This paper develops a hypothesis that the "normal" mode of operation for many organisations today is beyond their safe design capacity. Evidence for this has emerged from a number of studies carried out to promote systemic practice in local health communities in the U.K. This work has identified mismatches between how managers claim their organisations work and the observed behaviour, which can only be explained by surfacing informal coping policies, many with unintended consequences for patient care and costs. There are important messages in the paper for Health and Social Care management, the meaning of data and for modelling, and the paper contains reflections from senior management involved in the studies. The key message of the paper is that affordable and sustainable downstream capacity additions in patient pathways can be identified, which both alleviate upstream problems and eliminate the need for excessive coping policies.
In a continuing study of the toxicity of 90Sr in beagles exposed continuously from mid-gestation to 1.5 years of age, a myeloproliferative disorder has arisen in dogs fed the two highest dose levels, 12 and 4 µCi 90Sr/day, respectively. Ten cases have occurred thus far at the highest level and 4 at the second highest, the difference in incidence being approximately equal to the threefold difference in dose rate. Age at onset has ranged from 14 to 72 months, and cumulative dose rates up to the time of death have varied from about 1,000 to 10,000 rads.
The 14 cases of myeloproliferative disorder present a morphologic spectrum which manifest in the acute form as granulocytic leukemia and in the chronic form resemble myelofibrosis with myeloid metaplasia (MMM). Anemia, poikilocytosis, anisocytosis, hypochromasia and terminal thrombocytopenia were constant features. Terminal leukocyte counts ranged from 3,300 to 38,900 cells/ mm3, with various degrees of shift to the left. Splenomegaly was the salient gross finding in most dogs. Major histologic lesions were pronounced granulocytic proliferation in bone marrow and spleen, with concomitant erythroid and megakaryocytic depletion. Liver, lymph nodes and a variety of other organs had less extensive and less frequent involvement. In the most acute cases, bone marrow and spleen contained cell populations composed almost entirely of blast cells.
This experimental situation should serve to shed light on fundamental aspects of radiation-induced granulocytic leukemia and might help to clarify the relationship between granulocytic leukemia and MMM.
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