Cost Considerations in Sedation, Analgesia, and Neuromuscular Blockade in the Intensive Care Unit

Sedation of critically ill patients is a costly endeavor. Costs of commonly used intensive care unit (ICU) sedatives range from pennies to more than $500 per day. Although the agents account for some of this expense, complications related to the use of these drugs in the ICU produce even greater costs. Prolongation of mechanical ventilation and length of stay are some of the common complications resulting from non-ideal use of these drugs. Sedative agents also impair neurological evaluation in many critically ill patients, which may mask detection of acute delirium resulting from intercurrent illness or intracranial catastrophes and can lead to excessive diagnostic testing. Opiates may result in gastrointestinal dysfunction with resulting malnutrition and perhaps bacterial translocation and sepsis. Neuromuscular blocking agents may cause prolonged paralysis and disability in critically ill patients who receive them. Simple dosing strategies based on pharmacological principles may decrease the incidence of these costly problems.

Outcomes of critically ill patients denied consideration for liver transplantation

Patients with advanced liver disease (ALD) leading to admission to the ICU are often evaluated for possible orthotopic liver transplantation (OLT). Those deemed ineligible for listing for OLT must be managed by medical therapy. The number of patients not eligible for OLT listing will likely increase given the current organ transplant shortage. We performed a retrospective multivariate analysis of mortality predictors for patients denied listing for OLT. One hundred and eighty-three patients denied OLT listing were evaluated over a 3(1)/(2)-yr period, beginning in 1994. Overall mortality was 56% for those not listed versus 12% for those listed for OLT (p < 0.001). Independent predictors of increased mortality among those not listed were APACHE II score (p = 0.001; OR 1.11), sepsis (p = 0.04; OR 2.41), and the need for mechanical ventilation (p = 0.001; OR 3.71). Gastrointestinal (GI) bleeding was associated with decreased mortality (p = 0.02; OR 0.44). We conclude that critically ill patients with ALD denied OLT listing have substantially higher mortality than those listed for OLT. APACHE II score, sepsis, and the need for mechanical ventilation predict increased mortality in this group. Conversely, GI bleeding predicts decreased mortality; therefore, aggressive resuscitative measures seem merited in these patients.

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

BACKGROUND

Conous infusions of sedative drugs in the intensive care unit may prolong the duration of mechanical ventilation, prolong the length of stay in the intensive care unit and the hospital, impede efforts to perform daily neurologic examinations, and increase the need for tests to assess alterations in mental status. Whether regular interruption of such infusions might accelerate recovery is not known.

METHODS

We conducted a randomized, controlled trial involving 128 adult patients who were receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit. In the intervention group, the sedative infusions were interrupted until the patients were awake, on a daily basis; in the control group, the infusions were interrupted only at the discretion of the clinicians in the intensive care unit.

RESULTS

The median duration of mechanical ventilation was 4.9 days in the intervention group, as compared with 7.3 days in the control group (P=0.004), and the median length of stay in the intensive care unit was 6.4 days as compared with 9.9 days, respectively (P=0.02). Six of the patients in the intervention group (9 percent) underwent diagnostic testing to assess changes in mental status, as compared with 16 of the patients in the control group (27 percent, P=0.02). Complications (e.g., removal of the endotracheal tube by the patient) occurred in three of the patients in the intervention group (4 percent) and four of the patients in the control group (7 percent, P=0.88).

CONCLUSIONS

In patients who are receiving mechanical ventilation, daily interruption of sedative-drug infusions decreases the duration of mechanical ventilation and the length of stay in the intensive care unit.

The incidence and pathogenesis of cardiopulmonary deterioration after abrupt withdrawal of inhaled nitric oxide

