According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

1. Introduction and Overview. 2. Detecting Influential Observations and Outliers. 3. Detecting and Assessing Collinearity. 4. Applications and Remedies. 5. Research Issues and Directions for Extensions. Bibliography. Author Index. Subject Index.

Regression Diagnostics: Identifying Influential Data and Sources of Collinearity

Economic Control of Quality of Manufactured Product.

https://www.commed.vcu.edu/Chronic_Disease/2012/cochranrvwrschbias.pdf

The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

A nurse with a history of childhood asthma describes her experiences with intubation and mechanical ventilation. It is important for nurses to recognize that mechanical ventilation is very stressful for patients and for the patients' families. It is essential for nurses to keep the patient as the focus of their care. A key part of that focus is to reorient patients who are receiving mechanical ventilation frequently.

A Nurse’s Experience Being Intubated and Receiving Mechanical Ventilation

Background: Critically ill patients receiving prolonged
mechanical ventilatory support are at risk for loss of muscle mass and muscle
strength from immobility. Feasible, non-invasive methods are needed to accurately
obtain data on markers of muscle mass to design effective interventions and
monitor patient progress during recovery from
critical illness. Bioelectric impedance has been used in other settings to
obtain data on body composition and muscle mass. Purpose: The aims of this
study were to determine the feasibility of bioelectric impedance as a marker
of muscle mass in a sample of mechanically ventilated patients and to assess
data trends in these obtained values. Methods: A descriptive design was used to
obtain standard bioelectric impedance
parameters (total body resistance,
legs resistance, and percent lean body mass) over 4 days from eligible
patients already enrolled in a randomized clinical trial. Results: Bioimpedance
parameters were readily obtained over 4 days in a sample of 43 patients (age 59
+ 15.7 years, 56% male) receiving prolonged ventilatory support (mean 9.4 +
10.4 days) due to respiratory failure. Reasons for not obtaining impedance
measures included skin impairment, monitoring devices, or presence of implantable cardiac defibrillator or pacemaker. Average total body impedance was 464.3 + 117.1 ohms, while average impedance of legs
was 479.1 + 146.4 ohms. Lean body mass was 68.4% (+10.8).
Conclusions/Implications for Practice: With carefully trained staff and a standardized measurement protocol, bioimpedance is a feasible method to obtain body
composition data reflective of muscle mass in mechanically ventilated patients.
Further research will determine the utility of bioimpedance to monitor recovery
and effectiveness of interventions to restore function after prolonged periods
of ventilatory support and immobility in mechanically ventilated patients.

/pdf/feasibility-of-bioelectric-impedance-as-a-measure-of-muscle-2y1xkio59a.pdf

Feasibility of bioelectric impedance as a measure of muscle mass in mechanically ventilated ICU patients

Abstract Background Delirium is a highly prevalent and morbid syndrome in mechanically ventilated intensive care unit (ICU) patients. Music is a promising non-pharmacological intervention with beneficial effects on anxiety and stress, while its effects on delirium duration and severity are not well understood. Methods/design Our study is a two-arm, randomized parallel-group, clinical trial to evaluate the efficacy of music intervention compared to a silence-track attention control on delirium/coma duration in mechanically ventilated critically ill older adults. One hundred sixty mechanically ventilated adults 50 years of age or older will be randomized to one of two arms within 72 h of ICU admission: (1) 1-h music listening sessions twice daily through noise-canceling headphones, or (2) 1-h sessions of a silence track twice daily through noise-canceling headphones. Our primary aim is to compare delirium/coma-free days after randomization during the 7-day study intervention phase using the Confusion Assessment Method for the ICU (CAM ICU) and the Richmond Agitation Sedation Scale (RASS) for delirium and coma. Secondary outcomes include pain and anxiety evaluated twice daily during the intervention phase and throughout the duration of ICU stay using the Critical Care Pain Observation Tool (CPOT) and visual analog scale-anxiety (VAS-A). Enrolled participants will be followed after hospital discharge to further measure cognition as well as screening for depression and anxiety using the following telephone-based instruments: Indiana University Telephone-Based Assessment of Neuropsychological Status (IU TBANS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). Discussion This randomized clinical trial will measure the efficacy of a music listening intervention for delirium and coma duration early in the intensive care unit among older adults. Trial registration. ClinicalTrials.gov. NCT04182334 . 

/pdf/decreasing-delirium-through-music-listening-ddm-in-2dc2kabc.pdf

Decreasing delirium through music listening (DDM) in critically ill, mechanically ventilated older adults in the intensive care unit: a two-arm, parallel-group, randomized clinical trial

Background Although potent sedative and opioid drugs are some of the most commonly used medications to manage pain, anxiety, and discomfort in critically ill patients, conducting clinical trials where sedative and opioid medications are outcome variables within a longitudinal research design can be a methodological challenge. Objectives The purpose of this article is to provide in detail a conceptual discussion of the concept and analysis of sedative exposure: A novel research analysis method for aggregating sedative and opioid medication doses from disparate drug classes commonly administered to critically ill patients and used by our team in several clinical research studies. Methods Comparing the dose of each sedative and opioid administered to an individual patient (within a defined time interval) to all other patients in a research study receiving the same medications allows for ranking of dosages for each medication by quartiles. Rank values for all sedatives and opioids received can be summed to a single value resulting in a Sedation Intensity Score. In addition, a simple count of how many hours at least one dose of a sedative or opioid medication has been administered can determine sedation frequency. Results This method can allow for comparison of sedative exposure with medications from disparate drug classes and for analysis of estimates of change in medication use over time. Discussion This novel research analysis method can overcome the challenges and limitations of determining changes in sedative and opioid medication regimens in cohort and clinical trial study designs.

/pdf/a-novel-research-method-for-determining-sedative-exposure-in-53083zf00t.pdf

A Novel Research Method for Determining Sedative Exposure in Critically Ill Patients.

Clinical staging of chronic rejection in transplanted lungs has been evaluated in a group of transplant recipients using a paperless, electronic spirometer/diary instrument for home monitoring. Five of 60 subjects doing home monitoring were diagnosed with chronic rejection. Clinic and home spirometry variables were used in the staging algorithm to determine the onset and rate of clinical decline related to the rejection. Clinic and home FEV1 provided comparable onset and rates of decline; home FEF/sub 25%-75%/ detected onset from 65-477 days earlier than either FEV1 measure, and was more sensitive to declining function than FEV1. Detection of chronic rejection can be achieved with the home monitor, and home FEF/sub 25%-75%/ provides a new indicator that should be considered in future staging systems.

Linda L. Chlan

Papers

A Nurse’s Experience Being Intubated and Receiving Mechanical Ventilation

Feasibility of bioelectric impedance as a measure of muscle mass in mechanically ventilated ICU patients

Decreasing delirium through music listening (DDM) in critically ill, mechanically ventilated older adults in the intensive care unit: a two-arm, parallel-group, randomized clinical trial

A Novel Research Method for Determining Sedative Exposure in Critically Ill Patients.

Clinical staging of chronic rejection in lung transplantation using home spirometry