Monday, November 1, 2010

Effective budgeting and management by all means more money for patient needs


$650,000 more now available for equipment!

By John Aldis,
Vice-President,
Corporate Services
and Chief Financial Officer


Efficiency is contagious.

Our directors and managers, and their teams, have kept the Capital Equipment Planning Committee updated as to the status of medical and related equipment needs and purchases from our approved capital list. Regular monitoring and management of our capital list of approved equipment needs allows us to maximize investment of our limited resources for our patients and communities.

Aligning personal business commitments, the strategic plan, our Lean philosophy and a concentrated focus on efficiency from all departments – including finance, of course – is paying off for the patients of our hospital. This focus has spread at all levels of our management structure and among our staff teams.

Now, let me skip to the good news: The Capital Equipment Planning Committee (CEPC) recently reallocated approximately $650,000 of “freed up” capital funds to additional items our hospital needs for patients.

Fiscal responsibility, one of our four strategic dimensions – is not simply a function of our finance department. Indeed, the better we all are at fiscal responsibility, the better positioned we are to improve in our three other strategic dimensions: service excellence; access to care; and team engagement.

There are many reasons for this recent positive development, but it all stems from the fact that our professionals at Rouge Valley Health System are becoming more efficient and better stewards of tax dollars for patient care.

The $650,000 is available because:
• Approved capital expenditures from 2008/09 and 2009/10 were completed under budget;
• A number of items were deemed to be no longer necessary;
• Through closer collaboration between the RVHS Foundation and CEPC, some items on our capital list have been funded through the foundation’s efforts to direct donor giving to specific items

- So who is CEPC and what are the results? -

The group is comprised of managers, directors and vice-presidents representing our program and service areas at both hospital campuses.

The CEPC has been a very productive and cohesive team, reallocating funds mid-year using a criteria based framework. In fact, there was unanimous agreement by the team on where to reallocate the funds to address key needs, such as buying new:
• Dedicated equipment, such as vital signs monitors, in isolation rooms;
• Portable vital sign monitor in the children’s program;
• A defibrillator in the surgical program;
• Medication carts;
• Two ventilators;
• A chemistry analyzer;
• And more.

I’d like to thank the members of our Capital Equipment Planning Committee, our finance team and all our hospital staff for their engagement in this and other corporate initiatives.

Optimizing our limited resources throughout our hospital supports better patient care everyday. This efficiency bug is one contagion we want to continue spreading.

Amino acids in skeletal muscle: Are protein supplements as good as advertised?

When protein-rich foods, like meat, are ingested they are first broken down into peptides through digestion. As digestion continues, peptides are broken down into amino acids, which then enter circulation, becoming part of the blood plasma. They are then either incorporated into various tissues, such as skeletal muscle, or used for other purposes (e.g., oxidation and glucose generation). The table below shows the amino acid composition of blood plasma and skeletal muscle. It was taken from Brooks et al. (2005), and published originally in a classic 1974 article by Bergström and colleagues. Essential amino acids, shown at the bottom of the table, are those that have to be consumed through the diet. The human body cannot synthesize them. (Tyrosine is essential in children; in adults tryptophan is essential.)


The data is from 18 young and healthy individuals (16 males and 2 females) after an overnight fast. The gradient is a measure that contrasts the concentration of an amino acid in muscle against its concentration in blood plasma. Amino acids are transported into muscle cells by amino acid transporters, such as the vesicular glutamate transporter 1 (VGLUT1). Transporters exist because without them a substance’s gradient higher or lower than 1 would induce diffusion through cell membranes; that is, without transporters anything would enter or leave cells.

Research suggests that muscle uptake of amino acids is positively correlated with the concentration of the amino acids in plasma (as well as the level of activity of transporters) and that this effect is negatively moderated by the gradient. This is especially true after strength training, when protein synthesis is greatly enhanced. In other words, if the plasma concentration of an amino acid such as alanine is high, muscle uptake will be increased (with the proper stimulus; e.g., strength training). But if a lot of alanine is already present in muscle cells when compared to plasma (which is normally the case, since alanine’s 7.3 gradient is relatively high), more plasma alanine will be needed to increase muscle uptake.

