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Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

Plasma glucose, insulin, and triglyceride concentration, blood pressure, and insulin action on isolated adipocytes were determined in weight-matched Sprague-Dawley, Dahl salt-resistant, and Dahl salt-sensitive rats. Blood pressure and plasma glucose concentrations were not significantly different in the three groups. However, Dahl salt-sensitive rats had significantly higher plasma insulin (39±2 microunits/ml) and triglyceride (213±11 mg/dl) concentrations than did SpragueDawley rats (27±2 microunits/ml and 101±6 mg/dl, respectively). Values for insulin (34±4 microunits/ml) and triglyceride (159 ±11 mg/dl) were intermediate in Dahl salt-resistant rats. In contrast, maximal insulin-stimulated glucose transport was significantly lower in adipocytes isolated from Dahl salt-sensitive as compared with Sprague-Dawley rats (400 ±16 versus 523 ±14 ft/cell/sec), with Dahl salt-resistant rats again having intermediate values. However, the ability of insulin to maximally inhibit catecholamine-stimulated lipolysis was similar in all three groups, averaging -20% of the activity present in the absence of insulin. All of these differences were seen when the rats were eating conventional chow and did not change in Dahl rats after 2 weeks of an 8% NaCl diet On the other hand, the predicted rise in blood pressure took place in Dahl salt-sensitive rats, increasing from 147±4 to 181 ±6 mm Hg. These data indicate that Dahl rats have higher values for plasma triglyceride and insulin concentration than control Sprague-Dawley rats, associated with a defect in insulin-stimulated glucose uptake by isolated adipocytes. These metabolic changes are not dependent on Dahl rats eating a high salt diet and do not vary as a function of salt intake. (Hypertension 1991;18:630-635) I t has recently become apparent that patients with high blood pressure tend to be hyperinsulinemic, hypertriglyceridemic, and resistant to insulinstimulated glucose uptake. -5 Similar changes have also been demonstrated in rats with spontaneous hypertension (SHR), 6 -8 as well as in normal Sprague-Dawley (S-D) rats when the cornstarch in their diet is replaced with fructose. 9 -12 Furthermore, it has been possible to show that adipocytes isolated from SHR are resistant to insulin-stimulated glucose uptake, 7 and the magnitude of this cellular defect is significantly related to the associated increases in blood pressure and plasma insulin and triglyceride concentrations.8 Because plasma triglyceride concentrations also seem to be increased in Dahl salt-sensitive (S) rats, 13 the current study was initiated to see if changes in insulin action and concentration accompany the previously noted abnormality in lipid metabolism in this genetic form of rodent hypertension. MethodsMale Dahl S and salt-resistant (R) Brookhavenderived rats were obtained from Harlan Sprague Dawley, Inc., Indianapolis, Ind., as were male control S-D rats. They were fed ad libitum with conventional rat chow (Ralston Purina Co., St. Louis, Mo.) containing 0.6% NaCl, which in some experiments was replac...

Background-Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood.

RSV may cause outbreaks in LTCFs that traditional diagnostic methods do not detect. RT-PCR can provide a more timely and accurate diagnosis of outbreaks, which allows for early symptomatic treatment, rational use of antibiotics, and improved infection control.

The cases of 14 patients seen 6 weeks to 7 years after gunshot wounds with painful, restrictive joint disease and retained intra-articular bullets were reviewed. Twelve patients had radiographic findings characteristic of lead synovitis. The earliest finding was a fine, punctate deposition of radiopaque lead on the articular cartilage that resembled chondrocalcinosis but was of greater density. This was followed by more discrete lead speckling of hypertrophied synovium. The opacities became larger, coarser, and more confluent over time, ultimately outlining the synovium, articular cartilage, and joint capsule. Synovial hypertrophy and diffuse chronic inflammation and fibrosis were seen in seven patients on gross pathologic examination. The lead was deposited extracellularly in the subsynovial layer and within the marrow spaces of subarticular and periarticular bone. Electron-microscopic study suggests that lead is initially incorporated within cells and secondarily deposited extracellularly after cell death. Bullets in joints are not physiologically inert and should be removed when encountered.

Resident, family, and staff priorities for culture change vary, and diverse priorities of stakeholders should be considered to inform culture change efforts on a local and national level.

Objectives Computerized order entry algorithms can improve the quality of care; but are rarely used in nursing homes (NHs). We conducted a pilot study to: (1) develop order entry algorithms for 5 common NH problems, and (2) test their acceptance, use, and preliminary impact on quality indicators and resource utilization. Design Pre-post, quasi-experimental study. Setting: 2 Veterans Affairs NHs. Participants Randomly selected residents (n=265) with one or more target conditions, and 42 nursing home providers. Intervention Expert panels developed computerized order entry algorithms based on clinical practice guidelines. Each was displayed on a single screen and included an array of diagnostic and treatment options, and means to communicate with the interdisciplinary team. Medical records were abstracted for the 6 months preceding and following deployment. Results Despite positive provider attitudes toward the computerized order entry algorithms, their use was infrequent and varied by condition: Falls (73%), Fever (9%), Pneumonia (8%), UTI (7%), and Osteoporosis (3%). In subjects with falls, we observed trends for improvements in quality measures for the 6/9 measures, including measuring orthostatic blood pressure (17.5% to 30%, p=0.29), reducing neuroleptics (53.8% to 75%, p=0.27), reducing sedative-hypnotics (16.7% to 50.0%, p=0.50), prescription of calcium (22.5% to 32.5%, p=0.45), vitamin D (20.0 to 35.0%, p=0.21), and external hip protectors (25.0 to 47.5%, p=0.06). Little improvement was observed in the other conditions. There was no change in resource utilization. Conclusion Computerized order entry algorithms were used infrequently, except for falls. Further study may determine whether their use leads to improved care.