David Rosenbloom

Heparin for 5 Days as Compared with 10 Days in the Initial Treatment of Proximal Venous Thrombosis

It is common practice to begin anticoagulant treatment of deep-vein thrombosis with a 10-day course of intravenous heparin, with warfarin added on day 5 to 10 and continued for several months. We performed a randomized, double-blind trial comparing a shorter course of continuous intravenous heparin (5 days, with warfarin sodium begun on the first day) with the conventional 10-day course of heparin (with warfarin sodium begun on the fifth day) in the initial treatment of 199 patients with acute proximal venous thrombosis documented by venography. The frequency of objectively documented recurrent venous thromboembolism was low and essentially the same in the two groups (7.1 percent in the short-course group vs. 7.0 percent in the long-course group). Because the observed difference between the groups was 0.1 percent in favor of the long-course group, it is unlikely (P less than 0.05) that a true difference in favor of this group would be greater than 7.5 percent; the difference could be as much as 7.3 percent in favor of the short-course group. Major bleeding episodes were infrequent, and the rate was similar in both groups. We conclude that a five-day course of heparin is as effective as a 10-day course in treating deep venous thrombosis. Furthermore, using the shorter course would permit earlier discharge from the hospital and thus offer substantial cost savings.

Readiness for organizational change: A longitudinal study of workplace, psychological and behavioural correlates

To examine factors influencing readiness for healthcare organizational change, 654 randomly selected hospital staff completed questionnaires measuring the logistical and occupational risks of change, ability to cope with change and to solve jobrelated problems, social support, measures of Karaseks (1979) active vs. passive job construct (job demand× decision latitude) and readiness for organizational change. Workers in active jobs (Karasek, 1979) which afforded higher decision latitude and control over challenging tasks reported a higher readiness for organizational change scores. Workers with an active approach to job problem-solving with higher job change self-efficacy scores reported a higher readiness for change. In hierarchical regression analyses, active jobs, an active job problem-solving style and job-change self-efficacy contributed independently to the prediction of readiness for organizational change. Time 1 readiness for organizational change scores and an active approach to job problem-solving were the best predictors of participation in redesign activities during a year-long re-engineering programme.

The impact of re-engineering and other cost reduction strategies on the staff of a large teaching hospital: a longitudinal study.

OBJECTIVES To examine changes over time in the hospital staffs perceptions of how rapid organizational change, caused by fiscal constraints imposed by governments, affects them, their work environment, and the quality of care and services that they provide. METHODS A random sample of hospital employees (n = 900) of a large Ontario teaching hospital participated in a longitudinal study which involved surveys at 3 measurement periods over a 2-year period. The questionnaire used in this study included scales reflecting work environment, emotional distress, personal resources, spillover from work to home and vice versa, and perceptions regarding patient care and the hospital as an employer. RESULTS Significant increases in depression, anxiety, emotional exhaustion, and job insecurity were seen among employees, particularly during the first year of the change process. By the end of the second year, employees reported deterioration in team work, increased unclarity of role, and increased use of distraction to cope. Job demands increased throughout the period whereas little change occurred in the employees job influence or decision latitude. Overall, the work environment was negatively affected. Although patient care was unaffected in the first year, a significant decline in perceptions of patient care, attention to quality improvement, and overall quality of care were later seen. CONCLUSIONS This study raises questions about whether hospital re-engineering and mergers will be able to achieve the cost reductions sought without sacrificing quality of work life. Along with the rapid change, there was increase in emotional distress among staff and a deterioration in their relationship with their employer.

Changes in general health and musculoskeletal outcomes in the workforce of a hospital undergoing rapid change: a longitudinal study.

This article aimed to examine changes in general health and time with back pain and neck pain and to identify predictors of any such changes. Hospital workers were studied longitudinally with surveys in 1995, 1996, and 1997 (N = 712). Back and neck pain were reported only at the 2nd and 3rd surveys. There was a significant decline in general health and significant increases in time with neck pain and back pain. Predictors of changes in these outcomes were mainly work-related variables (initial or change values), such as job interference with family, job influence, work psychological demands, and hours worked.

Can sodium valproate improve learning in children with epileptiform bursts but without clinical seizures

This study aimed to determine whether sodium valproate (VPA) improves cognitive performance and behaviour in children with learning and behavioural problems associated with electrographic epileptiform discharges but without clinical seizures. A randomized, double‐blind, single‐crossover trial was carried out with VPA or placebo on eight participants with different learning and behaviour problems. Participants also underwent neuropsychological testing under video EEG and the parent and teacher Behaviour Check List (CBCL; Achenbach 1991a, b) during each treatment phase. Clinically none of the children improved on VPA. On formal testing children were more distractable, had increased delay in response time, and showed lower memory scores while on VPA. In addition, parents reported higher internalizing scores on the CBCL while children were on VPA. Our data do not support the use of VPA in similar patients.

An N of 1 Service: Applying the Scientific Method in Clinical Practice

The N of 1 service at our institution acts as a full referral service for clinicians who want a definitive answer to a difficult management question, and an instructional environment for clinicians who have more time and want to learn to run their own N of 1 RCT. The trial design is a double blind, randomized pair, multiple crossover. A number of methodologic issues are discussed, such as appropriateness of the patients problem to N of 1 trials, feasibility, types of measurement, such as clinical objective measurement and quality of life measurement, as well as timing of these measurements. The analysis issues include developing a reporting method which is statistically powerful and understandable to clinicians with little research background. Some of these issues have been well investigated and some have not.

Drugs and exercise

In this article, we have examined some pharmacologic principles as they apply to drug use by healthy individuals. With the present emphasis on community activities, we have dealt with the impairment of thermoregulation by athletes and fun runners who may take normal over-the-counter medications for a variety of reasons. However, many of these drugs impair thermoregulation. Our additional focus has been on drug abuse, again by healthy people, often striving to enhance their performance. Here we have dealt principally with the anabolic and androgenic steroids and stimulants. Finally, we have reproduced the current list of medications permitted by the International Olympic Committee, but have also offered some suggestions of common medications that may be required by athletes for such illnesses as hay fever, upper respiratory tract infections, and other simple disorders (Table 2). These medications do not contain any ingredients prohibited by the International Olympic Committee regulations. It is important to remember that many of the compound medications often sold over-the-counter contain substances such as caffeine, codeine, and ephedrine, which the unwitting athlete, trainer or coach could prescribe for a legitimate indication but which could, and have in the past, cost such athletes Olympic medals.

Determinants of job stress and job satisfaction among supervisory and non-supervisory employees in a large Canadian teaching hospital.

This article explores the extent to which hospital workers at a large teaching hospital at different managerial/supervisory levels (designated and non-designated supervisors, and non-supervisory staff), experienced job stress and job satisfaction prior to the re-engineering of hospital services. For all groups, increased levels of job demands were associated with higher levels of stress. Lower levels of decision latitude were associated with increased job stress for designated supervisors. Increasing levels of decision latitude were associated with both job stress and satisfaction for the other two groups. Co-worker support and teamwork contributed to increased job satisfaction for all groups.

Job Loss among Hospital Workers: Antecedents and Consequences

This article looks at hospital workers in a large Canadian teaching hospital that was surveyed from 1995 to 1997. It compares the perceptions of the working environment and the coping mechanisms of employees who lost their jobs with those of the workers who remained with the hospital. Those who left perceived themselves to be significantly more emotionally exhausted than those who remained. In 1997, employees still with the hospital reported greater anxiety and emotional exhaustion than the workers who had left. The conclusion reached is that as the public sector attempts to become more efficient, the human cost of downsizing should be considered.