Tailoring Interventions: Understanding Medical Practice Culture

This article describes the results of a study that used intensive direct observations of eight medical practices to assess the factors affecting the barriers and facilitators to adult immunization for influenza and pneumonia. The study aimed to describe the culture of these practices by identifying key features that facilitate or deter the immunization process. The article presents profiles of six of the eight practices describing their cultural and organizational frameworks. Six features that are critical to an understanding of the cultures of these practices, particularly as they relate to receptivity to influenza immunization for diverse practices and patient populations, are highlighted. These include policies and procedures, funding source, physician philosophy, patient receptivity to provider recommendation, and physical environment and social environment. The article also discusses strategies for applying knowledge about the culture of each practice to introduce appropriate and feasible interventions aimed at increasing immunization rates.     

Long-term follow-up of nonmyeloablative allogeneic stem cell transplantation for renal cell carcinoma: The University of Chicago Experience

Nonmyeloablative allogeneic stem cell transplantation (NST) has considerable activity in patients with metastatic renal cell carcinoma (RCC), although there are limited long-term follow-up data. Between February 1999 and May 2003, 18 patients with metastatic RCC underwent 19 matched-sibling NSTs after conditioning with fludarabine and cyclophosphamide with tacrolimus and mycophenolate mofetil as post-transplant immunosuppression. Among the four objective responses, all were partial and have relapsed with a median response duration of 609 days (range, 107-926). All responders are alive at a median of 41 months. Median overall survival for the entire cohort was 14 months. There were four early treatment-related deaths and one late treatment-related death. Eight patients died from progressive disease and five (28%) from treatment-related mortality. Stratifying transplant outcome as early death, intermediate (no response, no early death), or response, the combination of pre-treatment anemia and decreased performance status, was associated with adverse outcome (P = 0.015) and reduced survival (HR 5.4, 95% confidence interval of 1.4 to 21, P = 0.007). Responders demonstrated prolonged survival compared to nonresponders (P = 0.002). NST leads to durable responses in a minority of metastatic RCC patients. Appropriate patient selection is paramount. Anemia and decreased performance status may enable risk stratification.     

Renal hemodynamic effects of a selected calcium antagonist

Calcium antagonists are unique antihypertensive drugs that appear to exert selective blood pressure-lowering and possibly renal hemodynamic and functional effects in hypertensive patients and animals. There is evidence for inhibition of tubular sodium reabsorption and renal vasodilatation when certain of these agents are given by acute intravenous or intrarenal arterial administration. These renal effects have been observed to occur either independently or together. Both natriuresis and diuresis have been found to occur with these drugs. In the deoxycorticosterone-salt hypertensive dog, chronically administered diltiazem reduces blood pressure, transiently increases renal blood flow and increases urine volume. Administered either acutely or chronically to these hypertensive dogs, diltiazem depresses renal vascular reactivity. Pressor and renal vasoconstrictor responses to angiotensin II and norepinephrine are attenuated to a similar degree. The chronic blood pressure-lowering effect of diltiazem is most likely a function of depressed vascular reactivity; however, actions at other sites cannot be ruled out based on our experiments. Postprandial renal vasodilatation readily occurs in the conscious instrumented dog, and although this response is blocked by the acute administration of a calcium antagonist, the response is unaltered during the chronic administration of diltiazem.     

Nursing home staff perspectives on adoption of an innovation in goals of care communication

Nursing homes (NH) are important settings for end-of-life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross-sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.     

Authors’ reply to the letter about “loss of seton in patients with complex-anal fistula: a retrospective comparison of conventional knotted loose seton and knot-free seton” by Horeman-Franse

Techniques in Coloproctology -     

An evaluation of outcome from intensive care in major medical centers

We prospectively studied treatment and outcome in 5030 patients in intensive care units at 13 tertiary care hospitals. We stratified each hospital's patients by individual risk of death using diagnosis, indication for treatment, and Acute Physiology and Chronic Health Evaluation (APACHE) II score. We then compared actual and predicted death rates using group results as the standard. One hospital had significantly better results with 69 predicted but 41 observed deaths (p less than 0.0001). Another hospital had significantly inferior results with 58% more deaths than expected (p less than 0.0001). These differences occurred within specific diagnostic categories, for medical patients alone and for medical and surgical patients combined, and were related more to the interaction and coordination of each hospital's intensive care unit staff than to the unit's administrative structure, amount of specialized treatment used, or the hospital's teaching status. Our findings support the hypothesis that the degree of coordination of intensive care significantly influences its effectiveness.     

