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Purpose – This paper aims to present the argument that effective physician leadership is needed to improve the quality and efficiency of healthcare delivery in the USA and around the world. Design/methodology/approach – This paper is based on an in-depth literature review, interviews with physician leaders and a study of the competencies required for physicians to successfully lead healthcare organizations. Findings – The paper finds that a clear need exists for training to improve specific leadership competencies among physicians, regardless of their career stage or career path. Research limitations/implications – Limited research has been conducted on the value of physician leadership and its impact on quality outcomes and patient safety. Practical implications – This paper establishes the need for physician leadership in healthcare organizations. Social implications – This paper will influence public attitudes within the healthcare sphere on the value that physician leaders can bring to healthcare. Originality/value – This paper fulfils a need for more study on the impact that physician leadership brings to quality and patient care, and establishes the need for physician leaders to obtain specific leadership competencies.

Physician leadership is increasingly recognized as pivotal for improved change in health care. Multi-professional care teams, education and leadership are evolving trends that are important for health care's future.

To the Editor:Drs. Dhaliwal and Sehgal1 raise some excellent points in their essay on the need to demystify leadership training during graduate medical education. As care delivery in the United States becomes increasingly complex, the need increases for strong, effective leadership from physicians.

Objective: The objective of this article was to provide a guide to health care providers on patient and family involvement in health care. Methods: This article evaluated the latest published studies for patient and family involvement and reexamined the objectives, the requirements for achieving these objectives, and the evidence of how to involve patients and families. Results: Critical components for patient safety include changing the organizational culture; including patients and families on teams; listening to patients and families; incorporating their input into leadership structures and systems; providing full detail about treatment, procedures, and medication adverse effects; involving them on patient safety and performance improvement committees; and disclosing medical errors. Conclusions: The conclusion of this article is that, for the future, patient and family involvement starts with educating patients and families and ends with listening to them and taking them seriously. If patient and family input is emphatically built into systems of performance improvement, and if patients and families are taken seriously and are respected for their valuable perspectives about how care can be improved, then organizations can improve at improving. Resources in health care are in short supply, yet the resources of patient and family help and time are almost limitless, are ready to be tapped, and can have a huge impact on improving the reliability and overall success for any health care organization.

Objective: The National Quality Forum (NQF) Safe Practices are a group of 34 evidence-based Safe Practices that should be universally used to reduce the risk of harm to patients. Four of these practices specifically address leadership. A recently published book, 7 Lessons for Leading in Crisis, offers practical advice on how to lead in crisis. An analysis of how concepts from the 7 lessons could be applied to the Safe Practices was presented nationally by webinar to assess the audience's reaction to the information. The objective of this article was to present the information and the audience's reaction to it. Method: Recommendations for direct actions that health care leaders can take to accelerate adoption of NQF Safe Practices were presented to health care leaders, followed by an immediate direct survey that used Reichheld's "Net Promoter Score" to assess whether the concepts presented were considered applicable and valuable to the audience. In a separate presentation, the challenges and crises facing nursing leaders were addressed by nursing leaders. Results: Six hundred seventy-four hospitals, with an average of 4.5 participants per hospital, participated in the webinar. A total of 272 safety leaders responded to a survey immediately after the webinar. A Net Promoter Score assessment revealed that 58% of those surveyed rated the value of the information at 10, and 91% scored the value of the webinar to be between 8 and 10, where 10 is considered a strong recommendation that those voting would recommend this program to others. Conclusions: The overwhelmingly high score indicated that the principles presented were important and valuable to this national audience of health care leadership. The 2010 environment of uncertainty and shrinking financial resources poses significant risk to patients and new challenges for leaders at all levels. A values-grounded focus on personal accountability for leading in crisis situations strongly resonates with those interested in or leading patient safety initiatives.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Podcasting is a recent creation combining old and new technologies allowing rapid, inexpensive delivery of media content (primarily audio) to the end user, both via the desktop environment and personal media players. The authors' group (the Society of Critical Care Medicine) saw the educational and communication potential for the podcasting concept, and have successfully designed and implemented the first podcast of a national medical society. As of this writing, there are an average of (mean +/- SD) 664 +/- 290 total downloads per podcast, and their podcast feed has been hit over 68,000 times in its first seven months. In this manuscript, the authors provide documentation of their successful endeavor, as well as a structured framework for other organizations to create similar products.