We studied the effect of abrupt discontinuation of inhaled nitric oxide (iNO) in patients receiving this drug for treatment of acute hypoxemic respiratory failure (AHRF), in order to determine the need for continued therapy, the incidence and nature of adverse events, and the risk factors predicting these adverse events. Thirty-one patients who showed an initial increase in Pa(O(2)) of > 20 mm Hg in response to iNO underwent a discontinuation trial at 10 to 30 h after beginning iNO. Indwelling arterial and pulmonary artery catheters facilitated monitoring of hemodynamic and gas-exchange parameters. For the group, discontinuation of iNO caused a significant decrease in Pa(O2 ), arterial and mixed venous oxygen saturation, and ratio of Pa(O(2)) to fraction of inspired oxygen (FI(O(2))). Three patterns of response were observed. Eight of 31 (25.8%) patients had minimal changes in oxygenation or hemodynamics, suggesting no need for ongoing therapy. Fifteen of 31 (48%) patients had worsened gas exchange as a predominant response. Eight of 31 patients exhibited hemodynamic collapse, defined as > 20% fall in cardiac output and/or mean arterial blood pressure. In this last subgroup, the pattern of cardiovascular changes suggested that this response arose from an acute increase in right ventricular afterload, and was not a consequence of gas-exchange abnormalities. In all cases, reinstitution of iNO promptly reversed worsened hemodynamics and gas exchange. Independent factors associated with an increased risk of cardiovascular collapse included multisystem organ failure, older age, and initial blood pressure increase in response to iNO; a smaller change in the ratio of Pa(O(2)) to FI(O(2)) with initiation of iNO therapy also tended to correlate with this phenomenon. We conclude that careful and monitored discontinuation of iNO in patients with AHRF will identify substantial fractions of patients who are either receiving no benefit from this therapy or who require iNO to maintain an adequate circulation and are therefore at risk for adverse outcome with transport or inadvertent discontinuation of iNO. Future trials of iNO should recognize this complication of such therapy and include assessments for it.

Sexual dysfunction following vulvectomy

OBJECTIVE

This is a pilot study to evaluate sexual dysfunction in women after vulvectomy.

METHODS

An 88-question survey was used to assess body image and the DSM IV criteria for sexual dysfunction on women who had undergone vulvectomy.

RESULTS

Forty-seven women agreed to participate in the study and 41 women (87%) returned the survey. There was a significant alteration of body image in these women after vulvectomy (P = 0.004). Sexual frequency significantly decreased after surgery (P = 0.001) and there was significant sexual dysfunction in the categories of sexual aversion disorder (P = 0.01), arousal disorder (P = 0.02), and hypoactive sexual disorder (P = 0. 001). The extent of surgery did not correlate with degree of sexual dysfunction in any category. Women who were depressed at the time of survey (as determined by the PRIME-MD scale) were more likely to suffer sexual aversion disorder (P = 0.05) and tended to have more body image disturbance (P = 0.1) and global sexual dysfunction (P = 0.06).

CONCLUSIONS

Women experience significant sexual dysfunction after vulvectomy and the extent of surgery or type of vulvectomy did not correlate with degree of sexual dysfunction. There is a significant need to address sexual problems with all women after any vulvectomy. Age, depression, worsening GOG performance status, and preoperative hypoactive sexual dysfunction were risk factors for sexual dysfunction after vulvar surgery. Appropriate counseling and treatment of depression may be of benefit to this patient population.

Outcomes of critically ill cancer patients in a university hospital setting

Critically ill cancer patients constitute a large percentage of admissions to tertiary care medical intensive care units (ICUs). We sought to describe outcomes of such patients, and to evaluate how conditions commonly seen in these patients impact mortality. A total of 348 consecutive medical ICU cancer patients were evaluated. Subgroup comparisons included the three most common cancer types (leukemia, lymphoma, lung cancer), as well as three different treatments/conditions (bone marrow transplant [BMT] versus non-BMT, mechanical ventilation [MV] versus non-MV, neutropenic versus non-neutropenic). There were no mortality differences between patients with leukemia, lymphoma, or lung cancer. By logistic regression, mortality predictors were: MV, hepatic failure, and cardiovascular failure for the group as a whole (41% overall mortality); MV and allogeneic (as compared with autologous) BMT for the BMT group (39% overall mortality); hepatic failure, cardiovascular failure, and persistent acute respiratory distress syndrome (ARDS) for the MV group (67% overall mortality); and MV for the neutropenic group (53% overall mortality). Neutropenia showed no independent association with mortality in the group as a whole or any subgroup analyzed. We conclude that respiratory, hepatic, and cardiovascular failure predict mortality, whereas neutropenia does not. Additionally, we have noted an encouraging improvement in survival in many groups of critically ill cancer patients.

Is age a barrier to the aggressive treatment of ovarian cancer with paclitaxel and carboplatin?

OBJECTIVE

The objective of this study was to determine whether the toxicities associated with chemotherapy are age related in women treated for ovarian cancer.

