Pediatric mechanical ventilation.

Mechanical ventilation has become a cornerstone of management of critically ill children in the intensive care unit. Indications for mechanical ventilation are numerous and strategies to effectively support patients yet minimize iatrogenic injury are imperative. This review aims to provide a broad overview of pediatric mechanical ventilation. A discussion of core principles of respiratory physiology integral to mechanical ventilation and an overview of commonly used ventilators and ventilator modes will be provided. Focus will then turn to general goals of mechanical ventilation with emphasis on pathophysiology. The latter half of the review will examine general indications for mechanical ventilation and mechanical ventilation in different disease states, including restrictive lung disease, obstructive lung disease, congenital heart disease, and shock. Finally, indications for and methods of weaning from mechanical ventilation will be discussed.

Mid-esophageal traction diverticulum: rare cause of massive upper gastrointestinal bleeding.

Traction diverticula of the mid-esophagus are usually incidental findings on barium swallow or upper endoscopy. They are thought to arise secondary to adjacent inflammation in the mediastinum, usually from granulomatous infection such as histoplasmosis. They are usually asymptomatic. Rarely, erosion or extension of the inflammatory process into the adjacent lung or bronchial arteries can result in clinical symptoms such as pneumonia or gastrointestinal bleeding. Diagnosis is often delayed due to the rarity of clinical symptoms. We present a case of massive upper gastrointestinal bleeding due to a mid-esophageal diverticulum.

Zero defections: quality comes to services.

Companies that want to improve their service quality should take a cue from manufacturing and focus on their own kind of scrap heap: customers who won't come back. Because that scrap heap can be every bit as costly as broken parts and misfit components, service company managers should strive to reduce it. They should aim for "zero defections"--keeping every customer they can profitably serve. As companies reduce customer defection rates, amazing things happen to their financials. Although the magnitude of the change varies by company and industry, the pattern holds: profits rise sharply. Reducing the defection rate just 5% generates 85% more profits in one bank's branch system, 50% more in an insurance brokerage, and 30% more in an auto-service chain. And when MBNA America, a Delaware-based credit card company, cut its 10% defection rate in half, profits rose a whopping 125%. But defection rates are not just a measure of service quality; they are also a guide for achieving it. By listening to the reasons why customers defect, managers learn exactly where the company is falling short and where to direct their resources. Staples, the stationery supplies retailer, uses feedback from customers to pinpoint products that are priced too high. That way, the company avoids expensive broad-brush promotions that pitch everything to everyone. Like any important change, managing for zero defections requires training and reinforcement. Great-West Life Assurance Company pays a 50% premium to group health-insurance brokers that hit customer-retention targets, and MBNA America gives bonuses to departments that hit theirs.

The profitable art of service recovery.

In services, mistakes are a fact of life. No matter how hard companies try, they can't prevent the occasional late flight or missed delivery. But they can learn to recover from them. Consider how Club Med-Cancun turned a service nightmare into a memorable experience. When a flight to Cancun left New York six hours late, made two unexpected stops, ran out of food, and had a rough landing, the vacationers on board were certain their holiday was ruined. But the Club Med manager greeted the travelers with food and music and chauffeured them back to the resort. In the end, the vacationers had a better time than if the flight had gone like clockwork. Service recovery starts with identifying the problem. The Bank of Maine in Portland pays customers $1 for writing a letter about the service they received. American Express uses an "800" number to solicit customer complaints. Once they've identified a problem, service companies must act fast. When Smith & Hawken realized that it was taking months to resolve customers' problems by mail, the company decided to use the phone instead. Most important, service companies should encourage frontline employees to deviate from the rules when necessary. Some companies use role playing to help employees develop the creative thinking needed to deal with unusual situations. Sonesta Hotels uses a game in which teams win points for coming up with good solutions to realistic problems. Also, employees must have the authority and responsibility to act on their beliefs-to make phone calls, credit accounts, or send flowers.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical and pathologic aspects of asbestosis.

We studied 12 patients with occupational exposure to asbestos to evaluate the pulmonary diseases that result from protracted exposure to this fibrogenic and oncogenic fiber. The spectrum of diseases includes diffuse interstitial fibrosis, bronchogenic carcinoma, and malignant mesothelioma. Cigarette smoking is found to be a cocarcinogen with asbestos. Because of the impairment of pulmonary function in these patients, surgery plays a limited role in their management.

Let first-level supervisors do their job.

Performing well as a first-level supervisor is like walking the circus high wire. In both positions, the ability to maintain one's balance when shifting forces pull in opposite directions is a measure of one's success. First-level supervisors must be able to harmonize the demands of management, the demands of the collective work force (often represented by unions), and the demands of workers with the requirements for doing the tasks at hand. These needs are more often than not conflicting and even at times mutually exclusive. First-level supervisors usually have mixed emotions about their situation and often lose their sense of identity as they try to perform this precarious balancing act. Today these supervisors are part of management, but chances are they were once among the employees they are now trying to supervise. Although first-level supervisors have the responsibility for implementing the goals of upper management, their organizational authority to carry out the necessary actions is frequently unclear and often insufficient. By allowing these lowest-level managers to use the levers of influence inherent in their position, higher-level managers will be improving the performance of the whole organization.