STAFFING RATIOS IN A REHABILITATION PROGRAM

Staffing ratios for professional personnel functioning in an intensive physical rehabilitation program at Rancho Los Amigos Hospital, representing experience with treatment of patients with severe physical disabilities on the one hand and budget pressures and procedures on the other, are as follows:Physician to patients..... 1:33Nursing service per patient per day (including registered nurse, licensed vocational nurse, attendant).....4 hoursPhysical therapy to patients..... 1:7Occupational therapy to patients.... 1:14Medical social service to patients.... 1:35Psychology or vocational counselor to patients (needing service)..... 1:35     

Factors Affecting Admission to a Coronary Care Unit

Of 103 patients with suspected myocardial infarction admitted to an intensive care unit in a general hospital half were admitted within four and a half hours of the onset of symptoms. In general, patients who attended the casualty department were under intensive care sooner than patients who sought attention from their general practitioner before admission. Patients who were seen by a locum from the emergency treatment service at night or weekends were more likely to remain at home until seen the next day by their own general practitioner, compared with patients seen by their own general practitioner initially.     

A Markov Analysis of the Service System for Severe Mental Illness

Based on one year of services utilization data in Santa Clara County, we modeled the mental health service system as a time-continuous Markov process with corresponding Kolmogorov differential equations. The dynamics of the system's operations in that year can be expressed by the results derived from the intensity matrix and the explicit solution of Kolmogorov differential equations. The key problem with the system is linked to its emergency service. An unexpectedly high proportion of patients had a certain period in which they did not receive any services. Most of patients desired more intensive services. Some tentative thoughts about the stabilization of the system are discussed.     

The Canadian general internist: education and future role.

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

Morphology of Salmonella typhi in different inactivation techniques

Heat-phenol treatment of Salmonella typhi results in a denaturation of the cytoplasm and a smoothing of the cell wall with numerous ruptures. Following acetone inactivation the cell wall changes similarly, the cytoplasm is shrunken and its structures remain intact. Destruction is more intensive following heat-phenol treatment than after acetone precipitation. In both cases three contrasting layers of the cell wall can be seen.     

Vascular memory: can we broaden the concept of the metabolic memory?

ABSTRACT: Based on the results of recent randomized, controlled clinical trials and analyses of their follow-up periods the concept of metabolic memory cannot be restricted to antihyperglycaemic treatment only, rather it can be extended to lipid-lowering and antihypertensive treatment and even life-style modification. This broadened concept can be designated as vascular memory. According to this new concept, not only immediate and short-term but long-term effects of the metabolic and cardiovascular risk milieu are of great importance. Consequently, early and intensive lifestyle interventions, treatment of hyperglycaemia, lipid abnormalities and hypertension can result in beneficial effects on cardiovascular outcomes even in the long run. On the contrary, failing in target-oriented treatment from early detection of abnormalities can be associated with life-threatening cardiovascular events subsequently. Additional experimental studies are needed to characterize the exact pathomechanism of vascular memory and further clinical trials are also essential to explore its real clinical significance.     

Frequent infections of neutropenic pediatric patients and therapeutic modalities

Neutropenia, resulting from intensive chemotherapy is a common problem. The appearance of fever in neutropenic patients should always raise the suspicion of infection and should be followed by an intensive diagnostic evaluation and start of antibacterial treatment. The authors analyzed the association between isolated bacteria from blood cultures and the clinical background of all febrile episodes that occurred in neutropenic children in a two-year long period. Comparable to the international trends, our results suggest an increased prevalence of the Gram-positive organisms causing bacteriaemia. The clear majority of the isolated bacteria was coagulase-negativ Staphylococcus (cnS), which is a multiresistant strain, and sensitive only to the glycopeptide antibiotics. This latter fact can be a consequence of the frequent use of central venous catheters. The empirical therapy, the therapy used in microbiologically and clinically proved infections, and the supplementary and prophylactic methods of treatment are presented.     

