The lag between the publication of clinical and health-services research and the application of this information is substantial and delays health-care improvement. A wide range of corrective strategies are being used to address this issue.

This article examines the two categories of learning strategies that physicians use in clinical practice. The strategies are similar in their overall architectures and differ (1) according to nature of the clinical problem that precipitated the need to learn, and (2) the ways in which learning resources are used.

To understand the theory and results of how to improve physician performance, as part of overall health-care quality improvement. In particular, to study whether and how guideline production and dissemination affects physician performance.

Practice guidelines have been developed by a myriad of government, subspecialty, and local organizations in an attempt to reduce undesirable variations in care and to improve the quality of care. Despite the current enthusiasm driving the creation of thousands and thousands of guidelines, their longevity will depend on the ability to demonstrate measurable improvements in patient care caused by the dissemination and implementation of guidelines. In order for guidelines to improve care, they must influence the decisions that physicians and other health-care providers make as they care for patients on a day-to-day basis. Studies on this topic show that some guideline implementation strategies are consistently effective, meaning that they lead to changes in care that benefit patients. Other strategies have been shown to be consistently ineffective. Using an evidence-based approach to selecting guideline dissemination and implementation strategies may facilitate the greatest chance of success, and enhance the probability that patient care will be meaningfully improved as a result of these efforts.

With the increased use of nonprescription vitamin supplementation, physicians involved in critical care must be aware of the potential complications of these medications. We report the case of a 31-year-old African-American man presenting to the emergency department with acute renal failure. He had previously been well and initially denied the use of any drugs except for vitamin C tablets obtained at a local health food store. This case report and review of the literature is utilized to illustrate the importance of historical data in patients presenting with acute renal failure to a critical care service.

Isolated pulmonary cryptococcosis (IPC) is an infrequently diagnosed infection, the management of which is not well defined. In past years, IPC traditionally has not been treated in the immunocompetent host, given its perceived benign and self-limited course and the toxicity associated with amphotericin B. However, some patients manifest prominent and disabling symptoms, and infection occasionally may disseminate. Fluconazole is active against Cryptococcus neoformans, is easily administered, and has an excellent safety profile. We present four healthy hosts with IPC who were treated with oral fluconazole for 6 to 8 weeks. A review of the literature was conducted to identify other cases of IPC in healthy hosts who were also treated with fluconazole. Our results and the limited experience reported in the literature suggest that fluconazole may be an appropriate choice for the treatment of IPC in the immunocompetent host. Indications for treatment are not defined, but symptomatic patients, those with multiple nodules or extensive infiltrates on chest radiographs, and/or those testing positive for serum cryptococcal antigen might be potential candidates for therapy.

To review the concept of proinflammatory cytokines.

To evaluate the causes, risk factors, and mortality rates associated with unexpected readmission to medical and surgical ICUs.

Coronary artery calcification quantification (scoring) has been done with electron beam CT (EBCT), but is now being done with spiral or helical CT. Many radiologists and cardiologists who do not have EBCT but do have access to spiral CT will now be able to do coronary artery calcification scoring, and will now need to know the spiral CT appearance of the coronary artery anatomy. This pictorial review will demonstrate the anatomy needed for coronary artery calcium scoring.

Intracardiac thrombus formation is a rare but serious complication of Behçet's disease. We aimed to review the clinical and pathologic correlates of cardiac thrombus formation in the context of Behçet's disease.

Severe hypertension is a common clinical problem in the United States, encountered in various clinical settings. Although various terms have been applied to severe hypertension, such as hypertensive crises, emergencies, or urgencies, they are all characterized by acute elevations in BP that may be associated with end-organ damage (hypertensive crisis). The immediate reduction of BP is only required in patients with acute end-organ damage. Hypertension associated with cerebral infarction or intracerebral hemorrhage only rarely requires treatment. While nitroprusside is commonly used to treat severe hypertension, it is an extremely toxic drug that should only be used in rare circumstances. Furthermore, the short-acting calcium channel blocker nifedipine is associated with significant morbidity and should be avoided. Today, a wide range of pharmacologic alternatives are available to the practitioner to control severe hypertension. This article reviews some of the current concepts and common misconceptions in the management of patients with acutely elevated BP.

The role of infection in exacerbations of COPD remains controversial and incompletely understood. Although some investigators believe that bacteria are not important for patients with exacerbation, we disagree and believe that patients with at least two of the three cardinal symptoms of exacerbation should receive antibiotic therapy. With an open-minded view of the area, we review the data, showing that bacteriologic studies, pathologic investigations, and clinical trials all support roles for bacteria and antibiotic therapy in this disease. Still, many questions remain, and future studies will be needed to better define the mechanisms of bacterial invasion in the bronchitic patient and to develop effective vaccines to prevent exacerbations. In the meantime, we must rely on antibiotic therapy, and we will need prospective studies to corroborate preliminary findings showing that different patients may require different therapies; thus, patient subsetting may be vital in the selection of antibiotic therapy for exacerbations of COPD.

Exacerbations of COPD, which include combinations of dyspnea, cough, wheezing, increased sputum production (and a change in its color to green or yellow), are common. The role of bacterial infection in causing these episodes and the value of antibiotic therapy for them are debated. An assessment of the microbiological studies indicates that conventional bacterial respiratory pathogens, such as Streptococcus pneumoniae and Haemophilus influenzae, are absent in about 50% of attacks. The frequency of isolating these organisms, which often colonize the bronchi of patients in stable condition, does not seem to increase during exacerbations, and their density typically remains unchanged. Serologic studies generally fail to show rises in antibody titers to H influenzae; the only report available demonstrates none to Haemophilus parainfluenzae; and the sole investigation of S pneumoniae is inconclusive. Trials with vaccines against S pneumoniae and H influenzae show no clear benefit in reducing exacerbations. The histologic findings of bronchial biopsies and cytologic studies of sputum show predominantly increased eosinophils, rather than neutrophils, contrary to what is expected with bacterial infections. The randomized, placebo-controlled trials generally show no benefit for antibiotics, but most have studied few patients. A meta-analysis of these demonstrated no clinically significant advantage to antimicrobial therapy. The largest trials suggest that antibiotics confer no advantage for mild episodes; with more severe attacks, in which patients should receive systemic corticosteroids, the addition of antimicrobial therapy is probably not helpful.

Apoptosis is a form of cell death that has gained enormous attention during the past few years, and its mechanisms, important to biology and medicine, are being unraveled at an accelerating pace. Apoptosis of lung cells occurs during lung infections and may be either a host defense mechanism or reflect the pathogenesis of the infection. In the first part of this review, the biochemistry and physiology of apoptotic pathways and its regulators are discussed. This is followed by an overview of apoptotic mechanisms in selected lung infections. The implications of apoptosis in host immunity, pathogenesis, and treatment of pulmonary infections will be discussed in this context.

Congenital malformations of the right atrium (RA) and the coronary sinus (CS) are rare, and only sporadic cases have been reported. Little is known about the clinical relevance of this disorder. We report on two patients, one with a giant RA diverticulum, the other with a diverticulum of the CS, and review 103 cases of such malformations that have been reported previously.

To evaluate the activity and evolution in the field of lung volume reduction surgery (LVRS) performed at surgical centers in Europe.