The health care resource allocation debate. Defining our terms

The problem of health care distribution in the United States demands immediate action. Many different solutions have been proposed to slow rising health care costs and to improve access to care for the poor and uninsured. Debate among proponents of these various proposals might be advanced if a common language were adopted with regard to certain key terms instead of the various meanings currently assigned to these terms. For this reason, we propose and defend the following three definitions: (1) rationing is the societal toleration of inequitable access to health services acknowledged to be necessary by reference to necessary-care guidelines; (2) health care needs are desires for services that have been reasonably well demonstrated to provide significant net benefit for patients with specified clinical conditions; and (3) basic benefit plans are insurance packages that provide for all and only acknowledged health care needs, again by reference to appropriate clinical guidelines.     

Evaluation of ambulatory care training by graduates of internal medicine residencies

In 1984, 154 physicians who had completed residencies in internal medicine at 15 major teaching hospitals in 1982 evaluated their residency training in ambulatory care. A majority of the physicians would have liked more experience in practical areas related to career planning and office management, more input from subspecialties such as orthopedics and dermatology, greater knowledge about the management of psychosocial problems, and more information about exercise and nutrition. Although many physicians also wanted more time devoted to several other topics, less than 20 percent recommended spending less time on 26 of the 27 topics being evaluated. Since these recommendations are similar to those reported in evaluation studies published over the past 25 years, it appears that training programs in internal medicine have not been successful in restructuring their curricula to meet many of the needs of practicing physicians.     

Reliability of two-dimensional echocardiography in the assessment of clinically significant abnormal hemidiaphragm motion in pediatric cardiothoracic patients: Comparison with fluoroscopy.

OBJECTIVE: To assess the utility and reliability of echocardiographic assessment of hemidiaphragm motion abnormalities in pediatric cardiothoracic patients. DESIGN: Retrospective observational study, with post hoc blinded assessment of echocardiographic and fluoroscopic results. SETTING: Tertiary care center. PATIENTS: Thirty-six consecutive pediatric cardiothoracic patients with suspected hemidiaphragm paralysis were identified and included in the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The results of both echocardiographic and fluoroscopic studies on all patients were included. In addition, blinded review of study results were performed. The sensitivity and specificity of fluoroscopy in identifying hemidiaphragms that needed plication were 100% and 74%, respectively. The positive predictive value was 55%; negative predictive value was 100%. Comparing reported diagnoses with blinded review of the studies showed poor agreement; reviewers agreed with 89% diagnosed as normal, 44% of paralyzed, and 76% of paradoxical hemidiaphragms. The sensitivity and specificity of echo in identifying hemidiaphragms that needed plication were 100% and 81%, respectively. The positive predictive value and negative predictive value were 66% and 100%. Comparing reported diagnoses with blinded review, reviewers agreed with 97% diagnosed as normal, 81% of paralyzed, and 100% of paradoxical hemidiaphragms. Echocardiography was less accurate in discriminating between paralyzed and paradoxical diaphragm motion. Echocardiography was specific for paradoxical motion, since both patients identified by echocardiography were confirmed by fluoroscopy, but it was not sensitive. In nine patients, echo showed paralyzed motion that was identified by fluoroscopy as paradoxical. CONCLUSIONS: This study supports the use of echocardiography in the assessment of diaphragm function. When the diaphragms are clearly visualized by echo, as they are in the majority of cases, the addition of an additional fluoroscopic study adds no clinical value. The differentiation between paralyzed and paradoxical motion is unreliable by both imaging modalities.     

Oral aminoglycoside and ofloxacin therapy in the prevention of gram-negative sepsis after irradiation

To investigate whether oral gentamicin or ofloxacin therapy protects against gram-negative sepsis after irradiation, B6D2F1 mice were exposed to 7.5 Gy of radiation from 60Co, infected with 10(7) Pseudomonas aeruginosa or Klebsiella pneumoniae orally 3 days after irradiation, and treated with oral (15 mg/kg/day) or intramuscular (im; 7.5 mg/kg/day) gentamicin or oral (40 mg/kg/day) ofloxacin. For P. aeruginosa, gentamicin therapy was started orally 10 and 24 h and im 24 h after inoculation. For K. pneumoniae, gentamicin was started orally 24, 48, and 72 h and im 24 h after inoculation; ofloxacin was started 24 h after inoculation. Mice that received oral gentamicin early (10 h for P. aeruginosa, 24 h for K. pneumoniae), im gentamicin, or oral ofloxacin showed significantly (P less than .05) reduced colonization, translocation, and mortality compared with mice that received oral gentamicin late. These data support the use of selective antimicrobial therapy to reduce colonization, translocation, and mortality from gram-negative bacteria in irradiated animals.     

Clinical diagnosis of disorders of puberty

The authors emphasize the orderly sequence of events (consonance) characteristic of normal puberty. Loss of consonance of normal puberty indicates an underlying endocrine disorder.     

The 24-hour growth hormone secretion in a boy with giantism

The endocrinological and radiological findings in a 7.5-year-old boy with giantism are reported and compared with an age and sex matched normal tall boy. A 24-h GH profile demonstrated a persistently elevated GH concentration (mean GH concentration: giant 19.3 mU/l; tall boy 5.4 mU/l) with loss of the dominant GH periodicity of 3 h seen in the boy with tall stature and substitution with one of 8 h. These data support the view that giantism and acromegaly are similar diseases occurring prior to and following epiphyseal fusion, respectively.