The financing of NMR equipment

Cost-containment regulations and possible legislative changes in the tax area are creating new environments for the acquisition of nuclear magnetic resonance (NMR) systems. Shared services, management groups, and free-standing clinics are being established. Creativity in financing will be required to assure the cost-effectiveness of NMR services.     

Hypnotizability and dissociation

The author describes the multidimensionality of hypnosis itself and hence of hypnotizability. He also points to the lack of clarity regarding the concept of dissociation and the extent to which its roots lie in the clinical experience of hypnosis. The concept of dissociation increasingly preempts repression and other defense mechanisms in current nosological thinking. The author cautions against equating hypnotizability scores with dissociative capacity and advocates a clearer elaboration of the concept of dissociation. Meanwhile, restraint in the use of the term "dissociation" is recommended.     

Der(16)T(1-16) is a nonrandom secondary chromosome aberration in many types of human neoplasia, including myxoid liposarcoma, rhabdomyosarcoma and Philadelphia-chromosome-positive acute lymphoblastic-leukemia

An unbalanced translocation between chromosomes 1 and 16, der(16)t(1;16), resulting in trisomy 1q and loss of genetic material from 16q, has been thus far suggested to constitute a nonrandom secondary abnormality in two types of closely related solid tumors - Ewing sarcoma and peripheral primitive neuroepithelial tumor (PNET). We report on three cases of soft tissue tumors, a myxoid liposarcoma, a PNET and a rhabdomyosarcoma, and four cases of hematologic disorders, two acute lymphoblastic leukemias (ALL), an acute mixed leukemia and a refractory anemia, that in addition to primary chromosome abnormalities displayed the presence of the der(16)t(1;16). All three cases of acute leukemia were Philadelphia (Ph) chromosome-positive and all displayed both lymphoid and myeloid antigens. Our results and review of the literature indicate that the occurrence of der(16)t(1;16) is not limited to Ewing sarcoma and PNET, but that acquisition of this abnormality may represent a more general pathway of clonal evolution in several different tumor types including Ph chromosome-positive ALL, myxoid liposarcoma, rhabdomyosarcoma, breast cancer, endometrial adenocarcinoma, myelodysplastic syndromes, acute myeloid leukemia, retinoblastoma, and Wilms' tumor.     

The hospital admissions study in England: are there alternatives to emergency hospital admission?

STUDY OBJECTIVE--To assess the potential for substituting alternative forms of care for admission to an acute hospital in particular groups of patients. DESIGN--A screening tool, the intensity-severity-discharge review system with adult criteria (ISD-A), developed for hospital utilisation review in the USA, was used in a cohort of hospital admissions to identify a group of patients who could potentially have been treated outside the acute hospital. These patients were further assessed by a panel of general practitioners (GPs) to determine the most appropriate alternative form of care. A cost analysis was performed on the results obtained. SETTING--General medicine and geriatric specialties in one acute hospital in the south western region. PATIENTS--Patients comprised a sample of 701 admitted to general medical and geriatric specialties. MAIN RESULTS--The screening tool identified 19.7% of admissions for whom there was potential for treatment outside the acute hospital. Assessment by the GP panel reduced this potential to between 9.8% and 15.0% of emergency admissions. The alternatives most frequently identified as "most appropriate" were the community hospital/GP bed and the urgent outpatient assessment (within either 24 or 48 hours). Potential resource savings based on the average cost were relatively small. This potential seemed to be greater for the alternative of the urgent outpatient assessment. CONCLUSIONS--Potential exists for treating a proportion of patients in lower intensity alternatives to the acute hospital. If this potential were exploited few resource savings would occur.     

Botox for rejuvenation of the periorbital region

Botulinum toxin (Botox) has become accepted as a unique and effective agent for treating various aesthetic concerns. The periorbital anatomy is particularly well suited for Botox treatments and is the most frequent site to benefit from the cosmetic application of the toxin. Therapy is aimed at paralyzing specific muscles in order to reverse their effects on the overlying skin. Cosmetic benefits of Botox treatment include smoother, line-free skin, improved brow contour, and optimal post surgical healing in certain circumstances. Botox therapy is simple, effective, and forgiving, making it very popular among physicians and patients alike. This chapter provides a review of botulinum toxin and practical information regarding its use for aesthetic application in the periorbital region.     

Respiratory and ventilatory management of critically ill children during transport

As more and more pediatric intensive care units are established throughout the country, transport systems for critically ill children assume increasing importance. This article concerns the personnel, equipment, and other requirements for a transport system and reviews the respiratory and ventilatory management of pediatric patients during transport.     

