The association between for-profit hospital ownership and increased Medicare spending.

BACKGROUND AND METHODS: The rate of conversion to for-profit ownership of hospitals has recently increased in the United States, with uncertain implications for health care costs. We compared total per capita Medicare spending in areas served by for-profit and not-for-profit hospitals. We used American Hospital Association data to categorize U.S. hospital service areas as for-profit (meaning that all beds in the area were in for-profit hospitals), not-for-profit (all beds were in not-for-profit hospitals), or mixed in 1989, 1992, and 1995. We then used data from the Continuous Medicare History Sample to calculate the 1989, 1992, and 1995 spending rates in each area, adjusting for other characteristics known to influence spending: age, sex, race, region of the United States, percentage of population living in urban areas, Medicare mortality rate, number of hospitals, number of physicians per capita, percentage of beds in hospitals affiliated with medical schools, percentage of beds in hospitals belonging to hospital chains, and percentage of Medicare beneficiaries enrolled in health maintenance organizations. RESULTS: Adjusted total per capita Medicare spending in the 208 areas where all hospitals remained under for-profit ownership during the study years was greater than in the 2860 areas where all hospitals remained under not-for-profit ownership ($4,006 vs. $3,554 in 1989, $4,243 vs. $3,841 in 1992, and $5,172 vs. $4,440 in 1995; P<0.001 for each comparison). Mixed areas had intermediate spending rates. Spending in for-profit areas was greater than in not-for-profit areas in each category of service examined: hospital services, physicians' services, home health care, and services at other facilities. The greatest increases in per capita spending between 1989 and 1995 were for hospital services (a mean increase of $395 in for-profit areas and $283 in not-for-profit areas, P=0.03 for the comparison between for-profit and not-for-profit areas) and home health care (an increase of $457 in for-profit areas and $324 in not-for-profit areas, P<0.001). Between 1989 and 1995, spending in the 33 areas where all hospitals converted from not-for-profit to for-profit ownership grew more rapidly than in the 2860 areas where all hospitals remained under not-for-profit ownership ($1,295 vs. $866, P=0.03). CONCLUSIONS: Both the rates of per capita Medicare spending and the increases in spending rates were greater in areas served by for-profit hospitals than in areas served by not-for-profit hospitals.

Regression of hepatic steatosis in morbidly obese persons after gastric bypass.

Morbid obesity has been associated with hepatic steatosis and occasional cirrhosis. Despite producing weight loss, intestinal bypass procedures formerly performed to correct morbid obesity, often worsened steatosis and fibrosis, and occasionally resulted in hepatic failure. Current surgical procedures of choice for morbid obesity involve gastric bypass with gastrojejunostomy. Ninety-one liver biopsies taken at the time of gastric bypass for morbid obesity (mean body weight 125.8 kg), and 106 biopsies taken from the same patients from 2 to 61 months later (mean body weight 89.4 kg) were studied. Steatosis and perisinusoidal fibrosis were assessed in histologic sections. Serum albumin, alkaline phosphatase, aspartate aminotransferase (AST), and total bilirubin levels were measured before most biopsies were taken. Both pre- and post-gastric bypass hepatic steatosis varied directly with body weight (r = .5231, P < .001). Steatosis varied inversely with length of time after gastric bypass (r = .4590, P < .001). Of the original biopsies, 37% had lipid vacuoles in at least 26% of hepatocytes. After gastric bypass, 65 patients had reduced steatosis, 18 patients with no steatosis, and 5 patients with minimal steatosis had no change, and 3 patients had increased steatosis. Pre-gastric bypass biopsies from 13 patients had perisinusoidal fibrosis (PSF) that was marked with bridging in three patients, was moderate in one patient, and slight in nine patients. Following gastric bypass, PSF was eliminated in 10 patients, reduced in one patient, and the same in two patients. One patient developed PSF after gastric bypass. Of the three patients who had undergone previous intestinal bypass procedures, two had slight PSF in the biopsies taken at the time of gastric bypass, and one of these had slight PSF in the follow-up biopsy. Serum biochemical abnormalities tended to be slight. Before gastric bypass, serum albumin was low in 11% of cases, alkaline phosphatase was high in 14% of cases, AST was high in 11% of cases, and total bilirubin was high in 1% of cases. After gastric bypass, there was a small reduction in mean serum albumin from 43 g/L before to 41 g/L afterward (P < .05), and a slight rise in mean total bilirubin from 7.0 mumol/L before to 9.6 mu mol/L afterward (P < .01). Most hepatic fatty change and probably some PSF occurring in morbidly obese persons is reduced or eliminated with weight loss following gastric bypass surgery.

Chronic lymphocytic leukemia presenting in the marrow of a phalanx.

Systemic disease may present first in the foot. The authors present a case in which the marrow of resected bone tissue from a phalanx showed the changes of chronic lymphocytic leukemia (CLL). Subsequent blood examination confirmed this diagnosis.

