Increasing Case Load Research Articles

Retrospective analysis of chest HRCT findings in coronavirus disease pandemic (COVID-19)- An early experience.

Context:Corona virus disease (COVID-19) has spread in a rampant manner all over the World causing severe acute respiratory illness. Prompt recognition of disease is invaluable to ensure timely treatment, and rapid patient isolation is crucial for containment of this communicable disease.Aims:To evaluate the performance of high resolution CT (HRCT) in the diagnosis of COVID-19. To establish the role of HRCT in prognosis of affected patients and to assess severity of disease based on HRCT findings.Settings and Design:This retrospective study included 216 patients admitted to our institute with a diagnosis of COVID-19 infection confirmed by nucleic acid RT-PCR testing.Subjects and Methods:Patients underwent non contrast HRCT chest examination and images were reconstructed in thin 1.25 mm lung window. Images were evaluated for presence of lung lesions & CT severity score was assigned to each patient based on number of lung lobes involved.Results:Ground-glass opacities (GGOs) with or without consolidation, interlobular septal thickening, the “reversed halo” sign (Atoll sign) and GGO's with rounded nodular pattern are common CT features of COVID-19Conclusions:Typical peripheral subpleural distributions of GGO's with bilateral asymmetrical lung involvement are characteristic features of COVID19 pneumonia. Chest HRCT can be a very useful and standard imaging method to assess the severity and progression of the disease and thereby optimizing the management of patients. With increasing case load all over the world HRCT can be used as a one stop radiological investigation for the diagnosis and prognosis of corona virus disease.

Arterial Resection in Pancreatic Cancer Surgery: Effective After a Learning Curve.

To investigate the perioperative and oncologic long-term outcomes of patients with LAPC after surgical resection at a high-volume center for pancreatic surgery. The role of surgery in LAPC with arterial involvement is controversial. We analyzed 385 consecutive patients undergoing PAR (n = 195) or PAD (n = 190) of the encased artery for LAPC between January 1, 2003 and April 30, 2019. There were 183 total pancreatectomies, 113 partial pancreatoduodenectomies, 79 distal pancreatectomies, and 10 resections for tumor recurrences, including 121 multivisceral resections and 171 venous resections. Forty-three patients (11.4%) had resectable oligometastatic disease. All of the 190 patients undergoing PAD (100%) and 95 of the 195 patients undergoing PAR (48.7%) received neoadjuvant chemotherapy. The R0 (circumferential resection margin negative) resection rate was 28%. The median hospital stay was 15 days (range: 3-236). The median survival after surgery for LAPC was 20.1 months and the overall 5-year survival rate 12.5%. In-hospital mortality was 8.8% for the entire patient cohort (n = 385). With increasing case load and growing expertise, there was a significant reduction of in-hospital mortality to 4.8% (n = 186) after 2013 (P = 0.005). The learning curve of experienced pancreatic surgeons for PAR was 15 such procedures. Our data demonstrate that an arterial surgical approach is effective in LAPC with promising long-term survival. PAD after neoadjuvant treatment is safe. PAR is a technically demanding procedure and requires a high level of expertise.

Acute pancreatitis in a patient with COVID-19: A case report

Introduction: The world is in the middle of the COVID-19 global pandemic. Case load is rising on exponential rate and we have already crossed 20 million mark. Typical presenting feature of COVID-19 is asymptomatic/mild or symptoms/acute respiratory illness and death. Gastrointestinal (GI) manifestations are common like loose stools, nausea, and abdominal pain. Case Report: A case of a 19-year-old girl without previous comorbidities presented with typical symptoms of COVID-19. During hospital stay she developed abdominal pain and diagnosed severe pancreatitis. All common causes of acute pancreatitis were ruled out by doing relevant investigations. Her pancreatitis was severe and required percutaneous drainage of necrotic material. She was discharged after prolonged hospital stay even after her negative COVID test. Conclusion: Atypical presentation of COVID-19 is increasing with increasing case load. Abdominal pain in a patient with COVID should be evaluated for acute pancreatitis and be treated accordingly to lessen morbidity and mortality.