The vasa vasorum and angioplasty

Interruption of flow in the vasa vasorum may lead to medial necrosis and aneurysm formation. The purpose of this study was to determine whether angioplasty produces significant alterations in the morphology or blood flow of the vasa vasorum of the dilated artery. The morphology of the canine vasa vasorum was studied before and after angioplasty; in a separate experiment vessel wall blood flow (VWBF) in canine carotid arteries was measured after angioplasty to determine whether physiologic regulation of the blood flow was disrupted by arterial dilation. No morphologic changes could be demonstrated in the vasa vasorum of the dilated artery; however, VWBF was increased by 1194 +/- 215% (mean +/- standard error, p less than 0.01) between 90 and 120 minutes after angioplasty. VWBF in the adjacent nondilated arterial segment was also increased (720 +/- 177% between 10-30 minutes, p less than 0.01) but returned toward normal after 60 minutes. Adenosine caused a "paradoxical" decrease in VWBF (p less than 0.05) of the dilated arterial segment while causing increased VWBF (p less than 0.05) in the thoracic aorta. Angioplasty appears to produce persistent hyperemia in the dilated arterial wall. A paradoxical response to adenosine suggests that vasa vasorum in the dilated arterial segment are maximally vasodilated. This may be due to mechanical disruption of vasomotor tone or to release of vasoactive substances.     

Clinical pharmacology of oral all-trans retinoic acid in patients with acute promyelocytic leukemia.

All-trans retinoic acid (RA) induces leukemic cell differentiation and complete remission in a high proportion of patients with acute promyelocytic leukemia (APL). However, remissions induced by all-trans RA tend to be brief, and relapses are associated with resistance to further treatment in vivo, although the leukemic cells appear to retain sensitivity to the cytodifferentiating effects of all-trans RA in vitro. The clinical pharmacology of all-trans RA was examined in 13 patients with APL. The drug was administered at a constant dose of 45 mg/m2/day, given as a single dose on the first day of therapy and in two divided doses thereafter. Plasma and urinary concentrations of the parent drug and metabolites were quantitated by reverse-phase high-performance liquid chromatography and, where required, by a combination of normal-phase liquid chromatography/negative chemical ionization mass spectrometry. In patients with APL, basal levels of endogenous retinol and natural retinoids were within the normal range. Peak plasma levels of all-trans RA (347 +/- 266 ng/ml, mean +/- SD) were reached 1-2 h after drug ingestion and decayed in a monoexponential fashion with a half-life of 0.8 +/- 0.1 h. The only drug metabolite detected in plasma or urine was 4-oxo-all-trans RA (present in urine as the glucuronide conjugate). This metabolite accounted for less than 10% of the circulating drug in plasma, and its cumulative urinary excretion accounted for less than 1% of the administered dose. The drug was not found in cerebrospinal fluid. Continued oral administration of all-trans RA was associated with a significant decrease in both the plasma peak levels and the area under the concentration-time curve (P = 0.01 and 0.004, respectively) when measured after 2-6 weeks of treatment. We previously reported that a decrease in plasma area under the concentration-time curve was highly correlated with clinical relapse. Observations in a subset of patients in this study suggested that, in fact, the major decrease occurred early, within the first 7 days of treatment. These changes were associated with a 10-fold increase in urinary excretion of 4-oxo-all-trans RA glucuronide, suggesting that the accelerated clearance from plasma was associated with increased drug catabolism. The rapid disappearance may explain early relapse from remissions induced by all-trans RA; clinical "resistance" to all-trans RA may either wholly or in part result from an inability to sustain effective plasma concentrations of all-trans RA during continuous treatment.(ABSTRACT TRUNCATED AT 400 WORDS)     

The uninsured and the debate over the repeal of the Massachusetts universal health care law.

OBJECTIVES--The debate in Massachusetts over the repeal of the first state-based "pay or play" universal health plan is discussed using data from a survey of 1066 Massachusetts households. The survey attempted to measure the problems of the uninsured, to estimate the likelihood that they would buy insurance if offered, and to calculate the proportion of the uninsured who would be covered under an employer mandate. DESIGN--A survey conducted in person and by telephone in 1066 households, with an oversample of uninsured households, using stratification, clustering, disproportionate sampling, and poststatistical weighting. PARTICIPANTS--Adults aged 18 years and older who were knowledgeable about the insurance status of persons in their household. MAIN OUTCOME MEASURES--Insurance status, employment status, access to and use of health services, and willingness to purchase health insurance. RESULTS--First, the present system of hospital-based uncompensated care in Massachusetts is inadequate by itself to meet the needs of uninsured residents. Uninsured persons are less likely than insured ones to seek medical care for chronic health problems and serious symptoms requiring evaluation. Second, 83% of uninsured families and 24% of uninsured individual respondents would purchase one of several insurance options with 30% of the cost subsidized. Last, the employer mandate provisions of the legislation would cover 43% of the uninsured in Massachusetts. CONCLUSION--In the current economic climate, the political viability of the universal health care plan and similar national initiatives is uncertain given the intractable conflict between perceptions of the financial stability of small businesses that do not offer insurance and the health care needs of uninsured individuals.