C-reactive protein concentrations pre- and post-transfusion

In a prospective study, serum C-reactive protein (CRP) levels were analysed before and after 18 transfusional episodes, using a fluorescence polarization immunoassay. Only patients with a stable CRP value for two consecutive days before transfusion were assessed. Although small rises in CRP concentrations occurred following 55.6% of transfusions, there was no statistically significant difference between pre- and post-transfusion CRP values, and these increases also failed to reach clinical significance. An increase in CRP post-transfusion of greater than 100 mg/l occurred on only one occasion, and was more likely to be due to underlying infection.

Multiple teeth showing invasive cervical resorption - an entity with little known histologic features

Invasive cervical resorption is a relatively uncommon form of external root resorption, characterized by resorption of the cervical region of the root. There is progressive loss of cementum and dentine with replacement by fibrovascular tissue derived from the periodontal ligament, with deposition of cementum-like hard tissue. In most cases, a single tooth is involved. We report a case of invasive cervical resorption that resulted in loss of multiple teeth from two different quadrants. The case highlights the diagnostic difficulty that may arise in this uncommon lesion, the pathologic features of which may be mistaken for a fibro-osseous lesion or a low-grade sarcoma.

Ammonia emission and deposition in Scotland and its potential environmental impacts

The main source of atmospheric ammonia (NH₃) in Scotland is livestock agriculture, which accounts for 85% of emissions. The local magnitude of emissions therefore depends on livestock density, type, and management, with major differences occurring in various parts of Scotland. Local differences in agricultural activities therefore result in a wide range of NH₃ emissions, ranging from less than 0.2 kg N ha⁻¹ year⁻¹ in remote areas of the Scottish Highlands to over 100 kg N ha⁻¹ year⁻¹ in areas with intensive poultry farming. Scotland can be divided loosely into upland and lowland areas, with NH₃ emission being less than and more than 5 kg N ha⁻¹ year⁻¹, respectively.Many semi-natural ecosystems in Scotland are vulnerable to nitrogen deposition, including bogs, moorlands, and the woodland ground flora. Because NH₃ emissions occur in the rural environment, the local deposition to sensitive ecosystems may be large, making it essential to assess the spatial distribution of NH₃ emissions and deposition. A spatial model is applied here to map NH₃ emissions and these estimates are applied in atmospheric dispersion and deposition models to estimate atmospheric concentrations of NH₃ and NH₄⁺, dry deposition of NH₃, and wet deposition of NHx. Although there is a high level of local variability, modelled NH₃ concentrations show good agreement with the National Ammonia Monitoring Network, while wet deposition is largest at high altitude sites in the south and west of Scotland. Comparison of the modelled NH_x deposition fields with estimated thresholds for environmental effects (“critical loads”) shows that thresholds are exceeded across most of lowland Scotland and the Southern Uplands. Only in the cleanest parts of the north and west is nitrogen deposition not a cause for concern. Given that the most intense effects occur within a few kilometres of sources, it is suggested that local spatial abatement policies would be a useful complement to traditional policies that mitigate environmental effects based on emission reduction technologies.

An ozone budget for the UK: using measurements from the national ozone monitoring network; measured and modelled meteorological data, and a 'big-leaf' resistance analogy model of dry deposition

Data from the UK national air-quality monitoring network are used to calculate an annual mass budget for ozone (O3) production and loss in the UK boundary layer during 1996. Monthly losses by dry deposition are quantified from 1 km x 1 km scale maps of O(3) concentration and O(3) deposition velocities based on a big-leaf resistance analogy. The quantity of O(3) deposition varies from approximately 50 Gg-O(3) month(-1) in the winter to over 200 Gg-O(3) month(-1) in the summer when vegetation is actively absorbing O(3). The net O(3) production or loss in the UK boundary layer is found by selecting days when the UK is receiving "clean" Atlantic air from the SW to NW. In these conditions, the difference in O(3) concentration observed at Mace Head and a rural site on the east coast of the UK indicates the net O(3) production or loss within the UK boundary layer. A simple box model is then used to convert the concentration difference into a mass. The final budget shows that for most of the year the UK is a net sink for O(3) (-25 to -800 Gg-O(3) month(-1)) with production only exceeding losses in the photochemically active summer months (+45 Gg-O(3) month(-1)).

