Intensive care at two teaching hospitals: an organizational case study

OBJECTIVE: To examine structural and organizational characteristics at two ICUs with marked differences in risk-adjusted survival. METHODS: We performed on-site organizational analysis in two ICUs at two major teaching hospitals. Our main outcome measures were interviews and direct observations by a team of clinical and organizational researchers; demographic, clinical, and survival data for 888 ICU admissions; and questionnaire responses from 70 nurses and 42 physicians on ICU structure and organization. ICU performance was measured using risk-adjusted survival and the ratios of actual to predicted ICU length of stay and resource use. RESULTS: Structural and organizational questionnaires, self-evaluation by staff members, and the research team's implicit judgments following detailed on-site analysis failed to distinguish units with higher and lower risk-adjusted survival. Both units exhibited practices to emulate and practices to avoid. CONCLUSIONS: The methods used in this study can identify organizational problems and potential means for improvement. The best practices and suggestions for improvement at these units provide examples of methods for improving ICU management.

Intensive care at two teaching hospitals: an organizational case study

OBJECTIVE

To examine structural and organizational characteristics at two ICUs with marked differences in risk-adjusted survival.

METHODS

We performed on-site organizational analysis in two ICUs at two major teaching hospitals. Our main outcome measures were interviews and direct observations by a team of clinical and organizational researchers; demographic, clinical, and survival data for 888 ICU admissions; and questionnaire responses from 70 nurses and 42 physicians on ICU structure and organization. ICU performance was measured using risk-adjusted survival and the ratios of actual to predicted ICU length of stay and resource use.

RESULTS

Structural and organizational questionnaires, self-evaluation by staff members, and the research team's implicit judgments following detailed on-site analysis failed to distinguish units with higher and lower risk-adjusted survival. Both units exhibited practices to emulate and practices to avoid.

CONCLUSIONS

The methods used in this study can identify organizational problems and potential means for improvement. The best practices and suggestions for improvement at these units provide examples of methods for improving ICU management.

Restrictive cardiomyopathy associated with the eosinophilia-myalgia syndrome

OBJECTIVE

We report the first case of restrictive cardiomyopathy occurring in a patient with the eosinophilia-myalgia syndrome.

DESIGN

In this article, we discuss the various clinical manifestations of the eosinophilia-myalgia syndrome.

MATERIAL AND METHODS

In a 46-year-old woman with the eosinophilia-myalgia syndrome, orthopnea, chronic persistent edema, and severe dyspnea on exertion developed 2 years after she had discontinued use of L-tryptophan. Doppler echocardiography showed ventricular filling confined to early diastole and no atrial filling during ventricular systole--the Doppler hallmarks of restrictive disease. Right-sided cardiac catheterization revealed that the pulmonary wedge pressure equaled the pulmonary artery diastolic pressure and the mean right atrial pressure. A myocardial biopsy specimen showed dense endocardial fibrosis. Special immunofluorescent stains for eosinophilic granule major basic protein showed substantial deposition along the endocardial myocardial interface, an indication that eosinophils were present some time in the past.

RESULTS

A follow-up telephone call 14 months after the patient's initial assessment at the Mayo Clinic revealed that she had class III symptoms of congestive heart failure. She was receiving high doses of three diuretics daily, and her condition had improved considerably since her first examination at our institution.

CONCLUSION

Restrictive cardiomyopathy may occur in the setting of the eosinophilia-myalgia syndrome and should be considered in patients with this disease in whom exertional dyspnea and peripheral edema occur.

