The impact of COVID-19 on the hot food takeaway planning regulatory environment: perspectives of local authority professionals in the North East of England

AIMS

Planning regulations have been used to prevent the over-proliferation of hot food takeaways, minimising the impact of local obesogenic environments. To help mitigate the effects of lockdown, the UK government introduced temporary changes in March 2020 to Planning Regulations for England, allowing food retailers to open for takeaway services beyond 'ancillary' level without needing to apply for planning permission through permitted development rights (PDR). Businesses are required to notify their local authority (LA) when they implement PDRs. To better understand the impact of regulations on the policy and practice of key professional groups, Public Health England commissioned Teesside University to undertake scoping research in the North East of England.

METHODS

A focus group and interviews were conducted with 15 professionals from 7 of 12 North East LAs. Professions included Planners, Public Health Leads, Environmental Health Officers and Town Centre Managers. Data were analysed using a codebook thematic analysis approach. An interpretation meeting with some participants was conducted.

RESULTS

LAs were not aware of most businesses notifying them of new regulation adherence despite taking up PDRs, but were considered low-priority with many lacking formal recording procedures. There were concerns about health consequences of the changes, and consensus relating to ongoing issues with capacity across all professional groups, largely due to the continuing pandemic and absence of a strategy out of temporary measures. Concerns existed around ensuring cessation of restaurants trading as takeaways, and hygiene inspections backlog. Many (personally) saw new takeaways as a lifeline, offering broader menus and preserving local economies.

CONCLUSION

Lack of information around the number of restaurants/pubs using PDR to trade as takeaway services, ongoing capacity issues of LAs and, at the time, the absence of a strategy post regulation changes, meant there were high levels of uncertainty regarding the impacts of these temporary measures.

Regulatory mechanisms to create healthier environments: planning appeals and hot food takeaways in England

AIMS

To explore existing regulatory mechanisms to restrict hot food takeaway (HFT) outlets through further understanding processes at local and national levels.

METHODS

The Planning Appeals Portal was utilised to identify recent HFT appeal cases across England between December 2016 and March 2020. Eight case study sites were identified using a purposive sampling technique and interviews carried out with 12 professionals involved in planning and health to explore perceptions of and including factors that may impact on the HFT appeal process. Additionally, documents applicable to each case were analysed and a survey completed by seven Local Authority (LA) health professionals. To confirm findings, interpretation meetings were conducted with participants and a wider group of planning and public health professionals, including a representative from the Planning Inspectorate.

RESULTS

Eight case study sites were identified, and 12 interviews conducted. Participants perceived that LAs would be better able to work on HFT appeal cases if professionals had a good understanding of the planning process/the application of local planning policy and supplementary planning documents; adequate time and capacity to deal with appeals cases; access to accurate, robust, and up to date information; support and commitment from elected members and senior management; good lines of communication with local groups/communities interested in the appeal; information and resources that are accessible and easy to interpret across professional groups.

CONCLUSIONS

Communication across professional groups appeared to be a key factor in successfully defending decisions. Understanding the impact of takeaway outlets on health and communities in the long term was also important. To create a more robust appeals case and facilitate responsiveness, professionals involved in an appeal should know where to locate current records and statistical data. The enthusiasm of staff and support from senior management/elected officials will play a significant role in driving these agendas forward.

Radiation Oncology: Future Vision for Quality Assurance and Data Management in Clinical Trials and Translational Science

The future of radiation oncology is exceptionally strong as we are increasingly involved in nearly all oncology disease sites due to extraordinary advances in radiation oncology treatment management platforms and improvements in treatment execution. Due to our technology and consistent accuracy, compressed radiation oncology treatment strategies are becoming more commonplace secondary to our ability to successfully treat tumor targets with increased normal tissue avoidance. In many disease sites including the central nervous system, pulmonary parenchyma, liver, and other areas, our service is redefining the standards of care. Targeting of disease has improved due to advances in tumor imaging and application of integrated imaging datasets into sophisticated planning systems which can optimize volume driven plans created by talented personnel. Treatment times have significantly decreased due to volume driven arc therapy and positioning is secured by real time imaging and optical tracking. Normal tissue exclusion has permitted compressed treatment schedules making treatment more convenient for the patient. These changes require additional study to further optimize care. Because data exchange worldwide have evolved through digital platforms and prisms, images and radiation datasets worldwide can be shared/reviewed on a same day basis using established de-identification and anonymization methods. Data storage post-trial completion can co-exist with digital pathomic and radiomic information in a single database coupled with patient specific outcome information and serve to move our translational science forward with nimble query elements and artificial intelligence to ask better questions of the data we collect and collate. This will be important moving forward to validate our process improvements at an enterprise level and support our science. We have to be thorough and complete in our data acquisition processes, however if we remain disciplined in our data management plan, our field can grow further and become more successful generating new standards of care from validated datasets.