METHODS

Patients with stage II-IV epithelial ovarian cancer underwent cytoreductive surgery. Adjunctive therapy was given to each patient consisting of intravenous (IV) paclitaxel 175 mg/m(2) over 3 h with a subsequent 30-min IV infusion of carboplatin. Carboplatin dose was calculated to achieve a targeted area under the curve (AUC) of 5.0-7.5. Treatment was repeated at 21- to 28-day intervals for six cycles. Toxicities were graded after each dose of chemotherapy. Results were analyzed using the Wilcoxon rank sum test and log likelihood ratio to compare toxicities in women age <60 years old to women >/=60 years old.

RESULTS

Fifty-three women, 22 of whom were >/=60 years old, were treated with 309 cycles of chemotherapy. Forty-eight patients (92%) completed all six cycles. AUC dosing of carboplatin was equivalent for both groups. Carboplatin dose reduction occurred in 75% of patients for grade 4 neutropenia or thrombocytopenia. No patient required a reduction in the paclitaxel dose. Neutropenia was less frequent in women >/=60 years old than in women <60 years old (P = 0.02). There was no difference between women <60 years old and women >/=60 years old in the incidence of anemia, thrombocytopenia, or the use of growth factors. A 68% complete clinical response rate was observed in women >/=60 years old compared to a 74% complete response rate for women under age 60 (P = 0.22).

CONCLUSION

Age is not a barrier to the aggressive treatment of ovarian cancer with this regimen of paclitaxel and carboplatin.

Oxygenation in status asthmaticus improves during ventilation with helium-oxygen

OBJECTIVES

To determine the effect of breathing helium-oxygen (HELIOX) mixtures on pulmonary gas exchange during severe asthma.

DESIGN

A retrospective case-match control design was used to compare the changes in alveolar to arterial gradient [(A-a)gradient] in the first 2 hrs of mechanical ventilation (MV) for status asthmaticus (SA) in patients who received HELIOX with those who did not. Patients were matched for diagnosis of asthma, ventilatory failure, ventilator mode and settings, and equivalent pharmacologic therapy.

SETTING

The adult and pediatric intensive care units of a tertiary-care hospital.

SUBJECTS

Adult and pediatric patients undergoing MV for SA.

INTERVENTIONS

Use of HELIOX or standard nitrogen-oxygen mixtures during MV.

MEASUREMENTS AND MAIN RESULTS

A total of 11 patients receiving HELIOX in the first 2 hrs of MV for SA were compared with 11 case-matched controls who did not. At baseline, the HELIOX and control groups had similar (A-a)gradients (216+/-92 torr and 226+/-82 torr, respectively). The (A-a)gradient decreased significantly to 85+/-44 torr after initiation of ventilation with HELIOX (p < .0003), whereas it did not change significantly in the control group in a similar time frame and during identical treatment without HELIOX. The reduction in (A-a)gradient in the HELIOX group facilitated a reduction in F(IO)2 from 0.8+/-0.2 initially to 0.4+/-0.1 at the time of the second blood gas determination, thus permitting greater concentrations of helium to be administered.

CONCLUSIONS

MV with HELIOX improves (A-a)gradient in patients with SA. Although this improvement adds little to routine therapy with supplemental oxygen, it does permit reduction in concentration of inspired oxygen to levels that maximize helium concentration and thus permit full benefits of HELIOX on lung mechanics to be realized in even the most severely ill asthmatics.

Cyclophosphamide in the treatment of pulmonary diseases: survey of use, training, and practitioner knowledge base

OBJECTIVE

To assess pulmonologists' use, training in the use, and knowledge base of the drug cyclophosphamide.

DESIGN

Survey through questionnaire. Testing of knowledge base before and after instructional conference.

PARTICIPANTS AND METHODS

Pulmonologists (94 attendings, 31 fellows), selected randomly at the 1996 and 1997 annual meetings of The American Thoracic Society, completed surveys of their use and training in the use of cyclophosphamide. Thirty-five attending at the 1998 meeting completed a test of knowledge base of the drug. Members of the pulmonary teaching service at The University of Chicago Hospitals completed the test before and after a case-based conference designed to educate pulmonologists in the use of the drug.

