Purchasing oncology services. Kerr L. White Institute/American Cancer Society Task Force on Purchasing Oncology Services

BACKGROUND: A multidisciplinary panel representing various stakeholders in the health care delivery and oncology services marketplace was convened to develop specific criteria for healthcare purchasers to consider when evaluating the structures and processes of health plans. These rank ordered criteria also can be used by oncologic service providers and health plan designers as a yardstick for the services they offer. METHODS: A multidisciplinary 31-member Task Force was assembled by the Kerr L. White Institute and the American Cancer Society in March 1997. Task Force members were selected for their ability to offer expert insight as purchasers, suppliers, policymakers, consumers, or stakeholders in the health care marketplace. A preference-weighted majority voting rule was used to identify the three most important recommendations of the 10 that were generated through a modified Delphi technique. To test the practicality of the top three recommendations, leaders of large managed care organizations (MCOs) were surveyed; the results of this survey then were compared with the results of the Task Force survey. RESULTS: The three most important recommendations from the Task Force were that health plans provide access to: 1) comprehensive cancer care, 2) preventive and screening services, and 3) second opinions and treatment options supported by scientific evidence. The difference between the responses of the Task Force and the MCOs was that MCOs placed the highest importance on evidence-based decision-making, with their next three rankings coinciding with those identified by the Task Force. CONCLUSIONS: The value of these summary recommendations will be realized through their use by both purchasers and suppliers to influence the structure and content of the delivery of oncologic services.     

Cervicovaginal fistula: an apparent increased incidence with prostaglandin F2alpha

A rare but difficult to treat complication of midtrimester abortion is cervicovaginal fistula. It has been reported as a consequence of criminal, spontaneous, and induced abortions with either laminaria, Hegar dilatation, puncture of the ovum, or by injection of soap. This condition was recently reported as a consequence of intraamniotic hypertonic saline or prostaglandin (PG) instillation. At the Women's Hospital in Los Angeles, 5291 midtrimester abortions with intraamniotic instillation of hypertonic saline had been performed since the advent of elective abortion. There were 4 cases of central cervical rupture (cervicovaginal fistula) for a net incidence of 1:1000. 3 out of 373 intraamniotic PGF2alpha-treated patients developed cervical fistula for an incidence 10 times higher than saline abortion. Other studies confirm this finding. If all such studies are combined, the net incidence is 9 in 678 cases or 1.3%. High risk patients include those who are pregnant for the 1st time, are less than 21 years old, and are treated with hypertonic saline augmented by oxytocin. The fistula may occur with intraamniotic PGF2alpha alone, but the incidence is greater in patients receiving PGs and oxytocin together. A recurring feature is a moderate to severe cramping pain without cervical response even before oxytocin is started. The use of mechanical dilatation of the cervix with the introduction of either laminaria tents or Foley catheters is suggested for primigravid patients receiving hypertonic saline and intravenous oxytocin augmentation. If cervical spasm is the mechanism of action of PGF2alpha, initial insertion of laminaria should be considered with all primigravid patients. Further study of a larger series should be done to elucidate the role of PGs in the development of cervicovaginal fistula. 7 case reports are presented.     

Nosocomial respiratory syncytial virus infections in an intensive care nursery: rapid diagnosis by direct immunofluorescence.

A nosocomial outbreak of respiratory syncytial virus infections involved 8 of 17 infants in an Intensive Care Nursery and one additional infant in the adjoining Newborn Nursery. Immunofluorescent staining of nasopharyngeal specimens was positive in six of seven virologically confirmed cases (86%). One additional case with negative viral cultures was also identified by this technique. Viral isolation in tissue cultures required an average of 4.9 days, whereas results of immunofluorescent studies were available in two to four hours. Rapid identification of infected infants by immunofluorescence permitted prompt institution of infection control measures.     

Nodular lymphoid hyperplasia of the bowel in primary hypogammaglobulinaemia: study of in vivo and in vitro lymphocyte function.

In vitro and in vivo lymphocyte function was studied in six patients with primary hypogammaglobulinaemia and nodular lymphoid hyperplasia (NLH) of the bowel. Lymphocyte transformation, numbers of circulating T and B lymphocytes, and delayed hypersensitivity skin tests did not significantly differ when compared with hypogammaglobulinaemic patients without NLH. However, patients with NLH had higher jejunal juice IgM concentrations and a tendency to higher serum IgM concentrations than those without NLH. The morphological features of NLH are similar to the germinal centres of lymph nodes but more closely resemble the follicle zone of Peyer's patches. These findings suggest that NLH represents a local immune response to antigens originating in the gut lumen.