A national cross-sectional survey investigating the use of endoscopic ultrasound in the diagnosis and treatment of oesophageal cancer in the UK.

AIM: To evaluate variation in the pre-pandemic use of endoscopic ultrasound (EUS) for oesophageal cancer diagnosis and treatment planning up to 2019, and which factors contributed to this. MATERIALS AND METHODS: A UK-wide online survey of oesophagogastric multidisciplinary team lead clinicians was undertaken to determine perceptions towards, and the use of, EUS to aid staging and treatment planning in oesophageal cancer. RESULTS: Thirty-five responses were received, representing 97 UK National Health Service Trusts/Health Boards. A majority of centres (n=21, 60%) did not have formal written guidance for EUS use. Although all respondents had access to EUS, a perceived lack of utility (n=7) and concerns about delaying treatment start dates (n=8) each restricted EUS use for a fifth of respondents. For most centres (n=24, 68.6%), EUS use is case-specific, whereas for 10 (28.6%) EUS is used for all patients with potentially curable disease. A majority of centres use diagnostic positron-emission tomography for radiotherapy target volume delineation (TVD), whereas 22 (62.9%) use EUS. The factors contributing to decisions to use EUS for staging, TVD and surgical planning varied between centres. The proportion of centre respondents who would request EUS in each of six clinical scenarios varied considerably. CONCLUSION: There were substantial differences in the patient and disease characteristics that are perceived to be indications for EUS use for both staging and treatment planning. Research to clarify in which patients with oesophageal cancer EUS affords benefit is required, as is urgent standardisation of its role in the diagnostic pathway.

Use and costs of ambulatory care services among Medicare enrollees with schizophrenia.

OBJECTIVE: The objective of this study was to identify predictors of the use and cost of ambulatory care services among Medicare recipients with schizophrenia. METHODS: The design was a cross-sectional analysis of Medicare claims in 1991. The study subjects were a 5 percent random sample of all persons in the United States who had at least one Medicare service claim in 1991 and who were diagnosed as having schizophrenia in any care setting. Outcome measures included use and cost of any ambulatory care service, individual therapy, psychiatric somatotherapy, group therapy, or family therapy. RESULTS: For nearly 25 percent of the total sample of 12,440, no claims were filed for ambulatory care services in 1991. The mean+/-SD number of ambulatory care visits during the year was 7.9+/-21. The most frequently used type of therapy was individual therapy (5+/-14 visits). The mean+/-SD yearly cost of care for persons who received ambulatory care services was $470+/-$1,028. Among persons under 65 years of age, Caucasians were about 1.5 times as likely as African Americans to have received an ambulatory care service and 1.3 times as likely to have received individual therapy. Persons who were 65 or older were less likely to have received any service. Among service recipients, costs of care were lower for African Americans and for older people. CONCLUSIONS: The use of Medicare-funded ambulatory care services by persons with schizophrenia varied by race and age. Further investigation is required to determine whether subgroups of individuals who do not have additional insurance coverage or access to services are receiving substandard care.

What the dentist should know about a patient with HIV/AIDS.

Chances are good that oral health care providers will treat someone with diagnosed or undiagnosed HIV during their careers. The Centers for Disease Control and Prevention estimate that 650,000 to 900,000 U.S. residents are living with HIV infection, more than 200,000 of whom are unaware of their infection. As with any medical condition, it is possible for a dentist to do great harm by ignoring systemic manifestations of HIV. On the other hand, dentists who are ignorant of modern HIV disease management often request unnecessary medical consultations resulting in dental treatment delays. Since 1996, the growing use of highly active anti-retroviral therapy and ultrasensitive viral load testing has changed the picture of the dental patient with HIV. The goal of this article is to update and summarize information the oral health care provider needs to safely treat a person with HIV/AIDS. It is not intended to replace previous comprehensive publications on HIV and dentistry, as they are still excellent resources for information. Here, simple instructions for physical evaluation of a patient with HIV/AIDS will be presented and steps for determining safe procedures explained.

Decision-makers' use of pharmacoeconomics: what does the research tell us?

