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This essay offers a layered account of the origins and enactment of a narrative medicine program at the Ohio University Heritage College of Osteopathic Medicine titled the Open Book Project (OBP). Narrative medicine positions clinical judgment as involving both scientific and narrative reasoning, a set of practices particularly well-suited to fostering inclusive health care and social justice. The OBP involved first-year medical students who met bi-monthly to witness, reflect on, and write about literary passages, visual images, music and lyrics, and other works of art. Sessions also provided opportunities for participants to attentively listen and respond to others, opening themselves to diverse ways of knowing and being. The authors move between academic literature, participants' compositions developed during the project, and students' testimonies to illustrate the dividends and difficulties of narrative medicine.

Background: The Multicenter Osteopathic Pneumonia Study in the Elderly (MOPSE) is a registered, double-blinded, randomized, controlled trial designed to assess the efficacy of osteopathic manipulative treatment (OMT) as an adjunctive treatment in elderly patients with pneumonia., Methods: 406 subjects aged >/= 50 years hospitalized with pneumonia at 7 community hospitals were randomized using concealed allocation to conventional care only (CCO), light-touch treatment (LT), or OMT groups. All subjects received conventional treatment for pneumonia. OMT and LT groups received group-specific protocols for 15 minutes, twice daily until discharge, cessation of antibiotics, respiratory failure, death, or withdrawal from the study. The primary outcomes were hospital length of stay (LOS), time to clinical stability, and a symptomatic and functional recovery score., Results: Intention-to-treat (ITT) analysis (n = 387) found no significant differences between groups. Per-protocol (PP) analysis (n = 318) found a significant difference between groups (P = 0.01) in LOS. Multiple comparisons indicated a reduction in median LOS (95% confidence interval) for the OMT group (3.5 [3.2-4.0] days) versus the CCO group (4.5 [3.9-4.9] days), but not versus the LT group (3.9 [3.5-4.8] days). Secondary outcomes of duration of intravenous antibiotics and treatment endpoint were also significantly different between groups (P = 0.05 and 0.006, respectively). Duration of intravenous antibiotics and death or respiratory failure were lower for the OMT group versus the CCO group, but not versus the LT group., Conclusions: ITT analysis found no differences between groups. PP analysis found significant reductions in LOS, duration of intravenous antibiotics, and respiratory failure or death when OMT was compared to CCO. Given the prevalence of pneumonia, adjunctive OMT merits further study.

Objective: Treatment of tuberculosis is a time-consuming and expensive process, often complicated by patient non-adherence. Directly observed therapy (DOT), an out-patient management strategy designed to ensure adherence, is not widely used because it is perceived to be too expensive. This study compared costs of tuberculosis treatment in DOT to the same factors in traditional therapy., Design: A retrospective economic evaluation of 659 tuberculosis cases was reported to a major metropolitan county public health department between 1980 and 1994. Out-patient costs, in-patient costs and the cost impact of relapse and acquired resistance were estimated in 1995 dollars., Results: Treatment costs were lower with DOT: $15,670 per case for in-patient care and $700 per case for out-patient care (P < 0.001). These cost differences resulted from shorter therapy duration (334 vs 550 days), fewer patient hospitalizations (58 vs 75%) and shorter hospital stays (26 vs 55 days per hospitalized patient). Relapse or acquired resistance occurred in 10.9% of patients and accounted for 35.7% of cost with traditional therapy, as compared to 1.2% of patients and 6.0% of cost with observed therapy., Conclusions: Directly observed therapy is less costly than traditional therapy.

This monthly series was developed from the AOA Task Force on AIDS Writers' Workshop, held August 16 to 18, 1991, in New York. The workshop was sponsored by an educational grant from Burroughs Wellcome. It will provide brief clinical updates and perspectives on the human immunodeficiency virus (HIV). Readers may request tear sheets from the AOA editorial offices.

Coumarin skin necrosis is a rare and usually unpredictable complication of coumarin therapy, occasionally leading to death. Onset is usually between the third and sixth day of coumarin therapy. The patient most commonly complains of pain in a region of abundant subcutaneous fat, with progression to erythema, petechiae, and gangrenous necrosis. Thrombosis of the dermal and the subcutaneous veins is demonstrated pathologically. We describe a case and review the pathogenesis, treatment, and prevention of this lesion.

Although there are no prospective studies regarding the frequency of postviral bronchial hyperreactivity syndrome, it is a common complication of upper and lower respiratory tract viral infections. The respiratory symptoms closely resemble those of asthma, but they are present for only 3 weeks to 3 months following the acute infection phase. Defining the mechanisms of this syndrome may provide insight into the pathogenesis of asthma. Postviral bronchial hyperreactivity syndrome is frequently misdiagnosed and inappropriately managed because many physicians are unfamiliar with this illness. Because of its characteristic history, diagnosis is straightforward when the physician knows what to look for, and response to therapy is excellent. This report presents a case history followed by a review of the proposed mechanisms of bronchial hyperreactivity following viral respiratory infections. The clinical features and criteria for diagnosing postviral bronchial hyperreactivity syndrome are also discussed.

The duration of handwashing was studied in two community hospitals (teaching and nonteaching). The duration in seconds of 180 handwashes by health care personnel and 52 handwashes by non-health care personnel were recorded. The mean duration for health care personnel was 8.62 +/- 0.29 SEM; the degree of patient contact did not influence the duration of handwashing. The duration of handwashing was two times longer in health care personnel vs. non-health care personnel (8.62 +/- 0.29 vs. 4.14 +/- 0.42; t = 7.7; p less than 0.001). Comparisons revealed no statistically significant difference in duration between personnel at teaching and nonteaching hospitals or among those in different occupations. The data indicate that the duration of handwashing among health care personnel is below the standard recommended by authorities in hospital infection control. This may be an important factor in the transmission and persistence of nosocomial infection in critical care units. The antimicrobial efficacy of handwashing agents should be reevaluated considering the actual duration of handwashing by health care personnel within the hospital environment or efforts should be made to increase the duration of handwashing.

We studied the association between the movement of operating room personnel and bacterial contamination of the operative field during 12 clean operations. Settle plates placed on the patient's chest and instrument table were exposed during the operation. As a control, settle plates were exposed in the same locations when no personnel and patients were in the room. Bacterial contamination of the aseptic field was categorized as disseminating (Group A: greater than 42 combined movements) and nondisseminating (Group B: less than 42 combined movements). There were 24 persons in each group. There was a highly significant difference between the two groups in the colony counts on settling plates. More vigorous movement was associated with increased bacterial contamination of the operative field. Low bacterial colony counts were found in the control plates, ruling out environmental sources of contamination. Bacterial fallout correlated with the movement of personnel. Measures to reduce excessive movement in the OR are recommended.