Anesthesia Management for Pulmonary Cryoablation

Lung tumors represent a major health impact globally. Pulmonary cryoablation treatment as a palliative measure for patients with non-operable pulmonary lesions has gained popularity over the last decade. With increasing case load and patients medical status becoming more complex, preparation for pulmonary cryoablation requires the implementation of an enhanced perioperative anesthetic plan. Current literature as well as our institutional experience shows that this patient population presents with multiple comorbidities raising the challenge of providing anesthetic care. These procedures are done under challenging conditions with limited resources and in remote locations in the hospital. A team approach by the anesthesiologist, thoracic surgeon, and interventional radiologist is critical to the success of this treatment. The present review examines our institution’s anesthetic management of percutaneous cryoablation treatment (PCT) in the treatment of non-operable lung cancer and metastases. The objective of this article is to review the current literature guidelines and to discuss our retrospective institutional experience in anesthesia management of PCT procedures.

Accelerating Surgical Training and Reducing the Burden of Surgical Disease in Haiti Before and After the Earthquake

In general, university-based global health initiatives have tended to focus on expanding access to primary care. In the past, surgical programs may have been characterized by sporadic participation with little educational focus. However, there have been some notable exceptions with plastic surgery volunteer missions. We offer another model of regularly scheduled surgical trips to rural Haiti in plastic and general surgery. The goal of these trips is to reduce the burden of surgical disease and ultimately repair every cleft lip/palate in Haiti. Another principal objective is to accelerate the training of American residents through increased case load and personal interaction with attending surgeons in a concentrated period. Diversity of the case load and the overall number of surgeries performed by residents in a typical surgical trip outpaces the experiences available during a typical week in an American hospital setting. More importantly, we continue to provide ongoing training to Haitian nurses and surgeons in surgical techniques and postoperative care. Our postoperative complication rate has been relatively low. Our follow-up rates have been lower than 70% despite intensive attempts to maintain continued communication with our patients. Through our experiences in surgical care in rural Haiti, we were able to quickly ramp up our trauma and orthopedic surgical care immediately after the earthquake. Project Medishare and the University of Miami continue to operate a trauma and acute care hospital in Port au Prince. The hospital provides ongoing orthopedic, trauma, and neurosurgical expertise from the rotating teams of American surgeons and training of Haitian surgeons in modern surgical techniques. We believe that surgical residencies in the United States can improve their training programs and reduce global surgical burden of disease through consistent trips and working closely with country partners.

Invited Commentary

The term volume outcomes effect appeared in the literature in 1979 to describe the lower mortality rates experienced by hospitals performing a higher volume of specific surgical procedures [1Luft H.S. Bunker J.P. Einthoven A.C. Should operations be regionalized? The empiric relationship between surgical volume and mortality.N Engl J Med. 1979; 301: 1364-1369Crossref PubMed Scopus (1339) Google Scholar]. Numerous follow-up studies, including many involving cardiac surgical patients, seem to support these findings. Recently, a growing number of reports have found a breakdown in the volume outcomes effect. Few would argue that inexperienced clinicians caring for the occasional high-risk patient in an unstructured environment using insufficient resources should expect excellent outcomes. Yet there is a growing body of evidence that the relationship between volume and outcome is much more complex than originally described. This current study [2Pasquali S.K. Jacobs J.P. He X. et al.The complex relationship between center volume and outcome in patients undergoing the Norwood operation.Ann Thorac Surg. 2012; 93: 1556-1562Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar] uses a large, multicenter registry to evaluate the association of the number of Norwood procedures performed at a center with mortality results. Annual Norwood volume and preoperative risk tertiles were analyzed for association with mortality, revealing a modest association of center volume with outcome. Despite much improvement in surgical technique and perioperative care over the last two decades and a number of outstanding reports of interval results, it is important to note that approximately 20% of all patients undergoing the Norwood procedure and one third of high-risk patients do not survive more than 30 days. Higher-volume centers, on average, had lower mortality rates but the results were not universal. Center volume explained approximately 14% of between center variation, leaving the remainder of the causation uncertain. The use of center volume alone to predict outcomes overlooks the improvements that can occur in concert with increasing case load: hospital structure and process measures, level of expertise and availability of vital caregivers, development of evidence-based best practice guidelines, and ongoing quality assurance and quality improvement initiatives. The current analysis also does not account for the frequent changes in key personnel (e.g., experienced surgeons, intensive care unit physicians) that occur frequently in academic medicine. The fact that center volume does not completely explain differences in survival may be related to our place on the collective learning curve for the procedure. For example, drawing on the evolution of the arterial switch procedure, no amount of expert perioperative care (likely to exist in a high-volume center) could atone for the misdeeds of an inexperienced surgeon, whereas an experienced surgeon could routinely achieve excellent results working in a lower volume center. Many surgeons are currently comfortable with the technical aspects of the Norwood operation, and intraoperative deaths have become infrequent; however, perioperative care paradigms vary greatly and mortality still remains higher than expected. It may be inferred that there is still much to learn about the physiology and perioperative as well as interstage care of these patients. It is likely that these lessons, similar to the discovery of the importance of removing mechanical and vascular afterload and countless other innovations, will be gleaned from work in high-volume, experienced centers that are able and willing to invest the resources necessary to adequately study these patients. This important article helps to focus our future researchers into procedural specific outcomes. The next steps are to deconstruct and investigate other potentially overlooked factors that may be related to mortality and expand these studies to significant morbidities as well. The public and our payers demand it. The Complex Relationship Between Center Volume and Outcome in Patients Undergoing the Norwood OperationThe Annals of Thoracic SurgeryVol. 93Issue 5PreviewNorwood outcomes vary across centers, and a relationship between center volume and outcome has been previously described. It is unclear whether this volume-outcome relationship exists across all levels of patient risk or holds true for all centers. We evaluated the impact of patient risk status on the relationship between center volume and outcome, and the extent to which differences in center volume account for between-center variation in outcome. Full-Text PDF