Reductive dehalogenation of chlorinated benzenes and toluenes under methanogenic conditions

The anaerobic metabolism of chlorinated benzenes and toluenes was evaluated in soil slurry microcosms under methanogenic conditions. A mixture of hexachlorobenzene, pentachlorobenzene, and 1,2,4-trichlorobenzene (TCB) in soil slurries was biotransformed through sequential reductive dechlorination to chlorobenzene (CB). The metabolic pathway for hexachlorobenzene and pentachlorobenzene decay proceeded via 1,2,3,4-tetrachlorobenzene (TTCB)-->1,2,3-TCB + 1,2,4-TCB-->1,2-dichlorobenzene (DCB) + 1,4-DCB-->CB. In a mineral salts medium, the CB-adapted soil microorganisms dehalogenated individual 1,2,4,5-TTCB, 1,2,3,4-TTCB, 1,2,3-TCB, and 1,2,4-TCB but not 1,2,3,5-TTCB or 1,3,5-TCB. Similarly, a mixture of 2,3,6-trichlorotoluene (TCT), 2,5-dichlorotoluene (DCT), and 3,4-DCT was reductively dechlorinated in soil slurries to predominantly toluene and small amounts of 2-, 3-, and 4-chlorotoluene (CT). Toluene was further degraded. When tested individually in a mineral salts medium, the CT-adapted soil microorganisms dechlorinated several TCT and DCT isomers. Key metabolic routes for TCTs followed: 2,3,6-TCT-->2,5-DCT-->2-CT-->toluene; 2,4,5-TCT-->2,5-DCT + 3,4-DCT-->3-CT + 4-CT-->toluene. Among DCTs tested, 2,4-DCT and 3,4-DCT were dechlorinated via the removal of o- and m-chlorine, respectively, to 4-CT and subsequently to toluene via p-chlorine removal. Likewise, 2,5-DCT was dechlorinated via 2-CT to toluene. Evidently, microorganisms capable of removing o-, m-, and p-chlorines are present in the soil system, as reflected by the dechlorination of different isomers of CBs and CTs to CB and toluene, respectively. These findings help clarify the metabolic fate of chlorinated benzenes and toluenes in anaerobic environments.

Improving intensive care: observations based on organizational case studies in nine intensive care units: a prospective, multicenter study

OBJECTIVE

To examine organizational practices associated with higher and lower intensive care unit (ICU) outcome performance.

DESIGN

Prospective multicenter study. Onsite organizational analysis; prospective inception cohort.

SETTING

Nine ICUs (one medical, two surgical, six medical-surgical) at five teaching and four nonteaching hospitals.

PARTICIPANTS

A sample of 3,672 ICU admissions; 316 nurses and 202 physicians.

MATERIALS AND METHODS

Interviews and direct observations by a team of clinical and organizational researchers. Demographic, physiologic, and outcome data for an average of 408 admissions per ICU; and questionnaires on ICU structure and organization. The ratio of actual/predicted hospital death rate was used to measure ICU effectiveness; the ratio of actual/predicted length of ICU stay was used to assess efficiency.

MEASUREMENTS AND MAIN RESULTS

ICUs with superior risk-adjusted survival could not be distinguished by structural and organizational questionnaires or by global judgment following on-site analysis. Superior organizational practices among these ICUs were related to a patient-centered culture, strong medical and nursing leadership, effective communication and coordination, and open, collaborative approaches to solving problems and managing conflict.

CONCLUSIONS

The best and worst organizational practices found in this study can be used by ICU leaders as a checklist for improving ICU management.

The relative anticaries effectiveness of sodium monofluorophosphate and sodium fluoride as contained in currently available dentifrice formulations