Four patients with severe burn injuries received enoxaparin 40 mg twice/day subcutaneously for the prophylaxis of venous thromboembolism (VTE). Peak antifactor Xa levels were measured 4 hours after administration of a dose, and trough antifactor Xa levels were measured 30 minutes before the next scheduled dose. Ultrasonography was performed once/week to assess the presence of VTE. Any occurrence of major bleeding was documented in the patients' charts. All patients had trough antifactor Xa levels below 0.1 U/ml. Enoxaparin dosages were subsequently adjusted to achieve trough antifactor Xa levels of 0.1-0.2 U/ml. This required dosages higher than those typically recommended for VTE prophylaxis (40 mg every 24 hrs or 30 mg every 12 hrs). One patient needed more than 60 mg every 12 hours. No patient had a venous thromboembolic event or major bleeding. The low antifactor Xa levels that were observed suggest that a reduced dose-response relationship may exist between subcutaneously administered enoxaparin and antifactor Xa activity in patients with severe burn injuries. Prospective studies should be performed to further investigate this relationship.

Critical care medicine trainees and faculty must acquire and maintain the skills necessary to provide state-of-the art clinical care to critically ill patients, to improve patient outcomes, optimize intensive care unit utilization, and continue to advance the theory and practice of critical care medicine. This should be accomplished in an environment dedicated to compassionate and ethical care.A multidisciplinary panel of professionals with expertise in critical care education and the practice of critical care medicine under the direction of the American College of Critical Care Medicine.Physician education in critical care medicine in the United States should encompass all disciplines that provide care in the intensive care unit and all levels of training: from medical students through all levels of postgraduate training and continuing medical education for all providers of clinical critical care. The scope of this guideline includes physician education in the United States from residency through ongoing practice after subspecialization.Relevant literature was accessed via a systematic Medline search as well as by requesting references from all panel members. Subsequently, the bibliographies of obtained literature were reviewed for additional references. In addition, a search of organization-based published material was conducted via the Internet. This included but was not limited to material published by the American College of Critical Care Medicine, Accreditation Council for Graduate Medical Education, Accreditation Council for Continuing Medical Education, and other primary and specialty organizations. Collaboratively and iteratively, the task force met, by conference call and in person, to construct the tenets and ultimately the substance of this guideline.Guidelines for the continuum of education in critical care medicine from residency through specialty training and ongoing throughout practice will facilitate standardization of physician education in critical care medicine.

OBJECTIVE To provide preliminary data on the resolution profile of aortic intimal injuries treated nonoperatively and on the safety of nonoperative management of these injuries. METHODS Five blunt trauma patients diagnosed by transesophageal echocardiography (TEE) with traumatic intimal injury of the aorta were assigned to nonoperative management. This included beta-blockade to maintain systolic blood pressure between 80 and 90 mm Hg and heart rate between 60 and 80 beats/min, serial TEE studies, and invasive monitoring in the intensive care unit. The evolution of injury, the effectiveness of nonoperative treatment, and the potential need for an operative intervention were monitored. RESULTS The patients had a mean Injury Severity Score of 32 and sustained multiple associated thoracic and extrathoracic injuries. Aortic injuries were located at the level of the ligamentum arteriosum and in the descending aorta adjacent to the diaphragm in three and two patients, respectively. The mean size of injury was 12.5 mm (range, 5-20 mm) and a thrombus attached to the endothelium was present in three of the five patients. Complete resolution of injury occurred within 9.4 +/- 6.6 days (range, 3-19 days). All patients remained hemodynamically stable and adequately perfused. All demonstrated progressive resolution of their aortic intimal injuries. No complications related to the aortic injuries were identified during a mean follow-up of 16.8 months. CONCLUSION This small series suggests that aortic intimal injuries smaller than 20 mm in hemodynamically stable patients treated with beta-blockade resolve within several days. This approach appears safe when monitored by serial TEE studies performed by experienced experts, and continuous invasive hemodynamic monitoring.

