Revise or preserve? A flurry of views on revision of tax-exemption standards

Many groups would be affected if Congress changes the tax laws governing not-for-profit hospitals. The community benefit standard now in place focuses on nondiscriminatory treatment of patients whose care is paid for by public programs such as Medicaid. It also fosters universal access to emergency care regardless of ability to pay. In 1990, however, a U.S. General Accounting Office (GAO) report suggested that if Congress believes tax-exempt hospitals should provide more charity care, it should consider revising the criteria for exemption. This created a flurry of responses from the groups that would be affected. In response to the GAO's report, Rep. Edward R. Roybal, D-CA, introduced H.R. 790, and Rep. Brian J. Donnelly, D-MA, introduced H.R. 1374, bills linking tax exemption to charity care. The Roybal bill requires not-for-profit hospitals to have an open-door policy for Medicare and Medicaid patients and to provide services to a reasonable number of these patients. The Donnelly bill would in essence codify the IRS's interpretation of the community benefit standard and add to it a charity care requirement. The administration reported it was opposed to a change from the current community benefit standard to an express charity care standard. Nevertheless, it would not oppose a more limited change that codifies the current position. Not-for-profit hospitals have opposed any changes, arguing that the existing community benefit standard is sufficient and that the decision of how to benefit the community should be made by an individual hospital and its community.     

Urban Indians' smoking patterns and interest in quitting.

Little is known about smoking patterns of urban American Indians and their interest in quitting. Most published research has focused upon American Indians who live on rural reservations. In this study, personal interviews were conducted with a convenience sample of patients at Urban Indian Health Clinics in four geographically diverse sites: Milwaukee, WI, Minneapolis, MN, and Seattle and Spokane, WA. A total of 419 current smokers and 173 ex-smokers completed interviews. Current smokers reported a median cigarette consumption of 11 per day. Smokers indicated both a moderate desire to quit (mean 5.97, on a scale 0-10) and moderate confidence in their ability to do so (mean 5.56, on a scale 0-10). More than 70 percent of current smokers indicated having previously tried to quit. The most common reasons cited for relapse included craving, social situations, stress, and nervousness. The most common reasons for quitting given by ex-smokers included being "sick" of smoking, health concerns, respiratory problems, and pregnancy. The estimated quit-ratio (former smokers divided by current+former smokers) was 29.7 percent. This quit-ratio, although substantial, is lower than the 45 percent quit-ratio reported for the general U.S. population. Perhaps the most striking findings are the similarities between American Indians and the overall population in both interest in quitting and reasons for doing so. Smoking cessation previously has been viewed as a low priority for this population. The current results suggest the viability of systematic efforts to encourage urban American Indians to quit smoking.     

The influence of air bags and restraining devices on extremity injuries in motor vehicle collisions

The influence of air bags and other restraining devices on injury after motor vehicle collisions is not well defined. This study examined the relationship between the use of restraining devices and the incidence of extremity injuries in motor vehicle collisions. A retrospective analysis was performed on motor vehicle collision data submitted to the Pennsylvania Trauma Outcome Study database from 1990 through 1995. Criteria for submission included trauma patients who were admitted to the intensive care unit, who died during hospitalization, who were hospitalized for more than 72 hours, or who were transferred in or out of the receiving hospital. A total of 21,875 patients met these criteria. These patients were analyzed for the presence or absence of upper and lower extremity injuries and were compared based on their use of restraining devices. Restraining devices were categorized into four groups: air bag alone, air bag and seat belt, seat belt or carseat without air bag, and no restraining device. Statistical analysis was performed using the chi-squared test of association. For contingency tables with small expected frequencies, Fisher's exact test was used. Study participants included 11,688 men and 10,185 women with a mean age of 38 +/- 20 years. There were 16,033 drivers and 5,842 passengers. Air bags were deployed in 472 instances. In 297 of these cases, additional restraint was provided with a seat belt. In 6,632 cases, air bags were not deployed; however, patients were restrained with either a seat belt or a carseat. In 14,771 cases, patients were not restrained. When comparing restraining devices as a group vs. no restraint, there was a significant decrease in the incidence of upper (p = 0.018) and lower (p < 0.001) extremity injuries. Air bags, however, were associated with an increased incidence of both upper (p = 0.033) and lower (p = 0.002) extremity injuries when compared with no restraint or when compared among patients who were restrained. As a group, restraining devices decrease the incidence of upper and lower extremity trauma sustained by patients injured in motor vehicle collisions. Air bags, however, are associated with an increased incidence of upper and lower extremity injuries when compared with seat belts alone or when no restraining devices are used.     

Absence of 185delAG mutation of the BRCA1 gene and 6174delT mutation of the BRCA2 gene in Ashkenazi Jewish men with prostate cancer.

