What influences patients' reports of three aspects of hospital services?

OBJECTIVES: Market forces make it essential to know what policies and actions influence patients' reports of hospital services. No studies have examined the role of patient characteristics, labor quality and staff characteristics, nonlabor resources, managerial practices, and employee attitudes within a single investigation. METHODS: The authors collected, simultaneously, data about labor, management and service processes, nonlabor resources, and employee attitudes on 117 nonintensive medical-surgical inpatient units in 17 hospitals selected from a pool of 69 institutions within a metropolitan area by a stratified random sample. Of the 2,595 patients who agreed to participate, 2,051 (79%) completed telephone interviews regarding their experiences with physical care, education, and pain management services within 26 days of hospital discharge. RESULTS: A significant amount of variation in patients' service reports was explained (adjusted R2 = 0.41 physical care, 0.35 pain management, 0.44 education). Although the predictors varied for each service report, patient characteristics, especially those related to personal resources, had a large explanatory role. A labor assignment pattern that could explain why earlier studies found labor quality and staff characteristics to have only a weak role in the prediction of patients' service reports was noted. CONCLUSIONS: The results related to patient characteristics may indicate opportunities to improve care by confronting service design strategies that erroneously rely on a homogeneous patient population. Measurement challenges identified by this study must be addressed to determine the role of labor quantity and staff characteristics.     

Complement resistance of capsulated strains of Aeromonas salmonicida

1. We investigated the effect of exercise on plasma adrenomedullin, atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations and studied the relationship between these peptides and haemodynamic parameters in nine patients with old myocardial infarction (MI) and in eight normal subjects. 2. The exercise protocol consisted of two fixed work loads (40 and 80 W) for 4 min each and venous blood samples were taken at rest, during each exercise stage and after exercise while monitoring the mean arterial pressure (MAP) and heart rate (HR). In MI, pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), left ventricular end-diastolic pressure (LVEDP) and cardiac output (CO) were measured throughout exercise. 3. Adrenomedullin levels did not significantly increase with exercise. Adrenomedullin levels correlated with PAP and PCWP at rest (P < 0.05). Atrial natriuretic peptide levels correlated with PAP, PCWP and LVEDP throughout exercise (P < 0.05) but, on multiple regression analysis, PCWP correlated only with ANP (P < 0.01). Brain natriuretic peptide levels correlated with LVEDP throughout exercise (P < 0.01) and its increment correlated closely with basal BNP levels at rest (P < 0.01). 4. These results suggest that adrenomedullin does not respond to the acute haemodynamic changes of exercise, whereas ANP responds to it and PCWP is the major stimulus factor. Brain natriuretic peptide responds to exercise in proportion to the basal synthesis of BNP in patients with left ventricular dysfunction and LVEDP may play a role in increasing BNP during exercise.     

Genetics of sarcoidosis

Hereditary susceptibility to sarcoidosis is suggested by ethnic preponderance, familial clustering, and multigenerational involvement. The genetics of sarcoidosis cannot be adequately addressed in small samples of patients; a large-scale study with stratification for patient phenotypic differences is necessary. A study that uses both genetic marker and environmental data would be able to control for and examine different causative mechanisms. Until such a well-designed, comprehensive study is carried out, we are left with interesting patterns of disease in families and uncertain allelic associations.     

Trypanosoma cruzi: nitrogenous-base-containing phosphatides in trypomastigote forms--isolation and chemical analysis

Increasingly clinicians attempt to base decisions regarding patient management on the results of clinical studies in addition to expert opinion and their own practical experience. In this article, the author reviews the published studies available to assist clinicians to make evidence-based decisions in three topics related to small volume red blood cell (RBC) transfusions for preterm infants; namely, studies examining the effects of RBC transfusions on possible symptoms of anemia such as tachypnea, apnea or other cardiorespiratory irregularities, studies investigating the collection and transfusion of umbilical cord blood and finally studies addressing the duration of storage and use of additive solutions for RBCs for transfusion to neonates. Based on the review of these studies, guidelines for small volume RBC transfusions in preterm infants are suggested.     

The renal and hepatic distribution of Bence Jones proteins depends on glycosylation: a scintigraphic study in rats

The aim of the present study was to evaluate renal and liver distribution of two monoclonal immunoglobulin light chains. The chains were purified individually from the urine of patients with multiple myeloma and characterized as lambda light chains with a molecular mass of 28 kDa. They were named BJg (high amount of galactose residues exposed) and BJs (sialic acid residues exposed) on the basis of carbohydrate content. A scintigraphic study was performed on male Wistar rats weighing 250 g for 60 min after i.v. administration of 1 mg of each protein (7.4 MBq), as the intact proteins and also after carbohydrate oxidation. Images were obtained with a Siemens gamma camera with a high-resolution collimator and processed with a MicroDelta system. Hepatic and renal distribution were established and are reported as percent of injected dose. Liver uptake of BJg was significantly higher than liver uptake of BJs (94.3 vs 81.4%) (P < 0.05). This contributed to its greater removal from the intravascular compartment, and consequently lower kidney accumulation of BJg in comparison to BJs (5.7 vs 18.6%) (P < 0.05). After carbohydrate oxidation, there was a decrease in hepatic accumulation of both proteins and consequently a higher renal overload. The tissue distribution of periodate-treated BJg was similar to that of native BJs: 82.7 vs 81.4% in the liver and 17.3 vs 18.6% in the kidneys. These observations indicate the important role of sugar residues of Bence Jones proteins for their recognition by specific membrane receptors, which leads to differential tissue accumulation and possible toxicity.     

Time courses of calcium and calcium-bound buffers following calcium influx in a model cell

Fixed and diffusible calcium (Ca) buffers shape the spatial and temporal distribution of free Ca following Ca entry through voltage-gated ion channels. This modeling study explores intracellular Ca levels achieved near the membrane and in deeper locations following typical Ca currents obtained with patch clamp experiments. Ca ion diffusion sets an upper limit on the maximal average Ca concentration achieved near the membrane. Fixed buffers restrict Ca elevation spatially to the outermost areas of the cell and slow Ca equilibration. Fixed buffer bound with Ca near the membrane can act as Ca source after termination of Ca influx. The relative contribution of fixed versus diffusible buffers to shaping the Ca transient is determined to a large extent by the binding rate of each buffer, with diffusible buffer dominating at equal binding rates. In the presence of fixed buffers, diffusible buffers speed Ca equilibration throughout the cell. The concentration profile of Ca-bound diffusible buffer differs from the concentration profile of free Ca, reflecting theoretical limits on the temporal resolution which can be achieved with commonly used diffusible Ca indicators. A Ca indicator which is fixed to an intracellular component might more accurately report local Ca concentrations.