Early Stages in the Institutionalization of Integrated Project Delivery

Integrated project delivery (IPD), an emerging form of project organization for North American construction projects, offers a compelling case study to understand how new innovative infrastructure project delivery models can emerge and institutionalize. This article frames the early stages of IPD through the actions of an institutional entrepreneur—Sutter Health—working to construct a new arrangement for the delivery of its large healthcare projects. The resulting account uses Suchman’s (1995) multistage model of institutionalization to understand the early-stage actors, processes, conditions, and actions present for creation of an innovative delivery model within a fragmented, project-based industry context.

Lords of the Dance: Professionals as Institutional Agents

More so than other types of social actors, the professions in modern society have assumed leading roles in the creation and tending of institutions. They are the preeminent institutional agents of our time. Different professions work in various ways: some attempt to create general cultural-cognitive frameworks; others to devise normative prescriptions to guide behavior; and still others to exercise coercive authority. Also, individual professionals assume varying roles within their professional community: some concentrate on devising and testing general principles, others transport these ideas to varying communities; and still others work to apply the principles to individual cases. Professions themselves adhere to an institutional model, but this model has undergone important changes over time.

Ad Astra per Aspera: A Journey from the Periphery

I review my scholarly career, focusing first on the places and people important to my development as an organizational sociologist. Then, drawing on distinctions proposed by Boyer, I discuss four types of scholarly work in which I have been engaged: (1) the scholarship of discovery, in which I studied principally authority systems, organizational effectiveness and institutional structures and processes; (2) the scholarship of teaching, where I describe the variety of courses I have taught; (3) the scholarship of application, involving primarily my work with policy groups at the national level; and (4) the scholarship of integration, including my writing of textbooks and attempts to create community among organizational scholars. I assert that more value should be placed by the academy on the latter three types of scholarship.

The TGF-beta 1 gene codon 10 polymorphism contributes to the genetic predisposition to nephropathy in Type 1 diabetes

AIMS

We hypothesize that transforming growth factor-beta (TGF-beta), a multifunctional growth factor which plays a key role in the development of tissue fibrosis, may be involved in the pathophysiology of diabetic nephropathy. Our aim was to examine three polymorphisms within the TGF-beta 1 gene, in codons 10, 25 and 263, for association with nephropathy in Type 1 diabetes.

METHODS

We conducted a large case-control study using cases with Type 1 diabetes and clinical nephropathy. Controls were Type 1 diabetic subjects who have been injecting insulin for at least 50 years and have extremely low risk of nephropathy. Genotyping was by polymerase chain reaction with sequence-specific primers.

RESULTS

There was a significant difference in the frequency of the TGF-beta 1 codon 10 genotypes in the diabetic nephropathy group (n = 420) when compared with the controls (n = 410, P = 0.007). There were no significant differences when the frequencies of the TGF-beta1 codons 25 and 263 genotypes in the diabetic nephropathy group were compared with the control group.

CONCLUSIONS

In our study the TGF-beta 1 codon 10 polymorphism is associated with nephropathy in Type 1 diabetes and variation in this gene may contribute to the genetic predisposition to this complication in Type 1 diabetes.

Curling of flap tips in HIV-1 protease as a mechanism for substrate entry and tolerance of drug resistance

BACKGROUND

The human immunodeficiency virus type 1 (HIV-1) protease is an essential viral protein that is a major drug target in the fight against Acquired Immune Deficiency Syndrome (AIDS). Access to the active site of this homodimeric enzyme is gained when two large flaps, one from each monomer, open. The flap movements are therefore central to the function of the enzyme, yet determining how these flaps move at an atomic level has not been experimentally possible.

RESULTS

In the present study, we observe the flaps of HIV-1 protease completely opening during a 10 ns solvated molecular dynamics simulation starting from the unliganded crystal structure. This movement is on the time scale observed by Nuclear Magnetic Resonance (NMR) relaxation data. The highly flexible tips of the flaps, with the sequence Gly-Gly-Ile-Gly-Gly, are seen curling back into the protein and thereby burying many hydrophobic residues.

CONCLUSIONS

This curled-in conformational change has never been previously described. Previous models of this movement, with the flaps as rigid levers, are not consistent with the experimental data. The residues that participate in this hydrophobic cluster as a result of the conformational change are highly sensitive to mutation and often contribute to drug resistance when they do change. However, several of these residues are not part of the active site cavity, and their essential role in causing drug resistance could possibly be rationalized if this conformational change actually occurs. Trapping HIV-1 protease in this inactive conformation would provide a unique opportunity for future drug design.