RESULTS

Forty-three percent of the attending pulmonologists and 55% of the fellows were currently using the drug in the management of their patients; 77% of the attending pulmonologists had prescribed the drug in the past. Nonmalignant diseases for which the drug was prescribed included usual interstitial pneumonitis/desquamative interstitial pneumonitis, vasculitis, collagen vascular disease, constrictive bronchiolitis, sarcoid, and Goodpasture's disease. Sixty-eight percent of attending pulmonologists and 81% of fellows had no training in the drug's use. Of the attending pulmonologists who made use of the drug, 64% were prescribing and managing its use themselves. Of those who prescribed and managed the drug's use themselves, 65% had had no training in its use. Of those fellows who prescribed and managed the drug's use themselves, 73% had had no training in the drug's use. On knowledge-based testing, the average correct score was 30 +/- 10%. With an educational conference, average pre- and post-test scores rose from 40 +/- 10% to 80 +/- 10% (p < 0.001).

CONCLUSION

Cyclophosphamide had been used by the vast majority of pulmonologists, either currently or in the past, for a wide variety of lung diseases. Its use is commonly managed by physicians who have no specific training relevant to this agent. Practitioner knowledge base of the drug is poor, and case-based conferences in fellowship may be an effective means of imparting information concerning this drug.

The use of adjuvant radiation therapy by members of the Society of Gynecologic Oncologists

OBJECTIVES. The aim of this study was to determine the attitudes of the members of the Society of Gynecologic Oncologists with respect to the use of adjuvant radiation therapy in women with endometrial cancer.

METHODS

An anonymous survey concerning the use of adjuvant radiation therapy in endometrial cancer was mailed to all members of the Society of Gynecologic Oncologists listed in the 1998 directory.

RESULTS

Of the 767 listed members, 325 (42%) returned completed surveys. Less than 20% of respondents recommended adjuvant radiation therapy in stage IA grade 1 or 2 and stage IB grade 1 endometrial cancer. Adjuvant radiation is recommended by 40 to 50% of respondents in women with stage IA grade 3 and IB grade 2 tumors. Most recommend adjuvant radiation for all women with >50% myometrial invasion or grade 3 tumors with any myometrial invasion. Lymph node sampling is attempted in all cases by 48% of respondents. For those familiar with Gynecologic Oncology Group (GOG) Study No. 99, 20% stated that they were more likely to recommend adjuvant radiation and 27% stated that they were less likely to recommend adjuvant radiation based on the preliminary results. Except in stage IA grade 1 tumors, the chance of recommending further therapy in women with all stages and grades was significantly less if a complete staging procedure including lymph node dissection had been performed.

CONCLUSIONS

Complete staging appears to decrease the chance that postoperative therapy will be recommended. The use of adjuvant radiation therapy seem to have declined slightly as a result of GOG Study No. 99. Future studies in women with endometrial cancer that do not require lymph node sampling should evaluate the frequency of adjuvant therapy in the absence of complete staging.

The impact of morbid obesity on oxygen cost of breathing (VO(2RESP)) at rest

Oxygen consumption dedicated to respiratory work (V O(2RESP)) during quiet breathing is small in normal patients. In the morbidly obese, at high minute ventilations, VO(2RESP) is greater than in normal patients, but VO(2RESP) during quiet breathing in these patients is not known. We postulated that such patients have increased VO(2RESP) at rest which may predispose them to respiratory failure when additional respiratory workloads are imposed. We measured baseline VO(2) in morbidly obese patients immediately prior to gastric bypass surgery and again after intubation, mechanical ventilation, and paralysis, and compared their change in VO(2) to nonobese patients scheduled for elective abdominal surgery. Baseline VO(2) was higher in the obese patients compared with control patients (354.6 versus 221.4 ml/min; p = 0.0001) and the change in VO(2) from spontaneous breathing to mechanical ventilation was significant in the obese patients (354.6 versus 297.2 ml/min; p = 0.0002) but not the control patients (221.4 versus 219.8 ml/min; p = 0.86). We conclude that morbidly obese patients dedicate a disproportionately high percentage of total VO(2) to conduct respiratory work, even during quiet breathing. This relative inefficiency suggests a decreased ventilatory reserve and a predisposition to respiratory failure in the setting of even mild pulmonary or systemic insults.

Determination of hemoglobin saturation in patients with acute sickle chest syndrome: a comparison of arterial blood gases and pulse oximetry

STUDY OBJECTIVES

To evaluate three different methods of measuring oxygen saturation in patients suffering from acute sickle chest syndrome.

DESIGN

A prospective, descriptive study of 9 months' duration.