Epidemiological studies have demonstrated a clustering of breast and prostate cancers in some families. Moreover, there is an increase in the number of cases of prostate cancer in families with inherited mutations of the breast cancer susceptibility gene BRCA1. We assessed the role of BRCA1 and BRCA2 in prostate cancer. We tested for the BRCA1 185delAG frameshift mutation, found in 0.9% of Ashkenazi Jews, and the BRCA2 6174delT mutation, found in 1% of Ashkenazi Jews, in Ashkenazi Jewish men with prostate cancer. We studied 60 Ashkenazi men with prostate cancer. A family history was obtained by interview or a self-report questionnaire. Histological confirmation of diagnosis was obtained for all subjects. Ethnic background was confirmed for all subjects by self-report or interview. Mutations of BRCA1 and BRCA2 were detected by amplification of lymphocyte DNA from peripheral blood according to standard polymerase chain reaction (PCR) and dot blot procedures. Patients'' ages ranged from 55 to 80 years (mean +/- s.d. 70 +/- 5.25). There were six men with a family history of prostate cancer; three of these had a father with prostate cancer. Five of the men had a family history of breast cancer, in a mother, a sister or an aunt. None of the men had a family history of both breast and prostate cancer. None of the 60 men carried the 185delAG BRCA1 or 6174delT BRCA2 mutations. Of 268 Ashkenazi Jewish women with sporadic breast cancer, tested in an unrelated study, 16 carried either the 185delAG mutation of BRCA1 or the 6174delT mutation of BRCA2. There was a significant difference in the incidence of the BRCA1 and BRCA2 mutations in the breast and prostate cancer cases (P = 0.05, two-tailed Fisher''s exact test). The contribution of germline BRCA1 and BRCA2 mutations to prostate cancer incidence is probably small and could be limited to specific subgroups.     

Exploring the decision-making preferences of people with colorectal cancer

OBJECTIVES: To explore patient views on participation in treatment, physical care and psychological care decisions and factors that facilitate and hinder patients from making decisions. DESIGN: Qualitative study using semi-structured interviews with patients. SETTING AND PARTICIPANTS: Three NHS Trusts in the north-west of England. Theoretical sampling including 41 patients who had been treated for colorectal cancer. RESULTS: For patients, participation in the decision-making process was about being informed and feeling involved in the consultation process, whether patients actually made decisions or not. The perceived availability of treatment choices (surgery, radiotherapy, chemotherapy) was related to type of treatment. Factors that impacted on whether patients wanted to make decisions included a lack of information, a lack of medical knowledge and trust in medical expertise. Patients perceived that they could have a more participatory role in decisions related to physical and psychological care. CONCLUSION: This study has implications for health professionals aiming to implement policy guidelines that promote patient participation and shared partnerships. Patients in this study wanted to be well informed and involved in the consultation process but did not necessarily want to use the information they received to make decisions. The presentation of choices and preferences for participation may be context specific and it cannot be assumed that patients who do not want to make decisions about one aspect of their care and treatment do not want to make decisions about other aspects of their care and treatment.     

Heterogeneity in the ultrastructure of the mucous (goblet) cells of the rabbit palpebral conjunctiva

Aim: The purpose of this study was to assess objectively the ultrastructure of the secretory granules in rabbit conjunctival mucin‐producing ‘goblet’ cells. Method: The upper eyelids from five young adult dioestrous female rabbits were dissected out, stretched onto a cardboard support and prepared for transmission electron microscopy by repeated application of an isotonic two per cent glutaraldehyde fixative at room temperature. Post‐fixation treatment included osmium tetroxide and staining with uranyl acetate and lead citrate. Low magnification micrographs were taken of the goblet cells of the conjunctiva, printed at a magnification of approximately 6,000 and the number, size and features of the secretory granules assessed. Results: Across the entire palpebral conjunctiva of ail five rabbits, the majority of mucous cells displayed a goblet shape and the secretory granules were uniformly pale in staining. The average width of the goblet cells was 10.8 ± 1.1 μm and the diameter of the secretory granules was 0.82 ± 0.16 μm. However, in localised regions across the palpebral conjunctiva of two of the rabbits, some goblet cells were different in that the secretory granules had either a denser‐staining core, in which some of the granules were densely staining (while others were pale) or most of the granules were densely staining. These mucous cells had an average diameter of 10.3 ± 1.7 μm and the granule diameters averaged 0.88 ± 0.01 μm. For these abnormal goblet cells, inflammatory cells were found in their immediate vicinity. Occasionally, goblet cells were seen to be in the process of degranulation with associated apparent cell necrosis and the mucin granule diameter was close to 1 μm. Conclusions: The ultrastructure of the mucin‐containing secretory granules of the conjunctival mucous cells is not necessarily homogeneous in character and further attention needs to be given to the effects of localised inflammation in the tissue and to possible hormonal influences.     

A review of Kallmann syndrome: genetics, pathophysiology, and clinical management

Kallmann syndrome is a genetic disorder with the hallmarks of anosmia and hypogonadotrophic hypogonadism. It has a male preponderance. With the elucidation of the genetic pathways involved, affected females and inheritance patterns are becoming more clearly identified. It is an eminently treatable disorder, but it must first be recognized by the physician. With treatment, favorable reproductive outcomes can be attained in addition to maturation of secondary sex characteristics.