Aligning compensation with education: design and implementation of the Educational Value Unit (EVU) system in an academic internal medicine department.

The authors report the development of a new metric for distributing university funds to support faculty efforts in education in the department of internal medicine at the University of Kansas School of Medicine. In 2003, a committee defined the educational value unit (EVU), which describes and measures the specific types of educational work done by faculty members, such as core education, clinical teaching, and administration of educational programs. The specific work profile of each faculty member was delineated. A dollar value was calculated for each 0.1 EVU. The metric was prospectively applied and a faculty survey was performed to evaluate the faculty's perception of the metric. Application of the metric resulted in a decrease in university support for 34 faculty and an increase in funding for 23 faculty. Total realignment of funding was US$1.6 million, or an absolute value of US$29,072 +/- 38,320.00 in average shift of university salary support per faculty member. Survey results showed that understanding of the purpose of university funding was enhanced, and that faculty members perceived a more equitable alignment of teaching effort with funding. The EVU metric resulted in a dramatic realignment of university funding for educational efforts in the department of internal medicine. The metric was easily understood, quickly implemented, and perceived to be fair by the faculty. By aligning specific salary support with faculty's educational responsibilities, a foundation was created for applying mission-based incentive programs.     

Treating the patient with upper gastrointestinal hemorrhage

The basic approach to a patient with upper GI hemorrhage is primarily stabilization of any hemodynamic insufficiency. A patient history that includes alcohol abuse, ulcer disease, or esophageal varices may call for immediate endoscopy. Approximately 20% of all patients fail to respond to any therapy except surgery; however, a majority of patients who receive appropriate support and resuscitation will stop bleeding.     

Pulmonary artery sarcoma--unusual pulmonary angiographic findings--a case report

The authors report unusual angiographic findings in a patient with pulmonary artery sarcoma who presented with clinical features suggestive of recurrent pulmonary emboli. These angiographic findings have not been described previously in pulmonary artery sarcoma.     

Nutrition in acute respiratory failure

Nutrition is receiving increasing attention in the management of critically ill in the intensive care unit patients. Patients with acute respiratory failure, secondary to primary lung disease, have nutritional needs that may vary from those of other ICU patients. Proper nutritional support of acute respiratory failure patients requires knowledge of nutrition’s effect upon the respiratory system as well as basic fundamentals of nutritional management.     

Nocturnal positive pressure ventilation via nasal mask

Five patients with chronic respiratory failure from neuromuscular disease and symptomatic worsening nocturnal hypoventilation were treated with nocturnal ventilation. Home ventilation at night was provided by a volume-cycled positive pressure ventilator attached to a nasal mask originally designed to administer nasal continuous positive airway pressure (CPAP) for obstructive sleep apnea. The device was well tolerated. Symptoms of headache, insomnia/somnolence, and impaired intellectual capacity rapidly disappeared with nocturnal ventilatory support. Daytime arterial PO2 and PCO2 improved after therapy. There are several advantages over commonly used, negative pressure devices for nocturnal ventilation. These include patient synchronization of tidal volume, ease of application, less cumbersome apparatus, more nocturnal patient mobility, and absence of production of upper airway obstruction.     

Breathing pattern abnormalities and arterial oxygen desaturation during sleep in the congestive heart failure syndrome. Improvement following medical therapy

We observed breathing pattern abnormalities and arterial oxygen desaturation in patients with stable congestive heart failure during overnight polysomnography. To determine whether congestive heart failure was the reason for these abnormalities, we then studied six additional patients before and after treatment of heart failure. Breathing was more abnormal (153 +/- 87 episodes/night) during decompensation of heart failure and improved with medical therapy (72 +/- 100 episodes/night) (p less than 0.05). Abnormal breathing patterns resolved in three patients, improved in two, and were unchanged in one patient after therapy. Allographic cardiac transplantation in one patient whose sleep study remained unchanged after medical therapy was associated with resolution of breathing pattern abnormalities and severe desaturation during sleep. Therapy-related improvement in nocturnal respiratory events suggests congestive heart failure is a contributing factor for breathing abnormalities and arterial oxygen desaturation during sleep.     

Pulmonary small lymphocytic lymphoma (mucosa-associated lymphoid tissue type) associated with pulmonary hyalinizing granuloma

A case of pulmonary hyalinizing granuloma (PHG) and concomitant low-grade, small lymphocytic lymphoma of the lung is presented. This is the first occurrence of pulmonary lymphoma in patients with PHG ever reported. The infiltrates around a left lower lobe nodule with left pleural effusion and thickening seen on chest CT were histologically proven to be lymphomatous infiltrates of the lung, pleura, and chest wall muscle. We believe that the lymphoma developed around the nodule and spread to the pleura and muscle in our patient. When infiltrates around the nodules, pleural effusion, or adenopathy are developed in a patient with proven PHG, close follow-up, biopsy, or careful cytology should be seriously considered to rule out a developing lymphoma.     

Triamcinolone aerosol. Treatment of aspirin-hypersensitive asthmatic patients

The efficacy of triamcinolone acetonide aerosol in the management of asthma in six patients with aspirin hypersensitivity was evaluated during a one-year trial. Five patients were previously chronically dependent on systemic corticosteroids and had undergone unsuccessful trials with cromolyn sodium therapy. Substantial reduction in corticosteroid requirements was observed; in two patients, oral prednisone therapy was completely eliminated. Forced expiratory volume and flow were maintained at levels better than those recorded before triamcinolone therapy throughout the year of follow-up. No substantial side effects due to triamcinolone were observed.     

Oropharyngeal candidiasis in patients treated with triamcinolone acetonide aerosol

Thirty asthmatic patients participating in a trial of triamcinolone acetonide aerosol were evaluated to determine the relationships among symptoms of sore throat or hoarseness, the appearance of the throat on physical examination, and the presence of yeasts on pharyngeal culture. Observations were recorded prior to aerosol therapy and repeated after 2 wk, 4 wk, 6 wk, 4 mo, and 6 mo of therapy. A total of 15 patients (50%) experienced sore throat or hoarseness, 15 (50%) had yeasts cultured from the pharynx on at least one occasion, and 11 (37%) at some point had an abnormal throat examination; however, there was no predictable relationship between symptoms or abnormal physical examinations and the presence of a positive culture. The frequency of positive cultures did not change significantly during the observation period. Twelve patients had positive yeast cultures on 50% or more of their samples. The incidence of symptoms was not sigficantly increased in these chronically colonized patients. Symptoms were usually transient, and discontinuation of the aerosol or antifungal therapy was unnecessary. Triamcinolone aerosol was not associated with significantly increased pharyngeal colonization with yeasts in this 6-mo study. Existing chronic colonization is not necessarily a contraindication to triamcinolone therapy. Sore throat and hoarseness are usually unrelated to yeast infection in patients using triamcinolone acetonide aerosol.