Human papillomavirus, p16, and epidermal growth factor receptor biomarkers and CT perfusion values in head and neck squamous cell carcinoma

BACKGROUND AND PURPOSE

Head and neck squamous cell carcinoma tumors positive for laboratory biomarkers hrHPV and p16 and negative for EGFR often respond better to nonsurgical organ-preservation therapy than hrHPV-negative, p16-negative, and EGFR overexpressing tumors. CTP has been shown to distinguish which locally advanced head and neck squamous cell carcinomas will respond to induction chemotherapy or chemoradiation. Our purpose was to determine whether a relationship exists between CTP measures and the expression of these laboratory biomarkers, because both appear to separate head and neck squamous cell carcinoma tumors into similar groups.

MATERIALS AND METHODS

We conducted an institutional review board-approved, Health Insurance Portability and Accountability Act-compliant retrospective review of head and neck CTP in 25 patients with locally advanced head and neck squamous cell carcinoma who had signed informed consent. Eight women and 17 men, 41-80 years of age, constituted a pretreatment group of 18 patients and a palliative group of 7 patients. Tumor biopsy samples were analyzed for overexpression of hrHPV, p16, and EGFR. The hrHPV, p16, and EGFR status of the tumors was correlated with CTP parameters (MTT, BV, BF, CP) by using the Wilcoxon evaluation and Fischer exact test.

RESULTS

There were significantly lower CP values in pretreatment tumors overexpressing EGFR (P = .04). CP values ≤17.23 were significantly correlated with EGFR overexpression (P = .015). A trend toward higher CP values was present in hrHPV-positive and p16-overexpressing pretreatment tumors (P = .14).

CONCLUSIONS

A significant correlation exists between CTP measures and EGFR overexpression in head and neck squamous cell carcinomas, suggesting an association between certain imaging findings and molecular biomarkers. These results may be related to a tumor cell survival mechanism linking perfusion and biomarker expression.

A novel approach to biomarker discovery in head and neck cancer using an autoantibody signature

Despite the dismal prognosis for patients with squamous cell carcinoma of the head and neck (SCCHN), there have been no novel treatments in over 40 years. Identification of novel tumor antigens in SCCHN will facilitate the identification of potential novel treatment targets. Tumor antigens are proteins selectively expressed by tumor cells and recognized by the host immune system. Phage-displayed tumor antigens were enriched by biopanning with normal and then SCCHN-specific serum. Ninety-six phage clones were sequenced for identification, and 21 clones were validated using Luminex. One of these proteins, L23, a novel tumor antigen in SCCHN, was validated as an oncogene. L23 is upregulated in SCCHN compared with normal keratinocytes. Knockdown of L23 inhibited proliferation, invasion and cell survival. Overexpression of L23 had the reverse effect. Overexpression of L23 in non malignant cells led to transformation. Injection of SCCHN cells with knockdown of L23 in mice, induced tumors that were significantly smaller than control tumors. In conclusion, the immunomic screen yielded a panel of antigens specific to SCCHN; one of these proteins, L23, is a novel oncogene in SCCHN.

The tumor suppressor gene rap1GAP is silenced by miR-101-mediated EZH2 overexpression in invasive squamous cell carcinoma

Rap1GAP is a critical tumor suppressor gene that is downregulated in multiple aggressive cancers, such as head and neck squamous cell carcinoma, melanoma and pancreatic cancer. However, the mechanistic basis of rap1GAP downregulation in cancers is poorly understood. By employing an integrative approach, we demonstrate polycomb-mediated repression of rap1GAP that involves Enhancer of Zeste Homolog 2 (EZH2), a histone methyltransferase in head and neck cancers. We further demonstrate that the loss of miR-101 expression correlates with EZH2 upregulation, and the concomitant downregulation of rap1GAP in head and neck cancers. EZH2 represses rap1GAP by facilitating the trimethylation of histone 3 at lysine 27, a mark of gene repression, and also hypermethylation of rap1GAP promoter. These results provide a conceptual framework involving a microRNA-oncogene-tumor suppressor axis to understand head and neck cancer progression.