Governments, organizations and industry routinely make decisions regarding the value of pharmaceuticals. The perspectives, techniques, decision constraints and available information differ across these decision-makers and sometimes within categories. Although pharmacoeconomics is consistent with the international trend toward evidence-based decisions in medicine and could benefit all of these decision-makers, the potential impact of these studies has been largely unrealized. Why is it that a field to which so much research funding has been devoted, has produced so little of clear use to major decision-makers? Would inflexible organizational barriers surrounding narrowly defined performance incentives and line item budget accountability limit the usefulness of even impeccably performed pharmacoeconomic studies? Or, are methodological and logistical considerations impeding the usefulness of pharmacoeconomics?

Lower body osteoarticular pain and dose of analgesic medications in older disabled women: the Women's Health and Aging Study.

OBJECTIVES: This study assessed use and dosage of analgesic medications in relation to severity of osteoarticular pain. METHODS: The type and dose of analgesic medication and the severity of pain in the lower back, hips, knees, or feet of 1002 older disabled women were assessed. RESULTS: Severe pain and the use of analgesic medications were reported by 48.5% and 78.8% of women, respectively. Among those who had severe pain, 41.2% were using less than 20% of the maximum analgesic dose. Overall, 6.6% of women were using more than 100% of the maximum dose. CONCLUSIONS: Severe pain is common. Additional, more effective, and safe analgesic treatments are needed for controlling pain in older persons.

The effect of managed care on prescription drug costs and benefits.

This review discusses the approaches to prescription drug payment practices taken by managed care to influence drug use and costs, and presents the research evidence supporting these interventions. In the US, drugs were infrequently covered as an ambulatory benefit under fee-for-service indemnity insurance; however, health maintenance organisations almost always provide outpatient drugs and consequently have developed approaches to influence drug use and manage its costs. Managed care as a set of tools and as an organisational form is moving toward more restrictions on direct access to pharmaceuticals as a covered benefit. Options for influencing drug use and cost may address access, ingredient costs, dispensing fees and cost sharing. The formulary process is the foundation for a managed pharmacy benefit and integrates these options. The limited empirical evidence for an effect of managed care on drug costs and use is reviewed. A proposed research agenda includes evaluation of the effects of restrictive formularies, capitation, disease management and other programmes to influence the cost and use of pharmaceuticals.

Services to families of adults with schizophrenia: from treatment recommendations to dissemination.

OBJECTIVE: Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability. METHODS: For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training. RESULTS: In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of 5,393 persons with schizophrenia in one state. Of the 530 patients in the field study who reported having contact with their families, 159 (30 percent) reported that their families had received information, advice, or support about their illness, and 40 (8 percent) responded that their families had attended an educational or support program. At the four agencies where staff received only didactic training, no changes in family services were found after one year. Three of the five agencies where staff participated in intensive training enhanced their family services. CONCLUSIONS: A minority of families of persons with schizophrenia receive information about the illness from providers. Implementation of model family interventions is possible with considerable technical assistance. A gap exists between best practices and standard practices for families of persons with schizophrenia.

Managed care pharmacy, socioeconomic assessments and drug adoption decisions.

A telephone survey of a representative national sample of 51 large managed care organizations in the U.S. (> 50,000 enrollees) was undertaken (1) to understand the role of socioeconomic assessments on drug adoption decisions; (2) to determine the sources of these assessments and the reliance of managed care pharmacy on each; and (3) to determine the resources for internally versus externally performed drug assessments. Socioeconomic assessments (clinical effectiveness, safety, cost of treatment, cost-effectiveness, and quality of life) are often tied to formulary decisions. Plans differ in their use of externally available socioeconomic assessments and in their ratings of the importance to decision making of drug assessments from the various sources. Those using a specific source of drug assessment information rated them in the following order of importance: PBM assessments, other HMOs, peer reviewed literature, evaluations performed by industry, articles in non-peer reviewed publications and, lastly, government reports. Timeliness and comprehensiveness are important components of the overall utility of information. A high percentage of plans reported using some of the various types of assessments, with clinical effectiveness most common, and cost-effectiveness second. The percentage of new drugs that undergo assessments in each of the plans covers a broad range, with 57% of the plans evaluating at least half of all new drugs. All but one surveyed managed care plan reported having either implemented or plans to implement a disease management program. Eighty percent of those surveyed are more concerned about drug assessments than in the past and 88% anticipate greater future use. Although 38 plans (75%) have a person in the organization responsible for drug assessments, this is the primary job in only 14 plans (37%). With greater reliance on drug assessments in the future, there are substantial opportunities for integrating drug assessments, formularies and disease management programs.

