Cherubism: case reports and literature review.

Two new cherubism cases have been documented and reported. Both were relatively mild clinically, being a Grade I within Motamedi's I to V clinical grading system. Each presented with bilateral posterior mandibular lesions having a multiloculated radiolucent appearance. In each case, detection with eventual diagnosis evolved from a mandibular molar failing to erupt (tooth No. 19). The partial literature review documented the wide spectrum of clinical expression of this disease and the consequent wide variation in its treatment.

Fracture-dislocation of the middle phalanx at the proximal interphalangeal joint: repair with a simple intradigital traction-fixation device.

Fracture-dislocation of the middle phalanx at the proximal interphalangeal joint is a difficult problem. Open reduction and internal fixation, the panacea for so many unstable fractures, has not been the solution to this injury. During the past three decades, a number of papers have combined old methods with newer concepts, including intradigital traction, "ligamentotaxis," and the beneficial effects of early motion on articular cartilage remodeling. This report describes a simple device, using these new concepts and constructed with available materials, which can be placed on the finger in the office or emergency department, thus avoiding open surgery. Results are compared with other intradigital techniques for treatment of this injury.

A survey of physicians who studied public health during medical school.

INTRODUCTION: The need for more physicians trained in prevention, research methods, and management has been argued by many leaders in medical education. Columbia University attempts to address this need by providing medical students with a variety of options for studying public health. METHODS: A survey of Columbia's medical graduates who had taken elective courses in public health explored the reasons they began their studies, why some did not continue, their assessment of the value of public health courses, and their careers after graduation. RESULTS: Responses were received from 60 graduates. Health policy, international health, and clinical prevention were the primary interests leading them to study public health. Courses in epidemiology, biostatistics, and policy and management were cited as most useful. The pressure of clinical training was the major reason why some did not complete the master of public health (MPH) degree in a timely fashion. Among students who had enrolled in the MPH program and finished medical school before 1990, 84% eventually received the MPH, although some took as many as 12 additional years to complete the degree. Medical students who studied public health did not differ greatly from their classmates in their specialty choices, but those who completed the MPH chose academic, governmental, and corporate practice settings more frequently than other young physicians, and devoted more time to non-clinical activities. CONCLUSION: Public health educators can serve a variety of career needs for future physicians. In addition to personal interests, the presence of role models is an important reason students begin studying public health.

Effect of utilization review in a fee-for-service health insurance plan.

BACKGROUND: Although utilization review is widely used to control health care costs, its effect on patterns of health care is uncertain. METHODS: In 1989, New York City and its unions temporarily replaced actual utilization review with sham review for half the participants in the city's fee-for-service health insurance plan. We compared the health services provided to 3702 enrollees whose requests were subjected to utilization review (the review group) with the services provided to 3743 enrollees whose requests received sham review and were automatically approved for insurance coverage (the nonreview group). The enrollees, physicians, and hospitals were all unaware of the group assignments. RESULTS: During the study period (mean duration, eight months), the members of the review group underwent 1255 procedures in 20 categories of procedures for which second opinions were required (such as breast, cataract, foot, hernia, and hip-replacement surgery, as well as hysterectomy and coronary bypass surgery), and the members of the nonreview group underwent 1365 procedures (P = 0.02). The members of the review group had 124 fewer procedures in doctors' offices and hospital outpatient departments (P = 0.002). In the following year, the members of the review group underwent 248 procedures from the 20 categories, and the members of the nonreview group underwent 234 (P = 0.46). No other differences in patterns of care were found between the groups, including rates of hospital admission to medical-surgical, substances-abuse, or psychiatric units; average lengths of hospital stay; the percentage of enrollees who received preadmission testing; or rates of use of home care. During the study period, the mean age-adjusted insurance payments per person were $7,355 in the review group and $6,858 in the nonreview group (P = 0.06). CONCLUSIONS: The utilization-review program reduced the performance of diagnostic and surgical procedures for which second opinions were required and did not merely delay them until the following year. Otherwise, the program had little effect. Alternatively, actual review and sham review may both have decreased the use of hospital services, with patients or their physicians choosing more efficient treatment when they believed that care would be reviewed.

Hospital preparedness for chemical accidents: the effect of environmental legislation on health care services.

BACKGROUND: Chemical accidents occur often across the United States, endangering the health and safety of many people. The Superfund Amendments and Reauthorization Act of 1986 (SARA) requires that communities increase their planning for medical response to these accidents. So far, little evidence has come forth that supports the notion that environmental legislation, such as SARA, improves preparedness for such accidents. METHODS: A one-group pretest/post-test longitudinal design was used to survey the medical directors of emergency departments in all acute care hospitals in the State of New York. Data were collected by mail survey and telephone follow-up in 1986 before the passage of SARA (Time1), and in 1989 after its implementation (Time2). RESULTS: Ninety-four percent of the directors responded at Time1 and 72% at Time2. In New York State, hospital preparedness for chemical accidents improved significantly during the study interval. The longer a hospital had a plan for response to chemical accidents, the more elements of preparedness were in place. Further, as a group, the hospitals that were the least prepared were located in the areas at highest risk. CONCLUSION: Environmental legislation can influence the manner by which health care organizations prepare for environmental emergencies.

Failure of an endodontic implant. Complications of removal and treatment.