A 36-month double-blind clinical caries study was conducted to determine the comparative anticaries efficacy of sodium monofluorophosphate (MFP) and sodium fluoride (NaF) as incorporated in dentifrice formulations. The test dentifrices which were utilized are commercially available in the United States and all have been granted the American Dental Association Seal of Acceptance for anticaries efficacy. The study was conducted in accordance with the 1988 Guidelines of the American Dental Association Council on Dental Therapeutics. The two formulations used in the NaF versus MFP comparison were Colgate Winterfresh Gel with 0.76% sodium monofluorophosphate in a silica base and Crest Regular Flavor Toothpaste with 0.24% sodium fluoride in a silica base. A third commercially-available NaF dentifrice, Colgate Junior Toothpaste with 0.243% sodium fluoride in a silica base, was included in the study for further comparison. Schoolchildren residing in Maine, U.S.A. received a baseline caries clinical examination and then were randomly assigned to the twice-daily use of one of the three dentifrices which were purchased in the marketplace and repackaged in plain white tubes. Caries clinical examinations were subsequently conducted after 2 and 3 years' use of the dentifrices. A total of 2,222 children participated in both the 2 and 3-year caries clinical examinations. The 36-month DFS (decayed and filled surfaces) and the DFT (decayed and filled teeth) mean caries increments for the three dentifrice groups were virtually identical. The children using the MFP formulation experienced a DFS of 1.50 and a DFT of 1.08; those using the Crest NaF formulation experienced a DFS of 1.48 and a DFT of 1.07; subjects in the third group (Colgate Junior Toothpaste, 0.243% NaF) had a DFS of 1.49 and DFT of 1.06. The statistical evaluation of the data consisted of the calculation of 90% confidence bounds for the ratio of (true) mean increments, in accordance with the 1988 American Dental Association Guidelines. Expressed in the language of the Guidelines, the analyses indicated that, (1) the anticaries efficacy provided by the MFP formulation, (Colgate Winterfresh Gel with 0.76% MFP) is "as good as" that provided by the NaF formulation, (Crest Regular Flavor Toothpaste, with 0.243% NaF), and (2) the anticaries efficacy provided by the one NaF formulation (Colgate Junior Toothpaste, with 0.243% NaF) is "as good as" that provided by the other, (Crest Regular Flavor Toothpaste, with 0.243% NaF).

Risk factors for suicide and undetermined death among in-patient alcoholics in Scotland

Approximately 32,000 patients, representing all those discharged alive from inpatient psychiatric care for alcoholism in Scottish hospitals between 1974 and 1983, were traced for up to 10 years by means of a national record-linkage study in order to ascertain the frequency of suicide and undetermined deaths. The cumulative mortality from these causes was 1.17% at 5 years and 2.01% at 10 years. Several risk factors were investigated, using survival analysis techniques. Sex, age, social class (males only) and marital status were not found to be useful predictors, but the different secondary diagnoses recorded at discharge were associated with major variations in outcome. Attention is drawn to the prognostic importance of a secondary diagnosis of both affective disorders and personality disorders, and some implications of the findings are noted concerning attempts to construct population models linking alcoholism, demographic characteristics and suicide.

The orbitomedial frontal syndrome

An orbitomedial frontal syndrome is proposed, characterized by anosmia, amnesia with confabulation, Go-NoGo deficits, personality change, and hypersensitivity to pain. The orbitomedial frontal syndrome is distinct from the clinical picture that results from dorsolateral frontal damage. Aspects of orbitomedial damage have been discussed previously in isolation, but we argue that recognition of this syndrome in toto is clinically important. It appears to be associated with poor social and vocational adjustment after brain injury, and the co-occurrence of features of the syndrome provides clues to underlying mechanisms for disinhibition and confabulation in frontal lobe patients.

Postchemotherapy rheumatism

PURPOSE

This report describes a previously unreported clinical phenomenon that occurs in some patients after completion of combination chemotherapy.

METHODS AND RESULTS

Eight case reports are presented. Affected patients developed a syndrome of myalgias/arthralgias within several months of completing cyclophosphamide/fluorouracil (5FU)-containing adjuvant combination chemotherapy for breast cancer. These symptoms did not appear to be related to cancer recurrence or any common rheumatologic disorder. The syndrome generally resolved over several months.

CONCLUSION

Postchemotherapy rheumatism is a syndrome of myalgias/arthralgias that usually develops 1 to 3 months after completion of adjuvant chemotherapy. Recognition of this syndrome can limit the need for extensive work-ups to exclude recurrent breast cancer or inflammatory rheumatologic diseases.