Ocular injuries due to projectile impacts

An animal model has been developed using enucleated porcine eyes to evaluate ocular trauma. The eyes were pressurized to approximately 18 mmHg and mounted in a container with a 10% gelatin mixture. The corneas of sixteen pressurized eyes were impacted by a blunt metal projectile (mass of 2.6 gm, 3.5 gm or 45.5 gm) at velocities of 4.0 to 38.1 m/s. The impacted eyes were evaluated by an ophthalmologist. A numerical classification scheme was used to categorize the severity of the ocular injury. A chi-squared test indicates that the injury level is associated with the kinetic energy (KE) and not the momentum of the projectile. The enucleated eyes began to experience lens dislocations when the KE of the projectile was approximately 0.75 Nm, and retinal injuries when the KE was approximately 1.20 Nm.

On using time-averaging restraints in molecular dynamics simulation

Introducing experimental values as restraints into molecular dynamics (MD) simulations to bias the values of particular molecular properties, such as nuclear Overhauser effect intensities or distances, (3)J coupling constants, chemical shifts or crystallographic structure factors, towards experimental values is a widely used structure refinement method. To account for the averaging of experimentally derived quantities inherent in the experimental techniques, time-averaging restraining methods may be used. In the case of structure refinement using (3)J coupling constants from NMR experiments, time-averaging methods previously proposed can suffer from large artificially induced structural fluctuations. A modified time-averaged restraining potential energy function is proposed which overcomes this problem. The different possible approaches are compared using stochastic dynamics simulations of antamanide, a cyclic peptide of ten residues.

Phase II study of vinorelbine in advanced and recurrent squamous cell carcinoma of the cervix

PURPOSE

To evaluate the efficacy and toxicity of intravenous vinorelbine as single-agent chemotherapy in patients with advanced or recurrent squamous cell carcinoma of the cervix.

PATIENTS AND METHODS

Between August 1993 and July 1995, 35 patients with advanced or recurrent squamous cell carcinoma of the cervix were entered onto this study. Patients had received no prior therapeutic chemotherapy. The initial dose of vinorelbine 30 mg/m2 was administered as a weekly intravenous infusion. Subsequent doses were unchanged, reduced, escalated, or omitted according to observed toxicity. Patients were evaluated for response and toxicity using standard Gynecologic Oncology Group (GOG) and World Health Organization criteria, respectively.

RESULTS

Thirty-three of 35 patients were assessable for response and 35 of 35 for toxicity. The overall response rate was 18% (one complete response [CR], five partial responses [PR]). The mean response duration was 5.2 months and the median survival from treatment for all patients was 11.0 months. The major toxicity was leukopenia, with 61% of patients who had grade 3 or 4. Gastrointestinal and neurotoxicity were infrequent and mild.

CONCLUSION

Vinorelbine has moderate activity in advanced or recurrent squamous cell carcinoma of the cervix. Further studies of combination regimens with this agent are justified in this patient population.

An organizational field approach to resource environments in healthcare: comparing entries of hospitals and home health agencies in the San Francisco Bay region

OBJECTIVE

To draw together insights from three perspectives (health economics, organizational ecology, and institutional theory) in order to clarify the factors that influence entries of providers into healthcare markets. A model centered on the concept of an organizational field is advanced as the level of analysis best suited to examining the assortment and interdependence of organizational populations and the institutional forces that shape this co-evolution. In particular, the model argues that: (1) different populations of healthcare providers partition fiscal, geographic, and demographic resource environments in order to ameliorate competition and introduce service complementarities; and (2) competitive barriers to entry within populations of providers vary systematically with regulatory regimens.

DATA SOURCES

County-level entries of hospitals and home health agencies in the San Francisco Bay Area using data from the American Hospital Association (1945-1991) and California's Office of Statewide Health Planning and Development (1976-1991). Characteristics of the resource environment are derived from the Area Resource File (ARF) and selected government censuses.

METHODS OF ANALYSIS

A comparative design is applied to contrast influences on hospital and home health agency entries during the post-World War II period. Empirical estimates are obtained using Poisson and negative binomial regression models.

RESULTS

Hospital and HHA markets are partitioned primarily by the age and education of consumers and, to a lesser extent, by urbanization levels and public funding expenditures. Such resource partitioning allows independent HHAs to exist comfortably in concentrated hospital markets. For both hospitals and HHAs, the barriers to entry once generated by oligopolistic concentration have declined noticeably with the market-oriented reforms of the past 15 years.

CONCLUSION

A field-level perspective demonstrates that characteristics of local resource environments interact with interdependencies of provider populations and broader regulatory regimes to affect significantly the types of provider organizations likely to enter a given healthcare market.

