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Single organ dysfunction in bone marrow transplantation appears to indicate a systemic dysfunction that can lead to multiple organ dysfunction syndrome (MODS) and death. Researchers studied 199 patients admitted to a hospital for bone marrow transplantation. Ninety-three (48.5%) of the patients had a single dysfunction of the pulmonary, central nervous, or hepatic system that strongly predicted MODS. Fourteen patients died during the transplantation, 10 of multiple organ failure. Low levels of naturally occurring anticoagulants, protein C (PC) and antithrombin III (ATIII), were associated with multiple organ dysfunction. Around 68% of the patients who eventualy suffered MODS could have been identified beofre the first organ failure using a ATIII levels lower than 83.2% as a marker. Supplementation of PC and ATIII may discourage the progression of single organ dysfunction to MODS., Objective.--To define the frequency and outcome of organ dysfunction in bone marrow transplantation (BMT) and to determine if patients with organ dysfunction have lower levels of protein C (PC) and/or antithrombin III (ATIII) than those without organ dysfunction. Design.--Inception cohort of patients undergoing BMT, followed for 28 days, until hospital dismissal, or until death. Setting.--Bone marrow transplant department of a university hospital. Patients.--A total of 199 consecutive patients admitted for BMT. Interventions.--Standard supportive care was given to all patients. Main Outcome Measures.--Definitions of organ dysfunction were arrived at prior to beginning the study. They include pulmonary, central nervous system (CNS), hepatic, and renal dysfunction. Protein C and ATIII levels were measured prior to beginning the preparative regimen and weekly thereafter. Results.--Single organ dysfunction, manifesting as pulmonary, CNS, or hepatic dysfunction, occurred in 93 (48.5%) of the 199 patients and was a strong predictor of multiple organ dysfunction syndrome (MODS) and death. Death occurred in 14 (7.0%) of the patients. Cause of death was precisely identified in only four patients. Low levels of either PC or ATIII were associated with death and pulmonary, CNS, and hepatic dysfunction. Multivariate analysis showed ATIII and PC levels were associated with single organ dysfunction independent of the type of transplant, the type of preparative regimen, and the presence of bacteremia. Conclusions.--Single organ dysfunction during BMT is a marker for a systemic abnormality that has a high likelihood of progressing to MODS, similar to that seen in other critically ill patient populations. MODS is the leading cause of death in series of BMT patients. Low levels of ATIII and PC are markers of and may be involved in the pathogenesis of MODS in BMT. (JAMA. 1995;274:1289-1295)

Objective: To learn more about current attitudes and expectations of recent (June 1995) graduates of gastroenterology fellowship programs, why they chose either a private practice or academic career, and what impact managed care or health care reform had in their decision. Methods: Between April and June 1995, an 8-page, 35-question survey questionnaire was mailed to graduating fellows and returned for evaluation. Results: Graduates believed managed care had an impact on job availability, but it was not a factor in their job choice. Forty percent of the respondents reported that finding a job was either difficult or very difficult. The majority of respondents (67%) are pursuing a career in private practice. Most private practice physicians (PP) trained in 2-yr programs whereas academic physicians (AC) trained for the most part in 3-yr programs. The principal criteria on which decisions regarding job selection were based were similar between the two groups: coworkers, geographic location, access to patient care, and ability to perform endoscopy. Respondents in PP and AC expected to work 50-70 h/wk, care for patients with similar diseases, and have ample time for family. They would choose GI again as a career and believed that there is a future in GI. Salary expectations varied markedly between the two groups, and AC physicians were more concerned about their future financial needs. Twenty percent of PP physicians and 71% of AC physicians plan to participate in clinical research. Conclusions: Recent graduates of gastroenterology fellowship programs continue to have high expectations of their future careers. Although some had difficulty finding a job and stated that, although managed care had an impact on the job market, it had not yet become a major factor in their job selection. [ABSTRACT FROM AUTHOR]