SETTING

A tertiary care university hospital.

PATIENTS

Adult patients with acute sickle chest syndrome scheduled to undergo RBC exchange transfusion.

INTERVENTIONS

None.

MEASUREMENTS

Baseline hemoglobin oxygen saturation was determined simultaneously by (1) calculation based on PaO2 and an oxyhemoglobin dissociation curve algorithm, (2) co-oximetry, and (3) pulse oximetry. These same measures were repeated after exchange transfusion. Baseline and postexchange hemoglobin electrophoresis was performed in all patients.

RESULTS

Baseline calculated saturation overestimated true saturation (determined by co-oximetry) with a baseline mean bias (co-oximetry minus calculated saturation) of -6.78 +/- 2.63% (95% confidence interval for bias: -8.37% to -5.19%). Pulse oximetry was not different than co-oximetry at baseline with a baseline bias of +1.86 +/- 3.25% (95% confidence interval: -0.1% to 3.82%). After exchange transfusion, there was no bias between either co-oximetry and calculated saturation (mean difference: -0.17 +/- 1.31% [95% confidence interval: -0.95% to 0.61%]), or co-oximetry and pulse oximetry (mean difference: +0.3 +/- 1.53% [95% confidence interval: -0.62% to 1.22%]).

CONCLUSIONS

Calculated saturation overestimates true saturation during acute sickle chest syndrome. This discrepancy abates after exchange transfusion. Pulse oximetry more closely follows co-oximetry than does calculated saturation during acute sickle chest syndrome.

The incidence of and clinical variables associated with vancomycin-resistant enterococcal colonization in mechanically ventilated patients

STUDY OBJECTIVES

(1) To determine in our ICU the incidence of vancomycin-resistant enterococcus (VRE) colonization in mechanically ventilated patients without a history of VRE infection or colonization; and (2) to determine the risk factors and outcome variables associated with VRE colonization in these patients.

DESIGN

A prospective cohort study conducted between January 1996 and March 1998.

SETTING

Medical and cardiac critical care units in a tertiary care urban university hospital.

PATIENTS

Mechanically ventilated patients without evidence of pneumonia at the onset of ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Patients underwent rectal cultures by standard methods on day 1, day 3 or 4, day 6 or 7, and day 14 of intubation to detect VRE. Thirteen of 83 patients (16%) had rectal cultures positive for VRE (VRE+) at some point while being mechanically ventilated during their stay in the ICU. In comparison, approximately 15 of 2,100 medical ICU patients (0.7%) had clinical VRE infections as determined by the hospital's infection control program during a 2-year period. VRE+ patients had a higher incidence of immunosuppression than patients who had rectal cultures negative for VRE (VRE-) (9 of 13 [69%] vs 16 of 70 [23%], respectively; p < 0.01) and neutropenia (4 of 13 [31%] vs 5 of 70 [7%], respectively; p < 0.01). Hospital length of stay (LOS) was longer in VRE+ patients than in VRE- patients (27+/-17 days vs 17+/-14 days, respectively; p = 0.05), whereas pre-ICU hospital LOS and ICU LOS were similar in both patient groups. Five of 67 patients (7%) were VRE+ on day 1 of intubation, suggesting colonization at a prior site of care. Three of 29 patients who had subsequent rectal cultures converted to VRE+ while in the ICU. This group had a higher incidence of immunosuppression and neutropenia, and received more vancomycin compared with the patients who remained VRE- (p < 0.01). However, there was no significant difference in the use of other broad-spectrum antibiotics (such as antipseudomonal penicillins, third-generation cephalosporins, quinolones, and clindamycin), enteral tube feedings, or sucralfate between the two groups. In addition, a topical antibiotic paste (a gentamicin, nystatin, polymixin slurry) that was placed in the oropharynx to prevent bacterial overgrowth was not found to increase the incidence of VRE colonization in this patient population.

CONCLUSIONS

The incidence of VRE colonization was surprisingly high: 16% in mechanically ventilated patients in a hospital in which VRE was not previously known to be endemic. Risk factors for the acquisition of VRE colonization included immunosuppression, neutropenia, and vancomycin use. Increased LOSs and hospital costs were seen in VRE+ patients compared to VRE- patients. Whether VRE colonization is a contributor to severe disease that leads to prolonged hospitalization and increased resource allocation or whether it is simply a marker of disease severity cannot be determined from this study. To the extent that specific antibiotic protocols are used to reduce antibiotic-resistant flora in the ICU, monitoring the incidence of VRE in the stool specimens of immunocompromised, mechanically ventilated patients can be a simple and useful tool to assess one effect of these strategies.

