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ContextThe sixth Joint National Committee (JNC-VI) classification system of blood pressure emphasizes both systolic blood pressure (SBP) and diastolic blood pressure (DBP) for cardiovascular disease risk assessment. Pulse pressure may also be a valuable risk assessment tool.ObjectiveTo compare relationships of SBP, DBP, and pulse pressure, separately and jointly, with cardiovascular disease-related mortality in men.Design and SettingData from the Multiple Risk Factor Intervention Trial (MRFIT), which screened men aged 35 to 57 years from 1973 through 1975 at 22 US centers, was used to assess cardiovascular disease-related mortality through 1996.ParticipantsA total of 342 815 men without diabetes or a history of myocardial infarction were divided into 2 groups based on their age at MRFIT screening (35- to 44-year-olds and 45- to 57-year olds). Participant blood pressure levels were classified into a JNC-VI blood pressure category based on SBP and DBP (optimal, normal but not optimal, high normal, stage 1 hypertension, stage 2-3 hypertension), and pulse pressure was calculated.Main Outcome MeasureCardiovascular disease-related mortality.ResultsThere were 25 721 cardiovascular disease-related deaths. Levels of SBP and DBP were more strongly related to cardiovascular disease than pulse pressure. Relationships of SBP, DBP, and pulse pressure to cardiovascular disease-related mortality varied within JNC-VI category. Concordant elevations of SBP and DBP were associated with a greater risk of cardiovascular disease-related mortality for both age groups of men. Among men aged 45 to 57 years, higher SBP and lower DBP (discordant elevations) also yielded a greater risk of cardiovascular disease-related mortality.ConclusionIn both age groups, cardiovascular disease risk assessment was improved by considering both SBP and DBP, not just SBP, DBP, or pulse pressure separately.

A manufacturing firm creates share-holder value by consistently earning a return on invested capital (ROIC) that exceeds its cost of capital (COC) (Copeland et al, 1995). The amount of value created is impacted directly by the amount of capital invested, highlighting the importance of effective capital allocation. Firms can add significant value through creative ways of balancing customer requirements and working capital needs. This paper describes a generic methodology that uses customer-buying behavior to construct product offerings that minimize working capital risk without impacting service performance. The methodology is specifically applied in an environment where product and option offerings can result in thousands of final product configurations. In these complex manufacturing environments, high-velocity product configurations and option packages are used to create hedge packages (a form of dynamic safety stock) of components with longer lead times than market requirements for finished product delivery. In many cases, the lead times of very complex and costly components can exceed customer delivery requirements by a factor of 10. For example, customers may expect delivery of final products within one week, yet key components of the finished product may require ten or more weeks of lead-time. Further exacerbating the situation are the realities that the longest lead items are by nature very complex and costly, and sales forecasting is very difficult. If inventory is managed too aggressively, part shortages, frequent un-planning or rescheduling messages to vendors, late deliveries, poor service reliability, and lost revenues are typical results. This paper describes a fact-based and market-based methodology to hedge the forecast of key product components and achieve the correct balance between working capital and service requirements. Central to the process is the use of the “Affinity Analysis” tool. This tool is used to process large arrays of product configuration data with the objective of recognizing significant affinities between elements. In an automobile example, when a customer purchases a manual transmission how often do they also choose sport suspension? Knowledge of all of the high-correlation or high-affinity product selections or options can be exploited in the material requirements planning process without having to individually forecast the usage of all options. Forecasting at the individual option level is very difficult and rarely correct. The knowledge of key component affinities facilitates the creation of high-velocity product configurations and option packages that maximize revenue and minimize working capital and manufacturing complexity. The paper includes a description of the affinity analysis tool, the input and output files, how the tool is used, and how the high-velocity and hedge packages are created. Furthermore, the reader is provided with a sample application of the methodology in a complex heavy-equipment manufacturing environment.