The amino acid makeup of skeletal muscle is a product of evolutionary forces, which largely operated on our Paleolithic ancestors. Those ancestors obtained their protein primarily from meat, eggs, vegetables, fruits, and nuts. Vegetables and fruits today are generally poor sources of protein; that was probably the case in the Paleolithic as well. Also, only when very young our Paleolithic ancestors obtained their protein from human milk. It is very unlikely that they drank the milk of other animals. Still, many people today possess genetic adaptations that enable them to consume milk (and dairy products in general) effectively due to a more recent (Neolithic) ancestral heritage. A food-related trait can evolve very fast – e.g., in a few hundred years.

One implication of all of this is that protein supplements in general may not be better sources of amino acids than natural protein-rich foods, such as meat or eggs. Supplements may provide more of certain amino acids than others sources, but given the amino acid makeup of skeletal muscle, a supplemental overload of a particular amino acid is unlikely to be particularly healthy. That overload may induce an unnatural increase in amino acid oxidation, or an abnormal generation of glucose through gluconeogenesis. Depending on one’s overall diet, those may in turn lead to elevated blood glucose levels and/or a caloric surplus. The final outcome may be body fat gain.

Another implication is that man-made foods that claim to be high in protein, and that are thus advertised as muscle growth supplements, may actually be poor sources of those amino acids whose concentration in muscle are highest. (You need to check the label for the amino acid composition, and trust the manufacturer.) Moreover, if they are sources of nonessential amino acids, they may overload your body if you consume a balanced diet. Interestingly, nonessential amino acids are synthesized from carbon sources. A good source of carbon is glucose.

Among the essential amino acids are a group called branched-chain amino acids (BCAA) – leucine, isoleucine, and valine. Much is made of these amino acids, but their concentration in muscle in adults is not that high. That is, they do not contribute significantly as building blocks to protein synthesis in skeletal muscle. What makes BCAAs somewhat unique is that they are highly ketogenic, and somewhat glucogenic (via gluconeogenesis). They also lead to insulin spikes. Ingestion of BCAAs increases the blood concentration of two of the three human ketone bodies (acetone and acetoacetate). Ketosis is both protein and glycogen sparing (but gluconeogenesis is not), which is among the reasons why ketosis is significantly induced by exercise (blood ketones concentration is much more elevated after exercise than after a 20 h fast). This is probably why some exercise physiologists and personal trainers recommend consumption of BCAAs immediately prior to or during anaerobic exercise.

Why do carnivores often consume prey animals whole? (Consumption of eggs is not the same, but similar, because an egg is the starting point for the development of a whole animal.) Carnivores consume prey animals whole arguably because prey animals have those tissues (muscle, organ etc. tissues) that carnivores also have, in roughly the same amounts. Prey animals that are herbivores do all the work of converting their own prey (plants) to tissues that they share with carnivores. Carnivores benefit from that work, paying back herbivores by placing selective pressures on them that are health-promoting at the population level. (Carnivores usually target those prey animals that show signs of weakness or disease.)

Supplements would be truly natural if they provided nutrients that mimicked eating an animal whole. Most supplements do not get even close to doing that; and this includes protein supplements.

Reference

Brooks, G.A., Fahey, T.D., & Baldwin, K.M. (2005). Exercise physiology: Human bioenergetics and its applications. Boston, MA: McGraw-Hill.