The American College of Physician Executives (ACPE) and the American Society of Health-System Pharmacists (ASHP) have a shared vision that health care professionals from multiple disciplines will work together in a coordinated fashion to improve the health and well-being of patients. Numerous recent

OBJECTIVE: To report a case of trovafloxacin-associated leukopenia, which occurred in a trauma patient shortly after administration and resolved following discontinuation of the drug. CASE SUMMARY: A 79-year-old white man was admitted to Yale New Haven Hospital after sustaining partial amputation of his right lower leg by an industrial lawn mower. After successful resuscitation, he underwent complete right lower amputation and was treated with intravenous alatrofloxacin mesylate. He developed leukopenia that resolved after discontinuation of the drug. DISCUSSION: Trovafloxacin is a broad-spectrum synthetic fluoroquinolone used for a wide variety of bacterial infections. We report, for the first time in the English-language literature, a case of trovafloxacin-associated leukopenia. The leukopenia resolved promptly after discontinuation of the drug. This association is further supported by the exclusion of other potential causes for this adverse effect. CONCLUSIONS: Leukopenia is a well-recognized adverse effect of several drugs. We report a case of trovafloxacin-associated leukopenia during treatment of a trauma patient. Healthcare personnel should be aware of this possible adverse reaction in patients treated with trovafloxacin.

The National Aeronautics and Space Administration (NASA) initially established a Commercial Space Center (CSC) in the Department of Surgery at Yale University School of Medicine to further develop and evaluate technologies in information systems, telecommunications applied to medicine, and physiologic sensors. The CSC is known as the Medical Informatics and Technology Applications Consortium (MITAC). The overall purpose for this NASA program is to leverage technology, innovation, and resources from industry and academia through collaborative partnerships. The Yale-NASA CSC/MITAC organized the Everest Extreme Expeditions (E3) for the spring Himalayan climbing seasons in the years 1998 and 1999. The primary mission was to deliver advanced medical support with global telemedicine capabilities to one of the world's most remote and hostile settings--Mount Everest. The purpose was both humanitarian (providing medical support) and scientific (conducting medical and technology research). The Yale team provided medical care for the Everest Base Camp community; conducted validation experiments for several types of advanced medical technologies in this remote, hostile environment; and performed real-time monitoring of selected climbers, while also assessing the basic science of altitude physiology. Additionally, the teams conducted outreach medical care to the citizens of Nepal and provided several educational forums for a variety of medical and nonmedical personnel--including school-age children. As part of the project's mission, the E3 medical teams at both Nepal and New Haven were on a 24-hour emergency call system to deliver medical care in the event of a crisis. Unlike most of the teams at Everest, the mission of E3 was not to climb the 29,028-foot mountain the Nepalese call Sagarmatha ("Sky Head"). The mountain served as an extreme testing ground for telemedicine. The lessons learned from this testbed are reviewed here and further clarify the abilities to provide better health care in remote and extreme environments--which for some may even be their home environment during/after a medical illness.

Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to improve quality of healthcare in hospital, nursing home, and remote environments. The objective of this study was to determine reliability of vital-signs monitoring systems in extreme environments. Three climbers were monitored 24 hours while climbing through Khumbu Icefall. Data were transmitted to Everest Base Camp (elevation 17,800 feet) and retransmitted to Yale University via telemedicine. Main outcome measures (location, heart rate, skin temperature, core body temperature, and activity level) all correlated through time-stamped identification. Two of three location devices functioned 100% of the time, and one device failed after initial acquisition of location 75% of the time. Vital-signs monitors functioned from 95%-100% of the time, with the exception of one climber whose heart-rate monitor functioned 78% of the time. Due to architecture of automatic polling and data acquisition of biosensors, no climber was ever without a full set of data for more than 25 minutes. Climbers were monitored continuously in real-time from Mount Everest to Yale University for more than 45 minutes. Heart rate varied from 76 to 164 beats per minute, skin temperature varied from 5 to 10 degrees C, and core body temperature varied only 1-3 degrees C. No direct correlation was observed among heart rate, activity level, and body temperature, though numerous periods suggested intense and arduous activity. Field testing in the extreme environment of Mount Everest demonstrated an ability to track in real time both vital signs and position of climbers. However, these systems must be more reliable and robust. As technology transitions to commercial products, benefits of remote monitoring will become available for routine healthcare purposes.