Communication attitudes of women who stutter.

This study sought to determine the appropriateness of the Andrews and Cutler (1974) modification of Erickson's (1969) S-scale to women who stutter. This tool, apparently valuable both in the description of stuttering symptomatology and in the prediction of therapy outcome, had been developed to differentiate male stutterers from male nonstutterers. The modification of the S-scale was administered to 10 female stutterers, 10 female nonstutterers, and 10 male stutterers. S-scores were found not only to differentiate female stutterers from female nonstutterers but also female stutterers from male stutterers. For both female and male stutterers, attitudes toward communication were independent of frequency of disfluency. Clinical implications of these findings are considered.

Women who stutter: personality and speech characteristics.

This investigation was undertaken to determine whether adult female stutterers, when compared to adult male stutterers, would (1) present a different pattern of speech fluency or (2) evidence reduced self-esteem or both. Spontaneous speech samples were obtained from 10 adult female stutterers, 10 adult male stutterers, and 10 adult female nonstutterers. All were administered the California Test of Personality and semantic differential forms designed to assess self-concept. The female stutterers produced significantly fewer instances of revision-incomplete phrase than either of the other two groups and were more heterogeneous with respect to total frequency of disfluency. The female stutterers evidenced a significantly higher level of self-esteem than the male stutterers. Moreover, unlike the male stutterers, the female stutterers did not consider themselves handicapped. This investigation indicates that there may be significant differences in the stuttering symptomatology of adults that are related to gender.

Presence of spermatozoa in cervicovaginal smears from young and old women.

Routine cervicovaginal (PAP) smears from 1,239 women from ages 16 to 92 were examined retrospectively for spermatozoa. The prevalence of spermatozoa in cervicovaginal smears was found to be highest (25%) in the 20-24 year age group, and fell gradually to 20% in the 70-79 year age group. The oldest woman in the study to have spermatozoa in her smear was 76 years old. In order to evaluate persistence of spermatozoa in the lower genital tracts of women, 697 smears were prepared from women who had volunteered the time of last coitus, birth control methods, and douching practices. Spermatozoa could be found in smears taken up to 10 days after coitus, although their number decreased due to vaginal douching and birth control. These findings confirm that coital activity in aging women can persist into the eighth decade of some women's lives.

Persistence of spermatozoa in the lower genital tracts of women.

Cervicovaginal scrapings from 675 women who had volunteered information about the time of their last coitus and their contraceptive and douching practices were stained with Papanicoalaou stain and screened for spermatozoa. Generally, as the interval between coitus and preparation of the smears (postcoital interval) increased, the percentage of smears with spermatozoa and the mean number of spermatozoa per smear decreased, but the percentage of spermatozoa with tails did not change significantly. Spermatozoa were found irregularly after the seventh and rarely after the tenth postcoital day. Vaginal douching, pregnancy, use of oral contraceptives, coitus interruptus, condoms, and vasectomy were associated with reduced prevalence of spermatozoa in smears.

Effect of the menstrual cycle on voice quality.

The question addressed was whether most young women with no vocal training exhibit premenstrual hoarseness. Spectral (acoustical) analyses of the sustained productions of three vowels produced by 20 undergraduates at and at premenstruation were rated for degree of hoarseness. Statistical analysis of the data indicated that the typical subject was no more hoarse of premenstruation than at ovulation. To determine whether this finding represented a genuine characteristic of women's voices or a type II statistical error, a systematic replication was undertaken with another sample of 27 undergraduates. The finding replicated that of the original investigation, suggesting that premenstrual hoarseness is a rarely occurring condition among young women with no vocal training. The apparent differential effect of the menstrual cycle on trained as opposed to untrained voices deserves systematic investigation.

Children's comprehension of time-compressed speech: effect of speaker's familiarity.

An experiment was conducted with 42 third grade children from a parochial school system in a large metropolitan area. 21 classmates whose teacher served as the speaker for this experiment comprised the experimental group. A matched group of 21 classmates from another third grade classroom formed the control group. Each subject individually listened to a 940-word narrative passage that had been compressed at a rate of 45% or 275 words per minute. 10 questions about the material presented in the final three-fourths of the passage were asked of the subjects. The difference between the mean number of correct responses produced by the experimental group (5.5) and the control group (4.9) was not statistically significant. The results indicate that familiarity with the speaker does not facilitate 8-yr.-olds' comprehension of time-compressed speech.

Bullet in the left ventricle from a remote gunshot wound to the heart.

A bullet was found at necropsy in the left ventricle of a man who died of carcinoma of the urinary bladder. The bullet had entered the body at an unknown time in the remote past. The bullet probably gained entrance to the heart through the left atrial wall and lodged in the left ventricle.

