Impact of baseline clinical and laboratory features on the risk of thrombosis in children with acute lymphoblastic leukemia: A prospective evaluation.

BACKGROUND: Children with acute lymphoblastic leukemia (ALL) have increased risk of thromboembolism (TE). However, the predictors of ALL-associated TE are as yet uncertain. OBJECTIVE: This exploratory, prospective cohort study evaluated the effects of clinical (age, gender, ALL risk group) and laboratory variables (hematological parameters, ABO blood group, inherited and acquired prothrombotic defects [PDs]) at diagnosis on the development of symptomatic TE (sTE) in children (aged 1 to ≤18) treated on the Dana-Farber Cancer Institute ALL 05-001 study. PROCEDURES: Samples collected prior to the start of ALL therapy were evaluated for genetic and acquired PDs (proteins C and S, antithrombin, procoagulant factors VIII (FVIII:C), IX, XI and von Willebrand factor antigen levels, gene polymorphisms of factor V G1691A, prothrombin gene G20210A and methylene tetrahydrofolate reductase C677T, anticardiolipin antibodies, fasting lipoprotein(a), and homocysteine). RESULTS: Of 131 enrolled patients (mean age [range] 6.4 [1-17] years) 70 were male patients and 20 patients (15%) developed sTE. Acquired or inherited PD had no impact on the risk of sTE. Multivariable analyses identified older age (odds ratio [OR] 1.13; 95% confidence interval [CI]: 1.01, 1.26) and non-O blood group (OR 3.64, 95% CI: 1.06, 12.51) as independent predictors for development of sTE. Patients with circulating blasts had higher odds of developing sTE (OR 6.66; 95% CI: 0.82, 53.85). CONCLUSION: Older age, non-O blood group, and presence of circulating blasts, but not PDs, predicted the risk of sTE during ALL therapy. We recommend evaluation of these novel risk factors in the development of ALL-associated TE. If confirmed, these easily accessible variables at diagnosis can help develop a risk-prediction model for ALL-associated TE.

Increased post-traumatic survival of neurons in IL-6-knockout mice on a background of EAE susceptibility.

Axonal injury initiates a process of neuronal degeneration, with resulting death of neuronal cell bodies. We show here that in C57BL/6J mice, previously shown to have a limited ability to manifest a post-traumatic protective immunity, the rate of neuronal survival is increased if IL-6 is deficient during the first 24 hours after optic nerve injury. Immunocytochemical staining preformed 7 days after the injury revealed an increased number of activated microglia in the IL-6-deficient mice compared to the wild-type mice. In addition, IL-6-deficient mice showed an increased resistance to glutamate toxicity. These findings suggest that the presence of IL-6 during the early post-traumatic phase, at least in mice that are susceptible to autoimmune disease development, has a negative effect on neuronal survival. This further substantiates the contention that whether immune-derived factors are beneficial or harmful for nerve recovery after injury depends on the phenotype of the immune cells and the timing and nature of their dialog with the damaged neural tissue.

Quality improvement, housestaff, and the role of chief residents.

PURPOSE: Little is known about the role of chief residents in utilizing and promoting continuous quality improvement (CQI) and quality assurance (QA) methods with housestaff. The purpose of this study was to ascertain how chief residents could be involved more formally in improving the quality of care in a major public teaching hospital. METHOD: Fourteen chief residents on the major services at Boston City Hospital participated in early 1994 in either a focus group or an individual interview. Data were analyzed qualitatively using a grounded-theory methodology. RESULTS: The chief residents saw themselves as central to service delivery, teaching, and administration of the hospital. While they identified many role conflicts and system obstacles to providing quality patient care, they were uniformly positive about the contributions they made to Boston City Hospital and its patient population. They distinguished between formal QA and the major improvements they made on their services. Very few knew much about CQI methodology. CONCLUSIONS: Given increasing competition as a result of the rapid growth in managed care, hospitals with residency programs, especially public hospitals, must integrate their teaching programs into patient care models. Chief residents and the housestaff they supervise receive little training in CQI methods. As housestaff will be training and practicing in an environment where costs and quality will be intertwined, chief residents, with their credibility, contacts, and concern, can help incorporate CQI into the environment of graduate medical education.