A home program of rehabilitation for moderately severe traumatic brain injury patients. The DVHIP Study Group

We have recently reported the results of a prospective controlled randomized trial comparing home versus inpatient cognitive rehabilitation for patients with moderate to severe head injury. That study showed no overall difference in outcomes between the two groups.(1) In this article, we provide further details of the home program arm of the study. All patients in the home program received medical treatment as needed, a multidisciplinary in-hospital evaluation, and TBI counseling before entering the eight-week home program, which then included guidance on home activities, as well as weekly telephone calls from a psychiatric nurse.

Modelling photochemical oxidant formation, transport, deposition and exposure of terrestrial ecosystems

The chemical processes responsible for production of photochemical oxidants within the troposphere have been the subject of laboratory and field study throughout the last three decades. During the same period, models to simulate the atmospheric chemistry, transport and deposition of ozone (O(3)) from individual urban sources and from regions have been developed. The models differ greatly in the complexity of chemical schemes, in the underlying meteorology and in spatial and temporal resolution. Input information from land use, spatial and temporally disaggregated emission inventories and meteorology have all improved considerably in recent years and are not fully implemented in current models. The development of control strategies in both North America and Europe to close the gaps between current exceedances of environmental limits, guide values, critical levels or loads and full compliance with these limits provides the focus for policy makers and the support agencies for the research. The models represent the only method of testing a range of control options in advance of implementation. This paper describes currently applied models of photochemical oxidant production and transport at global and regional scales and their ability to simulate individual episodes as well as photochemical oxidant climatology. The success of current models in quantifying the exposure of terrestrial surfaces and the population to potentially damaging O(3) concentrations (and dose) is examined. The analysis shows the degree to which the underlying processes and their application within the models limit the quality of the model products.

Women's reasons for and barriers to seeking care for breast cancer symptoms

Of note, these findings are based on women who did seek care for symptoms, rather than those who did not. However, the sample does include late care seekers; 23% of participants sought care after 3 months, and 3.6% waited more than a year. Delay often is defined as seeking care 3 months after symptoms are noted. Community health workers, such as public health nurses, may be able to document barriers among women who have symptoms but have not sought care. In this sample of predominantly low-income, minimally educated participants, women were motivated to seek care for their breast symptoms to obtain consultations and diagnoses, as well as to deal with their concerns about their symptoms and possible cancer diagnoses. Clinicians can recognize women's need to know the meaning of their symptoms, providing clarification as soon as possible and reassurance as appropriate. Clinicians and families can affirm that making time for women's symptom evaluations is a priority. Knowing that women's common barriers to accessing the health care system involve financial, time, and logistical considerations can direct health care administrators' agendas. Administrators, clinicians, and women can work for changes in health policies to assure universal coverage for preventive services for all women.

Integrating outcomes measurement into clinical practice improvement across the continuum of care: a disease-specific episode of care model

This article describes a model for incorporating outcomes measurement into a comprehensive, continuum-wide clinical practice improvement program developed at Lovelace Health Systems (Albuquerque, N.M.). Created in 1993, the Lovelace Episode of Care Program currently includes nine disease-specific multidisciplinary teams that are working to improve care by addressing such issues as severity, appropriateness, efficiency, continuous quality improvement indicators, practice guidelines, care maps, and outcomes. Key features and advantages of the model are discussed, as well as implementation issues, successes, lessons learned, program restructuring and improvement, and applicability of the framework across diseases and health organizations.

