Purchasing. The wasted millions

In the wake of the Child B rationing controversy, the Anti-Rationing Group challenged purchasers to allow them to scrutinise their practice. Eight health authorities accepted and, say Colin Roberts and colleagues, the results show public money being needlessly wasted on a staggering scale.     

Paclitaxel in Advanced Urothelial Carcinoma: Its Role in Patients with Renal Insufficiency and as Salvage Therapy

Purpose

We evaluated the role of paclitaxel in patients with advanced urothelial carcinoma and renal insufficiency or as second line therapy for metastatic disease.

Materials and Methods

Nine patients with advanced urothelial carcinoma received 175 to 250 mg./m.² paclitaxel intravenously as a 24-hour infusion. Six patients had renal insufficiency with a median serum creatinine of 2.25 mg./dl. (range 1.9 to 3.2) and 3 with normal renal function were treated after disease progression following 1 to 2 prior chemotherapy regimens.

Results

Of 9 patients 5 (56 percent) achieved a partial response, including 4 to 6 with renal insufficiency. Toxicity was primarily hematological with 4 patients experiencing febrile neutropenia. There was no adverse impact on renal function.

Conclusions

Paclitaxel as a single agent represents an effective therapeutic alternative for patients with advanced transitional cell carcinoma of the urothelium and renal insufficiency precluding cisplatin or gallium nitrate based chemotherapy. Additionally, paclitaxel appears to be effective in patients in whom prior cisplatin based therapy failed.     

The effect of exogenous testosterone on total and free prostate specific antigen levels in healthy young men

Purpose

We evaluated the effect of exogenous testosterone administration on serum total and free prostate specific antigen (PSA) in healthy young men.

Materials and Methods

Nine volunteers received either 100, 250 or 500 mg. testosterone by intramuscular injection each week for 15 weeks. Blood was drawn every other week for 28 weeks and at week 40. Serum total and free PSA, and total and free testosterone were measured and compared to baseline values.

Results

Significant elevations in total and free testosterone occurred but no significant change in serum total and free PSA was detected.

Conclusions

Serum PSA is not responsive to elevated serum testosterone levels in healthy young men. PSA metabolism in the normal prostate is unclear but our findings may have implications for differentiation of pathological conditions of the human prostate.     

Outcome of cold coagulation for the treatment of cervical intraepithelial neoplasia in a department of genitourinary medicine.

OBJECTIVE--To evaluate the outcome of "cold coagulation" as a treatment modality for major grade cervical pathology, cervical intraepithelial neoplasia (CIN 2 and 3) in a department of genitourinary medicine. DESIGN--Prospective programme trial with 18 month follow-up of patients undergoing "cold coagulation" of the cervical transformation zone following colposcopic assessment and biopsy. SETTING--A genitourinary medicine colposcopy clinic. PATIENTS--125 female patients with histologically proven major cervical pathology (CIN 2 and 3). The mean age of the patients was 24.5 years; 73% were unmarried, 43% currently smoked and 62% had a history of exposure to the human papilloma virus. MAIN OUTCOME MEASURES--Eradication of cervical abnormality with cytological findings at 4, 8 and 12 months and colposcopy at 18 months, with intervention colposcopic assessment if follow-up cytology was abnormal. RESULTS--Eradication of CIN was achieved in 96.5% of patients, the majority of treatment failures being detected at first cytology. Attendance for follow-up was good, with only a 16% default rate. Final colposcopy yielded five treatment failures. No major complications were noted. CONCLUSION--These results confirm that "cold coagulation" provides an acceptable, efficient and effective, low cost consumer friendly treatment for CIN 2 and CIN 3 in an out-patient genitourinary medicine colposcopy clinic.     

Effects of iron and culture filtrates on killing of Neisseria gonorrhoeae by normal human serum.

Neisseria gonorrhoeae GC9, both colony types T2 and T4, were killed by normal human serum, although populations of colony type T4 were more susceptible. Ferric ammonium citrate prevented the killing of populations of both T2 and T4 colony types. Other iron compounds tested showed no protective effect, nor did ammonium citrate or the divalent cations magnesium or calcium. A filtrate from cultures of an N. gonorrhoeae strain grown in a liquid defined medium showed a similar protective effect in the serum assay. The filtrate appeared to chelate iron, as measured by decreased ability of iron-free transferin to bind iron in the presence of the filtrate. However, the two effects did not appear to be related. Neither ferric ammonium citrate nor the culture filtrate sufficiently inactivated complement to account for protection.     

Radiographic studies of the ventricles in syringomyelia

Summary Radiographic investigations of 171 patients with communicating syringomyelia have been reviewed. Hydrocephalus was found in onethird of the cases and has occasionally progressed after operation on the posterior fossa, sometimes with accompanying clinical deterioration. The outlets of the fourth ventricle were usually abnormal; tonsillar descent, arachnoiditis and both together were seen. Arachnoiditis correlated strongly with a history of difficult birth. The foramen of Magendie was sometimes patent and sometimes blocked. There was no consistent level of occlusion corresponding to a persistent roof of the fourth ventricle. The cisterna magna was usually small or obliterated but some examples of large cisterns or subarachnoid pouches were found. Radiological demonstration of a communication from the fourth ventricle to the syrinx occurred in only seven patients by positive contrast material and not by air. It is suggested that a sizable communication is rare at the time when patients seek treatment.     

Planning and decision making for ambulatory surgery

There has been rapid growth in the number of ambulatory surgical centers in the United States over the past few years. Yet little research has been done to assist community health planners and surgeons in decision making and planning for ambulatory surgery. In this paper, an analytical framework is developed to assist surgeons in deciding whether to perform a procedure on an ambulatory or an inpatient basis. The Hospital Discharge Survey data collected by the National Center for Health Statistics are also analyzed to investigate their applicability in this analytical framework as well as to aid planners in developing community-wide ambulatory surgery projections. In spite of the limitations on the available data, the models developed here suggest possible future avenues for planning ambulatory surgeries.     

Where is group practice headed?

A CRAHCA educational program was held recently to determine the changes in the health service environment that are most likely to occur in the near future, and how these changes will affect medical group practice.