Managing medical mistakes: ideology, insularity and accountability among internists-in-training.

By the end of graduate medical training, novice internists (collectively known as the housestaff) were initiated into the experience of either having done something to a patient which had a deleterious consequence or else having witnessed colleagues do the same. When these events occurred, the housestaff engaged in social-psychological processes, utilizing a variety of coping mechanisms and in-group practices to manage these mishaps. Three major mechanisms were utilized by the housestaff for defining and defending the various mishaps which frequently occurred: denial, discounting and distancing. Denial consisted of three components: the negation of the concept of error by defining the practice of medicine as an art with 'gray areas', the repression of actual mistakes by forgetting them and the redefinition of mistakes to non-mistakes. Discounting included those defenses which externalized the blame; namely mistakes which were due to circumstances beyond their control. These included: blaming the bureaucratic system outside of medicine; blaming superiors or subordinates within internal medicine; blaming the disease and blaming the patient. When they could not longer deny or discount a mistake because of its magnitude, they utilized distancing techniques. Not withstanding this shared elaborate repertoire of denial, discounting and distancing, it was found that profound doubts and even guilt remained for many housestaff. These troublesome feelings neither easily nor automatically resolved themselves. Interspersed among their defenses were fundamental questions of culpability and responsibility as they vacillated between self and other blame. For many 'the case was never closed', even as they terminated formal training, a point neglected in the medical and sociological literature. Little in their 3 year graduate program allowed them to work through the attendant vulnerability and ambiguity accompanying the managing of mistakes. Hence, there were maladaptive aspects of the collectively acquired defense mechanisms. The whole system of accountability during graduate medical specialty training was found to be a variable, and at times, contradictory process. The housestaff ultimately sees itself as the sole arbiter of mistakes and their adjudication. Housestaffers come to feel that nobody can judge them or their decisions, least of all their patients. As they progress through training even internal accountability cohorts--the Department of Medicine, teaching faculty and peers--are discounted to varying degrees. They have developed a strong ideology justifying their jealously guarded autonomy.(ABSTRACT TRUNCATED AT 400 WORDS)

Getting rid of patients: contradictions in the socialisation of internists to the doctor-patient relationship.

This article examines the impact of the professional socialisation of internists on the doctor-patient relationship. Utilising observation and interviews, the study found that the world of house staff (interns and residents) was defined by a paradoxical perspective on patients--characterised as a "Get Rid of patients' (GROP) orientation. This perspective was shaped by the poor conditions of public institutions, administrative mandates, demographic and disease factors, a narrow definition of professional practice and normative standards of professional conduct. There was active support and reinforcement from colleagues for GROP behaviour; peers, rather than attending faculty became the most important socialisers. To implement the GROP perspective, coping strategies emerged within the house-staff culture. These included the utilisation of the hierarchy and techniques such as negotiation, objectification, intimidation, omission and avoidance. No time in their training was identified as the right time to acquire humanistic doctor-patient relationship skills. Contrarily, the structure of the socialising institution was organised into a hierarchy in which the most obvious criterion and consequence of status was autonomy over or removal from the establishment of meaningful doctor-patient relationships.

Strategies for enhancing collaboration between social workers and physicians.

Strains between the professions of medicine and social work continue to exist as a result of basic differences in histories, values and socialization processes of the two professions. This paper suggests that collaboration between them will be enhanced by the identification of social work as a resource for the physician. The concepts of negotiation and exchange are utilized as the basis for collaborative strategies by individual social workers and on the departmental level.

An evolving paradigm of supervision within a changing health care environment.

As hospitals attempt to decrease their costs to survive in today's health care market, they are implementing resizing strategies that promise greater efficiency. A by-product has been the elimination of many management and supervisory positions. A self-administered questionnaire was sent to a stratified random sample of 750 hospitals (yielding a 46% return rate) to study the types of supervisory models being utilized and the factors associated with their differential use. While concern is expressed about the erosion of clinical supervision, the data suggests that the majority of social workers are receiving supervision from a social worker.