In order to characterize further the developing field of surgical critical care, we mailed letters to surgical critical care fellowship directors requesting the addresses of their graduates. We then mailed out surveys to the graduates and analyzed their responses. Resident teaching is a prominent feature for 85% of the graduates, with 94% of them teaching surgical critical care and 84% teaching general surgery residents. Sixty-five percent of the respondents spend at least 25% of their time providing surgical critical care, and 56% actively practice some aspects of general surgery as well. Not surprisingly, trauma care is a large part of the surgical intensivist's practice, with 74% also spending at least 25% of their clinical time caring for trauma patients. With this mix of responsibilities, the respondents performed an average of 148 operations annually. Of the surgeons who responded to the survey, 66% have academic practices. Over 75% were salaried, with 95% earning over $100,000 annually and 40% earning in excess of $150,000. Practice arrangements and patient mix varied substantially within the field. Several issues regarding the career choice of surgical critical care have been raised in previous studies, and the current survey helps to clarify several of these issues. Further surveys and follow-up studies are urgently needed to better characterize the career profile for surgical critical care.

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance.During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively.Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR.PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

Objectives: Leaders representing healthcare quality, purchasing, and certifying sectors convened at a national leadership meeting to address the issue of Healthcare-Associated Infections (HAIs). A session entitled BThe Quality Choir: A Call to Action For Hospital Executives[ featured harmonization partner organizations for the National Quality Forum Safe Practices (SPs) for Better Healthcare-2009 Update. (NQF SPs) The objective of the meeting was to determine if zero HAIs should be the improvement target for hospitals and what a Chasing Zero Department (CZD) should be like. Methods: Discussion and consensus building among these experts determined what a CZD would look like and what it would take to implement it. Results: Given that zero HAIs must be the goal, Hospital Infection Control Departments need to be restructured. Conclusion: Key design issues to the CZD addresses leadership, resources, and systems. & Leadership: CEOs and boards must communicate to the organization that the typical Infection Control Group might be restructured into a CZD. The leader must provide Bwill, ideas and execution,[ recognize the power of collaboration, provide funding, and establish a roadmap through use of NQF SPs. & Resources: Funding for these efforts must be provided. Chief Financial Officers (CFOs) need to understand that zero HAIs will preserve revenue. & Systems: Change can be made through leaders_ championship, use of SPs, performing improvement, information flow and Automated Infection Identification and Mitigation System (AIIMS). These are the key to systems change toward zero HAIs.

OBJECTIVES Leaders from healthcare quality, purchasing, and certifying sectors convened at a national leadership meeting held September 8-9, 2008 in Washington, DC to address issues of Hospital-Acquired Infections (HAIs). This paper provides opinion interviews from leaders who spoke at a session entitled "The Quality Choir: A Call to Action For Hospital Executives" on whether zero HAIs should be the goal of our Hospitals. METHODS The successes of many hospitals in dramatically reducing their infection rates were examined toward goals of "Chasing Zero" infections. RESULTS They agreed that the rhetoric of Chasing Zero HAIs must become reality, that anything less than aspiring to eradicate the risk of giving infections to patients for whom we deliver care is unacceptable. CONCLUSION Every hospital leader must re-evaluate the strategy, structure, and function of their infection control and prevention services toward the following parameters: Zero HAIs must be the goal. Purchasers will no longer wait for hospital losses to act. Forces of harmonization are an unprecedented force. New-found hospitals' harmonized standards can move from "playing defense" to "playing offense" against HAIs. Leaders must ignite the passion of teams to make rhetoric a reality. Real stories about real people communicate through real caregiver values. The power trio of governance, administrative, and medical leaders must turn their potential energy into action. We have the "what" we need to aim for, the "how" to get the job done, and it is now about engaging the "who" to seize the opportunity. Embrace champions to lead the charge.