Mentoring program guides new hospital trustees. A religious institute ensures trustee orientation is mission and value based

In 1990 the Sisters of Charity began offering a mentoring program to ensure that sisters who serve on boards of its sponsored institutions can fulfill their commitment to effective stewardship. For participating healthcare facilities, the program offers an assurance that their trustees will have a clear direction, common information, and a mission- and value-based orientation process. The new trustees gain a basic understanding of their role and responsibilities as trustees, including the ministerial dimension. Mentors in the program benefit by refreshing their understanding of issues facing trustees. Participants in the mentoring program must meet the criteria for all trustees and demonstrate a special commitment to the congregation's mission and philosophy. The mentors are selected on the basis of their experience, availability, and commitment to the congregation's mission and philosophy. After participating in at least one board meeting, the new trustees, along with their mentors, attend an orientation seminar that focuses on sponsorship's history, purposes, principles, and policies and the system's services, roles, and functions. A second seminar is held nine months later for evaluation and follow-up. In addition, the mentors and trustees meet regularly before and/or after each board meeting to discuss pertinent issues, board dynamics, and the new trustee's participation.

Alternative agendas. System priorities for the 1990s will differ from those of the last decade

The Sisters of Charity Health Care Systems (SCHCS) was established in 1979 in response to changes in the U.S. healthcare system and to new needs of sponsors and Catholic healthcare facilities. However, the agenda that SCHCS leaders (and leaders of other systems) set at that time must now give way to an agenda that will address the new challenges and responsibilities facing the Catholic healthcare ministry in the 1990s. In its first decade of existence, SCHCS established and fulfilled a number of goals: It strengthened governance relationships, helped systems and sponsors better identify with local communities, enabled facilities to steward resources more effectively, and facilitated members' understanding of mission and sponsorship values. In the 1990s, however, systems will have to create more opportunities for regional, collaborative, and networking relationships among member facilities and between members and non-members. To achieve this, they will have to reevaluate their structures, find ways to faciliatate collaboration, make resources available to institutions outside the system, and develop an overall philosophy that enhances both the fiscal and spiritual well-being of member facilities.

Revitalizing the ministry

The twentieth century's last decade presents religious institutes with a golden opportunity to confront the dilemmas surrounding sponsorship. Sponsors can develop a number of strategies to allay current anxieties and to transform potential crises into advantages. One is to revitalize the corporate mission by basing it on professed values rather than on existing structures. Institutes can also articulate their mission by building networks that encourage cooperation between those involved in traditional services and those in alternative services. Strengthening collaboration with the laity is also critical. Sponsorship forums are one way to promote mutual understanding and reflection. In addition, involving lay leaders in planning and decision making will broaden their understanding of issues that affect the healthcare institution. Finally, with the laity assuming a greater share of responsibility in Catholic healthcare, many institutes will have to develop strategies that allow them to "let go." The process will require inner transformation. Recognizing the institute's contribution to the development of the Catholic healthcare ministry can help members accept the need for change. Actively planning for the changes will also help members cope with them.

United they thrive: merger of two healthcare systems

On March 15, 1987, the Sisters of St. Francis of Perpetual Adoration of Colorado Springs and the Sisters of Charity of Cincinnati agreed to consolidate. It marked the culmination of years of building mutual trust and months of intense negotiations. The Sisters of St. Francis realized in 1983 that some major decisions had to be made regarding the future direction of its healthcare ministry because of rapid changes within the healthcare industry and declining numbers of Franciscan sisters working in healthcare. In January 1986 leaders of the two institutes and their healthcare systems sat down for the first time to discuss issues surrounding the collaborative effort and to recommend a list of objectives, including joint ventures in various areas. Other recommendations included the formation of a joint steering council to direct the collaborative effort and the formation of a Colorado Springs Task Force to end the rivalry existing between two local hospitals--one Franciscan-sponsored, the other Charity-sponsored. Additional hurdles included finding an affiliation model that all parties would accept (the one endorsed allows the Sisters of St. Francis to continue to exercise substantial control over the future of its healthcare institutions but gives the Sisters of Charity Health Care System much of the operational control); due diligence reviews of legal and financial documents; canonical review; detailed financial analysis; review of all state and federal regulatory requirements, including antitrust; and educating and preparing members of the Franciscan Healthcare Corporation.