The second move: health and geographic mobility

Litwak and Longino (1987) proposed a life course typology of elderly migration in which the second type of move is associated with the development of chronic disabilities that make it difficult to perform everyday household tasks. We examined this intermediate type of move, classified between "amenity moves" in early retirement and "institutional" moves in late old age, a type of migration that had not been verified in existing research. Using data from the 1984 and 1986 waves of the Longitudinal Study of Aging by the National Center for Health Statistics, we tested the proposition that the proportion of moves increases with higher levels of instrumental functional disability over time. The probabilities generated by our model have an impressive range as predicted by Litwak and Longino in the second move portion of their model of retirement migration.     

Asymptomatic glomerulonephritis after nonstreptococcal upper respiratory infections.

Two hundred forty previously healthy military personnel with nonstreptococcal upper respiratory infections were prospectively studied to define the incidence and clinicopathologic characteristics of possible virus-associated glomerulonephritis. Nine patients without preceding streptococcal infection had erythrocyte casts on urinalysis and glomerulonephritis on biopsy. Of these nine, four had a reduction in total hemolytic complement and five had serologic evidence of infection with adenovirus, influenza A, or influenza B. Initial renal biopsy showed either focal or diffuse mesangial proliferation in all nine, with mesangial C3 deposits in six specimens. Repeat biopsy in three showed histologic improvement or loss of immunofluorescent staining, or both. Sequential creatinine clearances were reduced to 74 to 90 mL/min.1.73 m2 in five patients for the duration of follow-up. We conclude that nonstreptococcal upper respiratory infection is frequently associated with glomerulonephritis and that abnormal glomerular structure and decreased creatinine clearances may persist for at least 2 to 8 months.     

Treatment of end-stage diabetic nephropathy: over a decade of experience at one institution

Results of treatment of end-stage renal disease in 139 patients with diabetes mellitus revealed survival of 76% at 1 year and 48% at 5 years. These results compare favorably with other reports from Europe and the United States, probably because of the greater number of patients receiving renal transplants, and possibly because of the use of continuous ambulatory peritoneal dialysis as a recent treatment modality. Patients not receiving transplants were much older (mean age, 47.8 years) than those receiving transplants. Of those not given transplants, survival was best on CAPD. Comparison of those surviving at least 3 years was made with those expiring in the first year. Long-term survivors were younger, had diabetes for a shorter period, but had higher mean blood pressures and serum creatinine values than short-term survivors. Short-term survivors also had over a 50% incidence of prior myocardial infarction or cardiorespiratory arrest, while no long-term survivors had such a history. Long-term survivors were also more likely to have received a transplant, and short-term survivors were more likely to have received intermittent peritoneal dialysis or hemodialysis. A transplant from a living related donor is the treatment of choice for diabetics under age 40 and perhaps for older patients as well. The choice among CAPD, hemodialysis and cadaver transplant requires consideration of many factors.     

Liver involvement in the sulfone syndrome

A patient being treated with dapsone developed a hypersensitivity reaction with typical features of the "sulfone syndrome," including fever, malalse, and hepatitis. All abnormalities rapidly reversed with discontinuance of the dapsone regimen and institution of prednisone therapy. Hepatic involvement may be a prominent feature of the sulfone syndrome and may be of the hepatocellular or cholestatic type. Based on our review of the Food and Drug Administration reports, this syndrome appears to be relatively uncommon, but physicians need to recognize that expression of this syndrome may be incomplete. More clinical data are necessary to better define the incidence and pathogenesis of sulfone-induced liver disease.