Response to inhaled nitric oxide in patients with acute right heart syndrome

Inhaled nitric oxide (iNO), a selective pulmonary vasodilator, has been shown to decrease pulmonary artery pressures but not increase cardiac output in hemodynamically stable patients with a variety of causes of pulmonary hypertension. The response to iNO in hemodynamically unstable patients with acute right heart syndrome has not been previously described. We determined the response to iNO in 26 critically ill adult patients with acute right heart failure defined by echocardiographic criteria. Patients received iNO through the inspiratory limb of the ventilator in increments of 10 ppm with hemodynamic and gas-exchange measurements made before and after each level. When maximal effect was seen, iNO was discontinued to compare parameters with baseline. iNO significantly increased cardiac output (5.5 +/- 3 to 6.4 +/- 4 L/min), stroke volume (54 +/- 27 to 65 +/- 38 ml), and mixed-venous oxygen saturation (69 +/- 8 to 73 +/- 10%), all p < 0.01. With discontinuation of iNO, all parameters returned immediately to baseline. These parameters of improved perfusion were related to a decrease in pulmonary vascular pressures and resistance. In a subset of approximately 50% of patients, these changes were substantial (> 20%) and in approximately 25% of all patients, the improvement in hemodynamic measures permitted a decrease in other vasoactive drug administration. The mean concentration of iNO required to achieve these effects was 35 ppm, and 85% of patients exhibiting a substantial improvement in hemodynamics did so at a concentration of iNO of less than or equal to 40 ppm. Underlying causes of right heart failure and baseline hemodynamics did not predict response to iNO, but the use of alpha-agonist catecholamines did. We conclude iNO improves hemodynamics in patients with respiratory failure, shock, and right ventricular dysfunction. Although mortality was not a key end point in this pilot study, it was high for both responders and nonresponders to this therapy. Further evaluation of the role of iNO in this patient population is supported by these data.

Liberation from mechanical ventilation: a decade of progress

Multiple complications associated with mechanical ventilation mandate that clinicians expeditiously define and reverse the pathophysiologic processes that precipitate respiratory failure and then, detect the earliest point that a patient can breathe without the ventilator. Over the past decade, numerous laboratory and clinical studies have been reported that may inform transformation of the "art of weaning" to the science of liberation. We review these studies and use them to formulate a systematic approach to assure early, safe, and successful liberation of patients from mechanical ventilation.

Effect of nutritional management, trace mineral supplementation, and norgestomet implant on attainment of puberty in beef heifers

We conducted a study to evaluate the influences of nutritional management, trace mineral supplementation, and exogenous progesterone on attainment of puberty in beef heifers. Heifers (n = 180) were assigned at weaning to blocks and treatments. Treatments included two dietary regimens (corn silage vs pasture + oatlage), trace mineral supplementation, and puberty induction strategy (with or without progestin implant). Heifers that received pasture + oatlage were managed on grass-legume pastures from October 14 until December 14 and were then placed in pens and fed an oatlage-based diet through May 1994. Heifers fed the corn silage-based diet were housed in pens throughout the study. Norgestomet was implanted in half of the heifers on April 11 for 10 d. Progestin implant increased (P < .05) the number of heifers that had attained puberty by the end of the study, compared with nonimplanted heifers (89% vs 71%). Trace mineral supplementation did not affect percentage of heifers that reached puberty before the implant period. Plasma copper levels were below recommended levels in heifers fed oatlage-based diets without trace minerals. We conclude that heifers can be placed on regrowth in irrigated pastures during the fall and still make acceptable gains for attainment of puberty the following spring and that progestin treatment can aid in inducing heifers to reach puberty.

Primary care by obstetricians and gynecologists: attitudes of the members of The South Atlantic Association of Obstetricians and Gynecologists

OBJECTIVE

Our purpose was to determine the extent of primary care delivered by obstetrician-gynecologists and compare practice patterns with published primary care and preventive service guidelines.

STUDY DESIGN

All 277 active fellows of The South Atlantic Association of Obstetricians and Gynecologists were mailed a self-administered questionnaire. The type of primary care offered by these physicians and their attitudes about the training of residents in obstetrics and gynecology were surveyed. Physicians were categorized as generalists or specialists on the basis of the completion of a fellowship program. Descriptive statistics and chi 2 analysis were used for statistical analysis.

