Developing a service line approach to quality improvement.

A specialty hospital in New England is undergoing a radical change in its quality program. It is shifting from a traditional quality assurance structure with 41 segregated committees to an integrated model based on service lines. The goals for this shift were fourfold: to reduce duplication of effort, to improve the level of integration of quality efforts across disciplines, to design a comprehensive system to evaluate care, and to enhance the communication of quality efforts. The article describes the rationale for selecting a service line model for performance improvement, the process of setting this change in motion, and the lessons learned along the way.

Na(+-) Cl(-)- and HCO3(-)-dependent base uptake in the ciliary body pigment pigment epithelium.

Segments of whole ciliary body dissected from Dutch belted rabbits were incubated for 60 min at 36 degrees C in a 30 microM Ca2+ Ringer's. The inner limiting membrane with its adherent non-pigmented epithelium then was mechanically removed from the surface. The newly-exposed viable layer of pigmented cells was then loaded with the fluorescent probe 2'-7'-bis (carboxymethyl)-5(6) carboxyfluorescein by incubating the segments for 45 min at RT with the cell permeable acetoxymethoxy form of the dye. These loaded tissues were perfused in a flow-through chamber, mounted on the heated stage of a microscope equipped for quantitative epifluorescence, and the intracellular pH (pHi) of small groups of cells was derived from the ratio of emission intensities generated by excitations at 490 and 440 nm, respectively. In N[2-hydroxyethyl] piperazine-N"-[2 ethane sulfonic acid](Hepes)-buffered Ringer's the intracellular pH was 7.23 +/- 0.21 (+/- S.D., n = 20). Replacement of 28 mM Hepes by 28 mM HCO3-/5% CO2 led to a 0.14 +/- 0.04 increase in pHi. This increase required the presence of Na+ and Cl- and was inhibited by 0.2 mM diisothiocyanatostilbene-2-2'-disulfonic acid. These observations as well as characteristic pHi, responses to the removal or introduction of Na+ or Cl- indicated the presence in the pigmented cells of a Na(+)- and Cl(-)-dependent HCO3- transporter responsible for base uptake.

Separation of the rabbit ciliary body epithelial layers in viable form: identification of differences in bicarbonate transport.

Sections of whole ciliary (CB) dissected from Dutch belted rabbits were incubated for 2 hr at 36 degrees C in a 30 microM Ca2+ Ringer's. This incubation resulted in the spontaneous dissociation of the two cell layers comprising this epithelium, each remaining firmly cohesive with its own basement membrane. The inner limiting membrane with its adherent non-pigmented epithelium (NPE) was then mechanically removed from the surface exposing the apical surface of the pigmented epithelium (PE). Ultrastructural examination revealed no noxious effects in most cells although gross morphological changes in the NPE cells were noted. The newly separated layers were loaded with the cell-permeable acetoxymethyl ester form of the fluorescent probe BCECF. Most cells of both layers acquired stable BCECF fluorescence indicating viability. To achieve a preliminary evaluation of differences in PE and NPE bicarbonate transport, dye-loaded tissues were perfused in a flow-through chamber which was mounted on a microscope equipped for quantitative epifluorescence. The intracellular pH (pHi) of groups of cells (5-10) was derived from the ratio of emission intensities generated by excitations at 490 and 440 nm. In Hepes-buffered Ringer's the pHis for the PE and NPE were 7.20 +/- 0.10 and 7.33 +/- 0.14 (+/- S.D., n = 6), respectively. Replacement of 28 mM Hepes by 28 mM HCO3-/5% CO2 led to a 0.13 pHi increase in the PE and a decrease of 0.27 U in the NPE. The pHi responses of the two cell layers to removal and/or reintroduction of Na+ and/or Cl- were also highly dissimilar.(ABSTRACT TRUNCATED AT 250 WORDS)

Screening indices for cytomegalovirus retinitis in patients with human immunodeficiency virus.

Cytomegalovirus retinitis, the major cause of blindness in patients with the acquired immunodeficiency syndrome, can be arrested by early detection and treatment. We identified 9 screening indices for early CMV retinitis: T-4/T-8 ratio less than 0.11, T-4 count less than 30, T-8 count less than 500, leukocytes less than 4,200, platelets less than 240,000, hemoglobin less than 11.6, hematocrit less than 35, less than 6 for a diagnostic profile which incorporates these 7 indices, and less than 2 for the IA-sum which compounds T-cell inversion and anemia. A threshold value was determined for each index, identified by retrospective review of charts of 15 patients with CMV retinitis and 30 without. Sensitivity, specificity, positive predictive value, negative predictive value, and receiver operating characteristic curve area was calculated. The best screening index was the T-cell ratio, which had the highest sensitivity (0.93), negative predictive value (0.94-0.99) and receiver operating characteristic curve area (0.89), and a positive predictive value among the highest (0.50-0.82).

Technique for the measurement of spatial vorticity distributions.

A method for measuring mean spatial vorticity content has been described for flows where the primary convective velocity (free stream) is larger than the mean crossflow components. Employing an ''X''-geometry hot-wire probe and linearized anemometer system in conjunction with a precision probe traversing mechanism, this relatively simple technique can be used to evaluate the circulation associated with various spatial contours. Errors associated with the technique are computed exactly and in simple linearized forms to illustrate its validity in a wide range of flows. A priori knowledge of the flow character and resultant careful selection of the integration paths for a given flow situation is observed to result in minimal measurement errors. Application to the problem of an isolated trailing vortex is presented as an example. Experiments at the trailing edge of a lifting wing confirm the accuracy of the method when compared with existing theories and other experimental data. The method can be extended to periodically driven unsteady flows using phase-lock techniques.