Differential tumor and normal mucosa biomarker modulation by epidermal growth factor receptor (EGFR) inhibition using erlotinib in oral cavity squamous cell carcinoma (OCSCC)

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Background: Targeted therapy may improve the therapeutic index in locally advanced head neck cancer if differential EGFR inhibition in tumors compared to the normal mucosa is demonstrated. Based on prior published data, EGFR degradation is an important biomarker of cytotoxicity in a preclinical model. The aim of this pilot study was to determine if there are differences in biomarker modulation between tumor and the normal mucosa and confirm our initial preclinical findings regarding EGFR degradation. Methods: Patients with primary OCSCC requiring surgical resection had normal mucosa and tumor biopsies prior to a test course of erlotinib. Patients received one week of erlotinib 150 mg qd. Repeat tumor and normal mucosal biopsies were obtained at the time of surgical resection to evaluate the effect of the EGFR inhibitor on both tumor and the normal mucosa. Changes in known preclinical markers of EGFR activity (phospho, total EGFR, AKT, STAT3) were measured by immunoblotting assays. In addition, changes in distribution of these biomarkers were analyzed by immunohistochemical analysis. Results: 12 pts were enrolled; 7 pts with paired tumor and normal mucosa biopsies. Tumor specimens showed over-expression of EGFR compared to the normal mucosa (p = 0.005). Erlotinib treatment led to marked inhibition of both pEGFR and EGFR protein (p = 0.004 and p = 0.007, respectively) in tumor biopsies. In contrast, we found heterogeneity in EGFR inhibition in the normal mucosa following erlotinib. (p = 0.1 [pEGFR], and p = 0.07 [EGFR)]) We noted dramatic reduced levels of pSrc and pSTAT3 following erlotinib in tumors compared to untreated matched tumor samples. In addition, levels of p27 were enhanced. Conclusions: Differential EGFR inhibition in tumors compared to the normal mucosa, may suggest that the addition of EGFR inhibitors to chemo-RT or accelerated RT, whose dose limiting toxicity is acute mucositis, may select patients who will benefit from targeted therapy. Our results demonstrate that EGFR inhibition by erlotinib led to marked reduction in EGFR protein levels. EGFR degradation may be an important biomarker in selecting patients predicted to have a response to TKI. These results need further validation.

No significant financial relationships to disclose.

English health profiles--did they do what was expected? An evaluation of Health Profiles 2006

OBJECTIVES

To assess the impact of Health Profiles 2006 by English local authorities, and to determine what changes need to be made to the profiles to have an impact on their target audience.

STUDY DESIGN

A telephone- and web-based survey of a sample of the health profiles' target audience was conducted, along with an analysis of web statistics.

METHODS

In total, 285 telephone interviews were undertaken. Fifty-three percent of the respondents were National Health Service employees. An evaluation form was also available through the Health Profiles website, which elicited 117 responses (19 scrutiny officers and 83 members of the public).

RESULTS

There was a positive response to the content and format of Health Profiles 2006. The majority of respondents felt that the profiles provided a unique summary of local-authority-based health and health inequality information that was both accessible and understandable.

CONCLUSIONS

A number of recommendations are made to improve health profile production as a tool for information for health improvement. These include simplifying graphics, greater local input into commentary, and a more interactive website so that the data can be accessed and explored. However, the recommendations for change must be viewed alongside the number of comments specifically relating to the English health profiles that nothing should be changed other than updating the data and filling in the gaps.

The effect of multidirectional mechanical vibration on peripheral circulation of humans

The physiological response of humans to vibration has intrigued researchers for some time, and recently in relation to its potential as a non-pharmacological means to improve peripheral blood flow. A new vibration device [Arapal Technologies Ltd (ATL), Christchurch, New Zealand] for pain relief that purportedly delivers multidirectional vibration waveforms, has been developed. The aim of the study was to quantify the effect of 30 min of mechanical vibration (60 Hz) using two ATL massage devices concurrently upon local peripheral blood flow in healthy humans. On the basis of past work it was expected that acute exposure of the body to the vibratory stimulus would increase local peripheral blood flow. In a randomized cross-over design, mean blood flow (MBF) to the calf was measured using venous occlusion plethysmography before, during 3 min and after 30 min exposure to the vibratory devices or placebo (non-vibratory) devices. Statistical analysis revealed no consistent differences between conditions and considerable individual variability. The MBF increase tended to be higher in the vibration condition than the placebo condition (P=0.16, 95% likely range=-14.4% to 82.2%), the mean increase from resting blood flow at the post-test was 26+/-49% in the vibration condition and 12+/-39% in the placebo condition. It took approximately 22 min of exposure to the vibratory stimulus to elicit peak blood flow (18 min with the placebo). Improvements in local blood flow may be beneficial in the therapeutic alleviation of pain or other symptoms resulting from acute or chronic musculoskeletal injuries.