Zertifizierung von Brustzentren

The primary focus of the establishment and certification of specialized cancer centers in the context of the National Cancer Plan is to improve the quality of care for patients with various carcinoma entities. The era of organ center certification started with the establishment of specialized breast cancer centers in line with the high incidence of breast cancer, the high mortality rate and the high level of interdisciplinary cooperation in the diagnosis and therapy of breast cancer. The introduction of quality management and external monitoring aims to provide high quality care in the diagnosis and therapy of breast cancer and is expected to improve long-term quality data (disease-free survival and overall survival) and to reduce mortality rates by about 25-30%. Certification requires the implementation of a quality management system and care provision structures assuring diagnosis and therapy according to the quality guidelines and recommendations of the specialist societies. Basic requirements for improving the quality of breast cancer patient care are centralization, specialization and interdisciplinarity. It has been demonstrated that the improvement of overall survival is associated with an increasing annual case load of a center, an increasing case load per surgeon per year, study participation and interdisciplinarity. Tumor documentation will be harmonized in the future by the establishment of local clinical cancer registries and cross-linking them with the National Cancer Registry. The data collection and analysis of several quality markers and current follow-up and survival data for each breast cancer patient will allow direct comparison of participating institutions. Individual breast cancer centers may demonstrate quality improvement longitudinally. Both certification and specialization require additional services which are associated with a substantial increase in costs. Preliminary data suggest that certified breast cancer centers are dependent on cross-financing by the participating departments of a hospital. Up to now cost-effective analyses for certified breast cancer centers are not available due to a substantial lack of data defining the additional financial burden.

Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care

To describe how district-wide access to HIV/AIDS care was achieved and maintained in Thyolo District, Malawi. In mid-2003, the Ministry of Health and Médecins Sans Frontières developed a model of care for Thyolo district (population 587, 455) based on decentralization of care to health centres and community sites and task shifting. After delegating HIV testing and counseling to lay counsellors, uptake of testing increased from 1300 tests per month in 2003 to 6500 in 2009. Shifting responsibility for antiretroviral therapy (ART) initiations to non-physician clinicians almost doubled ART enrollment, with a majority of initiations performed in peripheral health centres. By the end 2009, 23, 261 people had initiated ART of whom 11, 042 received ART care at health-centre level. By the end of 2007, the universal access targets were achieved, with nearly 9000 patients alive and on ART. The average annual cost for achieving these targets was € 2.6 per inhabitant/year. The Thyolo programme has demonstrated the feasibility of district-wide access to ART in a setting with limited resources for health. Expansion and decentralization of HIV/AIDS service-capacity to the primary care level, combined with task shifting, resulted in increased access to HIV services with good programme outcomes despite staff shortages.