Hypertrophic synovitis and osteoarthritis of the cervical facet joint. Report of two cases

We report two cases of cervical facet joint osteoarthritis associated with radiculopathy. Contrast-enhanced computed tomography showed a halo of enhancing soft tissue surrounding the facet joints and narrowing the neural foramen. Hypertrophic synovial masses were discovered and removed at the time of operation in each case, resulting in relief of the radicular symptoms.

Phase I evaluation of thio-TEPA in combination with cisplatin for advanced gynecologic malignancies

Thirty-five patients with advanced gynecologic malignancies were entered into a phase I study evaluating thio-TEPA in combination with cisplatin (50 mg/m2) intravenously every 4 weeks. Thirty-four patients were evaluable for toxicity and response, and one was evaluable for toxicity only. Median age was 53 years (range 28-72), and performance status less than or equal to 2. Prior treatment included chemotherapy in 21 patients, radiation in 15, hormonal therapy in 3, and immunotherapy in 1. Thio-TEPA was given to three or more patients at each of the following dose levels: 15, 20, 25, 30, 40, 50, and 60 mg/m2. Thio-TEPA's primary toxicity was myelosuppression; at 50 mg/m2, grade 3 or 4 granulocytopenia occurred in 13 of 17 cycles, and grade 3 or 4 thrombocytopenia occurred in 8 of 17 cycles. The maximum tolerated dose (MTD) of thio-TEPA was 40 mg/m2; in 35 cycles at this dose, grade 3 or 4 granulocytopenia occurred in 19, and grade 3 or 4 thrombocytopenia occurred in 10 cycles; median granulocyte nadir was 1100 (range 110 to 3600) and median platelet nadir was 90,000 (range 10,000 to 289,000). Fifteen patients received three or more cycles at one dose level; cumulative myelosuppression was observed in 11. Two cases of partial alopecia occurred at 40 and 60 mg/m2 thio-TEPA. Responses were as follows: complete response, 5; partial response, 7; stable disease, 14; progressive disease, 8. In 16 patients with ovarian cancer (15 of whom had previously received cisplatin), there were 4 complete responses and 5 partial responses (overall response rate of 56%). The thio-TEPA dose recommended in combination with cisplatin (50 mg/m2) in phase II trials is 40 mg/m2. Cumulative hematologic toxicity may occur with this regimen.

Lumbar synovial cysts: report of eleven cases

Over the past 18 months we have encountered 11 cases of symptomatic lumbar synovial cysts. This experience occurred during a period during which some 1,800 lumbar computed tomographic scans were done. The apparent increased incidence of these lesions is most likely due to the increased diagnostic ability made possible by the advent of high-resolution computed tomography and magnetic resonance imaging. This is a report and discussion of our 11 cases with a review of the literature. There is nothing distinctive in the physical findings or in the histories of our patients, but we have found, as have others, that high-resolution computed tomographic scanning and magnetic resonance imaging significantly enhance the diagnosis of such lesions.

Intracerebral hemorrhage with rapid recovery

Occasionally, patients with small supratentorial intracerebral hemorrhages exhibit the sudden onset of neurologic deficits, followed by rapid improvement during the next several days. We analyzed the computed tomographic (CT) and clinical features of a group of nine such patients, who were drawn from a series of 120 patients with intracerebral hemorrhage. The temporal pattern of illness was similar to that of a cerebral ischemic event, but the correct diagnosis of intracerebral hemorrhage was made on the basis of the CT findings.

The impact of regulation on the administrative structure of hospitals: toward an analytic framework

The dramatic and recent regulatory changes in the hospital industry (e.g., TEFRA , DRG-based reimbursement) have given added impetus to the analytic framework developed here. Regulation will play an increasingly important role in the future of hospitals, affecting not only fiscal operations, but organizational and administrative arrangements as well. The conceptual framework developed in this article will be refined and augmented through empirical research. Healthcare executives will then have a stronger basis for adapting organizationally to changes in their regulatory environments, thereby increasing the effectiveness and survival of their institutions.

Does practice make perfect? Part II: The relation between volume and outcomes and other hospital characteristics

The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is investigated for almost 500,000 selected surgical and medical patients treated in over 1,200 nonfederal United States hospitals. In Part I the authors found strong and consistent evidence for surgical patients that high volume is associated with better outcome; evidence for medical patients was mixed. In this paper the authors include other hospital variables related both to volume and outcome--hospital size, teaching status, and expenditures--to determine whether they mask the true relationship; still, strong and consistent evidence that greater volume produces better outcome was found for both surgical and medical patients. This relation was significant for low-, medium-, and high-risk patients. Among the hospital variations added, only size was consistently and strongly related to outcome; greater size was associated with poorer outcome after accounting for volume. The potential importance of the findings for reducing deaths and days in hospital on a national level is discussed. The evidence is strongly supportive of the need for policies that would promote greater regionalization of a given service, and not greater size, to obtain better quality outcome for patients treated.

