Walter Baigelman

Sputum and blood eosinophils during corticosteroid treatment of acute exacerbations of asthma

Eleven patients with chronic bronchial asthma were studied during a noninfectious exacerbation. Each patient received 80 mg of prednisone daily for three days. Spirometric values, total blood eosinophil counts, and 24-hour quantitation of sputum eosinophils were studied. Three patients had total blood eosinophil counts of less than 250 at the time of presentation. Statistical comparisons with findings on Day 0 showed significant improvements for the one-second forced expiratory volume, total blood eosinophil count, and sputum eosinophil number. On Day 7, the one-second forced expiratory volume maintained a statistically significant difference from that on Day 0, but the total blood eosinophil count did not. Analysis of correlation coefficients showed significant relation between the total blood eosinophil count and one-second forced expiratory volume, the sputum eosinophil count and one-second forced expiratory volume, and the sputum eosinophil and total blood eosinophil counts. The conclusions are (1) blood eosinophilia is not an invariable feature of acute exacerbations of asthma; (2) numbers of blood and sputum eosinophils reflect the response of an acute exacerbation of asthma to corticosteroids; (3) sputum eosinophils may be more meaningful for monitoring the stable postcorticosteroid state; (4) there is no support for the belief that eosinophils disappear from the sputum of asthmatic patients with clinically effective doses of corticosteroids.

Congenital Bronchial Atresia: A Report Of 4 Cases And A Review Of The Literature

The clinical, radiographic, and pathologic findings in 82 patients with congenital bronchial atresia (CBA) have been reviewed, and we have discussed 4 additional cases. Most patients are asymptomatic and come to attention because of abnormal radiographic findings of a round or lobulated perihilar, solid, or cystic mass--the mucoid impaction sign. Typically, the region distal to the mass is hyperinflated. Recently, computed tomography has been shown to be diagnostic and its use obviates the need for other more complex imaging modalities or surgical exploration. Excisional surgery has been performed to preserve lung function in younger patients, because of lack of familiarity with the entity or, as in 2 of our cases, to prevent recurrent infections. Pathologic findings include a cystic, blindly terminating, mucus-filled bronchocele without connection to the main bronchial tree, but with normal subsequent generations of bronchi. Distally there is noncollapsible hyperinflation of the corresponding lung segment or lobe as the result of collateral ventilation from the surrounding lung. The anomaly is the result of an insult to the growing bronchial tree in early development. The differential diagnosis most often includes allergic bronchopulmonary aspergillosis, but cystic bronchiectasis, bronchogenic cysts, and intrapulmonary sequestration should also be considered. Unusual features in our 4 cases included recurrent pulmonary infections in 2 patients and thoracic cage asymmetry in 1.

Patient readmission to critical care units during the same hospitalization at a community teaching hospital.

The incidence and cause of patient readmission, during the same hospitalization, to a critical care unit was studied in an urban community teaching hospital. During a 12-month period, there were 1069 admissions to the critical care units with 640 patients being at risk for readmission. The readmission rate was 11.7%. Prematurity of transfer out of a critical care unit may have been a contributing factor in 4.2% of the readmissions. Cardiac and respiratory problems were the major contributing causes for readmission. Improved communication between physicians, nurses and therapists could probably decrease premature transfers that contribute to readmission. Enhanced awareness of need for, and ability to provide aggressive pulmonary toilet may diminish the incidence of respiratory relapse. More data is needed regarding acceptable readmission rates; prospective studies are needed to better define the patient population at risk.

Hospital economics of the hospitalist.

OBJECTIVEnTo determine the economic impact on the hospital of a hospitalist program and to develop insights into the relative economic importance of variables such as reductions in mean length of stay and cost, improvements in throughput (patients discharged per unit time), payer methods of reimbursement, and the cost of the hospitalist program.nnnDATA SOURCESnThe primary data source was Tufts-New England Medical Center in Boston. Patient demographics, utilization, cost, and revenue data were obtained from the hospitals cost accounting system and medical records.nnnSTUDY DESIGNnThe hospitalist admitted and managed all patients during a six-week period on the general medical unit of Tufts-New England Medical Center. Reimbursement, cost, length of stay, and throughput outcomes during this period were contrasted with patients admitted to the unit in the same period in the prior year, in the preceding period, and in the following period.nnnPRINCIPAL FINDINGSnThe hospitalist group compared with the control group demonstrated: length of stay reduced to 2.19 days from 3.45 days (p<.001); total hospital costs per admission reduced to 1,775 dollars from 2,332 dollars (p<.001); costs per day increased to 811 dollars from 679 dollars (p<.001); no differences for readmission within 30 days of discharge to extended care facilities. The hospitals expected incremental profitability with the hospitalist was -1.44 dollars per admission excluding incremental throughput effects, and it was most sensitive to changes in the ratio of per diem to case rate reimbursement. Incremental throughput with the hospitalist was estimated at 266 patients annually with an associated incremental profitability of 1.3 million dollars.nnnCONCLUSIONnHospital interventions designed to reduce length of stay, such as the hospitalist, should be evaluated in terms of cost, throughput, and reimbursement effects. Excluding throughput effects, the hospitalist program was not economically viable due to the influence of per diem reimbursement. Throughput improvements occasioned by the hospitalist program with high baseline occupancy levels are substantial and tend to favor a hospitalist program.

