American medical culture and the health care crisis.

The health care crisis is easily defined as a progressive and massive rise in costs coupled with a failure of the system to provide care to a large minority of the population (37 million). Multiple remedies have been proposed, none of which confronts the core problem. This crisis has been largely produced by the American medical culture--how our physicians practice, what they do to and order for patients. Clearly, medical culture in other Western democracies is different, yielding better overall health care at a lower cost. A brief analysis of any of the sectors of medicine or surgery reveals the overabundance of clinical interventions that take place. The solution will require a major reduction in clinical interventions so many of which are questionable, useless, or even harmful.

Breast cancer: early diagnosis of precursor lesions and clinically inapparent carcinoma by fine needle aspiration.

Breast cancer death rate has remained stable at 26 per 100,000 for over 50 years. This control failure is due in large part to difficulty in early diagnosis. Combined clinical evaluation, mammography and fine needle aspiration (FNA) offer the best opportunity for early diagnosis. Non-directed FNA is a useful adjunctive technique and three illustrative cases are presented. Cancer evolves from proliferative epithelial disease of ducts and lobules. Atypical duct hyperplasia in association with family history is a pertinent marker for development of cancer. Identification of hyperplastic lesions traditionally occurs after surgical biopsy and histopathologic review. FNA demonstrates patterns of both duct hyperplasia and atypical duct hyperplasia. Ploidy studies of such smears offer the possibility of selecting precancerous lesions for extirpation. A combination of directed and undirected punctures and ploidy studies may yield early diagnosis of precancerous lesions.

The quality of health care: the practical clinical view.

Quality assurance techniques involving review of charts and performance have been pursued for many years. The establishment of conformance standards, as well as other aspects of QA considered static and non-dynamic, have been subjected to critical analysis by quality workers pursuing a program of total and continuous quality improvement. These new concepts have evolved from a study of industrial methods which have produced perfect products by a process of progressive incremental improvement. The concept of the "bad apple" (which spoils the barrel) has been disparaged by the new quality improvement workers. The contention that deletion of the "bad apple" is a useless procedure is discussed and refuted. The difference between the "rotten apple" (venal or incompetent physician) and the "bad apple" (careless or aggressive physician) is cited. The importance of the physician in the quality process and failure of the quality literature to get physicians involved are discussed. Improvement of physician performance will require changes in basic educational training rather than attempting to improve current performance by rules and standards. In some countries the problem of poor access to the health system by millions of people is at this time a considerably greater problem than lack of quality within the health system. This may be an area toward which quality workers should direct their attentions.

Two cases with objective complete response to neo-adjuvant chemotherapy of breast carcinoma.

This report describes two patients in whom primary treatment with chemotherapy completely eliminated palpable, and in one case, histological evidence of previously cytologically verified breast carcinoma.

Aspiration cytology in Sweden: The Karolinska Group.

The method of aspiration biopsy cytology began to receive international attention after publications, innovations, and courses originating at the Karalinska Hospital in Sweden. Sixteen Franzen, Josef Zajieek, Pier Esposti, and Torsten Lowhagen were prime movers of this clinical and scientific development. The history of their arrival at the Karolinska and their seminal contributions is reviewed.

Aspiration cytology of metastatic hypernephroma.

The findings in aspiration cytology smears from 15 patients with metastatic hypernephroma (renal-cell carcinoma) are presented along with the criteria for cytologic classification of aspirates of primary hypernephroma. The distinctive cytopathology of needle aspirates of metastatic lesions is illustrated. A small nuclear-cytoplasmic ratio was evident in poorly differentiated cells. The cytoplasm was highly characteristic, particularly with Romanovsky stains, and was termed "opaque with or without vacuolization and granulation" to distinguish it from the so-called clear cell of histopathology, which has been denuded of its cytoplasmic content by the histologic process. Cytoplasmic vacuoles were punched out, bubbly or lacy. The partially extruded nucleus was a useful identifying feature. In 7 of the 15 cases, primary hypernephroma was indicated by the cytologic findings in the metastases. This finding may be clinically useful in diagnosing the broad spectrum of obscure paraneoplastic syndromes that may accompany this tumor.

Myeloid, erythroid, and immune system defects in a family. A new stem-cell disorder?

Four of six siblings, offspring of Sicillian first cousins, developed a clinical disorder in early adulthood affecting the hematopoietic and immunoglobulin-producing systems. A female sibling died at age 21 with myeloid aplasia and agranulocytosis. A male sibling, at age 17, presented with erythroid and plasma cell aplasia with hypogammaglobulinemia. Two other female siblings, ages 21 and 35, had a lymphoproliferative disorder associated with hypogammaglobulinemia. In two of the affected subjects there was complete absence of the enzyme leukocyte alkaline phosphatase. Electron microscopic studies of the peripheral leukocytes from these two subjects and from one of the two asymptomatic siblings showed curious intranuclear and intracytoplasmic linear "crystalloid" structures in the mature neutrophils. It is postulated that the family contains a genetic defect, transmitted as an autosomal recessive by the heterozygous parents, that produces a stem-cell disorder manifested by myeloid, erythroid, and plasma cell aplasias, unique electron microscopic findings, and morphologic and functional abnormalities in later generations of cells.