Plasmapheresis in Clinical Medicine

Large-volume plasma exchange can now be rapidly and safely done using cell separator technology. Significant depletion of immunoglobulins and immune complexes can be achieved by repeated intensive plasmapheresis, but sustained depletion of these constituents requires concomitant immunosuppressive therapy. Plasmapheresis appears to work in some disorders by removing pathogenic antibodies, but other mechanisms of action have been postulated. It is the treatment of choice for thrombotic thrombocytopenic purpura and for the hyperviscosity syndrome due to macroglobulinemia. Apheresis can be useful in the treatment of many other disorders, most notably myasthenia gravis, glomerulonephritis associated with hemoptysis (Goodpasture''s syndrome), refractory systemic lupus erythematosus, cryoglobulinemia and immune cytopenic disorders.     

Soluble receptors for IL-1 and IL-4: biological activity and therapeutic potential.

Cytokine research has yielded a range of products which have now reached the stage of clinical trials and a plethora of novel therapeutics may be expected. Recently, cytokine receptors have also become an area of intensive research. Preliminary results indicate that recombinant soluble receptors can interfere with the biological functions of cytokines and thus may be appropriate for the treatment of certain pathological conditions where cytokine activity needs to be modulated.     

沈阳铁西老工业区土地的集约利用特征

利用基于QUICKBIRD和IKONOS数据解译得到的铁西老工业区土地利用状况,采用地统计和常规统计方法,分析代表区域环境和社会经济服务功能的用地类型的时空动态和集约利用特征.结果表明： 工业用地和住宅用地是沈阳市铁西老工业区主要的用地类型.2000-2010年,铁西区土地利用发生了明显变化.工业用地面积呈快速降低趋势,住宅用地面积呈增加趋势,公园、商服用地和绿地面积迅速增加.城区环境明显改善,综合宜居水平提高,功能定位日益明晰,商住服务功能日趋完善,土地利用效率逐渐提高.2002年以来,铁西老工业区区域土地集约化利用水平有了明显改善,但土地资源的集约潜力仍旧可以进一步挖掘.
     

5. New approaches to the management of flail chest.

Although continuous positive-pressure ventilation (internal pneumatic fixation) was a great advance in the treatment of flail chest and is now the standard treatment of this condition, early and late complications related to tracheostomy and long-term ventilation are associated with this method. These complications can be avoided by use of three recently adopted techniques--expectant therapy, intermittent mandatory ventilation with positive end-expiratory pressure, and early surgical stabilization of fractures. All patients should continue to be treated in intensive care units so that impending respiratory failure can be identified and treated. These newer forms of therapy not only have the advantages of avoiding complications inherent in tracheostomy and prolonged ventilation, but also decrease the length of hospital stay and expense of treatment.     

Drug Addiction,Psychotic Illness and Brain Self-Stimulation: Effective Treatment and Explanatory Hypothesis

Similarities between drug addiction and psychotic illness suggested that drug addicts could be treated with intensive ECT and phenothiazine drugs, a therapeutic approach effective in more serious psychotic illnesses.The use of this intensive treatment method is described in six drug addicts. Successful results were achieved in four patients who have been followed up for two to five years. The treatment program, the preliminary investigations and the follow-up procedures are described.Particular reference is made to the brain self-stimulation studies of Olds and others in animals, and those of Heath in man. A hypothesis is advanced to explain the various aspects of the clinical picture in both psychotic illness and drug addiction.The intensive method of treatment should be considered for drug addicts whose prognosis is otherwise poor. Further investigations along the lines of the proposed hypothesis might be profitable in other types of abnormal and maladaptive behaviour.     