Despite repeated calls to emphasize the humanistic dimensions of care during medical education, these are few known techniques for effective teaching of humanism. We describe the barriers that inhibit humanistic teaching and suggest pragmatic teaching methods to overcome such barriers and teach humanistic care in clinical settings. We began by asking participants at a conference on patient-physician communications sponsored by the American Academy on Physician and Patient in June 1998, “What can we do in the patient’s presence to improve and teach the human dimensions of care? Please provide one or more examples of approaches you found to be effective.” We augmented this information with suggestions from a number of colleagues in other settings. In a series of iterations, we analyzed all their suggestions to identify key teaching methods. We found that barriers to teaching humanism largely consist of elements of the informal and hidden curricula in medical schools. We then defined methods to help teachers overcome these barriers. Specific methods fall into the 3 categories of taking advantage of seminal events, role modeling, and using active learning skills. We believe that formal courses and other well-motivated endeavors that take place away from patients fail to foster humanistic care. In contrast, we present pragmatic teaching methods that can be used in the fast-paced setting of the clinical environment.

Objective: To assess the extent to which actions reported by internal medicine trainees conflict with published guidelines on ethics. Methods: A confidential survey was sent to a random sample (N=1000) of associate members of the American College of Physicians (ACP). Questions were asked about ethical decision making in areas addressed by the guidelines in the ACP Ethics Manual. Quoted manual guidelines were provided, followed by 55 yes or no questions, such that a yes answer represented an action that conflicted with a guideline. There were two follow-up mailings to nonresponders. Results: Forty percent (n=397) completed the questionnaire; 17% indicated they were aware of the guidelines on ethics. On average, associates responded yes to 16% of questions where a yes response indicated they have acted outside guidelines on ethics one or more times. The mean number of responses (n=55) that conflicted with a guideline was 7.6 per person (SD, 4.7 responses; range, 0 to 33 responses). Ninety-eight percent of respondents reported actions falling outside a guideline one or more times and 80% did so four or more times. The most frequently reported reason (965/3219 [30%]) from a list of four choices for acting outside a guideline was "I was aware of the guideline, but this did not represent an ethical dilemma to me." Conclusions: Few responding ACP associates indicated awareness of the ACP guidelines on ethics. Physicians in training nevertheless reported acting according to the presented guidelines most of the time, although nearly all respondents acted outside a guideline at least once, and some did so many times. Reported behaviors were sometimes inconsistent with consensus ethical standards that apply to internists. Physicians in training need to know more about ethical standards that apply to their own practice and should be aware when their actions deviate from ethical norms. Before acting outside guidelines on ethics, trainees should discuss their conflicts with others, such as attending physicians, clinical ethicists, or hospital ethics committees. (Arch Intern Med. 1996;156:298-304)

Based on families seen in treatment, the authors identify characteristics of the celebrity family, which include issues of confidentiality and trust, family boundaries, parenting roles, unrealistic expectations of and for the children, and family isolation. The family is described as entering into a tacit contract enabling the celebrity to pursue his/her career by relinquishing the parental role to the spouse. A symptomatic child enters a parentified or “spousified” role, providing emotional support to the mother in the absence of the father. The child's position serves the needs of the system yet interferes with the child's own developmental tasks. A composite case study is presented as an illustration, and treatment recommendations are delineated.

The Human Resource Management Information Network (HRMIN) was conceived and developed "in-house" by the Navy Military Personnel Command (NMPC) and the Navy Personnel Research and Development Center (NPRDC) . This report is an attempt to ascertain the compliance of this in-house development with the Office of Management and Budget policy on the acquisition of commercial or industrial products and services needed by the government. A cost comparison of the in-house performance cost and the contract-out cost of providing the services required of HRMIN indicate that the present in-house performance is the most cost effective alternative. Therefore conversion to a contracted-out performance should not be undertaken. http://archive.org/details/thehumresourcema1094519363 Lieutenant Commander, United States Navy Approved for public release; distribution is unlimited.

The number of people with dementia who have not received a formal diagnosis is high, in the UK and also internationally. Government strategies aim to raise public and professional awareness about the condition and increase rates of timely diagnosis. Benefits associated with timely diagnosis include earlier access to medication and being able to plan future care. Despite these benefits, a number of factors contribute to delay in, or in some cases denial of, diagnosis to people with dementia. This article aims to provide nurses, who are important healthcare professionals in the diagnostic process, with an overview of the literature on disclosing diagnosis to people with dementia.