Chemo-selection of patients (pts) for organ preservation in advanced laryngeal cancer: Failure of chemotherapy (CT) as the sole treatment for complete histologic responders (CHR) to neoadjuvant chemotherapy

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Background: We conducted a phase II organ preservation trial for stage III/IV laryngeal cancer pts in an attempt to identify pts, who were CHR after 1 cycle of induction CT, who might be curable with CT alone. Methods: Pts received 1 cycle of cisplatin 100 mg/m2 & 5-FU 1000 mg/m2/day x 5 days (P+5FU). CHR received 1 cycle of P+5FU, followed by weekly docetaxel (D) 35 mg/m2 x 3 wks, followed by 1 cycle of P+5FU, & no radiotherapy (RT). Pts with >50% (but < 100%) response (PR) received chemoradiation (CRT) with 70 Gy & P 100 mg/m2 days 1, 22, & 43. Pts with < 50% response underwent laryngectomy. Final planned tumor assessment with direct laryngoscopy with biopsy was done 8 wks after CRT or 3 wks after the last cycle of P+5FU (CT alone arm). CHR after CT alone received 2 cycles of P+5FU alternating with 2 cycles of D. CHR after CRT received 2 cycles of P+5FU, & pts with residual disease had planned salvage surgery. Results: 32 eligible pts were enrolled, 24 M; 8 F; median age 56, stage III/IV- 7/25. After 1 cycle CT, 4 pts (13%) had CHR & received CT alone; 24 (75%) had PR & received CRT; 3 had surgery; & 1 refused surgery. Of pts who had CT alone, 4/4 had regional failures; 3/4 underwent neck dissection & 1/4 had laryngectomy & neck dissection; all had adjuvant RT because of multiple nodes or extracapsular spread; 3/4 are alive without disease & 1/4 is dead of complications. 5/24 who received CRT failed; 2/24 had surgery & 3/24 were unresectable. Toxicity: Gr 3/4 granulocytopenia 19%, Gr 3/4 mucositis with CT alone 12.5%. Median follow-up is 16.5 months. 2 yr overall survival is 88.2% (95% CI = 75.3%, 100%). 1 yr disease-free survival (DFS) is 81.8% (CI=67.2%, 96.5%). 2 yr DFS is 76% (CI=58.4%, 93.5%). The proportion of pts alive & free of cancer with intact larynx at 1 yr is 69.1% (CI = 51.9%, 86.3%) & at 2 yrs is 63.8% (CI=45%, 82.5%). 1 pt developed distant metastases. Larynx preservation was achieved in 24 pts (75%). Conclusions: CT alone is not an effective strategy for advanced laryngeal cancer pts, even in CHR after 1 cycle of induction CT, due to high nodal failure rate. Planned integration of early regional control by surgery or lower-dose RT may be necessary to allow treatment approaches that spare selected pts high-dose RT.

No significant financial relationships to disclose.

An unusual cause of hypocalcaemia: magnesium induced inhibition of parathyroid hormone secretion in a patient with subarachnoid haemorrhage

We describe a case of a woman with subarachnoid haemorrhage who developed hypocalcaemia and decreased serum parathyroid hormone levels due to hypermagnesemia. The patient had been receiving bisphosphonate therapy prior to admission and this may have contributed to the severity of the problem.

Tailored risk notification for women with a family history of breast cancer

BACKGROUND

Evidence indicates that although first-degree relatives of breast cancer cases are at increased risk of developing the disease themselves, they may be underutilizing screening mammography. Therefore, interventions to increase the use of mammography in this group are urgently needed.

METHODS

A randomized two-group design was used to evaluate an intervention to increase mammography use among women (N = 901) with at least one first-degree relative with breast cancer. A statewide cancer registry was used to obtain a random sample of breast cancer cases who identified eligible relatives. The mailed intervention consisted of personalized risk notification and other theoretically driven materials tailored for high-risk women.

