The limited utility of fibrinogen I 125 leg scanning.

Using venography as the reference procedure, this study examined the utility of fibrinogen I 125 scanning for the detection or demonstration of deep venous thrombosis. The results demonstrate the inability of leg scanning to detect accurately the presence or absence of thrombi in the deep venous system. Most striking was the lack of sensitivity of this procedure in areas where the propensity for embolization is greatest. Sensitivity is extremely low in the anatomic areas where leg scanning demonstrates reasonable specificity. The results are nearly identical in the extremity not operated upon. The validity of all prior studies relying heavily or exclusively on 125I leg scans to determine the presence or absence of thrombi must be critically reassessed.

Pulmonary mycotoxicosis.

Mycotoxicosis is a term used to define a toxic reaction due to the ingestion of toxins produced by fungi. Oral ingestion, however, may not be the sole means of exposure. We have recently observed ten patients who had inhaled massive amounts of fungi, which resulted in an apparent toxic pulmonary reaction. Immunologic studies showed no sensitivity to various fungal antigen preparations and histologic study of the lung showed a multi-focal acute process, with primary involvement of the terminal bronchioles containing large numbers of various spores. Cultures from lung biopsy material revealed at least five fungal organisms. A one to ten year followup indicates that avoidance of massive reexposure to fungal dust is the key to the prevention of recurrent pulmonary mycotoxicosis.

Distal propulsion of vena cava umbrella by cardiac massage.

Distal propulsion of a 28 mm umbrella filter from vena cava to femoral vein occurred in a 75-year-old woman during external cardiac massage. After cardiac massage, filter position must be checked roentgenographically. Optimal management of distal migration might include placement of a second umbrella to prevent recurrent emboli and proximal migration of the dislodged umbrella.

Detection of covert myocardial sarcoidosis by scalene node biopsy.

The antemortem diagnosis of myocardial sarcoidosis is rare in patients without overt signs of the disease. Two patients are presented to alert physicians to the value of early scalene node biopsy when sarcoidosis could be the cause of marked disturbances in cardiac conduction. The first patient, aged 29 years, had first, second, and third degree atrioventricular block and intermittent left and right bundle-branch block; the second, aged 59 years, had second degree atrioventricular block and complete right bundle-branch block. Both had diagnoses of sarcoidosis based on scalene node biopsy. The cardiac conductive disturbance improved, and the symptoms disappeared with steroid therapy.

Open pulmonary biopsy. Nineteen-year experience with 416 consecutive operations.

Four hundred and sixteen open pulmonary biopsies through limited thoracotomies are reported. Tissue sufficient for diagnosis was obtained in all cases. Case selection, operative technique, spectrum of diagnoses, complications, and comparisons with other techniques are defined. Diagnoses by category were as follows: occupational, 105 patients (25 percent); neoplastic disease, 80 patients (19 percent); specific histologic diagnosis, (ie, sarcoidosis), 70 patients (17 percent); specific infection, 23 patients (6 percent); vascular diagnosis, 16 patients (4 percent); and nonspecific pulmonary disease, 122 patients (29 percent). Pneumothorax, minor in most cases, was the most common complication. It occurred in 97 (23 percent) of the patients, but only 24 (6 percent) required the placement of a chest tube. Pleural effusion occurred in 106 patients (25 percent) and was minor. Hemothorax occurred in two (0.5 percent) and superficial wound infection in three (0.7 percent). Overall mortality was 4.5 percent (19 patients). Only two deaths (0.4 percent) were related to the procedure. Open pulmonary biopsy remains our diagnostic method of choice in diffuse lung disease of undetermined etiology.

The coin lesion story: update 1976. Twenty years' experience with thoracotomy for 179 suspected malignant coin lesions.

We reviewed 179 patients who had undergone thoracotomy and resection of a suspected malignant coin lesion of the lung over the past 20 years to see if a policy of early thoracotomy was therapeutically valid. The average diameter of all lesions was 1.6 cm; the average diameter of 27 malignant lesions (15 percent) was 1.8 cm. Follow-up of the 27 patients with malignant neoplasms was 100 percent. The present survival rate of the 19 patients with primary lung cancer is 89 percent (17/19). Of 12 cases of primary lung cancer followed for five years, ten (83 percent) survived. The five-year survival of the eight patients with metastatic lesions was 25 percent (2/8). There were no postoperative deaths and few serious postoperative complications (four patients or 2 percent). Very small primary lung cancers detected and treated early do have the same poor prognosis as larger primary cancers.

Can the frequency of myocardial infarction be reduced during coronary artery operations.

A prospective experiment was carried out in 56 patients undergoing coronary artery revascularization to determine whether those having a glucose-insulin-potassium (GIK) perfusion during the procedure would have fewer myocardial infarctions (MI) compared with patients given a control perfusion of Normosol-R. Six patients (11%) developed an MI, defined as a 24-hour creatine phosphokinase MB isoenzyme value of 100 IU per liter or greater. Four (13%) had control perfusions and 2(8%) had GIK perfusion. One MI in a double-graft recipient who had GIK perfusion occurred because of a technical surgical error; therefore, the corrected MI rate was 13% in control patients compared with 4% for the GIK group. These data, as well as the more frequent spontaneous defibrillation in patients who had GIK perfusion, suggest that GIK was of benefit.

