The gatekeeper model is inefficient for the delivery of dermatologic services

BACKGROUND: Gatekeeper-paradigm managed care systems may discourage the use of dermatologists in the management of skin conditions by limiting direct access. This may limit the quality of care patients with skin disorders receive and may be an inefficient use of medical resources. OBJECTIVE: The purpose of this study was to determine the likelihood that patients with dermatologic conditions who see a primary care provider will be referred to a dermatologist. METHODS: Data on the disposition of outpatient visits to primary care physicians for one and only one dermatologic diagnosis were obtained from the 1990-1994 National Ambulatory Medical Care Survey. These data were used in an econometric model to estimate the likelihood of referral to a dermatologist for an episode of care. RESULTS: Of all visits for a single dermatologic diagnosis, 39% were to primary care physicians. The disposition of referral was more common for these dermatology-related visits than for all office visits to primary care physicians (5.8% vs 4.5%, P < .001). The most frequent diagnoses associated with referral were common dermatologic problems, not rare disorders. The number of visits per episode of care was highly dependent on the assumptions of the analysis, resulting in estimate ranges for referral rates per episode between 6.8% and 18.5% for pediatricians, 8.2% and 23% for family and general practitioners, and 16.6% and 46.5% for internists. CONCLUSION: The relative difficulty for primary care providers of managing skin problems is reflected by their frequent need to refer patients with common skin problems and by the greater likelihood of referral for skin disorders than for other medical conditions. The high rates of referral per episode of care supports the cost-effectiveness of direct access to dermatologists.     

氯喹对烟雾吸入伤大鼠肺细胞膜ATP酶活性和丙二醛含量的影响

目的：探讨氯喹对烟雾吸入伤大鼠肺细胞膜ＡＴＰ酶活性及丙二醛含量的影响,方法：８０只Ｗｉｓｔａｒ大鼠随机分成正常对照组,烟雾吸入伤１,３,６,１２和２４ｈ组以及氯喹治疗６ｈ和１２ｈ组,分别于各时相点活杀动物,取肺制备膜制剂,用生化比色法测定膜上Ｎａ＾＋,Ｋ＾＋－ＡＴＰ酶Ｍｇ＾２＋－ＡＴＰ酶和Ｃａ＾２＋－ＡＴＰ酶活性,用比色法测定膜上丙醛含量,并用定磷法测定膜总磷脂含量,结果：烟雾吸入伤后,肺细胞膜３     

Histologische und audiometrische Studie über den alternsbedingten Struktur- und Funktionswandel des Innenohres

Zusammenfassung Die altersbedingte, schon vom 2. und 3. Dezennium an nachweisbare, mit zunehmendem Alter fortschreitende Hörverschlechterung wird beschrieben und kritisch auf die unvermeidliche Subjektivität bei der Festlegung dessen, was als altersbedingtes Normalgehör zu gelten hat, hingewiesen. Es ist notwendig, die ggf. krankheitsbedingten von den lediglich altersbedingten Hörstörungen abzugrenzen. Bei überschwelligen Messungen an über 100 Personen mit altersgemäßem Schwellengehör ergibt die Intensitätsunterschiedsschwellenbestimmung nachLüscher u.Zwislocki in der überwiegenden Mehrzahl normale bzw. vergrößerte Werte und die Geräuschaudiometrie denLangenbeckschen Gangliontyp mit ausgeprägter pathologischer Verdeckbarkeit. Im Sprachaudiogramm nahmen im höheren Alter die Kurventypen zu, bei denen eine stärkere Erhöhung der Intensität mit Zunahme des Diskriminationsverlustes einhergeht (R-Typ). Deutlicher tritt diese Erscheinung bei der Sprachprüfung im Geräusch hervor. Das Fehlen eines Recruitments im Tonaudiogramm macht wahrscheinlich, daß pathologische Verdeckbarkeit und zentrale Faktoren die Ursache sind. — Bei der histologischen Untersuchung der Felsenbeine von 100 Personen aller Altersgruppen, die zur Hälfte ein nachweislich normales Gehör vor dem Tode hatten, zeigt sich als einziger Befund, der regelmäßig nachweisbar und bei quantitativer Bestimmung sich als progredient erweist, der also dem Verhalten des Tongehörs voll entspricht, ein Schwund der Zellen im Ganglion spirale, vornehmlich in der basalen Windung. Andere Veränderungen amCorti-Organ, an Stria, Basilarmembran usw. sind ohne Regelmäßigkeit hinsichtlich Lokalisation und Altersverteilung, so daß sie als teils postmortalartifiziell, teils krankheitsbedingt-akzidentell, aber nicht altersbedingt angesprochen werden. Ausführungen zur morphologischen, cytochemischen, funktionellen und phylogenetischen Sonderstellung des Spiralganglions ergänzen die Darlegung der Befunde und kennzeichnen den altersbedingten Ganglienzellenschwund des Innenohres als einen Prozeß von hohem allgemeinem Interesse für die Erforschung der Gesetzmäßigkeit des Alterns.Mit 2 Textabbildungen     

