Proposals for funding graduate medical education: the Institute of Medicine report in context

Federal support of graduate medical education (GME) has been accepted as an intrinsic ingredient of the Medicare program since that program's inception. Streams of clinical income generated by teaching hospitals, medical faculty practice plans, Medicaid, and other state and federal sources have also made important contributions to GME. Although it is difficult to ascribe legislative intent precisely, Medicare funding seems to have been based on a 2-fold assumption: that GME was socially beneficial and that there were legitimate costs to teaching hospitals associated with their educational missions, even though such costs were hard to identify specifically. The benefits and costs include the high quality generally ascribed to a teaching hospital environment; extra services and teaching costs; active, unsponsored research; a higher proportion of complex medical conditions and care; and technology development and introduction. The argument for Medicare support of GME is thus partly based on better service to all Medicare beneficiaries, and partly on a broader social investment in education and teaching hospitals, with benefits accruing to both present and future Medicare participants. Teaching hospitals and their young physicians in training are also important in providing care to underserved poor populations.

The incidence of bacteria in middle ear effusions

Otitis media with effusion (OME) is a common condition in paediatric ENT practice. Whilst surgical management is in many cases the mainstay of treatment for resistant OME, the use of antibiotics has been advocated by some authorities. Over one quarter of middle ear effusions analysed in this study contained potentially pathogenic bacteria. Antibiotics may be of value in the treatment of OME in these children.

Nasendoscopy guided removal of fish bones from the base of tongue and the vallecula

Impaction of a fish bone at the base of tongue or the vallecula is a very common problem. Removal of the bone from these sites without a general anaesthesia can be challenging to surgeons and patients alike. Various manoeuvres to facilitate this procedure have been described, some are very successful but may require specialized instruments, while others may cause excessive discomfort to the patients and even inadvertent dislodgement of the bone. We describe a method using a flexible fibreoptic nasendoscope to provide a visual guide in order to facilitate peroral removal of the bone with a pair of forceps. This method is well tolerated by patients and avoids the need for a general anaesthesia in many cases.

Type II collagen autoimmunity and Ménière's disease

Antibodies to type II collagen have been reported by some authors to be raised in patients with Ménière's disease. In this study the antibody levels to type I and II collagen have been measured in 37 patients with Ménière's disease and 20 controls, using a solid-phase, double-antibody, enzyme-linked, immunoassay. No significant difference in antibody levels between the two groups was found. These findings do not support previously reported work which suggests that some cases of Ménière's disease are due to type II collagen autoimmunity.

An in vitro comparison of the Erbium: YAG laser and the carbon dioxide laser in laryngeal surgery

This study compares the relative thermal damage caused by a surgical CO2 laser and the Erbium:YAG laser when used to incise the human vocal fold in vitro. Results show that charring is completely eliminated when using the Erbium:YAG laser. The depth of coagulative necrosis adjacent to an incision is reduced from 510 microns (+/- 75) using the CO2 laser to 23 microns (+/- 12) using the Ebrium:YAG laser and at the base is reduced from 125 microns (+/- 45) using the CO2 laser to 12 microns (+/- 8) using the Erbium:YAG laser. The potential advantages regarding post-operative healing after laryngeal surgery are discussed.

Facial palsy after glomus tumour embolization

A case is presented of a patient undergoing pre-operative embolization of a glomus tumour who developed a facial palsy one hour after embolization. At the time of surgery it was found to be due to the embolization material (polyvinyl alcohol foam) blocking the stylomastoid artery. The blood supply of glomus tumours and the variations in the blood supply of the facial nerve are discussed.

Parental cigarette smoking and tonsillectomy in children

The deleterious effects of parental smoking on the upper respiratory tracts of children are becoming increasingly recognized. This study examines the effect of parental smoking on the frequency of tonsillitis and incidence of tonsillectomy in children. A group of children being admitted for tonsillectomy and a control group of children from an orthoptic clinic were studied. Details recorded about the children included a history of tonsillectomy and the number of courses of antibiotics taken for sore throats in the previous 12 months. Parents were questioned about their smoking habits. A marked and statistically significant association has been found between the incidence of tonsillectomy in children and parental smoking in the home environment. There was a higher frequency of attacks of tonsillitis requiring antibiotic treatment in those children whose parents smoked. This effect may be mediated by altered oropharyngeal flora, mucociliary dysfunction, increased cross infection or a combination of these. If parents are encouraged to stop smoking there will be a reduction in tobacco smoke levels in the home environment and this should lead to a fall in both the incidence of tonsillitis and the need for tonsillectomy in their children.