Infections of Gyrodactylus bullatarudis and Gyrodactylus turnbulli on guppies (Poecilia reticulata) in Trinidad.

Gyrodactylus bullatarudis Turnbull, 1956, and Gyrodactylus turnbulli Harris, 1986, are recorded from guppies (Poecilia reticulata) from the northern mountains of Trinidad. Mixed infections of the 2 species were found at 9 localities. Gyrodactylus turnbulli had a predominantly posterior distribution on the fishes, whereas G. bullatarudis was more anteriorly distributed. This is the first record of these species from guppies collected from within their original range.

A comparison of risk factors in juvenile-onset and adult-onset recurrent respiratory papillomatosis.

The clinical triad of a firstborn delivered vaginally to a young (teenage) mother has been previously noted among juvenile onset recurrent respiratory papillomatosis (JO-RRP) patients. This study was based on a questionnaire survey of JO-RRP patients, adult onset recurrent respiratory papillomatosis (AO-RRP) patients, and juvenile and adult controls. The survey results revealed that the complete or partial triad was observed in 72% of JO-RRP patients, 36% of AO-RRP patients, 29% of juvenile controls, and 38% of adult controls. As compared with juvenile controls, JO-RRP patients were more often firstborn (P less than .05), delivered vaginally (P less than .05), and born to a teenage mother (P less than .01). Among adult participants, AO-RRP patients reported more lifetime sex partners (P less than .01) and a higher frequency of oral sex (P less than .05) than reported by adult controls. AO-RRP and JO-RRP appear to have distinguishable epidemiologic features indicating that the mode of human papillomavirus (HPV) transmission is different in these two disorders.

Effects of fibrin glue on rat facial nerve regeneration.

Studies of nerve repair comparing fibrin glue with suture techniques have produced mixed results. To test the effect of fibrin glue on nerve regeneration without the confounding variables of distraction and/or movement of the anastomosis, nerve repairs were performed with and without fibrin glue on the intratemporal facial nerve of the rat. The location of the nerve transection was the same for control and experimental nerves, but on the experimental side the nerve was repaired with fibrin glue and on the control side of the nerve was reapproximated in the fallopian canal, without glue or sutures. Axon counts distal to the repair revealed no statistically significant difference between the two methods of repair. This result suggests that mechanical obstruction by the fibrin glue between the nerve ends has a negligible effect on nerve regeneration.

Bright ideas about parasites.

The Hamilton-Zuk hypothesis for parasite-mediated sexual selection in animals has generated much controversy. To resolve the arguments it will be necessary to incorporate many more details of the biology, ecology and evolution of hosts and parasites into studies of sexual selection.

Surgical unit time utilization review: resource utilization and management implications.

As health care providers seek ways to reduce the cost of health care services, hospital operating rooms (ORs) have been identified as potential areas for cost reduction efforts. Cost containment efforts which have shifted significant portions of the inpatient population to ambulatory areas have resulted in an inpatient population which is sicker and more procedure-intensive. Efficient management of operating rooms has assumed even greater importance in this environment. Inefficient or inaccurate scheduling of OR time often results in delays of surgery or cancellations of procedures, which are costly to the patient and the hospital. Approaches to efficient use of ORs include computerized scheduling, utilization monitoring, and refinement of scheduling policies and procedures. In the absence of commercially available software to meet operating room management information needs, Johns Hopkins developed its own system in 1983. This software provides detailed information for daily OR management and long-term planning. The computerized operating room scheduling and monitoring system is described in this article and an operational measure of scheduling accuracy is proposed. Suggestions are made for incorporating this measure into planning and allocation decisions.