Critical care medicine: opportunities and strategies for improvement

BACKGROUND: Like other areas of health care, critical care faces increasing pressure to improve the quality while reducing the cost of care. Strategies drawn from the literature and the authors' experiences are presented. STRATEGIES AND OPPORTUNITIES FOR IMPROVEMENTS: Ten process- or structure-related areas are targeted as strategically important focuses of improvement: (1) restructuring administrative lines to better suit key processes; (2) physician leadership in critical care units; (3) management training for critical care managers; (4) triage; (5) multidisciplinary critical care; (6) standardization of care; (7) developing alternatives to critical care units; (8) timeliness of care delivery; (9) appropriate use of critical care resources; and (10) tracking quality improvement. TIMELINESS OF CARE DELIVERY: Whatever the root cause(s) of unnecessary delays, the result is inefficient use of critical care resources-and ultimately either a need for more resources or longer wait times. Innovations designed to reduce wait times and waste, such as the establishment of a microchemistry stat laboratory, may prove valuable. APPROPRIATE USE OF CRITICAL CARE RESOURCES: Possible strategies for the appropriate use of critical care resources include better selection of well-informed patients who undergo procedures. Reduction in variation among physicians and organizations in providing therapies will also likely lead to a reduction in some high-risk procedures offering little or no benefit, and therefore a reduction in need for critical care services. Better preparation of patients and families should also make end-of-life decisions easier when questions of "futility" arise. Better information on outcomes and cost-effectiveness and consensus on withdrawal of critical care treatments represent two additional strategies.     

Anthocyanin Degradation in the Presence of Furfural and 5-Hydroxymethylfurfural

The influence of furfural (F) and 5-hydroxymethylfurfural (HMF) on degradation of cyanidin-3-glucoside (CG) was investigated in blackberry juice and in a citrate buffer model solution (pH 3,45) at 24°, 50° and 70°C. Presence of 0.012 M F or HMF accelerated pigment degradation. The acceleration was directly temperature-dependent, more pronounced in fruit juice, and considerably decreased in nitrogen. CG and HMF disappearance – but not the interaction between these compounds – followed the first-order reaction kinetics. The influence of formaldehyde (Fa) acetaldehyde (Aa) and benzaldehyde (Ba) on the stability of CG was investigated in blackberry juice. CG degradation effect of non-furane aldehydes (0.012 M) was Fa < Aa < Ba. CG and cyanidine (C) reactivities were studied by condensation with F and examination of molecular electrone properties (cyanidine, keto-pseudobase, anhydrobase, chalcone). Furfural did not react with CG but it did react with C. Electron charge distribution points to anhydrobase as the tautomeric form of C most reactive to F. Possible mechanisms of C decomposition in presence of F are proposed and discussed.     

A Novel and Efficient Feature Extraction Method for Iris Recognition

With a growing emphasis on human identification, iris recognition has recently received increasing attention. Iris recognition includes eye imaging, iris segmentation, verification, and so on. In this letter, we propose a novel and efficient iris recognition method which employs a cumulative‐sum‐based grey change analysis. Experimental results demonstrate that the proposed method can be used for human identification in efficient manner.     

Poly(1-vinyl-2-pyrrolidinone) hydrogels as vitreous substitutes: histopathological evaluation in the animal eye

A homopolymer of 1-vinyl-2 pyrrolidinone and its copolymer with 2-hydroxyethyl methacrylate, both cross-linked with divinyl glycol, were produced as possible substitutes for the vitreous body of the eye. The hydrated polymers behaved like viscoelastic gels, displaying excellent physical and optical properties. The sterile gels (0.7-1.5 ml) were injected into the vitreous cavity of rabbits, which previously underwent gas-mediated vitrectomy. Clinically, the eyes were quiet, with the exception of transient opacities in the vitreous. After 4 weeks, the operated eyes were enucleated and subjected to histopathological analysis using light and transmission electron microscopy. The common feature in all sections was the invasion of inflammatory cells. Vacuoles containing granular material, assumed to be polymer, were seen in the intercellular spaces of the neural retina, in the retinal pigment epithelium cells, and in macrophages. These findings indicated the fragmentation and phagocytosis of synthetic gels. It appeared that the biodegradation of the internalized polymers did not proceed further, however, the fate of polymers and their usefulness as vitreous substitutes should be investigated through long-term experiments.     

Lichtenstein herniotomy

All standard methods of hernia repair involve suturing together tissues which are not normally in apposition. This violates the basic surgical principle that tissue must never be approximated under tension and accounts for an unacceptable number of failures. Total reinforcement of the inguinal floor with a sheet of suitable biomaterial and employment of a "tension-free" technique is a more effective approach. Since June 1984, 3250 primary inguinal hernias have been repaired at the Lichtenstein Hernia Institute by the open tension-free technique using Marlex mesh. All operations were performed under local anesthesia. Patients were discharged from the hospital within two or four hours after the operation. The patients were followed from one to 8 years by physician examination. The follow-up rate was 87%. There were four recurrences. The causes of recurrence and how to avoid them are discussed.     

Intercostal thorascopic harvesting of the internal mammary artery for supercharging a pedicled rectus abdominis flap

This review on non-heartbeating donation focusses on three issues: the number of kidneys procured from a non-heartbeating donor programme, the transplant results and the influence of a non-heartbeating programme on public opinion regarding transplantation.     

Conjunctival nevi in Denmark 1960-1980. A 21-year follow-up

The clinicopathological characteristics of 343 naevi of the conjunctiva were studied. A significant increase in the number of naevi excised per year was observed. This may have been caused by an increased exposure to actinic rays. An approximately even distribution was found between the three main locations: caruncle, limbal area and eye ball. Intrastromal naevi were excised at a higher median age than compound naevi, and the lowest median age at excision was for junction naevi, which is in accordance with the known histopathological nature of naevi. Recurrence occurred in nine patients (2.7%), and one had transformed into a malignant melanoma. Eight of the recurring naevi were located in the limbal area. Eight of the nine patients were women, suggesting hormonal factors as a possible cause. Recommendations for the handling of conjunctival naevi are given, based on the present findings and on previous reports.