Does practice make perfect? Part I: The relation between hospital volume and outcomes for selected diagnostic categories

The effect of a greater volume of patients with similar conditions being treated at a hospital on the outcomes achieved is studied using a variety of categories of patients, 15 surgical and 2 medical, and involving 550,000 patients treated in over 1,200 nonfederal United States acute care hospitals. After demonstrating that there are significant differences in the outcomes of patients, taking into account patient health status, the authors examine the impact of being treated in a hospital with a high or low volume of similar patients. Strong and consistent evidence is found that high volume is associated with better outcomes for surgical patients, which supports regionalizing patient care by procedure. Two additional variables, relative difficulty of the procedure and risk level of the patients, are analyzed to determine whether they change the relationship between volume and outcome. Some evidence is found that low-volume hospitals are associated with the poorest outcome for low-risk surgical patients. The evidence for medical patients is weak and mixed. Possible alternative explanations for the observed findings for surgical and medical patients are discussed.

Measurement of lung emptying patterns during slow exhalations

Five subjects slowly inhaled a 200-ml bolus of sulfur hexafluoride (SF6) from residual volume (RV) followed by an O2-Ar mixture to total lung capacity, then exhaled to RV, either slowly or as rapidly as possible. Larger amounts of SF6 and N2 were recovered in fast than in slow exhalations. We calculated the gas volumes of the apical and basal halves of the parenchymal mass as functions of exhaled volume during slow exhalations from 1) the difference between SF6 recovered in slow and fast exhalations and 2) an estimate of the apex-to-base concentration profile of SF6 in the lung after inspiration. The maximal volume difference, where the apex contained 600 ml more gas than the base, occurred when 70% of the vital capacity had been exhaled. The same calculation, but using N2 data, gave unrealistically large volume differences. Apparently SF6 delivered as a bolus results in an apex-to-base gradient that is large relative to intraregional gradients, but dilution of the resident N2 by a non-N2 gas results in sizable intraregional gradients.

Effectiveness in professional organizations: the impact of surgeons and surgical staff organizations on the quality of care in hospitals

In this research, we examine the relative importance of different structural units in a professional organization, the hospital, as they affect organizational effectiveness. The difficulties of measuring effectiveness in a complex professional organization are discussed, and an adjusted measure of surgical outcome is developed. Data are drawn from a prospective study of over 8,000 surgical patients treated by more than 500 surgeons in 15 hospitals throughout the nation. Two different types of analyses are presented, both indicating that hospital features have more impact on surgical outcomes than do surgeon characteristics. The second analysis assesses the relative importance of specific attributes of the hospital, surgical staff organization, and surgeon characteristics on surgical outcomes.

Managing professional work: three models of control for health organizations

Three arrangements for structuring the work of professional participants in professional organizations are described, contrasted and evaluated. Arguments are illustrated by application to the organization of physicians within hospitals. The primary rationale, the support structures that have fostered its development, the key structural features and the advantages and disadvantages of each arrangement are described. The effect on these arrangements of structures and forces external to any particular professional organization is emphasized.

Seizures: a reaction to contrast media for computed tomography of the brain

Seven patients had seizures in association with the use of intravenous contrast media for cranial computed tomography. Caution and close observation are indicated when contrast agents are administered to patients with suspected focal brain disorders that may lower the seizure threshold. Patients with tumors metastatic to the brain appear to be at specially increased risk.

Measuring the complexity and uncertainty of surgery and postsurgical care

This article reports the results of a survey of a nationwide sample of more than 900 surgeons and post-surgical nurses, who were asked to rate the relative complexity and uncertainty of 71 surgical procedures frequently performed in hospitals. Average scores assigned to each surgical procedure by both types of raters are reported and the extent of agreement is assessed across indicator questions and types of raters. A surprisingly high level of agreement was observed. Explanations for the extent of agreement are discussed and uses for these scores are described.

Intracranial involvement of giant-cell arteritis

Two cases of giant-cell arteritis with cerebral arteritis are presented. The clinical situation and the suggestive but nonspecific angiographic features make the antemortem diagnosis possible. Greater awareness of this entity will facilitate its diagnosis and the institution of effective steroid therapy.

