ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer.

The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.     

From evolution to revolution: Restructuring the New Zealand health system

After a number of years of evolutionary changes to the New Zealand health system, the government announced a radical restructuring of all publicly funded health services in July 1991, to be implemented on 1 July 1993. The primary features of these changes are a splitting of the purchaser and provider roles, and a restructuring of health services along more business-like lines. The proposals have been highly contentious and have attracted little support from within the health sector. This paper outlines the reasons for and nature of the reforms and explores some of the issues behind the changes. These include problems of pricing services for purchasing purposes, the potential conflict between financial and social objectives, and questions of accountability of purchasers and providers. Considerable uncertainty surrounding these and other issues means that any potential efficiency gains cannot be guaranteed. The costs of the reform process have, however, already been high, both in financial terms and in terms of their impact on the morale of health workers.     

Biomechanical validation of a new nail-plate for the repair of stable proximal femoral fractures

The mechanical performance and the stress shielding effects of the Howmedica Spherolock MKII implant were evaluated. Three types of stable proximal femoral fractures were created in composite femurs and fixed with the nail-plate. The femurs were loaded to failure, and the yield strength, stiffness, and failure modes were noted. Additional intact composite femurs were fitted proximally with strain gauges, and the strain was examined under load. The femurs then underwent intertrochanteric fracture, plating, and re-testing. Comparative analysis showed that while the Spherolock system is less strong and stiff than other commonly used implants, it provides excellent and uniform load transfer across the fracture site. Varus rotation of the femoral head under load tended to open the fracture gap and localize the resultant load medially. Stress shielding of the calcar was less than 25% of the applied load even in the worst case. This very low stress shielding behavior was attributed mainly to the implant's low stiffness.     

Provider attitudes regarding use of an immunization information system to identify children with asthma for influenza vaccination.

OBJECTIVES: Despite longstanding national guidelines, many children with asthma do not receive annual influenza vaccinations. Information from Medicaid-administrative claims data was integrated into the Michigan Care Improvement Registry (MCIR) to prompt providers regarding influenza vaccination among children with high-risk conditions such as asthma. The attitudes of pediatric primary care providers regarding the implementation of this system were assessed. METHODS: A survey was sent in February 2006 to office-based general pediatricians (n = 300) and family physicians (n = 300) in Michigan. The survey focused on influenza vaccination during the 2005-2006 influenza season and attitudes regarding a reminder system for providers using the MCIR. RESULTS: Overall response rate was 67 percent. MCIR participation was high (91%) among respondents, and most (83%) had MCIR information available to them prior to visits with pediatric patients. Most physicians (75%) considered the MCIR high-risk indicator for influenza vaccination a feature that they would find helpful. Some respondents reported concerns that the reminder system is limited to Medicaid patients only (44%) and regarding the completeness of Medicaid data to identify children with asthma (24%). CONCLUSIONS: Physicians have a positive overall view of a statewide registry-based automated reminder system to assist in identifying children with asthma for influenza vaccination, albeit with specific areas of concern.