The principal goal in the development of endodontic implants is to improve the stability of periodontally and traumatically compromised teeth. When excessive forces exist and periodontal conditions are suboptimal, however, the system breaks down and ultimately fails. We report such a failure, a sequela of which contributed to subsequent fracture of the mandible. The patient's hospital course and complications of treatment are discussed.

Procedure-specific costs and savings in a mandatory program for second opinion on surgery.

Initial examination of the surgery experience of participants in a large employer-sponsored second opinion program revealed minimal savings in medical resource costs. But closer examination of relative savings for specific procedure categories showed that the greatest savings are for high-cost procedures: hysterectomy, prostatectomy, back surgery, and hip replacement. Furthermore, a nonconfirming second opinion does not dissuade patients from some procedures. Decisions about which procedures to include in a mandatory program should consider volume, costs, and effects of nonconfirmation, as well as the advantages of a mandatory second opinion for skeptical patients, or for patients for whom a controversial procedure has been recommended.

Patients' reactions and physician-patient communication in a mandatory surgical second-opinion program.

To assess patients' reactions to a mandatory second surgical opinion program and to measure the accuracy of communication between these patients and their physicians, questionnaires were sent to New York City municipal employees, retirees, and dependents who had received second-opinion consultations. The most frequent reactions, among 902 respondents, were that the consultations provided reassurance (59%), helped in deciding whether to proceed with surgery (49%), and provided a chance to ask important questions (29%). Relatively few patients felt that the program caused anxiety (12%) or confusion (5%). Patients were generally pleased with the administrative aspects of the program but less satisfied with the consultant physicians they had seen. Twelve percent of patient-physician pairs disagreed about the advice that had been communicated in their second-opinion consultation visits. Nonconcordance rates varied greatly with the nature and complexity of the advice rendered and were higher among patients who stated that their consultants' explanations were not thorough and understandable. In addition to their cost-containment functions, mandatory surgical second-opinion programs can be supportive and informative. Systematic feedback from patients can be used to enhance these strengths, to correct programmatic deficiencies, and to improve the accuracy of communication.

Complications of labor and delivery following uncomplicated pregnancy.

Renewed interest in less costly, less technologically oriented obstetrical care requires the accurate selection of women who may safely benefit from such alternatives. The distribution of complications of labor and delivery, among healthy women who had had uncomplicated pregnancies, was investigated by studying data from more than 240,000 birth certificates filed with the New York City Department of Health during the period 1971-1974. Complications of labor or delivery were reported for 21.0 per cent of births following apparently uncomplicated antepartum courses. Significantly higher rates of recorded complications were found for women who had initiated prenatal care earlier in pregnancy, for private patients as opposed to general service patients, for white patients compared to nonwhite patients, for married women than for unmarried women, and for better educated patients as opposed to those with less schooling. Labor and delivery complication rates were also noted to rise with maternal age. The positive association between earlier prenatal care and higher complication rates was found within all service, racial, marital, educational and age categories, and appeared to be independent of these variables. Factors which may contribute to these unexpected patterns, and further research to clarify them, are discussed.

Bridging the gap between clinical medicine and public health: an experimental course for medical students.

An experimental course for third-year medical students, held at Columbia University, was aimed at enlisting larger numbers of future clinicians in the identification of public health problems and the development of nonclinical interventions, such as environmental and health education strategies. The course sought to develop a new perspective for the analysis of clinical observations. Students chose clinical problems, identified factors influencing incidence or prevalence, or both, and devised intervention strategies while working in a district of the New York City Department of Health. Students found that they could carry out their responsibilities only by going beyond the limitations of care for individual patients and clinical medicine. Students' perceptions and behaviour were measured during periods of their clinical training. Those who had taken the experimental course perceived public health problems and suggested and took corrective actions much more frequently than students in control groups.

An eclectic approach to quality control in fee-for-service health care: The New York City Medicaid Experience.

A computer-based system for evaluating the quality of fee-for-service health care in the New York City Medicaid Program is described. Specific information is sought for use in educational, enforcement and managerial activities to improve health care quality. The gathering of this information necessitates coordinated assessment of the structure, process and outcome of health care, through inspection of offices, computerized analysis of patterns of practice as revealed by billing forms, and reexamination of patients. The program's focus on patterns of practice, its use of multiple assessment techniques, and its concentration on unequivocally substandard care circumvent several limitations on current evaluation technology. Implications for Professional Standards Review Organizations and national health insurance are explored.

Evaluation of isobaric oxygenation for the aged with cognitive impairment: pilot study.

The effect of isobaric oxygenation on psychogeriatric subjects, with mild cognitive impairment was assessed in a single-blind controlled pilot study. Three of the 7 subjects were treated with a mixture of 97% oxygen plus 3% carbon dioxide, and 4 treated with compressed air. The oxygen or air was administered during two 1.5 hr sessions daily for fifteen consecutive days. Use of a miner's type mask ensured a closed system which permits the maximal partial pressure of oxygen. Psychologic and clinical observations did not indicate any advantage for the oxygenation therapy. Minimal side effects, which arose only in the oxygen group, may have involved some interactions between CO2 sensitivity and anxiety. Careful differential diagnosis and the control of motivational factors are of major importance in any study of the effects of oxygenation upon symptoms in psychogeriatric patients.