Wise purchasing under healthcare reform

Group Health Cooperative of Puget Sound (Seattle, WA) believes that wise purchasing practices contribute both to cost efficiency and high quality healthcare delivery. At Group Health Cooperative, we came by this belief through a variety of forces all pushing for healthcare reform--legislative-, market-, and consumer-driven forces. At nearly fifty years of age, Group Health Cooperative of Puget Sound is the oldest health maintenance organizations (HMO) in the country. As in the beginning, Group Health is still a consumer-governed cooperative that has grown to over 400,000 enrollees, 44,000 of whom are seniors. The Co-op has a mixed staff/group/network physician model. Its 1994 budget was over $1 billion, with Medicare revenue accounting for about 30% of the budget. For nearly its first four decades, Group Health was just about the only show in town. If you wanted prepaid healthcare or independent consumer oversight for quality of care, you joined Group Health. But by the mid-1980s, there were over twenty other managed care competitors. Some were local health plans with a sideline managed-care business, but, increasingly, competitors included huge, national, for-profit corporations. In addition, two other streams of change pressured healthcare in the Seattle area and elsewhere--legislative and market reform. In Washington, legislative reform started in 1989 with the Basic Health Plan, a program to aid the working poor by subsidizing their healthcare insurance premiums based on financial need.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraoperative radiotherapy in the treatment of neuroblastoma: Report of a pilot study

Background: External beam radiotherapy in advanced neuroblastoma is limited by the volume of normal radiosensitive tissues included in the radiation field. Limitations to external radiation are the late effects to these tissues. Intraoperative radiotherapy (IORT) delivers a single high-radiation dose to a tumor while displacing normal tissues that would have been included in an external field. Standard external radiotherapy can still be done after boost IORT. Methods: Eight advanced-stage neuroblastoma patients who received IORT as part of their multimodality therapy were reviewed to identify the impact of IORT on operative time, complications, and tumor control in the treatment field. The IORT was accomplished by patient transport from the OR to the radiation therapy suite; these were separated by three floors. Results: IORT added 30–75 min to the operative procedure. Tumors in the resection/IORT fields showed no evidence of disease (one), stable tumor size (six), and tumor recurrence (one). Two complications were identified: a urinary fistula and CO₂ retention, which was detected and corrected before the IORT. Neither of these complications was related to the IORT. Two patients who had subsequent tumor resection after IORT demonstrated tumor differentiation to ganglioneuromatous tissue. Conclusions: IORT usually can be completed in less than an hour. No IORT-associated complications were identified. IORT along with maximal tumor resection, external radiation, and chemotherapy enhances local tumor control.Presented in part at the 47th Annual Symposium of The Society of Surgical Oncology, Houston, TX, March 17–20, 1994.     

Acute hyperthermia following stereotactic radiosurgery for pituitary adenoma

A 71-year-old male presented with a large pituitary adenoma with superior extension into the optic chiasm and suprasellar cistern. He was treated with stereotactic radiosurgery to a dose of 16 Gy. Approximately 1 h after radiosurgery he developed fever; his temperature peaked at 105.1 degrees F and normalized about 20 h later. This case demonstrates that acute hyperthermia is a potential complication following high dose stereotactic radiosurgery for large pituitary tumours.     

Selective neck dissections for squamous carcinoma of the upper aerodigestive tract: patterns of regional failure.

BACKGROUND: Surgeons have been using selective neck dissections in the treatment of squamous carcinoma of the upper aerodigestive tract for over 20 years. To date, no data is available that can answer the question "What are the patterns of failure in the neck following a selective neck dissection and is a selective neck dissection a reliable procedure for metastatic disease?" METHODS: To answer this question, the medical records of all patients with squamous carcinoma of the oral cavity, oropharynx, larynx, and hypopharynx treated at The University of Texas M. D. Anderson Cancer Center from January 1, 1985-December 31, 1990, with a selective neck dissection were reviewed. Five hundred seventeen neck dissections were analyzed: suprahyoid (41), supraomohyoid (284), and anterolateral (192). The end point of the study was regional failure and survival. RESULTS: Regional recurrence in patients treated with a suprahyoid dissection was 43% with pathologically positive nodes. The regional recurrence in the patients treated with a supraomohyoid neck dissection was 1.9% with pathologically negative nodes, 35.7% with path N1 without postoperative radiation therapy, and 5.6% with postoperative radiation therapy. The neck staged pathologically N2B failed with and without postoperative radiation, 8.3% and 14%, respectively. Thirteen percent of the anterior/lateral neck dissections failed regionally. If multiple pathologically positive nodes (N2B) were present, the regional failure with postoperative radiation was 30% and 33.3% without postoperative radiation. CONCLUSION: The results of this retrospective study suggest that a selective neck dissection is a satisfactory staging procedure and is a definitive operation if all the nodes are pathologically negative. However, if a node is found to be invaded with cancer, the use of postoperative radiation is advisable.     