Tryptophan-induced lung disease: an immunophenotypic, immunofluorescent, and electron microscopic study

L-tryptophan (LT) has been implicated as a causal agent in the recently recognized eosinophilia-myalgia syndrome (EMS). Pulmonary complications occur in up to 60% of patients. Lung biopsies have shown chronic interstitial pneumonia, mild eosinophilia, vasculitis and perivasculitis, and hypertensive pulmonary arteriopathy. Open lung biopsies from two women who developed respiratory symptoms associated with LT EMS were studied with a panel of antibodies to lymphoid cells, by transmission electron microscopy and by direct immunofluorescence for immunoglobulin and complement. The majority of the cells infiltrating the interstitium and around vessels were T-cells, with a predominance of CD8+ cells. Numerous alveolar macrophages were also identified. Rare polyclonal B-cells were also present. Ultrastructural studies confirmed the presence of interstitial and perivascular lymphocytes as well as occasional eosinophils. The inflammatory cells were also present in vessel cells. Fibrointimal thickening was not observed in the sections studied ultrastructurally. Immunofluorescent staining for IgG, IgA, C3, C4, albumin, kappa, and lambda was negative. There was scattered staining for fibrinogen in alveolar spaces. The etiology of LT EMS is still under investigation, although a contaminant acting in conjunction with host factors is the favored hypothesis. The results of this study indicate that T cytotoxic/suppressor cells may be intimately involved in the pathogenesis of the lung injury.

Epidemiology of Lyme disease in Olmsted County, MN, 1975-1990

Lyme disease has been reported in Minnesota since 1980. Until now, it has not been regarded as endemic in Olmsted County. We reviewed the medical records of all 68 cases of Lyme disease diagnosed in residents of Olmsted County for 1980-1990. Only 17 of the 68 cases met Centers for Disease Control surveillance criteria for definite Lyme disease (13 men, 4 women). Of these 17 cases, 3 were likely acquired in Olmsted County. The age and sex adjusted incidence rate was 2.3/100,000 (95% CI 1.1-3.4). Although reporting of Lyme disease is mandatory in Minnesota, only 7 suspected or definite cases were actually reported to public health officials. Of these, 4 met the case definition. In this population Lyme disease was both over-diagnosed and underreported. This observation questions current data and could have important health policy implications if confirmed nationally.

Exploring self-forgiveness

This article presents the results of a phenomenological study of the experience of self-forgiveness. On the basis of in-depth interviews with seven subjects, self-forgiveness is described not as an achievement but rather as a gift where one moves from estrangement and "brokenness" to a sense of at-homeness.

Weight gain prevention and smoking cessation: cautionary findings

OBJECTIVES

Weight gain is a consistent sequela of smoking cessation. A successful intervention might attract smokers who fear weight gain. If the gain causes smoking relapse, such an intervention might reduce smoking relapse risk.

METHODS

Using a sample of 158 smokers who completed a 2-week smoking treatment program, we compared an innovative weight gain prevention intervention with both a nonspecific treatment and standard treatment. Subjects were assessed on weight and smoking behavior and followed for 1 year.

RESULTS

A disturbing, unexpected finding was that subjects in both the innovative and nonspecific conditions had a higher risk of smoking relapse than did standard treatment subjects. Some differences were observed between abstinent and smoking subjects in weight gain by treatment condition.

CONCLUSIONS

Both active interventions may have been so complicated that they detracted from nonsmoking. Also, caloric restriction may increase the reinforcing value of nicotine, a psychoactive drug, thereby increasing smoking relapse risk. The magnitude of weight gain after smoking cessation may not merit interventions that increase smoking risk. Perhaps attitudinal modifications are the most appropriate.

Continuously improving patient care: practical lessons and an assessment tool from the National ICU Study

Pressure for hospitals to maintain quality while lowering cost or provide greater quality at a given level of cost is particularly critical in intensive care services for which it is increasingly difficult to match revenues with costs, given reimbursement limits. At the same time, twofold to threefold differences in intensive care unit risk-adjusted mortality have been reported. This article provides a model for thinking about continuous improvement of intensive care services, draws on the National ICU Study to identify fundamental organizational and managerial processes associated with better performance, and offers a validated assessment instrument to be used as a tool for continuous improvement.

