A method for identifying comparison counties: application to a rural telemedicine evaluation project

The evaluation of telemedicine activity in rural communities is complicated by the fact that most telemedicine sites are chosen because of their existing telecommunications infrastructure and institutional relationships, not by a random selection process. In addition, it is difficult to draw conclusions about the effects of telemedicine without a careful analysis of parallel changes in communities which do not have access to telemedicine services. We have developed a method of identifying comparable counties based on an aggregate measure of health status. A set of 66 variables was collected in a previous project to develop a model to evaluate the relative health status of the population in Missouri. A stepwise regression was used to identify a subset of 15 variables that had the highest predictive value for the health status of a county. Distance measures were then used to identify six counties which were most similar to three telemedicine counties. The method can be used with any study set chosen non-randomly, to identify similar objects that can be used for comparative purposes.     

Public involvement in health care priority setting: an economic perspective

Background  Public involvement in health care decision making and priority setting in the UK is being promoted by recent policy initiatives. In 1993, the British Medical Association called for public consultation where rationing of services was to be undertaken. The approach to priority setting advocated by many health economists is the maximization of quality adjusted life years (QALYs). Typically, for a particular health care programme, the QALY calculation takes account of four features: (1) the number of patients receiving the programme, (2) the survival gain, (3) the gain in quality of life and, (4) the probability of treatment success. Only one feature, that relating to quality of life, is based upon public preferences. If the QALY is to be used as a tool for health care resource allocation at a societal level then it should incorporate broader societal preferences.
Methods  This study used an interview-based survey of 91 members of the general public to explore whether the traditional QALY maximization model is a good predictor of public responses to health care priority setting choices.
Results and conclusions  Many respondents did not choose consistently in line with a QALY maximization objective and were most influenced by quality of life concerns. There was little support for health care programmes that provided a prognostic improvement but left patients in relatively poor states of health. The level of respondent engagement in the survey exercise was not sensitive to the provision of supporting clinical information.     

Fibrous nodules found at large-core needle biopsy of the breast: imaging features

PURPOSE: To describe the imaging and histologic features of large-core needle biopsy (LCNB) specimens of fibrous nodules. MATERIALS AND METHODS: Of 853 breast masses in which LCNB was performed, 38 (4%) revealed histologic findings of fibrous nodules. Repeat biopsy was performed in 16 lesions (surgical excision, 13 lesions; repeat LCNB, three lesions). The mammographic and ultrasonographic findings in these 16 cases, the histologic LCNB findings, and the repeat biopsy findings were retrospectively reviewed. RESULTS: Repeat biopsy findings confirmed the diagnosis of fibrous nodules in 15 of the 16 masses. In one mass, repeat LCNB findings showed a fibroadenoma. The imaging features of the fibrous nodules varied. Five nodules (33%) manifested as masses with indistinct margins; six (40%), as circumscribed masses. In four cases (27%), imaging suggested malignancy. None were calcified masses. An additional 22 masses had circumscribed or indistinct borders and were diagnosed with LCNB as fibrous nodules. None of these masses had suspicious findings, and repeat biopsy was not performed. CONCLUSION: Fibrous nodules usually manifest as masses with circumscribed or indistinct margins but can have findings suggestive of malignancy. LCNB can reveal histologic findings consistent with this diagnosis. In all masses in which repeat biopsy was performed, the diagnosis of a fibrous nodule was confirmed or another benign stromal lesion was diagnosed.     