Versorgungsforschung mit Routinedaten in der Onkologie

Cancer is in the focus of public and scientific interest as one of the leading causes of death, with an increasing case load due to demographic changes and rising treatment costs. Comparatively, little is known about health care utilization of cancer patients. This article first gives an overview of health services research and claims data of German statutory health insurance funds. Second, claims data of the Gmünder ErsatzKasse (GEK) for a period of 3 months (10-12/2008) are used to analyze patterns of drug prescriptions by oncologists. A total of 1.98 million prescriptions were included. Based on all prescriptions, the proportion of compounded prescriptions is about 17 times higher for oncologists compared to other physicians (34.4% vs. 2.0%). Fur- thermore, the costs of these solutions prescribed by oncologists are higher (median: 397.68 Euros vs. 15.45 Euros). Health services research in oncology is urgently needed. Claims data of German health insurance funds offer a broad range of opportunities, especially when linked with other data. However, in the case of individually prepared solutions, claims data provide no further information on the drug.

Collaborative transdisciplinary intervention in early years – putting theory into practice

Recent government initiatives in the UK encourage collaborative working among professionals and highlight the importance of a co-ordinated and collaborative approach in early years for families and children. There are many models of collaborative working but the evidence base for its effectiveness in early years (0-2.5 years) in a community setting in the UK is patchy. The aim of this study is to objectively evaluate the transdisciplinary model of collaborative working in this setting. This paper describes the development of a transdisciplinary early intervention team providing services to a 0- to 2.5-year-old age group in a community setting in the UK, between 2004 and 2007. The effects on waiting times, therapy session attendance and caseload were evaluated. Statistically significant reduction in waiting times from an average 114-35.6 days for the highest priority children was demonstrated. Attendance at therapy sessions increased significantly from 49% in 2005 to 56% in 2006 and 75% 2007, despite an increasing case load from 29 in 2004 to 64 in 2008 through more efficient utilization of time and resources. It is felt that this paper demonstrates, for the first time, the objective benefits to clients and fundholders/Primary Care Trust (PCT) of practical application of the theory of transdisciplinary working in a community paediatric service setting in the UK.

Treatment of Atlantic cnidarian envenomations

Envenomation syndromes induced by Atlantic cnidaria have been tabulated and their therapy discussed. The pharmacokinetics of the venom has been emphasized. Pain occurs instantly and reaches a zenith rapidly in the surf. The nematocysts have already penetrated the dermis and disease proceeds before help can arrive. This fact plus the relative impermeability of human epidermis hampers the efficacy of topical agents. Oral analgesics, the agents of choice, are seldom offered and systemic administration of these drugs is usually not necessary. The use of hot or cold applications has not been settled. Measures to inactivate nematocysts within tentacles adherent to skin post-sting have been demonstrated in vitro, but the clinical significance of these actions has not been shown. Using an abrader (sand, crystalline papain) to counter-irritate nearby skin might provide relief. Antivenoms for Atlantic cnidaria are not available. The instances when verapamil might be employed are very rare. The reasons for the increasing case load of these injuries are discussed and the need to discover more effective therapeutic agents is emphasized.

Increased Number of Deaths with Concomitant Diagnosis of Clostridium Difficile in a Community Hospital

BACKGROUND/OBJECTIVES: Clostridium difficile colitis is an important cause of morbidity and mortality in hospitalized patients. Because of a concern about increasing lethality we reviewed deaths associated with Clostridium difficile in a community hospital setting. METHODS: All patient deaths for 2002, 2003, and 2004 were reviewed for a primary or concomitant diagnosis of Clostridium difficile. A comparison between the number of deaths for each of the 3 years relative to the total number of deaths in each of those years was made. The prevalence of Clostridium difficile for each year was determined and the relative risk (RR) for death associated with Clostridium difficile was calculated. RESULTS: For 2002 and 2003. 4.0% and 5.7%. of all deaths respectively were associated with Clostridium difficile infection. The difference between 2002-2003 and 2004 was highly significant with p > .001. However, the prevalence of Clostridium difficile increased from .68% of hospital discharges to 1.18%. The RR for death associated with Clostridium difficile in 2004 compared to 2002-2003 was 1.3 (95% CI=.91-1.8). Clostridium difficile Associated Deaths Year Total Deaths C.difficile+ Proportion (%) 95% Confidence Interval 2002 570 23 4.0 2.7-6.0 2003 509 29 5.7 3.9-7.9 2002-2003 1079 52 4.8 3.7-6.2 2004 476 47 9.9 7.5-12.9 Clostridium difficile Infection Rates Per 100 Discharges Nosocomial vs Community Acquired Year Patients Nosocomial % Community % Total % 2002 15,486 47 (.30) 74 (.48) 121 (.78) 2003 16,710 79 (.47) 77 (.46) 156 (.93) 2002-2003 32,196 126 (.39) 151 (.47) 277 (.86) 2004 16,463 72 (.44) 122 (.74) 194 (1.18) CONCLUSIONS: Clostridium difficile associated mortality has increased significantly. Although the RR of death associated with Clostridium difficile was > 1, statistical significance was not acheived. The higher death rate may reflect a combination of increased case load and greater virulence. Further study is clearly warranted. Enhanced attention to judicious antibiotic use in susceptable patients is imperative to reduce the frequency of this lethal illness.

