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.     

提高力反馈速率陀螺动态特性的优化设计

陀螺带宽窄将影响系统的动态特性.本文采用比例-积分控制和迟后-超前网络相结合的校正方法,通过优化校正网络的参数、合理配置零极点、设计控制回路,使陀螺系统的带宽提高到150 Hz、输出噪声小于10 mV.并通过仿真验证了控制回路设计的合理性.     

Mass spectrometry fragmentation pattern of coloured flavanol‐anthocyanin and anthocyanin‐flavanol derivatives in aged red wines of Rioja

Background and Aims: During wine ageing, a great variety of reactions take place, resulting in an immense variety of products whose structure sometimes remains unknown. The aim of this work is the study of different fragmentation patterns of flavanol‐anthocyanin derivatives formed along the wine ageing; these patterns are useful for elucidating the different structures of these compounds and other new related ones. Methods and Results: Several wines from the Protected Denomination of Origin Rioja have been studied by an analytical method that combines column chromatography and high‐performance liquid chromatography with diode array and mass and tandem mass spectrometric detections. Thirty‐five coloured flavanol‐anthocyanin compounds formed by direct reaction or by acetaldehyde‐mediated condensation have been identified. For direct reaction derivatives, two different fragmentation patterns (one of them not previously reported) have been observed depending on the position of flavanol in the coloured derivative. Several compounds have been identified in aged wines for the first time to the authors' knowledge, like (+)‐gallocatechin‐cyanidin‐3‐glucoside and (+)‐catechin‐cyanidin‐3‐glucoside Conclusions: The developed analytical procedure has allowed the identification of some compounds for the first time, and two different fragmentation patterns have been observed depending on the position of flavanol in the pigment. Significance of the Study: The establishment of different fragmentation patterns allows the structural elucidation of unknown compounds.     

Confirmation of the human-pathogenic microsporidia Enterocytozoon bieneusi, Encephalitozoon intestinalis, and Vittaforma corneae in water

Microsporidia, as a group, cause a wide range of infections, though two species of microsporidia in particular, Enterocytozoon bieneusi and Encephalitozoon intestinalis, are associated with gastrointestinal disease in humans. To date, the mode of transmission and environmental occurrence of microsporidia have not been elucidated due to lack of sensitive and specific screening methods. The present study was undertaken with recently developed methods to screen several significant water sources. Water concentrates were subjected to community DNA extraction followed by microsporidium-specific PCR amplification, PCR sequencing, and database homology comparison. A total of 14 water concentrates were screened; 7 of these contained human-pathogenic microsporidia. The presence of Encephalitozoon intestinalis was confirmed in tertiary sewage effluent, surface water, and groundwater; the presence of Enterocytozoon bieneusi was confirmed in surface water; and the presence of Vittaforma corneae was confirmed in tertiary effluent. Thus, this study represents the first confirmation, to the species level, of human-pathogenic microsporidia in water, indicating that these human-pathogenic microsporidia may be waterborne pathogens.     

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.     

Heptadecapeptide gastrin: measurement in blood by specific radioimmunoassay

The characteristics are described of an antibody (designated L6) which has virtually absolute specificity for heptadecapeptide gastrin. This antibody binds G17, but does not bind peptide fragments or molecular forms of gastrin comprising G17 with either amino acid deletions, or additions, at the carboxyl- and amino-terminals. In serum from patients with Zollinger-Ellison syndrome the only form of gastrin revealed by L6 was compatible with G17, and there was good agreement between estimated G17 concentrations in serum analyzed by gel filtration and by direct radioimmunoassay using L6. Using L6 in conjunction with antibodies specific for carboxyl- and amino-terminals of G17 it has been possible to measure concentrations of different forms of gastrin in serum of normal subjects after a meal in greater detail than previously possible. After a light meal consisting of eggs, toast, and Oxo, serum concentrations of G17 measured by L6 increased to a peak 20 min after feeding (delta gastrin, 19 pmoles per liter; n = 17). In contrast, concentration of G34 peaked at 50 min (delta gastrin, 27 pmoles per liter). Small amounts of amino-terminal fragments of G17 were present throughout the digestive period. Applying the known ratio of biological potencies of G34 and G17 for stimulation of acid secretion in man, it is estimated that G17 accounts for about 75% of the biological activity in blood after a meal, even though G34 is present in higher molar concentrations.     

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.     

Neocuproine, a selective Cu(I) chelator, and the relaxation of rat vascular smooth muscle by S-nitrosothiols

1. A study has been made of the effect of neocuproine, a specific Cu(I) chelator, on vasodilator responses of rat isolated perfused tail artery to two nitrosothiols: S-nitroso-N-acetyl-D,L-penicillamine (SNAP) and S-nitroso-glutathione (GSNO). 2. Bolus injections (10 microl) of SNAP or GSNO (10(-7)-10(-3) M) were delivered into the lumen of perfused vessels pre-contracted with sufficient phenylephrine (1-7 microM) to develop pressures of 100-120 mmHg. Two kinds of experiment were made: SNAP and GSNO were either (a) pre-mixed with neocuproine (10(-4) M) and then injected into arteries; or (b) vessels were continuously perfused with neocuproine (10(-5) M) and then injected with either pure SNAP or GSNO. 3. In each case, neocuproine significantly attenuated vasodilator responses to both nitrosothiols, although the nature of the inhibitory effect differed in the two types of experiment. We conclude that the ability of exogenous nitrosothiols to relax vascular smooth muscle in our ex vivo model is dependent upon a Cu(I) catalyzed process. Evidence is presented which suggests that a similar Cu(I)-dependent mechanism is responsible for the release of NO from endogenous nitrosothiols and that this process may assist in maintaining vasodilator tone in vivo.