Quadruple coronary artery bypass grafting.

In our last 150 consecutive revascularization operations, 30 patients (20%) have had 4 or more bypass grafts. One patient died after quadruple grafting (mortality, 3%). Twenty-two (75%) of the survivors have been rehabilitated to active work status and 25 (86%) were considered by their cardiologists to have improved function postoperatively by New York Heart Association criteria. Preoperatively 15 patients (50% of the group) had either a markedly diminished ejection fraction (EF) or extreme elevation in left ventricular end-diastolic pressure (LVEDP) or both. Complete revascularization, with resection of ventricular aneurysms when present, can be carried out successfully in a high-risk group of patients. Elevated LVEDP or diminished EF per se is not a valid contraindication to myocardial revascularization.

Composition of the subscribers in a rural prepair group practice plan.

To determine the degree to which enrollees of the Greater Marshfield Community Health Plan were representative of the community the plan was designed to serve, a telephone survey of 1,838 households in the 30-township area was undertaken. The response rate was 93%, and data were obtained from 1,718 households containing 5,260 persons. Of these, 484 households had at least one health plan member. Since the plan accepts only persons under age 65, analysis of the data was limited to those persons aged 64 and younger. Results indicate that enrollees showed good representation of demographic variables such as age, sex, and relationship to the household head when they were compared to the under 65 population of the area. When the enrollee's socioeconomic characteristics (education, income, and occupation) were studied, it was found that, although enrollees showed good representation for most categories they tended to underrepresent the under 65 area population in the lowest income and education classes, as well as in the semiskilled or unskilled occupations. The opposite was true for the upper income and educational classes. Data on location of residence indicated that a strong relationship existed between enrollment and proximity to Marshfield, where the major health care center is located. The use of health services was found to be positively related to membership, with enrollees overrepresented among those with recent hospital or physician contacts. The ability to obtain coverage through employment or by other means was found not to be related to membership. Satisfaction as expressed by participants was much higher in the prepaid program than among those with other forms of coverage.

A Ten-Year Survey of Snowmobile Accidents, Injuries, and Fatalities in Wisconsin.

In brief: Snowmobile accidents and resulting casualties in Wisconsin were surveyed from 1973 to 1982. The number and rate of accidents peaked in 1974-75 and then declined through 1982, apparently because of state legislation providing for safety programs and trail development. Drivers aged 12 to 30 and with more than 100 hours' experience accounted for most accidents. Faulty judgment by drivers caused 57% of all accidents, and alcohol was involved in 61% of the fatal accidents. During the study period the most common injury site shifted from the head to the extremities. Recommendations to further reduce accidents are offered.

Leaders as combat fighter pilots. Research project targets leaders who support money-losing business strategies.

When strategic plans go awry and begin losing money, the smart thing to do is change course. But some leaders get so involved with the plan, they fail to navigate properly and fly right into the target. The organization can lose millions. Examine why this happens and what you can do to prevent it from happening in your organization.

Conflict: an imperative for success.

Conflict in organizations of any type is inevitable. Medical institutions, particularly multispecialty clinics, are no exception. This paper presents an examination of the anatomy of conflict in group practice settings. Several case studies, including the "Hunterdon Experiment," are presented to illustrate the outcome of conflict situations where management was unable to direct its energy to productive ends. Recommendations are made for identifying, considering, and resolving conflicts in a proactive fashion. The conflict management role of the top management of the organization is described, with particular emphasis on the pivotal position of the Medical Director.

Competencies for health management practice: a practitioner's perspective.

The current health care environment will require executive leadership with a new set of management competencies to effectively lead and manage the various components of a restructured health care delivery system. The traditional management skills of planning, organizing, directing, controlling, and staffing resources will remain relevant, but the true measure of professional success will be the development of conceptual skills. This means the ability to look at the health care enterprise as a whole, and recognize how changes in the environment shape your strategic mission, goals, and objectives. The successful health care leader will have a demonstrated ability to apply these conceptual skills to the development of information systems and integrated networks that position their organization to accept capitated risks. This paper examines the United States and Canadian health care systems from the perspective of both the more traditional hospital and the emerging medical care organizations. New importance of the team approach to leadership and management and all that entails is stressed.

Managing managed care. Grouping together is the answer.

Working through an organization is the only way to manage in a managed care system. To be successful we need sophisticated management information systems, outstanding leadership and management, and a discretionary income distribution system. We must be willing to accept venture risk even though we will not win all the time. We must be aggressive in developing these systems. In order to survive, the successful organization will have to manage first, itself; second, the buyer of care; and third, its own image. It must also learn how to deal with the competition.