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Can mental patients say no to drugs?
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Collective bargaining is the right step.
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[Reflexions after visits and/or work at 4 major neuroradiology departments in Canada and the United-States (Institut Neurologique Mc Gill in Montreal, Massachusetts General Hospital in Boston, University of California at San Francisco and Stanford University in Palo Alto) July-August 1986].
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Communicating hospitals' concerns to legislators and the community.
The time is past when voluntary hospitals could afford to be uninformed and inactive in public affairs. As decisions in the public sector increasingly threaten not-for-profit institutions, Catholic hospitals particularly must pursue an action-oriented program of communication with legislators and the community. At Carney Hospital, Boston, an especially effective forum for the past eight years has been buffet dinners held on a quarterly basis with state and congressional legislators and representatives of the hospital's management team, board of trustees, associate board, and medical staff. These dinner meetings provide a singular opportunity for law-makers to learn hospitals' perspective on key issues such as the effect of tightened reimbursement on care of the poor. The dinners not only have enhanced relations with legislators but also raised the consciousness of the business community, consumers, and the general public. Frequent mailings to legislators and members of the board of trustees and the associate board also have beeN helpful. The associate board was formed to augment the expertise of the board to trustees and to increase lay participation in the hospital's affairs. Composed of 20 lay leaders representing a diversity of disciplines, the associate board provides a strong base for influencing public policy and community action. Moreover, the hospital's various constituencies--physicians, employees, volunteers, and auxilians-are recruited as appropriate to contact legislators, write letters to the editor, and give media interviews. Also important in the facility's public affairs efforts have been timely responses to requests for action from The Catholic Health Association, the American Hospital Association, and the state hospital association.
Pentoxifylline for the treatment of infection with human immunodeficiency virus.
Cytokine dysregulation in human immunodeficiency virus type 1 (HIV-1) infection has been documented in numerous studies and has been cited as an important component in the pathogenesis of this retroviral infection. Pharmacological modification of cytokine dysregulation, therefore, has been suggested as a therapeutic modality for HIV-1 infection. Dr. Dezube of Beth Israel Hospital (Boston) concisely reviews the state of our knowledge regarding the effects of pentoxifylline on expression of tumor necrosis factor-alpha, a cytokine known to influence HIV-1 replication and to play a possible role in the clinical manifestations of advanced infection with this virus. Pentoxifylline, a trisubstituted xanthine derivative, has been used to decrease blood viscosity and is reasonably well tolerated by most recipients of the drug. Results of preliminary studies, many of which were conducted by Dr. Dezube, suggest that use of this agent in combination with antiretroviral compounds may prove useful in the treatment of patients with HIV-1 infection.
The demise of autopsies. Losing key medical data.
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State medicine flayed by brilliant array of speakers at Boston meeting.
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Hospital-acquired infection: present and future impact and need for positive action.
Surveillance of infections at the Ottawa General Hospital between September 1, 1971 and August 31, 1972 showed that the overall infection rate was 13.5% of which 5.6% was community-acquired while 7.9% was of nosocomial origin. These figures are comparable to those for equivalent hospitals in the United States and lower than those reported from the Boston City Hospital, but they nevertheless indicate that over half the infected patients in the hospital were infected after admission. Urinary tract infections accounted for 44.8% of all nosocomial infections and clearly dominated the picture. The postoperative wound infection rate was 3.9% and accounted for only 18% of nosocomial infections. It is probable that these findings are representative of general hospitals throughout Canada and indicate conditions which will not long be tolerated. The knowledge and techniques exist for the prevention of all hospital cross-infection and much autogenous infection. Specific measures are suggested for working towards this goal. These are (1) the replacement of archaic hospitals and hospital facilities, (2) the establishment in every hospital of an efficient surveillance program, (3) the institution of good catheterization and catheter care techniques, and (4) the establishment by hospitals of a quality control program whereby a specific explanation is required for every infection occurring within the hospital.
Gorovitz, Samuel. Drawing the Line: Life, Death, and Ethical Choices in an American Hospital.
