Transfusion strategies: opportunities for improvement

Opportunities for improving transfusion practice that involve patient care, technological advancements, and technology changes in the clinical arena are discussed. Patient care should be enhanced by optimizing transfusion therapy and the source of donors of platelet concentrates, i.e., single donor platelets (obtained by plateletapheresis from a single donor) or to random donor platelets (containing a pool of six to eight platelet concentrates separated from whole blood donations). The availability of "third-generation" leukocyte-reduction filters provides the technology for significantly and consistently providing leukocyte-reduced blood components. The potential benefits of using these filters is presented. Platelet crossmatching represents a technology change involving clinical practice. Suggestions for incorporating this test into platelet transfusion algorithms are included.     

Critical care medicine

A postmortem case of HTLV-I associated myelopathy (HAM)/tropical spastic paraparesis (TSP) with a history of remission and exacerbation of neurological signs and symptoms, resembling those of multiple sclerosis is reported. MRI analysis revealed lesions in the periventricular white matter in addition to atrophy of the thoracic spinal cord, characteristic of HAM/TSP. The cerebral periventricular areas consisted of ill-defined paucity of myelin sheaths with astrocytic gliosis and hyaline thickening of blood vessels. The poorly demarcated white matter lesions found in both brain and spinal cord were different from plaques found in multiple sclerosis. It is suggested that, in some cases of HAM/TSP, inflammatory lesions that destroy myelin can involve not only the spinal cord but also the cerebral periventricular white matter.     

Infant formula, past and future: opportunities for improvement

Infant formulas provide nutritional support to health infants that promotes growth and development equivalent to that in healthy infants fed human milk. Formula-fed infants are not as well protected against infections, and there remain infants whose health, growth, and development may not be supported optimally by either the formulas currently available or human milk. Some infants may be better supported by genetically engineered formulas that contain immunity-enhancing antibodies or antigens. Formulas that contain cytokines promoting epithelial cell growth and integrity may be protective against necrotizing enterocolitis. Formulas containing proteins with genetically excluded allergenic epitopes or formulas with tolerogenic peptides may be useful in treating allergic diseases of suppressing the development of autoimmune disorders later in life. Formulas with genetically engineered biologically active substances might increase the absorption of nutrients in infants with compromised absorption or digestion, enhance host immunity and mucosal integrity, and, potentially militate or protect against the risk of disease.     

Challenges and opportunities in occupational medicine

Recent position papers of the American College of Physicians and the Institute of Medicine have emphasized the role of primary care physicians in occupational medicine. Although opportunities for physicians to become certified in occupational medicine have expanded, shortages in the specialty are likely to persist throughout the 1990s. To help acquaint osteopathic physicians with some of the challenges facing the specialty of occupational medicine, this article addresses the extent of occupational illnesses, health-related policies in the workplace, the delivery of occupational medical services, and graduate medical education.     

Critical care for organ failure

We retrospectively studied the critical care regimen for multiple organ failure (MOF) in 141 surgical MOF patients treated in the intensive care unit of Chiba University Hospital between January 1988 and April 1998. Patients with gut failure received parenteral instead of enteral nutrition for various reasons such as concomitant ileus. Of the patients with respiratory failure. 138 were placed on a ventilator and 6 received percutaneous cardiopulmonary support. Continuous hemodiafiltration (CHDF) was performed in 98 patients with renal failure. Plasma exchange was carried out in 13 patients with liver failure. Of these patients, 62 (44%) survived. Colloid osmotic pressure was used as an indicator for fluid therapy. For prophylaxis against bacterial translocation, we performed selective digestive decontamination. Recently blood purification methods, particularly CHDF, have become common in the critical care setting. CHDF is efficacious not only as continuous renal replacement therapy but also as a humoral mediator modulator and is currently the first-choice method for blood purification in critical care. In conclusion, there have been many advances in the critical care of patients with organ failure. Multidisciplinary treatment, including artificial support for failing organs, is necessary for the survival of these patients.     

Critical Path education: necessary components and effective strategies

Proper use of Critical Paths based on a solid educational foundation aids caregivers in meeting the ultimate challenge of today's healthcare environment: to provide a higher quality of care at a lower cost. The components for a comprehensive educational program for Critical Paths include general principles, Path contents, Path development, guidelines for documentation, variance data collection and evaluation. A strategy to provide large numbers of staff with background information is through the use of self-learning packets; the case study approach is an appropriate strategy for Path specific education. Evaluation data indicate that both strategies are effective in assisting staff to develop and implement Critical Paths.     