Pituitary response to bolus and continuous intravenous infusion of luteinizing hormone-releasing factor in normal women and women with polycystic ovarian syndrome.

Plasma luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels were measured in response to luteinizing hormone-releasing factor (LRF), given as a 100 microgram intravenous bolus and/or as a 4 hour infusion of 0.2 microgram per minute to 27 normal menstruating women and 15 women with the polycystic ovarian syndrome (PCOS). In PCOS, LH response to bolus LRF was significantly greater than those of normal women at days 1 to 4 and 8 to 10 of the cycle, whereas FSH responses were similar in all women studied. Continuous LRF infusion resulted in a biphasic LH release pattern. In normal women, the early phase was low until days 12 to 14 of the normal cycle, whereas the second phase rose progressively from the early follicular to the periovulatory period. In PCOS, the early phase was relatively large and qualitatively resembled the normal periovulatory pattern. The increased pituitary LH response to LRF in PCOS is associated with a relatively large early releasable LH pool and a low FSH response.     

Transrectal sonography of benign and malignant prostatic lesions

Using linear-array transrectal prostate sonography, malignant lesions in 43 patients and benign lesions in 74 patients were evaluated. Prostate sonography was sensitive to textural changes produced by both benign and malignant diseases. However, there was considerable overlap in the sonographic appearances of benign and malignant lesions, and there were no sonographic features that reliably predicted malignancy. Hyperechoic areas were present in 58% of the carcinomas, while 19% were purely hypoechoic. Lesions containing hypoechoic foci that were posterior or posterolateral had a high incidence of cancer. The results confirm the need to biopsy all suspicious palpable lesions of the prostate.     

Pharmacokinetics of tetrachloroethylene in steady stage conditions

Pharmacokinetic behaviour of tetrachloroethylene (clearance, pool, elimination kinetics, metabolic capacity) was studied by intravenous and inhalative long term administration. Concentrations of tetrachloroethylene in blood can be calculated from the concentration in the external air, as to be predicted for a substance, practically not metabolizable and eliminated totally by exhalation. The advantages of steady state techniques and their applicability to problems of industrial pharmacology are discussed.     

Ultrasound versus digitally directed prostatic needle biopsy

During an 8-month period 55 patients with suspected but unproved prostatic carcinoma were entered randomly into a study designed to evaluate the effectiveness of ultrasound-directed transperineal needle biopsy of the prostate. Each patient was biopsied with and without ultrasound assistance; the method used first was determined randomly. Of the 15 patients diagnosed as having adenocarcinoma only 9 were proved by conventional transperineal biopsy, whereas ultrasound-guided biopsy was accurate in all 15 patients (p less than 0.005). Transrectal ultrasound guidance significantly improves the yield of transperineal needle biopsy when it is performed for suspected malignancy.     

Antenatal diagnosis of renal abnormalities: a review of the state of the art

Antenatal diagnosis of fetal abnormalities is an important component of genetic counseling. This paper reviews the indications and techniques of antenatal diagnosis of renal and urinary tract abnormalities, and outlines their follow-up and modes of treatment.