Managing patients whose family members are physicians.

The ethical complexities involving physicians who treat their own family members are well known and it is generally accepted that such practice should not occur. We present three anonymous cases in which patient family members who worked as physicians complicated the medical care of their hospitalized relatives. When a health care worker's family member becomes a hospital patient, the situation can be emotionally charged due to the medical insight the multiple parties have, as well as the desire of relatives to be protective of their family members. Clinician-relatives need to allow the medical team to assume the role of caretaker when their family members are hospitalized. Teams may need to employ limit setting in order to ensure fair and consistent care for all patients on the ward, and to prevent escalation of emotionally charged situations.

The economic burden of Clostridium difficile.

Although Clostridium difficile (C. difficile) is the leading cause of infectious diarrhoea in hospitalized patients, the economic burden of this major nosocomial pathogen for hospitals, third-party payers and society remains unclear. We developed an economic computer simulation model to determine the costs attributable to healthcare-acquired C. difficile infection (CDI) from the hospital, third-party payer and societal perspectives. Sensitivity analyses explored the effects of varying the cost of hospitalization, C. difficile-attributable length of stay, and the probability of initial and secondary recurrences. The median cost of a case ranged from $9179 to $11 456 from the hospital perspective, $8932 to $11 679 from the third-party payor perspective, and $13 310 to $16 464 from the societal perspective. Most of the costs incurred were accrued during a patient's primary CDI episode. Hospitals with an incidence of 4.1 CDI cases per 100 000 discharges would incur costs ≥$3.2 million (hospital perspective); an incidence of 10.5 would lead to costs ≥$30.6 million. Our model suggests that the annual US economic burden of CDI would be ≥$496 million (hospital perspective), ≥$547 million (third-party payer perspective) and ≥$796 million (societal perspective). Our results show that C. difficile infection is indeed costly, not only to third-party payers and the hospital, but to society as well. These results are consistent with current literature citing C. difficile as a costly disease.

[Some special characteristics of vascular reactivity in heart failure].

We determined parameters of elasticity of peripheral arteries in patients with heart failure (HF) including those with pulmonary arterial hypertension. We also investigated pulmonary artery responses to vasoconstricting factors in vitro. Reactivity of the aorta and carotid artery was studied on the model of experimental HF. Lowering of elasticity of small arteries progressed with worsening of HF functional class and increase of pulmonary arterial hypertension. In the genesis of pulmonary hypertension definite role played elevated constrictor response of pulmonary artery to endothelin 1 at the background of dysfunction of endothelial ETB receptors. Endothelial dependent reactivity of the aorta and carotid artery was impaired and their constrictor effect augmented.

[Qualitative and quantitative changes of circulating in blood endotheliocyte precursor cells in patients with hypercholesterolemia].

Aim of this study was elucidation of diagnostic value of qualitative and quantitative parameters of circulating endotheliocyte precursor cells (EPC), in the state of apoptosis (apoptotic endotheliocytes A AE), as well as effect of main risk factors on the studied parameters in patients with coronary atherosclerosis and hypercholesterolemia. We examined 24 patients with ischemic heart disease (14 men, 10 women, mean age 58.4 +/- 2.3 years) with stenoses >75% in coronary arteries according to angiography data and hypercholesterolemia (main group). Control group comprised 15 healthy volunteers. Circulating EPC in peripheral blood were evaluated by cytofluorimetry. Functional parameters of isolated EPC were assessed after cultivation in human fibronectin. Adhesive properties were studied in cell culture by immunehistochemical method after 7 days of incubation. Proliferation capacity was assessed by number of EPC in 1 mm3 of medium at day 7 of incubation. Determination and counting of AE was carried out using cytofluorimetry with immunostaining of cells by anexin B and CDA31 after preliminary treatment of endotheliocyte culture with H2O2 and comparing the results with control culture of endotheliocytes. Number of circulating EPC in patients with IHD was 58.% less than in healthy persons. Adhesive capacity of EPC in patients with IHD was lowered by 43%. Number of EPC surviving in cell culture was 80.9% less than in control group. At the same time number of circulating AE in patients with IHD was 2.5 times greater. Reduction of number of EDC, adhesive capacity, and rise of number of AE correlated significantly with number of involved coronary arteries, presence of diabetes, and smoking status. Presence of arterial hypertension and blood cholesterol level did not correlate with quantitative and qualitative parameters of EPC. Thus qualitative and qualitative parameters of circulating EPC and apoptotic cells can be considered as markers of dysfunction of endothelium and predictors of atherosclerotic vascular lesions in patients with hypercholesterolemia.

[Changes of activity of the endothelial system in experimental heart failure].

Despite obvious participation of endothelins in pathogenesis of heart failure therapeutic approaches to the use of endothelin receptor antagonists remain to be elucidated. Experimental heart failure caused by prolonged infusion of norepinephrine is associated with diminished endothelin induced coronary constricting effect of stimulation of ET(A) receptors and inversion of coronary dilating effect of stimulation of these receptors. The latter effect is mediated by smooth muscle ET(B)-receptors and is indicative of functional derangement of vascular control by endothelial cells. The use of selective ET(A)-antagonist is effective on early stages of heart failure while on later stages administration of nonselective ET(AB)-antagonist produces more pronounced effect.

Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study.

UNLABELLED: Metabolic acidosis and changes in serum osmolarity are consequences of 0.9% normal saline (NS) solution administration. We sought to determine if these physiologic changes influence patient outcome. Patients undergoing aortic reconstructive surgery were enrolled and were randomly assigned to receive lactated Ringer's (LR) solution (n = 33) or NS (n = 33) in a double-blinded fashion. Anesthetic and fluid management were standardized. Multiple measures of outcome were monitored. The NS patients developed a hyperchloremic acidosis and received more bicarbonate therapy (30 +/- 62 mL in the NS group versus 4 +/- 16 mL in the LR group; mean +/- SD), which was given if the base deficit was greater than -5 mEq/L. The NS patients also received a larger volume of platelet transfusion (478 +/- 302 mL in the NS group versus 223 +/- 24 mL in the LR group; mean +/- SD). When all blood products were summed, the NS group received significantly more blood products (P = 0.02). There were no differences in duration of mechanical ventilation, intensive care unit stay, hospital stay, and incidence of complications. When NS was used as the primary intraoperative solution, significantly more acidosis was seen on completion of surgery. This acidosis resulted in no apparent change in outcome but required larger amounts of bicarbonate to achieve predetermined measurements of base deficit and was associated with the use of larger amounts of blood products. These changes should be considered when choosing fluids for surgical procedures involving extensive blood loss and requiring extensive fluid administration. IMPLICATIONS: Predominant use of 0.9% saline solution in major surgery has little impact on outcome as assessed by duration of mechanical ventilation, intensive care unit stay, hospital stay, and postoperative complications, but it does appear to be associated with increased perioperative blood loss.

Use of Q methodology for hospital strategic planning: a case study.

This study was designed to illustrate how Q Methodology can be used as a tool for strategic planning. Potential plans for the future of a small Indiana hospital were formulated and Q sorted to determine support or resistance by key leaders from within hospital management, the board, and the medical staff. The hospital was able to identify stakeholder perceptions that resulted in strong consensus that integration should be a priority for the hospital. This exercise provided a list of objectives for hospital leadership and the results were also used to justify the cessation of several programs that the hospital leadership had been pursuing.