Acute psychiatric care: approaches to increasing the range of services and improving access and quality of care

Acute services for mental health crises are very important to service users and their supporters, and consume a substantial share of mental health resources in many countries. However, acute care is often unpopular and sometimes coercive, and the evidence on which models are best for patient experience and outcomes remains surprisingly limited, in part reflecting challenges in conducting studies with people in crisis. Evidence on best ap­proaches to initial assessment and immediate management is particularly lacking, but some innovative models involving extended assessment, brief interventions, and diversifying settings and strategies for providing support are potentially helpful. Acute wards continue to be central in the intensive treatment phase following a crisis, but new approaches need to be developed, evaluated and implemented to reducing coercion, addressing trauma, diversifying treatments and the inpatient workforce, and making decision‐making and care collaborative. Intensive home treatment services, acute day units, and community crisis services have supporting evidence in diverting some service users from hospital admission: a greater understanding of how best to implement them in a wide range of contexts and what works best for which service users would be valuable. Approaches to crisis management in the voluntary sector are more flexible and informal: such services have potential to complement and provide valuable learning for statutory sector services, especially for groups who tend to be underserved or disengaged. Such approaches often involve staff with personal experience of mental health crises, who have important potential roles in improving quality of acute care across sectors. Large gaps exist in many low‐ and middle‐income countries, fuelled by poor access to quality mental health care. Responses need to build on a foundation of existing community responses and contextually relevant evidence. The necessity of moving outside formal systems in low‐resource settings may lead to wider learning from locally embedded strategies.     

Prophylaxis and follow-up after possible exposure to HIV,hepatitis B virus,and hepatitis C virus outside hospital: evaluation of policy 2000-3

Problem Prophylactic treatment and follow-up after exposure to HIV, hepatitis B, and hepatitis C outside hospital needs to be improved.Background and setting Until January 2000, people in Amsterdam could report exposure outside hospital to either a hospital or the municipal health service. If they reported to the municipal health service, they were then referred to hospitals for HIV prophylaxis, whereas the municipal health service handled treatment and follow-up related to hepatitis B and hepatitis C and traced sources. For cases reported to a hospital, hospital staff often did not trace HIV sources or follow up patients for hepatitis B and hepatitis C.Key measures for improvement Providing adequate treatment for HIV, hepatitis B and hepatitis C after exposure for all reported exposures outside hospital.Strategies for change On 1 January 2000, a new protocol was introduced in which three Amsterdam hospitals and the municipal health service collaborated in the treatment and follow-up of exposures outside hospital. Both municipal health service and hospitals can decide whether HIV prophylaxis is necessary and prescribe accordingly. All people exposed in the community who report to hospitals are subsequently referred to the municipal health service for further treatment and follow-up.Effects of change The protocol is effective in that most people comply with treatment and follow-up. When indicated, HIV prophylaxis is started soon after exposure. In nearly two thirds of cases the municipal health service traced and tested the source.Lessons learnt Provision of treatment and follow-up in one place enables treatment, tracing and testing sources, and follow-up, including counselling and registration of all reported exposures in Amsterdam, which allows for swift identification of emerging epidemiological trends. Since May 2004 all Amsterdam hospitals have participated in the protocol.     

Treatment strategies in acute myeloid leukemia (AML). A. First-line chemotherapy

Chemotherapy remains the backbone of treatment in AML. Of all adult patients 65% go into remission and have a chance of longer survival and of even being cured. Among the responders, 25% can be cured by intensive and long-term chemotherapy. Since the effect of chemotherapy appears not to be limited to a special period of time, its antileukemic and curative potential could be further exploited by multiple-step chemotherapy combining double induction, intensified consolidation and long-term maintenance. Improved antimicrobial treatment and the use of hematopoietic growth factors may help making multiple-step chemotherapy practicable, thereby increasing the cure rate in AML.     

