Compliance and quality in residential life. Rhetoric and realities in today's ICF/MR: control out of control.

Contrasts between the rhetoric of quality assurance and the realities of poor quality in today's ICFs/MR were explored. Comparative studies have shown that ICFs/MR provide the poorest quality of life for persons with mental retardation. The ICF/MR operational model was described here as paper-oriented, failure-based, and insensitive to the effects of its own practices. Recommendations, including the establishment of local control, a less-direct relation between funding and rule compliance, and alternate forms of program evaluation and monitoring, were made.

Rules: the new institutions.

Despite the pervasive philosophy of normalization and the more recent emphasis on "quality assurance," service provision in today's Medicaid-funded residential environment has become more regulation-oriented and less person-oriented. In this article, this argument was presented in the context of rule-governed versus contingency-shaped behavior of caregivers. The culpable process was identified as the coercive enforcement of inaccurate rules, which precludes responsive staff action and generates adverse consequences. The impenetrable system of rules was compared to the "old institutions," and solutions were advanced to bring staff members more in contact with the natural contingencies of teaching and caring.

Pulse oximetry in the accident and emergency department.

The early detection and treatment of hypoxia is important to reduce patient morbidity in the accident and emergency department. At present, the commonly used methods all have practical difficulties in the urgent situations that prevail in the department. Pulse oximetry has recently become a method of choice in many anaesthetic and intensive care units for the continuous monitoring of oxygenation and the early detection of hypoxia. As similar conditions prevail in the accident and emergency department, we have attempted to evaluate its ease of use and the quality of information obtained in our department. Patients presenting with chest pain to an accident and emergency department have their oxygen saturation measured by the pulse oximeter finger probe prior to the commencement of oxygen therapy. After 5 min of oxygen therapy, the measurement was repeated. Our result showed that although no patients could be judged as hypoxic on clinical grounds the pulse oximeter showed, within 30 s of admission, that a number had an abnormal oxygen saturation. Continuous monitoring with the probe after the application of low flow oxygen therapy also aided in monitoring their treatment and this improvement was again easily and quickly recorded. Our experience shows that the pulse oximeter may be a useful tool for evaluating hypoxia and oxygen therapy in the accident and emergency department and we feel that we should be one of the groups who should reply in the positive to Zorab's question, 'Who needs pulse oximetry?' (Zorab, 1988).

Serum potassium responses to nebulized salbutamol administered during an acute asthmatic attack.

A prospective study of 20 patients presenting to an accident and emergency department with an exacerbation of pre-existing reversible airways disease was undertaken in order to determine whether such patients incurred any changes in their serum potassium following administration of 5 mg of nebulized salbutamol. Electrolytes were estimated before and 30 min after administration of nebulized salbutamol. No other drug was administered during this period. Results indicate that nebulized salbutamol can cause a significant hypokalaemic response in such situations. Eight out of the 20 patients studied demonstrated falls in serum potassium of more than 0.3 mmol/l. Most of the falls in serum potassium occurred in patients with low pre-treatment PCO2 values; a group of patients with less severe respiratory distress. This preliminary study indicates that a further study aimed at elucidating the clinical significance of nebulized salbutamol-induced hypokalaemia is required.

Scanning electron microscopy of rheumatoid arthritis peripheral blood polymorphonuclear leucocytes.

Peripheral blood polymorphonuclear leucocytes (PMNs) were isolated from six normal individuals and from 27 patients with rheumatoid arthritis (RA) by the Ficoll-Hypaque rapid single step centrifugation technique, fixed in suspension, and examined by scanning electron microscopy (SEM). In addition, four of the preparations from normal individuals and eight from patients with RA were examined by transmission electron microscopy (TEM). Most PMNs in preparations from normal subjects were spherical, unpolarised, and had their surface membrane elaborated into irregular ridges and small ruffles; they contained few phagocytic vacuoles and large numbers of electron dense primary and secondary granules. A minority of the cells were non-spherical, polarised, and had portions of their surface membrane elaborated into ruffled pseudopodia. In contrast, preparations of RA PMNs frequently contained fewer unpolarised PMNs and a higher number of polarised PMNs than did preparations of normal PMNs. Some preparations of RA PMNs also contained substantial numbers of spherical cells whose surface was covered mainly by bulges and blebs. Concurrent examination by TEM showed that RA PMNs frequently contained more phagocytic vacuoles and fewer electron dense primary and secondary granules than normal PMNs. The morphological and ultrastructural changes seen in RA PMNs resembled those which normal PMNs are known to undergo on exposure to C5a in vitro, during adherence to endothelial cells in vivo, or during phagocytosis in vivo or in vitro. Our observations, therefore, provide a useful morphological correlation to those in vitro studies in which differences in the functional activity of RA and normal PMNs have been shown. The possibility that the difference seen between RA and normal PMNs is artefactual and does not represent the genuine in vivo states of these cells is discussed.