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Ethical climate in health care organizations.
An organization's policies, procedures and practices on ethical issues can influence the amount of risk nurses will take in voicing their opinions about patient care issues. While the concepts of organizational climate and culture are frequently referred to, the concept of ethical climate is relatively new.
Anterior cruciate ligament reconstructive surgery in adolescent soccer and basketball players.
OBJECTIVE: To evaluate trends in the frequency of anterior cruciate ligament (ACL) tears among adolescent soccer and basketball players resulting in reconstructive surgery, and to assess differences between female and male adolescent athletes. DESIGN: A retrospective review of ACL reconstructive surgeries performed from 1992 through 1997 and annual statewide participation rates obtained from the National Federation of State High School Associations. SETTING: Children's Hospital, Boston, Massachusetts, U.S.A. PATIENTS: Adolescent athletes 13 to 19 years of age (78 girls, 31 boys) admitted for ACL reconstruction due to soccer or basketball injuries. MAIN OUTCOME MEASURES: Number of ACL reconstructive surgeries and number of Massachusetts participants in high school soccer and basketball. RESULTS: A total of 69 soccer (49 girls, 20 males) and 40 basketball (29 girls, 11 males) players underwent ACL reconstruction. A greater proportion of girls underwent ACL surgery in both sports. The frequency increased over time for both sexes in both sports. Soccer-related surgeries increased at a faster rate among girls than boys. Basketball-related surgeries increased at a similar rate for both sexes, although in any given year more surgeries were performed on girls. CONCLUSION: The frequency of ACL surgery at our institution has increased among high school soccer and basketball players in a manner consistent with trends in sports participation. In our study, ACL surgery was more common among girls than boys.
Does your hospital have a policy for no-code orders? Part 2.
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Program to disseminate information on new hospital pharmacy practices.
A five-year program to stimulate interest in contemporary pharmacy practices and disseminate information to pharmacists and other health professionals in community hospitals throughout the State of Maine is described. Pharmacists from the New England Medical Center in Boston and the Maine Medical Center in Portland conducted a program from 1973 to 1978 that included consultative services, drug information, and continuing-education components. Pharmacy consultants visited about 50% of the hospitals in the state and met with the director of pharmacy, administrator, and director of nursing who received written reports of all findings and suggestions. Most frequently, hospitals requested recommendations on drug-distribution systems, design and use of medical profiles, and design of physician order forms. Surveys at the beginning and at the end of the program indicated that the number of hospitals with unit dose systems and i.v. admixture programs increased during the life of the program; pharmacy staffing levels also increased. The program successfully brought consultative services, drug information, and educational programs to pharmacists and other health professionals in community hospitals in Maine.
Wound infections on an orthopedic service. A prospective study.
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Governing population genomics: law, bioethics, and biopolitics in three case studies.
Existing scholarship on population genomics has only superficially addressed issues of power and political process. Accordingly, questions of politics and governance pervade the analysis of three population genomics case studies that follow: the Human Genome Diversity Project, Iceland's Health Sector Database, and "Clinical Genomics" as defined by the Beth Israel-Ardais collaboration. An examination of these case studies reveals that the common law, U.S. regulatory law, and international law have not developed the political sophistication to make the traditional promises of biomedical ethics--respect for autonomy, justice, and beneficence--come to fruition. Further, comparisons of these projects illuminate three areas ripe for reframing--informed consent, expert ethical oversight, and commercial benefits. Four avenues of reform are suggested.
A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators.
OBJECTIVES: To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. DESIGN: A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n = 2652) or control group (n = 2152). SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%. INTERVENTION: Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specifically trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication. RESULTS: The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR: 46% of do-not-resuscitate (DNR) orders were written within 2 days of death; 38% of patients who died spent at least 10 days in an intensive care unit (ICU); and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time. During the phase II intervention, patients experienced no improvement in patient-physician communication (eg, 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12). CONCLUSIONS: The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measured may be needed.
Excursions into epidemiology: selected studies during the past four decades at Boston City Hospital.
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