A review of patients attending a preliminary cochlear implant assessment clinic

The Cochlear Implant Programme at Manchester Royal Infirmary was established in 1988 and so far (January, 1992) 38 patients have been implanted with the Nucleus 22 channel intracochlear device and one with the Ineraid device. All patients who are referred for consideration for an implant are initially seen at a preliminary cochlear implant assessment clinic conducted by an ENT surgeon. One hundred and seventy three patients attended the initial outpatient screening clinic between 1987 and January 1992. Of these 112 patients (67.6 per cent) went on for further investigation regarding suitability for implantation. This paper details the aetiology and severity of deafness in these patients and explains how suitability for admission to the next stage of assessment was decided.

Ionomeric bone cement in neuro-otological surgery

The use of a polymaleinate glass ionomer cement in 80 neuro-otology cases is described. It has proved of great value in translabyrinthine acoustic neuroma surgery, reducing the incidence of CSF fistula to nil. It is the method of choice for fixation of the Nucleus cochlear implant, and has many other applications in the field of otology and neuro-otology. It is easy to use and appears to have no side effects.

The lateral soft tissue neck X-ray in accident and emergency medicine

Five patients with upper aerodigestive tract pathology seen acutely in the Accident and Emergency department at St Mary's Hospital, London are presented. The value of the lateral soft tissue neck X-ray in their diagnosis is discussed.

Cost effectiveness of colorectal cancer screening in the elderly

OBJECTIVE

To assess the cost effectiveness of a periodic program of colorectal cancer screening in the elderly.

DESIGN

A model was constructed of four strategies for the periodic screening of persons 65 to 85 years of age. The effect of each strategy on life expectancy and health care costs was estimated under assumptions that were uniformly unfavorable to screening. Cost and added years of life were discounted at 5% per year. Cost per year of life gained from screening was calculated for each screening strategy.

DATA SOURCES

Assumptions used in the model were based on a review of pertinent studies; those studies with results more unfavorable to screening were given more weight. Strengths and weaknesses of studies are discussed.

MAIN RESULTS

A program of annual fecal occult blood testing (FOBT) in the elderly would detect at least 17% of the expected cases of cancer and could cost $35,000 per year of life saved. Screening schedules that include periodic sigmoidoscopy would prevent more cases of cancer but could cost between $43,000 and $47,000 per year of life gained. These estimates are based on uncertain assumptions, but results were not extremely sensitive to further relaxation of the values of the most uncertain assumptions. In no case did the cost per year of life gained from annual FOBT exceed $55,000 or did the cost per year of life gained from FOBT with sigmoidoscopy every 5 years exceed $61,000.

CONCLUSIONS

Although colorectal cancer screening is costly in the aggregate, its potential medical benefits make it a reasonably cost-effective preventive intervention for the elderly.

Incidence and prevention of conjunctival contamination with blood during hazardous surgical procedures

The incidence and risks of conjunctival contamination with patients' blood during a range of otolaryngological surgical procedures was assessed. Risks were found to be highest in three groups of procedures; tracheostomy, operations preceded by local anaesthetic injections and procedures involving the use of the air drill. A simple and effective method of protection using spectacles with large plain lenses is presented.

Surgical treatment of obliterative otitis externa

Seven patients with fibrous obliteration of the ear canal due to long-standing otitis externa were seen at St Mary's Hospital during the past 10 years. Two patients underwent bilateral surgery making a total of 9 ear cases. Two patients developed early restenosis within 6 months of permeatal excision of the fibrous core and skin grafting, and one patient had late stenosis 4 years following postaural excision, meatoplasty and skin grafting. Two of these patients opted for revision surgery and a total of 6 patients (8 ear cases) underwent postaural excision with Körner flap canalplasty, enlargement of the bony ear canal and skin grafting. The average hearing gain was 25 dB in the speech frequencies and only one restenosis was seen at 3 years. This was successfully revised. Radical excisional surgery with a wide bony canalplasty is recommended in this condition.

Changing prognosis for very low birth weight infants

Obstetric decisions regarding extremely premature infants are based in part on their long-term prognosis. This review pools data from perinatal center reports to update mortality and morbidity trends for each subgroup of very low birth weight infants. Throughout the last 10 years, there has been steady and statistically significant improvement in neonatal mortality rates among inborn very low weight infants (1500 g or less). The most substantial improvement of the 1980s over the late 1970s is in the 750-1000-g birth weight group, in which today's infants have about a 70% chance of surviving if they have access to neonatal intensive care. Mortality in infants born weighing less than 750 g is still very high; overall about two-thirds die, but results are highly variable across centers, with several centers reporting 50-70% survival. The rate of serious long-term disability increases with decreasing birth weight, but within each birth weight group, the proportion of survivors who have serious handicaps has not changed significantly since the introduction of neonatal intensive care. For infants born between 1975-1985, 26% of surviving infants with birth weights below 800 g, 17% of survivors with birth weights between 750-1000 g, and 11% of survivors with birth weights between 1000-1500 g have major handicaps at 1 or 2 years of age. Because many very sick newborns who previously would have died are now surviving, an increasing rate of handicap might have been expected.

