechatLinked InRedditEmail Other access optionsGet e-Alertsclose Get e-Alerts