Breast Biopsies with ABBI(R): Experience with 183 Attempted Biopsies

When first introduced, the advanced breast biopsy instrumentation (ABBI^®) system seemed to have many advantages as a diagnostic procedure. Problems have arisen, however, both in terms of patient unsuitability and mechanical failure. In addition, there has been uncertainty as to whether the complete lesion removal it afforded could be considered definitive treatment in malignant cases. Incision margins were looked at to investigate that possibility. Of the 183 patients we saw in our first year of experience with ABBI, 48 (26%) were rejected for being poor candidates for it. In the remaining 132 biopsies there were 31 (23%) technical difficulties. All told, 14 malignancies were discovered, all of which appeared to have pathology-free incision margins radiologically. However, 13 of these 14 (93%) proved on pathologic examination to have residual malignancy. ▪     

Humiliation: Assessing the Impact of Derision, Degradation, and Debasement

This paper describes the development of a self-report scale to assess the internal experience of humiliation. After defining the construct, an item pool of 149 items was generated, utilizing a five-point Likert scale response format. A sample of 253 individuals ages 15 to 51 (M= 20.66) was used to conduct the item trial. The item pool was evaluated through item and factor analyses. Factor analysis identified two correlated factors accounting for 58% of scale variability. The 20 items loading on factor one were labeled the Fear of Humiliation Subscale and the 12 items loading on factor two were labeled the Cumulative Humiliation Subscale. The full scale of 32 items is called the Humiliation Inventory. Reliability analyses indicate that the subscales and the full scale have high internal consistency. Exploratory analyses of mean scores across six demographic groups indicate significant differences between male and female mean scores on the total scale and the two subscales.     

A comparison of the haemodynamic effects of intrathecal meperidine,meperidine-bupivacaine mixture and hyperbaric bupivacaïne

Purpose

To study the haemodynamic effects of intrathecal meperidine, administered either alone or mixed with bupivacaïne.

Methods

We studied 42 Chinese patients, aged 59–87 yr, scheduled for transurethral bladder or prostate surgery, randomized into three equals groups, that received either meperidine 0.8 mg · kg^{?1 meperidine 0.4 mg} · kg^?1 plus 1.5 ml of 0.5% heavy bupivacaïne or 3 ml of heavy bupivacaïne 0.5%. Non-invasive systolic (SAP) and mean (MAP) arterial pressures, central venous pressure and cardiac index, stroke index and heart rate (HR) measured by the BoMed NCCOM3-R7S bioimpedance device, were recorded over the first 25 min. Systemic vascular resistance index (SVRI) was derived. Onset of sensory and motor block was also measured. Decreases in MAP of 25% were treated with colloid and metaraminol. Results: The onset of block was slower in the meperidine group (P < 0.05). Decreases in SAP, MAP and SVRI (all; P < 0.001) occurred within five minutes in all three groups. The HR was increased in the bupivacaïne group (P = 0.03), but bradycardias treated with atropine occurred in six patients receiving meperidine and four patients receiving the mixture. Six patients receiving meperidine and two patients receiving the mixture required general anaesthesia for inadequate block. The incidence of nausea and vomiting was higher in the patients receiving meperidine (P < 0.05). No other complications were encountered.

Conclusions

Intrathecal meperidine used alone or mixed with bupivacaïne has no intra-operative advantage over heavy bupivacaïne 0.5%.     

Left ventricular-right atrial fistula following mitral valve replacement

Acquired intracardiac shunt after prosthetic valve replacement is a rare complication, and reoperation for correction of this disorder carries a high mortality rate. We report such a case of left ventricular-right atrial fistula after mitral valve replacement in which the patient died of multiple complications. Awareness, prevention, and early diagnosis are, therefore, extremely important.     

Computer tomography of cerebellopontine angle lesions.

Computer tomography (CT) was used in 53 consecutive patients with a working diagnosis of cerebellopontine angle tumor. The CT was performed with the 160 X 160 matrix scanner, height of sections was 13 mm. Metrizoate sodium (1.5 ml/kg of body weight) was used for tumor enhancement. Seventeen CT scans revealed tumors; one patient proved at operation to be false-positive. Thirty-six CT scans revealed no tumors; two examinations may prove to be false-negative, but surgical verification has so far not been obtained. The smallest tumor demonstrated by CT extended 7 mm into the angle, while one of the possible false-negative CT scans after iophendylate injection cisternography showed a tumor extending 5 mm into the angle. It is concluded that CT is a harmless, noninvasive neuroradiological procedure, and should precede invasive procedures. It can be used safely in patients with increased intracranial pressure.