Difference and ratio information in children's and adults' memory representations

A study was made of the choice reaction times of 8-, 10-, 12-year-olds and adults in order to investigate whether length information stored in memory was coded to preserve numerical relations between stimuli. Subjects learned unique line length-color associations and were later presented with pairs of colors and were instructed to choose the color that had been associated with the longer line. For all age groups, choice reaction times were related to both differences and ratios. These results were interpreted as supporting the analog theory of representation.

Eosinophilic fasciitis associated with use of L-tryptophan: a case-control study and comparison of clinical and histopathologic features

We investigated the relationship between use of L-tryptophan and development of eosinophilic fasciitis by two methods: a retrospective patient survey and a case-control study of patients with eosinophilic fasciitis diagnosed at the Mayo Clinic between 1977 and 1989. Before 1986, no traceable patients with eosinophilic fasciitis had taken L-tryptophan. Between Jan. 1, 1986, and July 31, 1989, 8 of 34 patients had ingested L-tryptophan (P less than 0.001). In the case-control study, traceable patients with eosinophilic fasciitis were matched with patients who had systemic sclerosis or rheumatoid arthritis and healthy control subjects who had undergone a general medical examination. Of the 60 matched control subjects, 2 had used L-tryptophan. Thus, the odds ratio was 19, indicating a 19-fold greater likelihood of use of L-tryptophan in patients with eosinophilic fasciitis than in the control group. A retrospective assessment of clinical features, response to treatment, and blinded review of biopsy specimens of skin and fascia in patients who had eosinophilic fasciitis with or without exposure to L-tryptophan disclosed no significant differences in the two groups. This retrospective study confirms a strong association between consumption of L-tryptophan and development of eosinophilic fasciitis in some patients. No clinical or histopathologic features were detected that distinguished this disorder on the basis of previous exposure to L-tryptophan.

A sibling-controlled study of intelligence and academic performance following Reye syndrome

The authors compared the intellectual, cognitive and academic abilities of 22 survivors of Reye syndrome attending normal schools with the sibling nearest in age as control. The British Ability Scales, visual and verbal IQ, short-term memory scales and attainment tests were administered to all children. Reye syndrome children as a group differed significantly from the controls only on the basic number skills test. However, children with severe encephalopathy and those whose illness occurred in infancy had significant deficits on many of the tests. 18 children recovered without requiring 'additional educational provision'; the mean IQ of the 22 Reye syndrome children was 101. Nonetheless, these children's poor performance on the basic number skills test has important implications for teachers, and careful monitoring of future educational performance is essential.

Association of age and social class with suicide among men in Great Britain

STUDY OBJECTIVE

The aim was to investigate suicide and "undetermined" deaths by age, economic activity status, and social class in Great Britain among males of working age.

DESIGN

The study was a cross sectional analysis of Registrar General's data for England and Wales around 1981, repeated for around 1971, and for Scotland around 1971 and 1981.

MEASUREMENTS AND MAIN RESULTS

For England and Wales around 1971, suicide and undetermined death rates showed a progressive increase with age and a markedly higher rate in the lower social classes. A significant interaction effect was identified in the central age groups of the lower occupational categories. This interaction was confirmed in the remaining three data sets, notwithstanding some differences in the profile of age specific mortality. Other findings included a higher standardised mortality ratio for the economically inactive, who also showed an earlier peak in age specific mortality, and a relative concentration of undetermined as compared to suicide deaths in the lower social classes, but not all these further results were fully replicated.

CONCLUSIONS

There is a concentration of suicide and undetermined deaths in the middle age groups of the lower social classes. Plausible explanations include both the social drift and the social genesis hypotheses, the latter including the effects of long term unemployment.