RESULTS

Completed surveys were returned by 82% of the fellows. The majority of the respondents perceived their practice as specialty care for women. Generalists offered recommended screening services to women of all ages with greater frequency than the specialists did (p = 0.05). Both groups did not provide care for the chronic medical illnesses most commonly seen in a primary care practice. The respondents favored more residency training in those common acute illnesses frequently encountered in a primary care setting.

CONCLUSIONS

Obstetrician-gynecologists in The South Atlantic Association of Obstetricians and Gynecologists selectively practice primary care. These physicians did not support caring for chronic medical problems frequently treated in an ambulatory care practice.

Effect of age and pattern of gain on induction of puberty with a progestin in beef heifers

Crossbred heifers (n = 75) fed for rapid (R; .82 kg/d) or slow-then-rapid (SR; .41 kg/d for 90 d then .82 kg/d) postweaning gain were used to examine the effects of age or pattern of gain on induction of puberty by a progestin. At 9.5, 11.0, and 12.5 mo of age, 12 prepuberal heifers from each growth treatment received progestin (a 6-mg Norgestomet implant for 10 d) or control treatments. Induction of puberty, LH secretory profiles, and ovarian follicular characteristics were assessed in Norgestomet-treated and control heifers. Body weights of R heifers were greater (P < .01) than those of SR heifers at all ages. At 12.5 mo, more Norgestomet-treated heifers exhibited a puberal estrus within 5 d after implant removal compared with controls (82% vs 9%, respectively), but Norgestomet did not induce puberty at 9.5 or 11 mo of age (progestin x age, P < .05) in heifers of either gain pattern. Norgestomet increased (P < .01) LH pulse frequency at all ages, whereas Norgestomet increased only mean LH concentrations at 12.5 mo of age (progestin x age, P < .03). Norgestomet treatment altered (P < .01) ovarian follicular characteristics at all ages. Gain pattern did not affect (P > .1) LH secretory profiles, ovarian characteristics, or induction of puberty by Norgestomet. We conclude that progestins induce puberty by hastening the normal cascade of endocrine and ovarian events associated with spontaneous puberty. Furthermore, age, but not pattern of gain, seems to be the critical factor influencing the efficacy of progestins to induce puberty in heifers.

Effects of a medical intensivist on patient care in a community teaching hospital

OBJECTIVE

To determine the effect of adding a trained intensivist on patient care and educational outcomes in a community teaching hospital.

MATERIAL AND METHODS

We retrospectively reviewed outcomes for patients admitted to the medical intensive-care unit (MICU) of a 270-bed community teaching hospital between July 1992 and June 1994. Mortality rates and durations of stay were determined for the year before (BD, 1992 through 1993) and the first year after (AD, 1993 through 1994) introduction of a full-time director of critical care. Performance of resident trainees on a standardized critical-care examination was measured for the same periods.

RESULTS

Overall, 459 patients in the BD period were compared with 471 patients in the AD period. The mix of cases and severity of illness (acute physiology and chronic health evaluation or APACHE II scores) on admission were similar for the BD and AD periods. MICU mortality decreased from 20.9% during the BD to 14.9% during the AD period (P = 0.02), and in-hospital mortality decreased from 34.0% to 24.6% (P = 0.002). Disease-specific mortalities were lower during the AD period for most categories of illness. Detailed analysis of a subgroup of patients (those with pneumonia) demonstrated no differences in distribution of patients by gender, race, or acuity of illness (APACHE II scores). The mortality rate due to pneumonia decreased from 46% during the BD period to 31% during the AD period. This decrease was consistent across categories of APACHE II scores. From BD to AD periods, mean durations of total hospital stay decreased from 22.6 +/- 1.4 days to 17.7 +/- 1.0 days, and mean MICU stay decreased from 5.0 +/- 0.3 days to 3.9 +/- 0.3 days (P < 0.05). Critical-care in-service examination scores for 22 residents increased from 53.8 +/- 1.7% to 67.5 +/- 2.2% (P < 0.01), and AD scores were significantly higher than BD scores for residents at similar levels of training.

CONCLUSION

Addition of a medical intensivist was temporally associated with improved clinical and educational outcomes in our community teaching hospital.