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%.

This study examined the application of an artificial intelligence technique, the neural network (NET), in predicting probability of survival (Ps) for patients with penetrating trauma. A NET is a computer construct that can detect complex patterns within a data set. A NET must be "trained" by supplying a series of input patterns and the corresponding expected output (e.g., survival). Once trained, the NET can recall the proper outputs for a specific set of inputs. It can also extrapolate correct outputs for patterns never before encountered. A neural network was trained on Revised Trauma Score, Injury Severity Score, age, and survival data contained in 3500 of 8300 state registry records of all patients with penetrating trauma reported in Pennsylvania from 1987 through 1990. The remaining 4800 records were analyzed by TRISS, ASCOT, and the trained NET. Sensitivity (accuracy of predicting death) and specificity (accuracy of predicting survival) were 0.840 and 0.985 for TRISS, 0.842 and 0.985 for ASCOT, and 0.904 and 0.972 for the neural network. This represents a decrease in the number of improperly classified ("unexpected") deaths, from 73 for TRISS and 72 for ASCOT, to 44 for the neural network. The increased sensitivity was statistically significant by Chi-square analysis. The NET for penetrating trauma provided a more sensitive but less specific technique for calculating Ps than did either TRISS or ASCOT. This translated into a 40% reduction in the number of deaths requiring review, and the potential for more efficient use of quality assurance resources.

Childbirth Connection hosted a 90th Anniversary national policy symposium, Transforming Maternity Care: A High Value Proposition, on April 3, 2009, in Washington, DC. Over 100 leaders from across the range of stakeholder perspectives were actively engaged in the symposium work to improve the quality and value of U.S. maternity care through broad system improvement. A multi-disciplinary symposium steering committee guided the strategy from its inception and contributed to every phase of the project. The "Blueprint for Action: Steps Toward a High Quality, High Value Maternity Care System", issued by the Transforming Maternity Care Symposium Steering Committee, answers the fundamental question, "Who needs to do what, to, for, and with whom to improve the quality of maternity care over the next five years?" Five stakeholder workgroups collaborated to propose actionable strategies in 11 critical focus areas for moving expeditiously toward the realization of the long term "2020 Vision for a High Quality, High Value Maternity Care System", also published in this issue. Following the symposium these workgroup reports and recommendations were synthesized into the current blueprint. For each critical focus area, the "Blueprint for Action" presents a brief problem statement, a set of system goals for improvement in that area, and major recommendations with proposed action steps to achieve them. This process created a clear sightline to action that if enacted could improve the structure, process, experiences of care, and outcomes of the maternity care system in ways that when anchored in the culture can indeed transform maternity care.

Introduction: Surgical critical care (SCC) and trauma fellowships have developed in a variety of formats. Although SCC fellowships must meet specific requirements for accreditation by the Accreditation Council for Graduate Medical Education, trauma fellowships do not. As the American Board of Surgery is considering combining SCC, trauma, and emergency surgery into “acute care surgery” fellowship training, a better understanding of current program structures is needed. Methods: The Education Committee of the Surgery Section of the Society of Critical Care Medicine sent surveys by e-mail to all SCC program directors. The survey included questions regarding the content of the fellowship, specifically, subspecialty rotations, trauma content, and operative experience. If they offered a trauma fellowship, the survey queried its structure also. Results: A total of 39 of 82 surveys were returned. About one third of the programs have only SCC fellowships, one third combine SCC/trauma in 1-yr programs, and the remainder combine SCC/trauma in 2 yrs. Of the programs, 79% provided operative experience: 15% on a separate rotation and 39% on call during intensive care unit coverage. About half of the operative experiences were related to trauma and one quarter to emergency general surgery. The great majority of rotations were in general surgical or trauma intensive care units. Conclusion: SCC programs already include meaningful trauma and emergency general surgery operative experience. Surgical subspecialty intensive care unit and operative rotations may contribute to optimal training of the “acute care surgeon.”