Application of "cusp writer" findings to practical and theoretical occlusal problems. Part II

The cusp writer is a teaching aid to facilitate understanding of the correlation between cusp angulations and the various occlusal determinants. The cusp writer provides graphic evidence that the occlusal determinants which influence configurations (i.e., incisal guidance, condylar guidance, plane [curve] of occlusion, curve of Spee [compensating curve], and plane of motion) are reciprocal, one tempering the value of the other. Cusp writings demonstrate the following: (1) The angle of the plane (curve) of occlusion to the plane of motion in concert with the other occlusal infuluence determines the optimal height and angulation of the cusps. (2) Cusps appear to be steep or shallow relative to each other, to the plane of occlusion, and to the plane of motion. (3) The steepness of the curve of Spee determines the relative cusp height and angulation of one tooth to another, from an anterior to a posterior direction in the dental arch. (4) The angle of the tangent to any segment of the curve of Spee to the plane of motion determines the optimal height and angulation of the cusps of the segment. (5) The graphs show that the flatter the curve of Spee, the more uniform the cusp height and angulations are from anterior to posterior teeth. The steeper the curve of Spee, the more irregular the cusp height and angulations are with steeper anterior cusps and flatter posterior cusps. (6) The steeper the curve of Spee, the flatter the molar cusp angulations must be to avoid deflective and/or interceptive occlusal contacts on the balancing side. (7) With the syndrome of a steepening curve of Spee due to the loss of one or more lower posterior teeth, the cusps of the remaining opposing teeth must be constantly flattened by wear or selective grinding and reshaping to avoid traumatic occlusion, unless the drifting is interrupted by restorative dentistry. (8) Cusp angulation of artificial teeth should be chosen to harmonize with the angle of incidence of the compensating curve tangents to the plane of motion. (9) Condylar guidance has less influence on cusp angulation in comparison to incisal guidance and the other occlusal determinants. (10) Changing the hinge axis location 1/2 inch (12.5 mm.) distally and/or superiorly has very little effect on the influence of the above occlusal determinants on cusp configuration, if the vertical dimension of occlusion remains constant.

Application of "cusp writer" findings to practical and theoretical occlusal problems. Part I

The cusp writer is a teaching aid used to facilitate understanding of the correlation between cusp angulation and the various occlusal determinants. Cusp writings represent an on-edge view of mandibular movement occurring in translation and rotation. Cusp writings demonstrate that: (1) the influence of incisal guidance on cusp angulation is almost 60 per cent greater in molars and 100 per cent greater in pre-molars than the influence of the condylar guidance; (2) steepening or flattening by wear, grinding, or reconstructing the lingual contour of the upper canine or other incisal guide teeth by as little as 1 mm. can change the incisal guide angulation from 15 to 25 degrees depending upon the vertical overlap; (3) these changes can create interceptive or deflective occlusal contacts with trauma and pain on the balancing side in the molar and temporomandibular joint areas; and (4) the incisal guidance of denture teeth is inevitably altered when teeth are tilted, uprighted, or turned for esthetics or phonetics. Such changes alter the occlusal function, harmony, and stability of the dentures.

The Use of Computer Tomography in Ophthalmology

Fifty-three orbital lesions of various types were studied by computer tomography to assess the capabilities and limitations of this technique. Although CT scanning in ophthalmology is in its infancy, results showed that it is useful in the investigation of a number of pathological conditions, including congenital anomalies, arteriovenous malformations, bone lesions, trauma, inflammation, granulomas, pseudotumors, epidermoid cysts, and tumors arising in or near the optic nerve, behind the optic bulb, or in the lacrimal region, as well as changes following eye surgery.

Computed tomography: immobilization of the head by dental holder

Movement of the patient's head during computed tomographic studies with the EMI scanner causes some degradation of the quality of the examination. With sufficient movement, major artifacts appear which may obscure intracranial pathology. A simple method of head fixation, utilizing a dental mold, greatly reduces the incidence of unsatisfactory scans.

Computed tomography with the EMI scanner in the diagnosis of primary and metastatic intracranial neoplasms

The findings and diagnostic results in 600 examinations of primary and metastatic intracranial neoplasms performed at one hospital with the EMI scanner are presented and the effectiveness of this method is compared with that of radionuclide imaging, cerebral angiography, and pneumoencephalography. The computed scan proved to be highly reliable in the diagnosis of glioma, cerebral metastases, meningioma, and acoustic neuroma.

Sensitive technique for measuring differences in reflectivity

A new technique for measuring reflectivity differences between two samples is reported. An electrically driven tuning fork is used to place the two samples alternately in the beam of a reflectometer, and a lock-in amplifier is used for detection of the difference signal. Advantages of this system include short deadtime, vacuum operation, and extremely high Q. The sensitivity is such that changes in reflectivity of the order of 0.001% can be observed.