Physician integration and retention in a large IDS: economic implications.

To implement an effective physician recruitment and retention policy, Fairview Health Services, a large, regional integrated delivery system (IDS) headquartered in Minneapolis-St. Paul, Minnesota, conducted a study to determine the degree to which its physicians behaved as integral members of the IDS. The study primarily consisted of interviews with physicians and IDS clinical executives and their support staff. Responses were evaluated based on the Meyer and Allen three-component model of organizational commitment. Results provided a basis for recommending initiatives Fairview could undertake to increase physician commitment to the organization. Final recommendations included focusing recruitment efforts on older, more experienced physicians and reassessment of Fairview's hospital-centered approach to governance.

Psychology & employee commitment. Promoting physician loyalty.

Physician and staff loyalty has become more important and more difficult to maintain. Group managers should realize that not all forms of commitment are equal and should actively work to build commitment to the organization, not just to the practice of medicine.

Anaphylaxis to protamine sulfate mediated by a complement-dependent IgG antibody.

Anaphylactoid reactions to protamine sulfate have been attributed to its capacity for nonimmunologic mast cell degranulation and/or complement consumption. In the current study, evidence is presented for the occurrence of an immunologic anaphylactic reaction mediated by a complement-dependent IgG skin-sensitizing antibody. A retrospective study of blood component donors given protamine for heparin neutralization revealed that prior exposure to protamine is associated with increased risk of adverse reaction to the drug.

Generalized urticaria to cyclophosphamide: Type I hypersensitivity to an immunosuppressive agent.

A 6-yr-old white boy, Patient L. B., who was receiving cyclophosphamide (CY) for chemotherapy of a localized undifferentiated small cell sarcoma of the chest wall, developed generalized urticaria on three separate occasions immediately after CY administration. Serum samples were obtained 2 and 5 wk after the patient's last reaction and were examined for reaginic activity to the drug. Homocytotropic antibody activity to CY was found in the 2-wk postreaction sample by Prausnitz-Küstner type passive transfer skin testing to chimpanzees. This homocytotropic antibody was found to be of the IgE type, by means of an in vitro double-antibody coprecipitation assay measuring binding of free 14C-CY by specific immunoglobulin E and G fractions. Sera from 3 CY-treated patients who did not have adverse reactions to the drug and 6 normal, age-matched volunteers were used as control samples for the coprecipitation assay. None of the 3 CY-treated control patients had significant binding of 14C-CY by IgE when compared to normal individuals. However, it was found that all CY-treated patients had significant binding of 14C-CY by their IgG fraction when compared to normal subjects.

Selective immunoglobulin M (IgM) deficiency in two immunodeficient adults with recurrent staphylococcal pyoderma.

Two adult men with recurrent pyoderma due to Staphylococcus aureus and a selective deficiency of immunoglobulin M (IgM) antibody synthesis are described. An analysis of each patient's polymorphonuclear leukocyte chemotaxis, phagocytosis and killing of Staph. aureus, serum opsonizaiton of Staph. aureus, and serum and lymphocyte-mediated responses to antigenic stimulation was performed. Family studies revealed a possible autosomal dominant inheritance pattern with heterogenetic expression of various dysgammaglobulinemic states in each patient's first degree relatives. In vivo studies of delayed hypersensitivity and in vitro studies of polymorphonuclear leukocyte and lymphocyte function were normal. A defect in IgM, but not in IgG (immunoglobulin G), antibody synthesis to a number of antigens, and a mild decrease in serum opsonic activity to Staph. aureus correctable by heat inactivated normal human serum were found in each patient. In these patients, the recurrent staphulococcal pyoderma prompted an investigation of host defense mechanisms and revealed low to absent IgM levels and a defect in IgM antibody synthesis.

Competent cellular immunity in allergic rhinitis patients with elevated IgE.

Parameters of cell-mediated immunity (CMI) were studied in 17 allergic rhinitis patients selected for markedly elevated total serum IgE levels (greater than 300 IU/ml) and 14 normal controls. Mean serum IgE levels were 1,421 IU/ml and 101 IU/ml in the allergic and control groups, respectively (p less than 0.001). There were no significant differences between the allergic patients and the normal controls in delayed cutaneous hypersensitivity, in mitogen and antigen lymphocyte transformation in heterologous or autologous plasma, or in percentage of sheep erythrocyte rosettes. The allergic patient group had a significantly higher percentage of sheep erythrocyte-antibody-complement rosettes (p less than 0.05). Markedly elevated total serum IgE levels in allergic rhinitis patients were not associated with any detectable impairment of CMI.

Polymyxin B reactions, IgE antibody, and T-cell deficiency. Immunochemical studies in a patient after bone marrow transplantation.

A patient with aplastic anemia was immunosuppressed with cyclophosphamide and transplanted with allogenic bone marrow. While lacking demonstrable T-cell activity posttransplantation, he developed a generalized macular erythematous eruption and fever, clinically attributed to intranasal polymyxin B. A specific IgE antibody, demonstrated by direct skin testing, Prausnitz-Kustner passive transfer, and indirect passive hemagglutination was temporally related to the reaction. Discontinuation of the drug led to prompt defervescence and resolution of the drug eruption.

IgE antipolymyxin B antibody formation in a T cell-depleted bone marrow transplant patient.

The production of IgE-class antibody specific for polymyxin B is documented in an 18-year-old white female acute myelocytic leukemic patient in relapse. The patient was rendered T cell-deficient by total body X-irradiation and antihuman thymocyte globulin for the purpose of bone marrow transplatation. Thereafter, symptoms of nasal congestion, rhinorrhea, and perinasal urtication produced by topical application of a polymyxin solution were noted. Reaginic activity mediated by an IgE antibody against polymyxin is documented by Prausnbitz-Küstner-type passive transfer reactions and by an indirect hemagglutination technique developed for these studies. The occurrence of type I hypersensitivity to this topical antibiotic is rare. It is speculated that pharmaceuticals normally having a low sensitizing potential might demonstrate increased reaginic immunogenicity in a spontaneously or iatrogenically T cell-depleted patient.