An internist joins the surgery service: does comanagement make a difference?

OBJECTIVE: To determine the effect of internist comanagement of cardiothoracic surgical patients on patient outcome and resource utilization. DESIGN: Before/after comparison. SETTING: Tertiary care university-affiliated Veterans Affairs hospital. PATIENTS: 165 patients (86 before the intervention and 79 after the intervention) undergoing cardiothoracic surgery. INTERVENTIONS: All patients were seen preoperatively and at least daily through discharge by a comanaging staff internist who was a full-time member of the surgical team. MAIN OUTCOME MEASURES: Length of stay, in-hospital mortality, and laboratory and radiology utilization. RESULTS: Significant shortening of postoperative length of stay (18.1 days before and 12.1 days after, p = 0.05) and total length of stay (27.2 days before and 19.7 days after, p = 0.03) was noted. The in-hospital mortality rate for the patients undergoing surgery was 8.1% before the intervention versus 2.5% afterward (p = 0.17). There were significant reductions in the total number of x-rays (p = 0.02) and nearly significant reductions in total laboratory test utilization (p = 0.06). Referring physicians and surgeons both believed that the contribution of the internist was important. CONCLUSIONS: The addition of an internist to the cardiothoracic surgery service at a tertiary care teaching center was associated with decreased resource utilization and possible improved outcomes. Before becoming more widely adopted, this intervention deserves further exploration at other sites using stronger study designs.

Medical technologists using molecular epidemiology as part of the infection control team.

Two medical technologists were appointed as permanent members of a new epidemiology section in the diagnostic microbiology laboratory of a large Veterans Administration Medical Center in the fall of 1989. These positions accounted for 9% of the total microbiology staff and were created on a temporary basis 2 years earlier from a need to have dedicated technical expertise for use in the culture, isolation, and typing of nosocomial organisms. The technologists have evaluated outbreaks due to Clostridium difficile, methicillin-susceptible Staphylococcus aureus, and Serratia marcescens, and have begun work on a methicillin-resistant Staphylococcus aureus (MRSA)-typing scheme. Their major responsibility has been the development and application of molecular biology techniques for the typing of nosocomial isolates, including restriction enzyme analysis of genomic DNA, plasmid profiling with and without restriction enzyme analysis, ribosomal RNA probing of restricted genomic DNA, and selected DNA sequencing of target organisms. Medical supervision rests jointly between the directors of the infection control program and the microbiology laboratory. During their tenure, infections due to C. difficile have dropped from 95 cases per year to 57 cases annually, treatment of MRSA colonization with systemic agents has been curtailed, and a case control investigation involving S. marcescens was avoided. The inclusion of medical technologists in the infection control practice of large medical care facilities, particularly with the availability of molecular epidemiologic techniques and the emergence of increasing numbers of multiply-drug-resistant pathogens, will become an essential component of these programs.

Emergence of ciprofloxacin resistance in nosocomial methicillin-resistant Staphylococcus aureus isolates. Resistance during ciprofloxacin plus rifampin therapy for methicillin-resistant S aureus colonization.

We initiated a randomized, single-blinded trial of ciprofloxacin plus rifampin vs sulfamethoxazole and trimethoprim plus rifampin in the therapy for patients who underwent colonization with methicillin-resistant Staphylococcus aureus (MRSA). Patients who were colonized with MRSA received 2 weeks of either regimen. The study was terminated after the enrollment of 21 subjects due to the recognition of ciprofloxacin resistance in 10 of 21 new MRSA isolates during the last 2 months of the study. Five of the 10 patients with ciprofloxacin-resistant MRSA isolates had never received ciprofloxacin. Long-term (6-month) eradication had been achieved in only three of 11 ciprofloxacin plus rifampin and four of 10 sulfamethoxazole and trimethoprim plus rifampin recipients. The use of this new fluoroquinolone for the eradication of MRSA colonization is usually not effective and may risk the development of ciprofloxacin resistance in MRSA within the hospital environment.

Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program.

PURPOSE: To enhance influenza vaccination rates for high-risk outpatients at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization program was implemented during 1987. PATIENTS AND METHODS: The program consisted of: (1) a hospital policy allowing nurses to vaccinate without a signed physician's order; (2) stamped reminders on all clinic progress notes; (3) a 2-week walk-in flu shot clinic; (4) influenza vaccination "stations" in the busiest clinic areas; and (5) a mailing to all outpatients. Risk characteristics and vaccination rates for patients were estimated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without similar programs. RESULTS: Overall, 70.6% of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated. CONCLUSION: The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization.