Granulocyte adherence in the elderly.

Granulocyte adherence was measured in blood samples from 57 subjects more than 60 years old and 50 subjects 11 to 59 years old. In contrast to mean hemoglobin levels, leukocyte counts, and neutrophil counts, which were lower in the samples from the older group, granulocyte adherence was greater for the older subjects (mean = 78.4%) than for the younger subjects (mean = 65.7%). Ingested aspirin, chlorothiazides, methyldopa, digitalis, antihistamines, and barbiturates had no effect on granulocyte adherence. Alcohol ingestion within 24 hours was associated with reduced granulocyte adherence in the older group. Granulocyte adherence was slightly greater for aged black than for aged white subjects, but the difference was not statistically significant. Granulocytes of women showed greater adherence than those of men, and this difference persisted after menopause into the ninth decade of life.

Listeners' impressions of speakers with lateral lisps.

This paper reports research conducted to determine whether the lateral lisp is a speech defect. The specific purpose of this research was to determine whether the lateral lisp calls adverse attention to the speaker. Two groups of broadcast communication students rates the concept "The Person Speaking" on a 49-scale semantic differential. One group performed the task after listening to a tape recording of a young woman reading contextual material with a simulated lateral lisp. The other group performed the task after listening to a recording of the same woman reading the material in a normal manner. Analyses of the scale values computed for the two conditions indicated that the lateral lisp called adverse attention to the speaker. A systematic replication was undertaken to assess the generality of this finding. The procedures of the original investigation were followed except that business administration students served as judges. The results replicated those of the original investigation. These data indicate that the lateral lisp is probably a speech defect and suggest that the practice of eliminating school speech services for children whose only speech difference is a lateral lisp should be reconsidered.

Replication of "speech fluency fluctuations during the menstrual cycle".

This study tested the hypothesis suggested by our earlier research that the principal effect of heightened anxiety on speech fluency is an interference with language formulation. 20 women read contexual material aloud at ovulation (when the typical woman experiences her greatest feelings of well-being) and at premenstrution (when she experiences a significant increase in anxiety level). They were no less fluent at premenstruation than at ovulation. These data are consistent with the hypothesis tested.

Early and late histologic effects of stereotactic neurosurgery.

The histologic lesions produced in the brain by stereotactic chemosurgery and cryosurgery are reviewed in four patients who died from 25 days to 15 years postoperatively. Three of four patients had damage to the internal capsule and died of pulmonary emboli. The early lesions are histologically nonspecific, but the old lesions of chemopallidectomy and chemothalamectomy in one patient contained metaplastic bone. Lesions produced by freezing are more discrete than those made by chemical means.

Effect of threat of shock for being disfluent of fluency of normal speakers.

Each of 20 adult nonstutterers read a 330-word passage six times with a one minute pause between readings. Between the third and fourth reading or the fifth and sixth reading (determined by a table of random numbers) Ss were informed that at the conclusion of the next reading an electric shock would be administered for each instance of disfluency detected by E during that reading. Ss did not become less fluent as a consequence of the experimental condition. Their mean disfluency frequency during the threat-of-shock reading was lower than during the preceding one. Thus, threat of shock for being disfluent may be a condition which differentiates stutterers from nonstutterers since stutterers have been reported to become less fluent under this condition.

Effect of selected work attributes on preschoolers' speech disfluency: initial phoneme and length.

This study was designed to determine whether preschool nonstutterers tend to be disfluent on words that begin with consonants or on words that begin with vowels and whether they tend to be disfluent on long or on short words. Analyses of the spontaneous speech of 10 four-year-old boys sampled both in their nursery school classroom and in an interview situation indicated that initial phoneme exerted no influence on the distribution of their speech disfluencies. Word length, however, exerted an influence in the interview situation where the children tended to be disfluent on monosyllabic words. These data raise questions with respect to the applicability of Bloodstein's (1974) model of the development of stuttering to the disfluency behavior of nonstutterers.

Clinicopathologic review of 88 cases of carcinoma metastatic to the putuitary gland.

Clinical and pathologic features of 88 cases of carcinoma metastatic to the pituitary gland were reviewed. In 61 (69.3%), metastases were localized either in the posterior lobe alone or in the posterior and anterior lobes together; only 12 (13.6%) involved the anterior lobe alone. Diabetes insipidus was present in 6 patients (6.8%), one of whom also had clinical panhypopituitarism due to metastatic tumor and necrosis in the anterior pituitary lobe. Breast and lung were the most frequent primary sites in women and men, respectively. Sixty-four (72.7%) of these glands were grossly normal at necropsy. Metastases to the pituitary gland occur more frequently in the posterior lobe than in the anterior lobe, and my ve reflected clinically by diabetes insipidus in patients with diseminated carcinoma. Clinical panhypopituitarism is a rare accompaniment of anterior lobe involvement.