Sources of strain between physicians and social workers: implications for social workers in health care settings.

This paper analyzes the sources of strain between the professions of medicine and social work. The two professions are compared in relation to (1) the organization and socialization process of professional training; (2) perspectives on patient care, illness and role of the health care professional; (3) attitudes toward knowledge and data; (4) attitudes toward and preparation for team-work; (5) perspectives on the role of the patient; (6) perceptions of social work's function.

When social workers and physicians collaborate: positive and negative interdisciplinary experiences.

Interdisciplinary collaboration is becoming increasingly important as the current complexity and cost of health care require an efficient and well-coordinated service delivery system. To understand the factors contributing to positive and negative collaboration, 53 social workers and 50 physicians in 12 hospital settings were interviewed about their best and worst experiences collaborating on a case. Thirty precoded items were classified into three constructs that reflect aspects of collaboration related to the case, to interaction between collaborators, and to the competence of the collaborator. Differences between the two professions were greatest on the interactional factors, with social workers valuing them much more than physicians did. Communication appeared to be the only intrinsic or universal aspect of collaboration equally important to both groups in both types of cases. Implications for social work practice and leadership are discussed.

Effect of a changing health care environment on social work leaders: obstacles and opportunities in hospital social work.

The health care system is undergoing dramatic change in auspice, structure, and services delivery in response to an emphasis on market-driven, cost-containment strategies. Consequently, many hospital social work directors either have lost some of their administrative responsibilities or have expanded their span of control beyond social work services. This article examines the responses of social work administrators to the breadth of changes occurring throughout their hospitals; the major accomplishments of social work services within their facilities; and the failures, frustrations, and obstacles in the delivery of social work services. As a result of examining the relationship between their actual and anticipated behavior and changes in the hospital and external environment, the authors found that social work leaders in hospitals understand the complexities and challenges of the world around them. Overall, they have exhibited commitment, competence, and confidence in shaping organizational change.

Complexities of coalition building: leaders' successes, strategies, struggles, and solutions.

Government and private funding initiatives are promoting coalitions, collaborations, and other interorganizational approaches to address complex community, social services, and health issues. Social work organizers and administrators are increasingly leading coalitions themselves or representing their organizations in collaborative planning and problem solving, often without understanding how to manage the complexities involved in interorganizational relationships. This article reports on aspects of a larger quantitative and qualitative research project that studied coalition dynamics, operations, and outcomes. Coalition leaders interviewed defined success in multiple ways. Competent leadership was the factor most often identified with coalition success.

Preparation of social workers for a changing health care environment.

Rapid changes in health care have provided the impetus for social workers to reexamine their professional preparation for effective practice in health care settings today. Faculty teaching students and field instructors were asked to indicate on a questionnaire where specific subject matter is taught to social work students: in the classroom, in the field, or in both settings. Results of the study show a communication gap between school and field and a need for teaching models that enable educators to convey more of the profession's expanding knowledge base and to prepare students to deal with concurrent demands for expertise and expediency in practice. Programmatic changes to address these issues are suggested.

Collaboration between social workers and physicians: perspectives on a shared case.

As health care is being restructured, health care institutions are recognizing that interdisciplinary collaboration is an essential element of both effective patient care and organizational survival. This paper analyzes self-reported views of actual collaborative activities between 50 pairs of social workers and physicians on a specific shared case in an acute care hospital setting. Through examining the degree of congruence in perspectives of each pair of collaborators, we compare the two professions' views of the collaborative process and outcome. Additionally, each profession's outlook on its own and the other profession's roles and responsibilities in the case is examined. Our findings indicate that many social work and physician collaborators share similar perspectives about many aspects of their joint patient care endeavors. Where there was disagreement within a pair, almost always, it was a social worker selecting or discussing a variable when her physician counterpart did not. Physicians were less likely than their social work counterparts to identify patient/family problems related to adjustment to illness and problems connected to hospital and community resources as well. Social workers were much less satisfied with the collaboration, saw many more things that they or their collaborator could have done differently and even perceived more disagreement about the approach to the case than did their physician collaborators. It is important to understand, empirically, the dynamics of successful collaboration and to assist social workers in becoming influential and effective collaborators with other health professionals.