The recognition and management of the otolaryngological manifestations of AIDS

Between October 1984 and December 1987, 219 patients who fulfilled the criteria for Acquired Immune Deficiency Syndrome (AIDS), as set out by the Centers for Disease Control, Georgia, were seen at St. Mary's Hospital, London. The most common otolaryngological manifestations of the disease in these patients were oral candidiasis (60%), oesophageal candidiasis (16%), persistent generalized lymphadenopathy (27%) and Kaposi's sarcoma (26%). Our management of the patients is described.

Kaposi's sarcoma of the head and neck in patients with AIDS

Over a 40 month period, 219 patients with AIDS were seen at St. Mary's Hospital, London. Kaposi's sarcoma, one of the criteria for diagnosing the syndrome, was the presenting feature in 62 patients. Eighty four patients developed Kaposi's sarcoma at some stage of their disease and the head and neck region was involved in 56 of them. Although Kaposi's sarcoma is rarely life threatening in AIDS, potential airway obstruction, pain or cosmetic disfigurement may justify treating the lesion. Whilst cutaneous tumours may be managed by using radiotherapy (16 Gray in four fractions over four days), this treatment produces a sever mucositis when used to treat mucosal disease; we, therefore use a combination of vincristine and bleomycin for this.

Chondrosarcoma of the sphenoid--a case report and review

The case of 57-year-old woman is presented with a chondrosarcoma of the sphenoid. The main symptom was rapid loss of vision and in order to halt this the tumour was debulked. The literature relating to chondrosarcomas of the head and neck is reviewed. These rare tumours are not radio-sensitive and surgery represents the best form of treatment at the present time. The prognosis is poor.

Program planning in the Office of Technology Assessment's Health Program

This paper describes the Congressional Office of Technology Assessment's Health Program and the role that its process of program planning has played in the selection of studies and the allocation of Program resources. It discusses the primary areas in which studies have been conducted--assessment methods, specific technologies, environmental health, information technologies, and financing/structural aspects of health care--and examines the changes in relative emphasis placed on the areas over time and the factors that lead to changed emphasis. Internal factors--e.g., judgments of whether a topic is of national importance, fiscal and staff resources available, and whether the issue is appropriate for OTA--and thus program planning have played their strongest role in the areas of assessment methods and of specific technologies. Activities in the financing/structural areas and some types of studies in the environmental health areas are being driven more by external factors--e.g., expressed needs of Congress, availability of data, and developments in science and technology.

Polycystic renal disease: a new experimental model

A single injection of any one of several long-acting adrenal corticosteroids at birth induces progressive cystic changes in nephrons which develop in the subcapsular zone of the rabbit kidney until 10 days after birth. These cystic lesions enlarge progressively and become visible within a few days after birth. When the animal is 2 weeks old, renal size has become three times as large as that of uninjected littermates. Adrenal corticosteroids prolong the duration of nephrogenic activity in the renal cortex. The cysts are blind and represent dilatation of the developing end of the collecting ducts. When the steroid-induced hypokalemia is prevented with repeated potassium chloride injections, renal cystic disease is almost completely prevented. Certain long-acting steroids induce cystic renal changes without systemic signs of toxicity.

Light chain distribution in immune deposits on glomeruli of kidneys in human renal disease

The gammaG-immunoglobulin (IgG) deposited on glomeruli of 32 percutaneous renal biopsies from 30 patients with various forms of renal disease was examined by fluorescent techniques to determine its light chain composition. Serum kappa: lambda light chain ratios were determined on 17 serum samples from 16 of the 30 patients. Glomerular IgG staining with only antikappa antiserum, only antilambda antiserum, and with both antisera was demonstrated. No correlation of serum kappa: lambda light chain ratios with the type or types of light chains demonstrable on the glomeruli was observed. We concluded that the IgG deposited on glomeruli of patients with various forms of renal disease is not a nonspecific sample of the circulating immunoglobulin pool but may well reflect more specific selection, as in the deposition of specific antibody formed against exogenous or endogenous antigens during the development of the renal lesion.