Acceptance of hepatitis B vaccine by hospital personnel.

Personnel at high risk of acquiring hepatitis B in two university-affiliated teaching hospitals were offered immunization against this disease. Of the 1,193 employees, 454 (38%) requested immunization. Individuals who declined or deferred immunization were sent questionnaires requesting the reasons for their decisions. Responses to the questionnaire were received from 487 of 674 personnel (72%). Most respondents (greater than 90%) indicated that they: 1) were aware of being at risk of acquiring hepatitis B, and 2) recognized the potential danger of the disease. A majority of respondents (56%) indicated that they had decided not to be immunized because they wanted to wait until more was known about the vaccine. Concern about specific side effects (eg, Guillain-Barré syndrome or acquired immunodeficiency syndrome) was cited much less often as a reason for declining immunization. Nearly one-fifth of questionnaire respondents either did not know the date of their last tetanus-diphtheria immunization or had not received a booster within the past decade.

Evaluation of a medical interviewing course. Use of the helping relationship inventory.

Changes in beginning medical students' preferred interview responses appear attributable to a course that emphasizes communication techniques for developing patient rapport. For each of five successive classes, pre/postcourse preferences were obtained for alternative response modes (categorized as understanding, probing, interpretive, supportive, and evaluative. Analysis indicated significant increases in students' preferences for understanding responses and decreases in preferences for evaluative responses (p less than .001). Changes are in the desired direction with respect to course goals, since rapport is generally enhanced by conveying understanding and refraining from premature evaluation. Effects on response preferences of some instructor characteristics are analyzed. Implications for health professions education and research are discussed.

Crescentic glomerulonephritis and renal failure associated with malignant lymphoma.

Two cases of crescentic glomerulonephritis and renal failure associated with malignant lymphoma are reported. The relationship of the lymphoma to the immune-complex glomerulonephritis is discussed.

Experimental infection of chimpanzees with antihemophilic (factor VIII) materials: recovery of virus-like particles associated with non-A, non-B hepatitis.

Non-A, non-B viral hepatitis was transmitted to four colony-born chimpanzees by infusion of three lots of antihemophilic factor (factor VIII) implicated in the transmission of non-A, non-B hepatitis to two human recipients. All four inoculated animals showed histopathological evidence of viral hepatitis, and all demonstrated significant ALT elevations between seven and one-half weeks after inoculation. Acute-phase plasma from one of the infected chimpanzees (no. 771) was shown to induce non-A, non-B hepatitis in two other chimpanzees approximately three weeks after their inoculation. In addition, an acute-phase open liver wedge biopsy obtained from animal no. 771 was processed and examined by immune electron microscopy (IEM) for virus-like particles with convalescent serum from a serologically confirmed case of non-A, non-B hepatitis. Twenty-five to 30 nm (mean = 27 nm) diameter virus-like particles that were either "full" or "empty" were identified in this liver preparation by IEM. Two additional chimpanzees inoculated with a cesium chloride gradient fraction of an isopycnically banded liver homogenate (animal no. 771) also developed elevated ALT activity two to two and one-half weeks later. Our findings have experimentally verified that commercially produced factor VIII materials can induce non-A, non-B hepatitis in champanzees and that the disease can be subpassaged in these animals by inoculation of either acute-phase plasma or liver. These results also provide evidence for the association of 27 nm-diameter virus-like particles with non-A, non-B viral hepatitis.

Linkage relationship of C2 deficiency, HLA and glyoxalase I loci.

Immunogenetic analysis of a homozygous C2-deficient individual and family members demonstrated linkage of HLA-A25, B18 and C2o. HLA-D typing showed that 5 members typed with homozygous Dw2 typing cells from an individual with C2 deficiency but not with Dw2 typing cells from 2 individuals with normal C2. The homozygous C2-deficient propositus and brother were HLA-A and B homozygous but heterozygous at the HLA-D and glyoxalase I loci. Therefore, in this family, the C2o gene is linked with two distinct haplotypes: HLA-A25, B18, Dw2, GLO1 and HLA-A25, B18, D unknown, GL02. These results could be explained by an ancestral recombinant event, which occurred between the C2o locus and HLA-D locus in which C2o segregated with HLA-B. This would suggest that the locus for the C2o gene maps between HLA-B and HLA-D on the sixth chromosome.