Tuberculosis and HIV interaction in sub‐Saharan Africa: impact on patients and programmes; implications for policies

Sub-Saharan Africa carries the overwhelming share of the global burden of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and of HIV-associated tuberculosis (TB). The impact of HIV on TB patients and programmes has implications for TB control policies. The impact on patients includes the effect of HIV on diagnosis and on the patterns of HIV-related TB, the response of HIV-infected TB patients to TB treatment, the benefits of antiretroviral therapy (ART), and the quality and continuity of care for TB patients. The impact on national TB programmes (NTPs) includes increased case load, impaired NTP performance, increased need for access to ART and difficulties in reaching TB control targets. Implications for policies include the need to promote TB and HIV/AIDS programme collaboration, aimed at improving NTP performance (TB case-finding and treatment outcomes), quality and continuity of care, and monitoring and interpretation of progress towards TB control targets. In order to provide the recommended international standard of care for TB patients, clinicians need to be aware of the impact of HIV on TB patients and programmes and the implications for the policies that provide the framework for this standard. Conversely, policy-makers need to understand the impact of HIV on TB patients and programmes. This can help to ensure a firm evidence base for TB control policies aiming at the high standard of patient care that is at the heart of TB and HIV programmes.

Coping with Africa's increasing tuberculosis burden: are community supervisors an essential component of the DOT strategy? Directly observed therapy.

Tuberculosis incidence in Africa is increasing dramatically and fragile health systems are struggling to cope. Potential coping capacity may lie within affected communities but this capacity needs to be harnessed if tuberculosis is to be controlled. Since 1991 all patients with tuberculosis in Hlabisa health district, South Africa have been eligible for community-based directly observed therapy (DOT). Patients are supervised either by a health worker (HW) in a village clinic, or in the community by a community health worker (CHW) or a volunteer lay person (VLP). Tuberculosis incidence increased from 312 cases in 1991 to 1250 cases in 1996. By December 1995, 2622 (87%) of 3006 patients had received DOT, supervised mainly by VLP (56%) but also by HW (28%) and CHW (16%). The proportion supervised by HW fell from 46% in 1991 to 26% in 1995 (P < 0.0001). More patients supervised by VLP (85%) and CHW (88%) than by HW (79%, P = 0.0008) completed treatment. Case-holding by HW declined more between 1991 and 1995 (84% to 71%, P = 0.02) than did case-holding by both CHW (95% to 90%. P = 0.7) and VLP (88% to 84%, P = 0.4). Mortality was similar (4-6%) and stable over time, irrespective of the supervisor. High tuberculosis treatment completion rates are achievable and sustainable for several years in resource-poor settings despite a massively increased case load if community resources are harnessed. Patients may be more effectively supervised by voluntary lay people than by health workers under these circumstances, without being placed at increased risk. These findings suggest that community supervisors may be an essential component of any DOT strategy.

Video assisted thoracoscopic surgery (VATS) in Asia--its impact and implications.

Within a short period of time, video assisted thoracoscopic surgery (VATS) has revolutionised the practice of thoracic surgery. Most of the existing literature, however, is concentrated on the technical aspects. We examined the impact of VATS on our practice and its implications. We reviewed our thoracic case load two years before and two years after the introduction of VATS in our hospital. We have witnessed a rapid and progressive increase in our thoracic case load since the introduction of VATS. With increased experience, proportionally more cases were performed using VATS compared to conventional surgical access. The increased case load covered a wide range of thoracic diseases with the majority for spontaneous pneumothorax and pleural diseases. The higher case load is due to increased referrals which at least partly reflect earlier acceptance by both the patients and their physicians for surgical intervention. The changing indications for surgery and the high cost associated with VATS, however, could place extra demand on the healthcare, especially for some countries in Asia. Cost containment is therefore a high priority here. More research is greatly needed in this area.