Maladaptive behavior merits fair treatment: a response to Seltzer and Krauss.

This response is a reaction to a study by Seltzer and Krauss (1984), in which dichotomous measurement of the behavior-problem variable gave rise to some potentially misleading implications about community-placement planning. Some difficulties in measuring this complex variable were reviewed and a more functional behavior assessment advocated. The problem of maladaptive behavior as an obstacle to deinstitutionalization has not yet been resolved.

Aerophagia: an uncommon form of self-injury.

Aerophagia is a rarely recognized self-injurious behavior that consists of repetitive air swallowing with consequent belching, flatulence, and abdominal distention. The condition causes serious medical problems and can result in death. Possible causes of aerophagia and some attempts to treat it were reviewed briefly.

Effects of response satiation procedures in the treatment of aerophagia.

A contingent response that previously increased self-injurious air-swallowing (aerophagia) by a profoundly mentally retarded woman (Holburn & Dougher, 1985) was shown to decrease her air-swallowing when the response was presented in accord with the response deprivation/satiation hypothesis, which suggests that any free-operant response can serve as a reinforcer or a punisher depending upon specific contigency arrangements. The results offer an explanation for the earlier increase in air-swallowing.

Behavioral attempts to eliminate air-swallowing in two profoundly mentally retarded clients.

Attempts were made to eliminate the aerophagia (pathological air-swallowing) exhibited by two profoundly retarded clients in a state residential institution. In Experiment 1, a positive-practice overcorrection procedure (coactive mouth-covering) tripled the frequency of a female's air-swallowing and subsequent time-out failed to reduce it below free-operant levels. In Experiment 2, further unsuccessful attempts were made to reduce air-swallowing by the same subject using additional time-out procedures. For a second subject (Experiment 3), increased durations of positive-practice overcorrection produced corresponding reductions in air-swallowing. After physical opposition to treatment, overcorrection was withdrawn, resulting in near-baseline responding. Multiple baselines in each experiment showed no transfer effect. Findings were discussed with reference to investigators who reported negative side-effects of overcorrection and overcame them through continued experimental analysis.

A tannic acid based preparation procedure which enables leucocytes to be examined subsequently by either SEM or TEM.

A modification of the glutaraldehyde-osmium tetroxide-tannic acid-uranyl acetate (GOTU) fixation procedure is described which allows human leucocytes to be examined subsequently by either transmission electron microscopy (TEM) or scanning electron microscopy (SEM).

Centrifugation of normal and rheumatoid arthritis blood on Ficoll-Hypaque and Ficoll-Nycodenz solutions.

Attempts to use the rapid single-step Ficoll-Hypaque centrifugation procedure for the purification of mononuclear and polymorphonuclear leucocytes from the blood of normal individuals and rheumatoid arthritis patients have sometimes been unsuccessful, largely because the erythrocytes would not sediment through the centrifugation medium. Re-evaluation of the factors (e.g. Ficoll concentration, temperature, and ratio of the diatrizoate salts) which affect these separations showed that under our conditions it was advantageous to use a medium with a lower viscosity (Ficoll concentration) and/or a higher osmotic strength (increased sodium diatrizoate: meglumine diatrizoate) than had been recommended previously (Ferrante and Thong, 1978; 1980; Ferrante et al., 1982). Higher osmotic strength media must be used for separating the components of blood from rheumatoid arthritis patients than from normal individuals because rheumatoid arthritis erythrocytes have a lower buoyant density than normal erythrocytes.

Alterable correlates of extrinsic and intrinsic job satisfaction at a state residential facility.

A cross-section of employees at a state residential facility for mentally retarded persons was administered a composite questionnaire to assess factors associated with job satisfaction. Using a multivariate statistical approach, we examined two measures of job satisfaction (extrinsic and intrinsic) in relation to employee perceptions of organizational climate and selected job characteristics. Unique multiple regression analyses indicated that constraining conformity, decision frequency, and clarity of supervisor instructions were related to both measures of job satisfaction; organizational clarity, reward, and satisfaction with materials were related only to extrinsic satisfaction; and organizational standards and degree of resident contact were related only to intrinsic job satisfaction. Differences in variable contributions "ignoring" and controlling for other variables were emphasized. Variables were ranked according to their importance in predicting job satisfaction. Investigators are encouraged to consider the distinction between extrinsic and intrinsic job satisfaction in future research.