城市土地利用变化对生态系统服务的影响——以淮北市为例

城市是一类以人类活动为中心的社会-经济-自然复合生态系统.城市的快速蔓延及强烈的人类活动显著地改变了城市的土地利用结构,进而严重影响了城市生态系统服务及人居环境.通过遥感、GIS技术及生态系统服务价值评估等方法,对淮北市1987年、2000年和2007年3个时期20a间的土地利用结构及生态系统服务价值的演变进行定量评价.研究结果表明:1987-2007年间淮北市生态用地空间结构和面积发生剧烈变化,生态用地占城市面积的比例由91.45％降低至71.86％.1987-2000年,农田面积大幅度下降,而林地和水体都呈不同程度的增加趋势,建设用地面积增长迅速.2000-2007年,农田面积有所增加,林地和水体面积却明显下降,建设用地总面积虽然没有明显变化,但其聚集度显著增加.20年间,城市生态服务功能的价值呈现先增加后减少的趋势,在2000年达31.32亿元.2000-2007年,以废物处理和水源涵养功能退化最为严重.可见,城市土地利用结构的变化与生态服务功能密切相关,此结果可为淮北市景观格局优化及土地合理调控和管理提供一定的科学依据.     

Intensive Metabolic Support : Evolution and Revolution

ObjectiveTo describe a new aspect of critical care termed intensive metabolic support.MethodsWe performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data.ResultsIntensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness.ConclusionsIntensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness. (Endocr Pract. 2008;14:1047-1054)     

Cutaneous candidosis in immunosuppressed patients

One-hundred patients with candidosis of the skin, mucous membranes and nail plates (confirmed by cultivation) were examined. Topical or systemic antimycotic treatment was successful in 58 patients. After a complete evaluation, 42 patients were found to suffer from factors supporting candidosis —diabetes mellitus (12), anemia (3) and various local factors (10 patients); 27 patients showed a deficiency in cell-mediated immunity. In addition to intensive antimycotic therapy, successful treatment is affected by the actual immunity level and can be ensured by efficient immunomodulation treatment of immuno-deficiency.     

Mechanisms for flowering plants to benefit arthropod natural enemies of insect pests： Prospects for enhanced use in agriculture

Reduction of noncrop habitats, intensive use of pesticides and high levels of disturbance associated with intensive crop production simplify the farming landscape and bring about a sharp decline of biodiversity. This, in turn, weakens the biological control ecosystem service provided by arthropod natural enemies. Strategic use of flowering plants to enhance plant biodiversity in a well-targeted manner can provide natural enemies with food sources and shelter to improve biological control and reduce dependence on chemical pesticides. This article reviews the nutritional value of various types of plant-derived food for natural enemies, possible adverse effects on pest management, and the practical application of flowering plants in orchards, vegetables and field crops, agricultural systems where most research has taken place. Prospects for more effective use of flowering plants to maximize biological control of insect pests in agroecosystem are good but depend up on selection of optimal plant species based on information on the ecological mechanisms by which natural enemies are selectively favored over pest species.     

Establishing a robust chimeric antigen receptor T-cell therapy program in Australia: the Royal Prince Alfred Hospital experience

>himeric antigen receptor (CAR) T-cell therapy is a novel approved cancer treatment that has shown remarkable efficacy in the treatment of patients with relapsed leukemia and lymphoma. Implementation of CAR T-cell therapy in a hospital setting requires careful and detailed planning because of the complexities in delivering this specialist service. A multi-disciplinary approach with dedicated funding is required to meet clinical, scientific, logistic and regulatory requirements. Tisagenlecleucel was the first approved CAR T-cell therapy in Australia. The treatment has been made available to Australian patients in specialist public hospitals through federal and state funding. Royal Prince Alfred Hospital (RPAH) is one of Australia's oldest tertiary referral public health care institutions and was approved for the provision of CAR T-cell therapy service in 2019. A multi-disciplinary clinical program has been established for the collection and cryopreservation of donor cells shipped for manufacturing as well as for the receipt, storage and administration of CAR T-cell therapy and patient management. The program encompasses a Therapeutic Goods Administration-accredited apheresis unit and a state-of-the-art facility for cell processing, cryopreservation and storage. The program's clinical expertise extends to hematology, oncology, intensive care, pharmacy, neurology and radiology services with direct experience in managing patients receiving CAR T-cell therapies. The introduction of CAR T-cell therapies at RPAH was a complex undertaking facilitated by the existing infrastructure and clinical expertise.