Fundamental strategies for skin care

The Agency for Health Care Policy and Research (AHCPR) identified the need to develop clinical practice guidelines for the prevention and treatment of pressure ulcers, a segment of wound and skin diagnoses. The skin is the first line of defense in protecting the body from constant changes in the environment. Far too often, the attention needed for the skin is only realized after the integrity has been disrupted. This article examines the anatomy and physiology of the skin, factors that affect the skin (aging, bathing, cleansers, dryness, friction, lotions, moisturizers, nutrition, soaps and shearing forces), indications and contraindications of topical skin care products, and AHCPR's recommended interventions. These elements are integral to clinicians in proactively developing sound skin care prevention strategies. Yet without a thorough understanding of all components, the skin's integrity remains at risk.     

Evolutionary paths in strategy space: an improvement algorithm for life-history strategies

Life-history strategies are analysed using a matrix population model. Within this framework an organism can be characterized at a particular time by a suitable state variable such as age or size, or both. A life-history strategy specifies the action an organism takes in each state. Given a life-history strategy one can find the reproductive value of the various states under this strategy. One can then ask whether an organism following the strategy chooses actions to maximize the reproductive value of itself and its offspring in one year's time. It is shown that if it does not, then a simple procedure identifies a life-history strategy with higher fitness. This strategy-improvement result leads to a necessary and sufficient condition by which (globally) optimal life-history strategies in natural populations can be recognized. We can define two life-history strategies to be one step away from each other if they specify the same actions at all states but one. Using this concept one can then define a topology on the phenotypic space of all life-history strategies. The topology taken together with a fitness measure defines the landscape of "strategy space". Results on strategy improvement are used to show that, in contrast to the landscapes usually envisaged for genotype space, strategy space is unimodal: there are no local optima other than global optima, and from every strategy one can reach a global optimum by a non-descending path.     

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine

OBJECTIVES: To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies. DATA SOURCES: Pertinent literature in the English language. STUDY SELECTION: One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services. DATA EXTRACTION: Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought. DATA SYNTHESIS: Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue. CONCLUSIONS: Regionalization of critical care medicine probably is beneficial and the concept should be explored.     

Telehealth and the evolving health care system: Strategic opportunities for professional psychology.

Telehealth (previously telemedicine)—the use of telecommunications to provide health information and care across distance—has recently reemerged as a potentially effective way to provide general and specialty health care services and appears poised to enter mainstream health service delivery. Because telehealth may become a significant part of the future of health care, it is critical to all professions that it be defined broadly. Barriers to the appropriate development of telehealth must be examined and addressed. Professional psychology's ongoing integrated legislative, legal, marketplace, and consumer education strategies for dealing with recent broader market-driven changes in the health care system provide a solid framework for analyzing and ensuring that psychological practice is poised to manage the opportunities and challenges presented by this emerging field. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Rural America: Unique opportunities for health care delivery and health services research.

A general deterioration is occurring in the quality of life of rural Americans, and it is affecting the quality of health and mental health service delivery. About 24% of the U.S. population lives in nonmetropolitan areas where the citizens are older, less well educated, have lower incomes, and are more homogeneous in terms of ace and ethnicity. Medicare and private insurance discriminate against rural services in their reimbursement policies, and there is a shortage of health personnel in rural areas. However, there has been renewed congressional action to meet rural needs. Both the House and Senate have established rural caucuses, and an Office of Rural Health Policy has been established in the federal executive branch. Legislative successes were achieved between 1985 and 1988. Rural initiatives will provide psychology with unique opportunities in the next several years. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Community analysis for health planning: strategies for primary care practitioners

Primary care practitioners have an important role in planning for the health of individuals and selected target populations. Community analysis and needs assessment are the first steps in health planning. Community analysis involves identifying health issues within a community; gathering data about the community, the target group, and the health concern; analyzing data; and assessing community needs. Community needs assessment involves identifying both existing and potential health problems as well as health promotion needs. By using appropriate skills in carrying out needs assessments, primary care practitioners become active contributors in planning for the health of individuals, groups, and the nation as a whole. This article provides strategies for identifying, analyzing, and evaluating the health needs of a community.