The effects of scheduled intern rotation on the cost and quality of teaching hospital care

We studied the effect of scheduled intern rotations on the cost and quality of inpatient care at one teaching hospital. For all discharges from the internal medicine service between 1980 and 1986, we identified 1,705 rotation patients and 3,141 no-rotation patients. Using linear or logistic regression analysis to control for baseline differences, we evaluated for the effect of rotation. We found that rotation was significantly related to longer length of hospital stay, b = 0.341 days, p = 0.001, and higher hospital charges (for log charges, b = 0.053, p = 0.016. Hospital deaths, nursing home placements, and 30-day readmissions were not significantly related to rotation, p > 0.1. These results suggest that the systematic discontinuity induced by scheduled intern rotations may be another source of increased health care costs experienced at teaching hospitals.     

Preoperative combined modality therapy for pancreatic cancer

Combined modality therapy can be administered prior to surgical resection for patients with operable pancreatic cancer. One important criteria used to select patients for this treatment sequence is the absence of arterial vascular encasement by tumor on thin-section CT scanning; the absence of peritoneal seeding on surgical staging or laparoscopy has been another important parameter used in identifying patients with localized disease. Preoperative treatment with infusional chemoradiation uses multiple fields of irradiation delivering a dose of 50.4 Gy in 28 fractions over 51/2 weeks. This is done in conjunction with a continuous infusion of 5-fluorouracil intravenously at a dosage of 300 mg/m²/day with each day of radiotherapy treatment. The initial results of this protocol indicate acceptable toxicity and no evidence of increased perioperative morbidity or mortality compared to series using operation alone. We conclude that nearly all patients eligible for this combined modality treatment approach complete therapy as prescribed with acceptable toxicity.

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Resumen Se estima que el adenocarcinoma del páncreas será diagnosticado en 27.000 personas en los Estados Unidos en 1993. La etiología de este neoplasma sigue siendo oscura, su diagnóstico precoz es poco frecuente y sólo un pequeño porcentaje de los casos exhiben enfermedad localizada, susceptible de cirugía con propósito curativo, en el momento del diagnóstico. La sobrevida media para los pacientes sometidos a resección exitosa es del orden de 12 a 20 meses con sobrevida a largo plazo en menos del 25%. La modalidad principal de tratamiento no operatorio es la irradición externa con quimioterapia concomitante (quimio-radiación), la cual posee la capacidad de paliación de los síntomas cuando la enfermedad no es resecable. Esta modalidad ya está establecida como terapia adyuvante en el cáncer pancreático resecable. Tradicionalmente la cirugía ha sido utilizada para diagnosticar y evaluar la extensión de la enfermedad, para determinar resecabilidad y para establecer drenaje biliar previo a la radioterapia paliativa. Sin embargo, muchos de estos propósitos de la cirugía pueden ser logrados en la actualidad en los pacientes con tumores resecables mediante métodos no operatorios que permiten administrar quimio-radiación en la fase preoperatoria en vez de la postoperatoria. Gracias a los esfuerzos combinados de cirujanos, patólogos, radiólogos, radioterapeutas y oncólogos clínicos, los pacientes pueden hoy ser diagnosticados, estadificados y tratados con un enfoque multimodal basado en la historia natural y los patrones de falla del cáncer pancreático.

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Résumé En 1993, le diagnostic d'adénocarcinome du pancréas a été posé chez plus de 27000 patients aux Etats Unis. L'étiologic de ce cancer reste un mystère, le diagnostic précoce est rare, et seulement un pourcentage réduit de ces patients ont une maladie suffisamment localisée au moment du diagnostic pour envisager une chirurgie à visée curative. La médiane de survie après chirurgie à visée curative varie dans la littérature entre 12 et 20 mois mais moins de 25% des patients survivent à long-terme. La thérapeutique palliative la plus embloyée est la radiothérapie externe combinée à la chimiothérapie qui pallie le plus souvent avec succès les symptômes des tumeurs non réséquées et qui a également un rôle comme traitement adjuvant chez les patients ayant cu une résection. C'est par la chirurgie que l'on fait traditionnellement le diagnostic et établi le bilan du cancer, que l'on évalue la résécabilité et que l'on peut établir un drainage efficace avant de pratiquer la radiochimiothérapie palliative. Cependant, la plupart de ces objectifs peuvent être accomplis de nos jours par des moyens non chirurgicaux, permettant alors de proposer aux patients candidats à la chirurgie une radiochimiothérapie en pré-plutôt qu'en postopératoire. C'est grâce à un effort combiné de chirurgiens, d'anatomopathologistes, de radiologues diagnostiques et thérapeutiques ainsi que des oncologues médicaux et radiothérapeutes que l'on peut correctement diagnostiquer, faire le bilan et traiter les patients de façon multidisciplinaire en se basant sur les faits de l'histoire naturelle et la progression potentielle de la maladie cancéreuse.

     

Response from lieberman and colleagues

Respond on comments on Lieberman's article: Cyclosiloxanes Produce Fatal Liver and Lung Damage in Mice. Environ Health Perspect 107:161-165     

The infectious complications of anabolic-androgenic steroid injection

One million individuals in the United States alone are estimated to be current or past users of anabolic-androgenic steroids. In the United States fifty-percent of anabolic-androgenic steroid users administer their compounds intramuscularly, and twenty-five percent of adolescent anabolic-androgenic steroid users share needles, placing these young adults at risk for infections related to injection. To examine the medical literature for reports of infections attributable to anabolic-androgenic steroids, we conducted a MEDLINE (1966-1998) and AIDSLINE (1980-1998) world literature review to examine all references that attributed infections to anabolic-androgenic steroid injection. Infections associated with anabolic-androgenic steroid injection include three cases of HIV, one case of hepatitis B, one case of hepatitis C, eight abscesses, and a case of fungal endophthalmitis. No cross-sectional or prospective studies exist that document the risk of infections related to anabolic-androgenic steroid injection. These serious infectious complications of anabolic-androgenic steroid injection may be avoided with education and prevention techniques. Infections occurring in anabolic-androgenic steroid users are not as common as in intravenous drug users.