Water in the Wilderness, by blogger of the month Isaac Hatton

Jerusalem, heading to the En Gedi spring.
The schedule said "self-study."  No classes!  A whole day off to study . . . or to rent a car with friends and head east for a day of hiking around En Gedi followed by a relaxing float in the dead sea . . . followed, of course, by some studying in the evening!
Driving through the rocky, sun-scorched wilderness, it was hard to imagine there being any fresh water in the vicinity whatsoever, let alone waterfalls.  But as we started climbing, there it was, the sound of gurgling water, growing louder and louder.  And then we could see it: streams gushing out from the very dust and rocks that define the whole surrounding region as desert.  We quickly found our own secluded side-stream, away from the bus-load of screaming school girls, and plunged beneath the refreshing water, rinsing away the dust and sweat.


The En Gedi spring
It was not the waterfalls themselves that impressed me.  There are bigger and more beautiful streams to be found in the world.  But the thing about En Gedi is that watefalls are so unlikely.  Who would think of fresh water pouring out of the desert?  Its location makes it spectacular and I enjoyed soaking in the beauty. 
Last night I witnessed another location-defined miracle involving water.  I was sitting at my desk beside my open window enjoying the cool evening breeze when suddenly I heard the rain start.  Rain!  I haven't seen a drop of precipitation since moving to Israel over three months ago.  In fact, that's the longest I've ever gone before without seeing rain.  Back home in Northern Ireland three days without rain makes the evening news!  But there it was, a downpour in middle of the desert.
Got me thinking about the dry times in life, like being separated from loved ones and having to learn, sometimes with frustration, how to adapt to a new culture.  

Me (Isaac) and four of my MSIH first-years
Sure it can be difficult, but the dry days are always followed sooner or later by a good rain.  A phone call from home at just the right moment, or a friendly neighbor who is patient with your faltering Hebrew.  A really good lecture when a complicated biochemical pathway starts to make sense, or a "self-study" day.  If not for the desert, rain would just be rain, and a waterfall would be nothing but a waterfall. 

Macro vs.Micro - Getting to the source of your problems

     Do you see your problems with your body as the big picture or from a small point of view.  This is something I have discussed with many of our patients because it is how we are able to get superior results in solving many peoples problems.  Many doctors see the micro, meaning your elbow hurts while playing tennis, so lets look at the elbow and treat it, or the person who has knee pain and your doctor as well as you are obsessed with treating that problem.  Over the years, I have learned never to take things at face value when it comes to mechanical problems in the body.  Doing so assures expensive care that frankly is usually ineffective. Looking at the micro makes us miss what is really happening in your body.  Obsessing about the herniated disc and treating it as if it created itself because things just happen is fooling ourselves and setting you up for years of exacerbations and even surgeries.
    I look at the macro or the big picture because this is where you find the cause of peoples problems, looking past the obvious.  A great example of this is a tennis player I saw this weekend.  We started with some elbow, shoulder and flexibility issues which have markedly improved.  This weekend, she said she still felt some elbow pain however,   the ball is hitting the net alot.  Looking at the micro, she suggested it was her shoulder.  Looking at the macro, the left side was tight, recruiting into the left oblique restricting motion in the right shoulder, aggravating the elbow.  After properly treating the problematic core muscles, she notices a marked improvement in the way her shoulder worked on the right side.  She should notice her power return during this weeks game and the ball will be going over the net. 
    The majic sauce in our approach is looking at you, not just the symptoms you arrived with.  We do this for you, your family, friends and co workers who are only aware of the elbow or body part hurting, and are likely visiting doctors who also see things that way. The only way to get a better diagnosis, and consequently, more cost effective and appropriate care is to get it right on diagnosis, which yields more appropriate care.  Things are rarely what they seem at first glance in the human body which is why I look beyond your symptoms and think about function. I also dig deeper and ask the right questions to uncover those valuable clues which help me solve the equation of why you hurt. Think of me as the Sherlock Holmes of the musculoskeletal system. My goal is to get it right the first time, fix your true mechanical problem and as many of our patients already know, a number of other chronic problems that are affiliated with that complaint go away too. 
     It is all about finding the cause and fixing that, and the symptoms and the future exacerbations are much less likely.  Its not majic, its getting healthcare right.