RESULTS

An overall significant intervention effect was observed (8% intervention group advantage) in mammography at post-test. There was an interaction of the intervention with age such that there was no effect among women <50 years of age and a fairly large (20% advantage) effect among women 50+ and 65+. Health insurance, education, and having had a mammogram in the year before baseline assessment were positive predictors of mammography at post-test. Perceived risk, calculated risk, and relationship to index cancer case were not associated with mammography receipt.

CONCLUSION

The intervention was successful in increasing mammography rates among high-risk women 50+ years of age. Further work is needed to determine why it was ineffective among younger women.

Role of membrane type 1-matrix metalloproteinase and gelatinase A in head and neck squamous cell carcinoma invasion in vitro

The proteolytic activity of gelatinase A, a member of the matrix metalloproteinase (MMP) family, is considered to be a critical factor in tumor cell penetration of the extracellular matrix. To express catalytic activity, however, gelatinase A requires activation by another MMP, membrane type 1-matrix metalloproteinase (MT1-MMP). The head and neck squamous cell carcinoma cell line, UM-SCC-1, forms a quiescent monolayer atop collagen unless stimulated with epidermal growth factor (EGF; 3.5 nmol/L), which induces single cell invasion within 48 hours. To determine the role of the MT1-MMP/gelatinase A protease system in an in vitro stromal invasion model, expression vectors for MT1-MMP and gelatinase A were transfected into UM-SCC-1 (SCC-1/MT and SCC-1/gelA, respectively). SCC-1/MT tumor cells were found to invade in the absence of growth factor stimulation. Additionally, these cells displayed shorter onset to invasion and penetrated deeper into the collagen gel with EGF stimulation than did control vector transfectants. SCC-1/gelA cells similarly demonstrated invasion in the absence of EGF and a heightened invasive potential under EGF-stimulated conditions. These results suggest that the MT1-MMP/gelatinase A protease system participates in squamous cell carcinoma invasion of collagenous matrices.

Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group

Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose. In preclinical studies, its use in shock models was associated with an improvement in outcome compared with alternatives, such as albumin or 6% hetastarch in saline. In a prospective, randomized, two-center study (n = 120), we compared the efficacy and safety of Hextend versus 6% hetastarch in saline (HES) for the treatment of hypovolemia during major surgery. Patients at one center had a blood sample drawn at the beginning and the end of surgery for thromboelastographic (TEG) analysis. Hextend was as effective as HES for the treatment of hypovolemia. Patients received an average of 1596 mL of Hextend: 42% received >20 mL/kg up to a total of 5000 mL. No patient received albumin. Hextend-treated patients required less intraoperative calcium (4 vs 220 mg; P < 0.05). In a subset analysis of patients receiving red blood cell transfusions (n = 56; 47%), Hextend-treated patients had a lower mean estimated blood loss (956 mL less; P = 0.02) and were less likely to receive calcium supplementation (P = 0.04). Patients receiving HES demonstrated significant prolongation of time to onset of clot formation (based on TEG) not seen in the Hextend patients (P < 0.05). No Hextend patient experienced a related serious adverse event, and there was no difference in the total number of adverse events between the two groups. The results of this study demonstrate that Hextend, with its novel buffered, balanced electrolyte formulation, is as effective as 6% hetastarch in saline for the treatment of hypovolemia and may be a safe alternative even when used in volumes up to 5 L.

IMPLICATIONS

Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and a physiological level of glucose. It is as effective as 6% hetastarch in saline for the treatment of hypovolemia but has a more favorable side effects profile in volumes of up to 5 L compared with 6% hetastarch in saline.

Planned early neck dissection before radiation for persistent neck nodes after induction chemotherapy

Optimal management of advanced neck metastases as part of an organ preservation treatment approach for head and neck squamous carcinoma (HNSC) is unclear. Since 1989, our management paradigm for patients on organ preservation was modified to incorporate planned early neck dissection before radiation therapy for patients who did not achieve a complete response (CR) of neck nodes after induction chemotherapy (IC). The purpose of this study was to determine if planned early neck dissection is a safe and effective approach in the management of advanced nodal disease as part of organ preservation. Fifty-eight consecutive patients with advanced HNSC who were entered in organ preservation trials using induction chemotherapy and radiation with surgical salvage were studied. Median follow-up was 26 months. Of the 58 patients, 71% were stage IV. Patients were grouped by nodal response to chemotherapy and N class, and were analyzed with respect to patterns of recurrence, complications, and survival. Overall, the rate of CR of neck nodes was 49%. Fifty-one percent had less than a complete response of neck nodes after IC and required planned early neck dissection. There were no significant differences in patterns of recurrence, complications, interval time to start of radiation, recurrence, or survival rates between the CR and less than CR groups. These data suggest that planned early neck dissection for patients with less than CR in the neck after IC is not detrimental with respect to neck relapse or overall survival. We believe that planned early neck dissection can be safely incorporated into future organ preservation treatment protocols for patients with advanced head and neck carcinoma.