Vaccination with a Nogo-A-derived peptide after incomplete spinal-cord injury promotes recovery via a T-cell-mediated neuroprotective response: comparison with other myelin antigens.

The myelin-associated protein Nogo-A has received more research attention than any other inhibitor of axonal regeneration in the injured central nervous system (CNS). Circumvention of its inhibitory effect, by using antibodies specific to Nogo-A, has been shown to promote axonal regrowth. Studies in our laboratory have demonstrated that active or passive immunization of CNS-injured rats or mice with myelin-associated peptides induces a T-cell-mediated protective autoimmune response, which promotes recovery by reducing posttraumatic degeneration. Here, we show that neuronal degeneration after incomplete spinal-cord contusion in rats was substantially reduced, and hence recovery was significantly promoted, by posttraumatic immunization with p472, a peptide derived from Nogo-A. The observed effect seemed to be mediated by T cells and could be reproduced by passive transfer of a T cell line directed against the Nogo-A peptide. Thus, it seems that after incomplete spinal-cord injury, immunization with a variety of myelin-associated peptides, including those derived from Nogo-A, can be used to evoke a T cell-mediated response that promotes recovery. The choice of peptide(s) for clinical treatment of spinal-cord injuries should be based on safety considerations; in particular, the likelihood that the chosen peptide will not cause an autoimmune disease or interfere with essential functions of this peptide or other proteins. From a therapeutic point of view, the fact that the active cellular agents are T cells rather than antibodies is an advantage, as T cell production commences within the time window required for a protective effect after spinal-cord injury, whereas antibody production takes longer.

The changing scene of social work in hospitals: a report of a national study by the Society for Social Work Administrators in Health Care and NASW.

The Society for Social Work Administrators in Health Care and NASW collaborated on a national study of the changes affecting social work services in a sample of 340 hospitals drawn from the member list of the American Hospital Association. The findings suggest that the changes affecting social work need to be viewed within the context of the dramatic changes occurring in the hospital and health care field. Although social work departments are experiencing decreases, these decreases often are not occurring at the same rate as those within the hospital overall. Growth is occurring in the types and scope of services. Social work is not being singled out for change, but it is critical that these trends continue to be monitored and proactive strategies used to enhance social work viability within a changing hospital environment.

Factor XIIIa as a nerve-associated transglutaminase.

Recent findings have led to changes in the traditional concept of nerve recovery, including the realization that injured nerves, like any other injured tissue, need the assistance of blood-derived cells and factors in order to heal. We show that factor XIIIa (FXIIIa, the potentially active a2subunit of factor XIII), an enzyme that participates in blood coagulation by stabilizing the fibrin clot, is also active in the nervous system where it may play a key role in the healing of injured tissue. We demonstrate that the plasma, macrophages and nerves of fish contain a 55 kDa form of transglutaminase that cross-reacts immunologically with the a-subunit of FXIII in mammals (80 kDa). The fish enzyme in the plasma, unlike its mammalian counterpart, is active, pointing to a difference in control of the coagulation pathway in the two species. Analysis of FXIIIa expression in mammalian neural tissues and their response to injury revealed high levels of the enzyme in media conditioned by peripheral nerves as compared with medium conditioned by nerves of the central nervous system. Furthermore, similarity was observed in the postinjury behavior of FXIIIa in regenerating nerve tissues (peripheral nervous system of mammals and the central nervous system of fish). We suggest that the postinjury level of factor XIIIa in the nervous system may be related to the tissue's regenerative capacity, and that FXIIIa may therefore be a link underlying a possible association between the processes of blood coagulation and nerve healing.