Pulled between contradictory expectations: Norwegian mother/child service and the ‘new’ public health discourse

In public health discourses in Western societies from the late 1970s onwards, redistribution of power from health professionals to individuals has been defined as a key strategy to foster what is called ‘healthy citizens’. The idea of changing the power relations between ‘experts’ and ‘non-experts’ by ‘empowering’ the latter, however, has not been problematized within the ‘new’ public health literature to any real extent. The present paper focuses on the mother/child service in Norway, and the discussion touches on some of the challenges and tensions that arise when the rhetoric of such notions as ‘empowerment’ is put into practice. This study indicates that the ‘new’ public health discourse is not in harmony with the problematic everyday life of the health service. The analysis is based on qualitative data drawn from interviews with public health nurses.     

Exposure of health care workers to pentamidine isethionate.

Pentamidine isethionate is currently used for the prophylaxis and treatment of Pneumocystis carinii pneumonia. Its use has been associated with a number of symptoms in staff administering treatment, and there are some additional concerns about possible adverse health effects of long term exposure. The aim of this study was to quantify exposure of health care staff administering nebulized pentamidine to patients. Personal breathing zone and static air samples at the height of the patient's head were collected during the nebulization of pentamidine to nine sequential outpatients attending a haemophilia unit. These were analysed using a standard method allowing the exposure of staff to be estimated. The duration of treatment varied between 15 and 60 min. Personal breathing zone samples showed exposure to be between 2 and 100 micrograms/m3. Static samples showed the concentration of pentamidine in the room varied from 15 to 2,100 micrograms/m3. While these exposures were relatively low, they were higher than some other studies have reported, and may pose some risk of adverse effects to staff. Some simple measures could reduce staff exposure.     

The GABA(B) agonist CGP 44532 decreases cocaine self-administration in rats: demonstration using a progressive ratio and a discrete trials procedure

Previous self-administration experiments have shown that baclofen, the prototypical GABA(B) agonist, produces an apparent attenuation in the reinforcing effects of cocaine in rats. The present experiments examined the effects of CPG 44532, a novel and highly specific GABA(B) agonist, on cocaine self-administration using two distinctly different procedures. CGP 44532 (0.063-0.5 mg/kg) produced a dose dependent decrease in break point on a progressive-ratio (PR) schedule. A low dose of CGP 44532 (0.125 mg/kg) produced an apparent shift of the cocaine dose-response curve to the right. In contrast there was comparatively little effect on food-reinforced responding on the same PR schedule. Using a discrete-trials procedure that engendered a circadian pattern of self-administration, CPG 44532 (0.063-0.5 mg/kg) produced a dose-dependent suppression of cocaine intake in the 4 h period following treatment. When a concurrently available food reinforced lever was added to the discrete trials paradigm CGP 44532 failed to disrupt responding for food at any of the doses tested. Data from the PR and discrete-trials procedures taken together indicate that CGP 44532 produced a specific decrease in the motivation to self-administer cocaine.     

Discriminative stimulus properties of the benzodiazepine receptor partial agonist beta-carbolines abecarnil and ZK 95962: a comparison with chlordiazepoxide

Separate groups of rats were trained to discriminate one of three benzodiazepine receptor ligands from vehicle. The three ligands used, the benzodiazepine chlordiazepoxide, and the beta-carboline partial agonists ZK 95962 and abecarnil, have been reported to have different agonistic profiles. All three ligands formed specific benzodiazepine-receptor mediated discriminative stimuli antagonizable by at least one benzodiazepine antagonist. Different patterns of generalization were observed for each cue. As reported previously full and partial agonists substituted for chlordiazepoxide, whereas generalization to ZK 95962 was obtained more readily with partial agonists and antagonists with weak partial agonist activity. In contrast to the other two cues, the abecarnil discriminative stimulus was difficult to train and was unstable over time. Additionally, the abecarnil cue showed commonalities only with sedative or BZ1 receptor agonists. These results demonstrate qualitative differences between different benzodiazepine receptor ligands dependent on the intrinsic activity of the compound used.