Cross-sectional versus prospective predictors of screening mammography

Data from a population-based longitudinal study were used to compare cross-sectional versus prospective predictors of screening mammography. Although the results of the two analyses were not dramatically different, some important differences emerged. More attitudinal variables were related to future behavior compared with past behavior. Using purely cross-sectional data from this study to design an intervention would result in potentially important variables being deemphasized or omitted, which could have a significant impact on the strength of the intervention. Our findings strongly suggest that it may be unwise to generalize cross-sectionally obtained data to a longitudinal situation.

Effects of fenoxycarb on development and reproduction of the oriental cockroach, Blatta orientalis

In a laboratory study, groups of third-instar Blatta orientalis nymphs were reared to adulthood in arenas containing fenoxycarb (48 mg a.i./m2) treated ceramic or plywood tiles. The reproductive capacity of the emergent adults was assessed by pairing each individual with two untreated individuals of the opposite sex. Oothecal production, oothecal hatch and the numbers of nymphs emergent from each hatched ootheca were monitored. Exposure to 1-day-old deposits of fenoxycarb reduced adult emergence by 45-75% in comparison with an untreated control treatment. Substantial (> 40%) mortality also resulted when nymphs were exposed to deposits up to 3 months old on plywood and up to 6 months old on ceramic. Exposure to fenoxycarb significantly extended the time taken to reach adulthood of males contacting 6-month-old deposits on both surfaces, and of females contacting 1-year-old deposits on ceramic. Adult females exposed as nymphs to fenoxycarb were unable to produce oothecae, except one female laid a non-viable ootheca. Untreated females paired with treated males produced large numbers of oothecae of normal appearance but very low viability, with only 0-7.1% hatching. With marked effects on both development and reproduction in B.orientalis, fenoxycarb is a promising agent for control of this species.

Non-attendance at outpatient clinics: is it related to the referral process?

Non-attendance at outpatient clinics is a complex problem and previous studies have concentrated on hospital-related factors. It has been suggested that non-attendance might be related to the referral process, including the selection of patients for referral and the quality of communication between GP and patient. These issues are examined in a study of 1492 patients given first-time appointments at ENT and gastroenterology clinics. Non-attendance rates were 26 and 20% respectively. Non-attendance was not related to the nature, severity or duration of the patients' presenting problems at the time of referral or to their perception of the need for referral. Resolution of symptoms did not appear to be a major reason for non-attendance. Patients were significantly less likely to attend if they had been unable or only partly able to discuss their health problem with their general practitioner. Those who had requested referral were equally likely to default.

Marketing management enhances customer relations

The implementation of automated marketing management systems in hospitals across the United States can change dramatically the way in which a hospital builds business by managing relationships with prospective customers.

Strong medicine: rethinking the PFS (patient financial services) director's role

Burdened by accounts receivable problems and the growing complexity of patient accounting, hospitals soon may require an enhanced resume for individuals responsible for patient financial services (PFS) departments. Advanced skills in management, productivity, budgeting, analysis, and other areas increasingly must be put to work. Outdated perceptions also must change, giving PFS directors the influence needed to make change happen. A hospital's options include supporting course work toward an advanced degree, organizing rotation training in other hospital departments, or filling a PFS director position by searching for parallel skills in other service industries.

The hospital capital crisis: issues for trustees

The erosion of the capital position in the hospital industry--one of the most complex and overregulated industries in the United States--is a major challenge to trustees. Hospital trustees have often neglected to examine their hospitals' capital needs on more than a project-by-project basis. In dealing with their hospitals' capital needs, trustees, most of whom are successful business people, too often take off their "business" hats and put on their "social worker" hats. In doing so they not only neglect to subject their hospitals' capital and operating programs to searching cost-benefit review, but they also overlook much useful knowledge about how to use corporate organization to shelter new ventures and strengthen their hospitals' market position and solvency. In this article, the authors discuss how hospitals can adopt successful corporate restructurings and strategies to respond to the adverse financial developments they will have to face in the coming years.