Civil Procedure Reform in Germany

The Reunification of Germany in 1990 and ongoing European integration have in recent years led to an increasingly difficult economic situation in Germany, to empty public purses and to the Finance Minister pressuring the Minister of Justice,' in the hope of gaining additional funds from the relatively small justice budget to help cover the costs of restructuring in the East2 and of increased unemployment. Purely fiscal reasons are thus an inducement for the refashioning of the justice system into a slimmer and more effective machinery. At the same time the burden on the civil justice system in Germany is continuously increasing, as in most other industrial nations.3 In 1991 there were 1.63 million new claims, by 1993 the number had increased to 2.08 million,4 and in 1994, 2.12 million. An increase in the number of judges or other judicial personnel to balance the increased case load is not possible due to lack of funds. This too provides a considerable impetus to reform the justice system, while of course ensuring that individuals continue to be provided with a system of legal protection based on the rule of law which is popular, has a human face, and is efficient at the same time. Discussions for reform thus center on the consideration of various relief measures. Be-

12 Year Review of Testicular Tumour Treatment by the Army Medical Services

Between 1977 and 1988 144 patients with tumours of testicular origin were referred to the Queen Elizabeth Military Hospital at Woolwich. 140 of these were malignant and all but two were treated and followed. Three of the malignant lesions appeared to be extragonadal. During the 12 year period staging has become increasingly accurate and treatment protocols have improved. These changes are reflected in this series. Ten deaths from tumour occurred (6.9%) but only one of these in the last three years of the study period despite an increasing case load at the time. The clinical presentation, treatment, and results of treatment are presented and the advances of treatment and improvement of prognosis discussed.

Cytogenetic diagnosis of the fragile X syndrome: Efficiency, utilization, and trends

In order to assess the impact of the increasing awareness of the fra(X) syndrome and a broader approach to fra(X) testing, we analyzed our laboratory experience for 1980-1988. In 1981-1986, there was an average of 80 cases/year (62 male; 18 female). The 103 (74 male; 29 female) cases in 1987 represent a 45% increase over the prior 3 years; this sustained in 1988 with 106 cases. The fra(X) positive yield decreased from a high of 49% in 1980 to an average of 20% (range 15-24%) in 1981-1984, 10% (range 9-11%), in 1985-1987 and 7% in 1988. The positive rate for males and females was nearly identical in both time periods. The positive yield for mentally retarded individuals with a family history of mental retardation dropped from an average of 20% for 1981-1984 and 33% for 1985-87 to 13% for 1988; however, the positive fra(X) rate for mentally retarded individuals decreased from an average of 23% in 1981-1984 to 9% in 1985-1987 and 7% in 1988. The decreasing fra(X) yield and increasing case load are directly attributable to the relaxation of criteria for referral and testing related to the referral of all mentally retarded patients, and to the perceived malpractice liability for not doing a "complete" evaluation. Although the burden for cytogenetic laboratories is considerable, the yield of positive fra(X) cases is still worthwhile, and may be maximized by the use of improved screening criteria.

Rehabilitation Placement Services: Unlicensed Employment Agencies or Something Else?

Research into the roles and functions of rehabilitation, counselors has revealed job placement services to be among the most important duties reported. Yet, counselors have indicated they have insufficient time to perform placement services because of increased case load size. Thus, clients who are approaching job readiness generally have been referred to private not-for-profit rehabilitation facilities for placement services. More recently, private for-profit rehabilitation practitioners have discovered that placement efforts are enhanced by having smaller case loads which allows for attention to be focused toward job placement in a timely manner. However, both private not-for-profit rehabilitation facilities and for-profit practitioners generally charge a fee for client placement services. The dilemma confronting rehabilitation professionals and facilities who collect fees for placement is that they may be in violation of state statutes requiring such activities to be licensed as employment agencies, agents, or both. State statutes regulating employment agency functions are examined relative to fee-generating placement activities performed by rehabilitation personnel.

Improved management in the diagnosis of gonorrhoea in women.

In this paper an evaluation is made of the endeavours to improve diagnosis in women named as contacts of gonorrhoea. The problem was approached in three ways. (a) The number of sites sampled was increased. (b) The results of microscopical examination of smears made by clinical staff were regularly evaluated. (c) Cultural examinations by the supporting laboratory were dealt with more efficiently and speedily. It is concluded that the number of tests currently used to establish or exclude a diagnosis of gonorrhoea in women can safely be reduced to two, and that the methods currently in use allow a more cost-effective management of an increasing case load.