Background: Assessment of cardiac volumes and cardiac output (CO) using a pulmonary artery catheter (PAC) in mechanically ventilated patients can be inconsistent and difficult. The esophageal Doppler monitor (EDM) is emerging as a potential alternative to the PAC. This prospective study evaluated the comparative accuracy between the PAC and EDM for preload assessment and CO in mechanically ventilated surgical patients. Methods: The EDM was placed in 15 patients with PACs in place. A total of 187 simultaneously measured EDM and PAC comparative data sets were obtained. The Pearson correlation (r) was used to compare measurements, with significance defined as a value of p < 0.05. Results: CO measured by EDM and PAC correlated closely (r = 0.97, p < 0.0001). Corrected flow time (FTc), a measure of left ventricular filling, correlated with PAC CO to the same degree as pulmonary capillary wedge pressure (PCWP) when positive end-expiratory pressure (PEEP) was < 10 cm H 2 O (FTc, r = 0.51; PCWP, r = 0.56). When PEEP was ≥ 10 cm H 2 O, FTc correlated with PAC CO better than PCWP (FTc, r = 0.85; PCWP, r = 0.29). Conclusion: FTc correlates with EDM and PAC CO better than PCWP. On the basis of the current study, it is reasonable to conclude that the EDM is a valuable adjunct technology for CO and preload assessment in surgical patients on mechanical ventilation, regardless of the level of mechanical ventilatory support.

The Information Age has made profound changes in society and is slowly entering the healthcare field. Some of the most important areas are telemedicine, the Internet, and the world wide web (www). Millions of physicians, healthcare providers, and patients are accessing the web daily for patient information, consultation, and distant learning. Telemedicine is beginning to enter the mainstream of health care after decades of demonstration projects. There are many issues which have been raised, such as access to the information, the security of the information, and the quality of the content on the web. While telemedicine is beginning to Hower, there are numerous barriers that prevent its rapid implementation, such as licensure, reimbursement, liability, quality of service, and technical issues. In spite of the numerous challenges, telemedicine over the Internet was practiced in one of the most remote areas of the world--Mt. Everest--demonstrating that it is possible to utilize all the latest healthcare telecommunications tools in even the most extreme of settings.

Objective To evaluate the benefits and risks of selective angiography for the evaluation of acute lower gastrointestinal (GI) bleeding to identify the site of bleeding and theoretically limit the extent of colonic resection. Design Retrospective chart review. Setting Tertiary care hospital. Patients Sixty-five patients undergoing 75 selective angiograms for evaluation of acute lower GI bleeding. Mean age was 71 years (range, 27-93 years), and 37 (57%) were women. Main Outcome Measures Demographic data were collected that included any associated medical problems, potential factors contributing to an increased risk for bleeding, and the diagnostic methods used in evaluating the source of lower GI bleeding. The details of angiography procedures were recorded with special attention to the impact of the procedure on clinical management and any associated complications. Results Twenty-three patients (35%) had positive angiography findings, and 14 of them (61%) required operations. Forty-two patients (65%) had negative angiography findings, and 8 of them (19%) required operations. Surgery for the 22 patients included hemicolectomy in 11 patients, subtotal colectomy in 10 patients, and small-bowel tumor resection in 1 patient. In 9 patients, a hemicolectomy was performed on the basis of angiography findings. Three patients (2 with negative angiography findings) experienced rebleeding after a hemicolectomy and required a subsequent subtotal colectomy. Overall, only 8 (12%) of the 65 patients underwent a segmental colon resection that was based on angiography findings and did not bleed after their operation. Complications from angiography occurred in 7 patients (11%). Conclusion Selective angiography appears to add little clinically useful information in patients with acute lower GI bleeding and carries a relatively high complication risk.