Bacteriologic assessment of the lower respiratory tract in intubated patients

Twelve patients with an endotracheal tube and a new infiltrate were assessed for differences in the bacterio-logic information that could be obtained by routine tracheal suctioning (RTS), a double-lumen protected-sheath brush passed through a flexible fiberoptic bron-choscope (B-FFB), and suctioning through a flexible fiberoptic bronchoscope (S-FFB). Gram stains and cultures were performed on all specimens. There was 100% agreement for the culture results obtained by RTS and S-FEB. It is concluded that RTS obtains comparable information to that obtained by the more expensive and more personnel-intensive B-FFB.

Quantitative sputum gram stains in chronic bronchial disease

The assessment of bacterial flora of the bronchial system can provide useful information for determining the presence of acute bacterial infections in patients with chronic bronchial disease. The authors examined the value of quantitative sputum gram stains performed in patients during acute bronchial exacerbations, recovery from such exacerbations, acute allergic exacerbations of chronic extrinsic asthma, and a stable period. The mean number of each morphologic type of microorganism was determined for 20 oil immersion fields. Ninety-nine percent of the patients without clinical evidence of bacterial infection had fewer than 16Haemophilus influenzae-like, 10 pneumococcus-like, and 18Neisseria-like microorganisms per gram stain oil immersion field. Even during the recovery period, when the patients were on antibiotics, we noted few gram negative rods, diphtheroid-like, or staphylococcus-like microorganisms on gram stain. The data indicate that upper limits may be set for numbers of microorganisms seen on gram stain in the absence of clinically apparent acute bacterial infection in chronic lung disease.

Pulmonary effects of head trauma

Knowledge of the interrelation of the central nervous system-respiratory axis is crucial to the management of patients with head injuries with or without concomitant pulmonary-thoracic problems. Damage to the central nervous system (CNS) can result in unexplained hypoxemia, noncardiac pulmonary edema, altered patterns of respiration, and an increased risk of aspiration. The damaged thorax and lung can contribute to brain ischemia and rises in intracranial pressure. The treatment of one end of the CNS-respiratory axis is not without effect on the other end of the continuum. Corticosteroids, diuretics, mannitol, iatrogenic hyperventilation, barbiturates, and vasopressors are used in the management of patients with head trauma, but may have an impact on oxygenation and ventilation. When positive end expiratory pressure is used in the management of a pulmonary process, it should be optimized and used with caution while monitoring for its effect on intracranial pressure. Pulmonary toilet, while remaining a necessity, must be performed in a manner so as to minimize potential negative effects on the brain. Hyperoxia and hypothermia should be avoided. Mechanical ventilation should be used as dictated by the desired PaCO2 and not as a mandatory adjunct to endotracheal intubation.

Overutilization of serum electrolyte determinations in critical care units

Electrolyte (E) utilization by medical and surgical house staff in the critical care units of a community teaching hospital was audited over a two-month period. One hundred forty-five patients involved in 708 patient days had 924 sets of electrolytes (SE). Of the 581 SE that were ordered as an additional set within 24 h, 10% were considered unnecessary and 65% could have had a single E substituted for the complete set. The conclusion of this study and literature review are: (1) Electrolytes are excessively ordered in the management of critical care patients. (2) When additional electrolyte data is required within 24 h, a single electrolyte will usually suffice. (3) Misutilization is equally prevalent among medical house staff and surgical house staff. (4) The cost savings to be realized from improved laboratory utilization are only a small percentage of the potential savings in charges. (5) No single, proven modality has been identified which will consistently, continually, and appropriately decrease laboratory overutilization.

Identifying Physicians and Patterns Generating Unnecessary In-Hospital Days An Exploratory Stage of Developing an Institution-Specific Physician-Focused Utilization Effort

A focused, concurrent utilization review effort identified the existence of a large number of unnec essary hospital days remaining even after a highly successful utilization review effort. Within a group of physicians identified as having the highest acuteness adjusted average lengths of stay, 38.3% of their pa tients hospital days were unnecessary, with 83% of those days being within physician control. Observa tion, diagnostic undertakings or therapeutic efforts that were unnecessary or appropriate for the out patient setting represented 81.3% of the unnecessary days. A future utilization study will compare the practice patterns among physicians in the same de partment in order to define future goals and develop necessary corrective actions that will be acceptable to the medical staff.

Relationship between Practice Characteristics of Primary Care Internists and Unnecessary Hospital Days

Background. Inpatient utilization review remains a useful approach for hospitals to achieve cost sav ings, however utilization review efforts need to be come more focused and sophisticated. Methods. In order to identify physicians with a higher percentage of unnecessary hospital days, and to analyze how their practice characteristics distin guished them from their colleagues, 364 consecutive admissions of 57 primary care internists were re viewed concurrently, on a daily basis. Days without acute hospital level of care that occurred while pa tients were awaiting placement in a rehabilitation or in a chronic care facility were adjusted out of the calculation. Analysis was undertaken to assess the impact of physician age, location of training, Board Certification, practice location, participation in med ical training programs, years of experience, and par ticipation in various types of managed-care programs on the level of unnecessary hospital days. Character istics of the patients and their illnesses were included in the analysis. Results. A large number of unnecessary hospital days occurred although there was no useful segrega tion of good from poor physician utilizers. Board certification and suburban practice location were as sociated with a significantly lower percentage of ad justed unnecessary days. Physician members of a closed-panel health maintenance organization had a lower percentage of adjusted unnecessary hospital days (14% vs. 41%, P < .001) when compared with the other primary care internists. Explanations for the difference are discussed. Conclusions. 1) The patients of primary care in ternists are still responsible for a large number of unnecessary hospital days; 2) Utilization review ef forts need to become more sophisticated and focused; and 3) A change in physician incentives coupled with appropriate staff and systems possibly would be the simplest, large-scale remedy.