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Management is the recognition, harnessing, and channeling of all available appropriate forces and resources toward meeting defined goals and objectives. What is "managed" in managed care? How a physician practices, among other things. Managed care is the application of management principles in a comprehensive, prepaid health care delivery system that controls input and output to optimize efficiency and effectiveness with the prior consent of providers and patients. In 1982, 10 million Americans were in managed care; in 1992, 90 million—a megatrend that continues to expand.Victor Cohn of the Washington Post says, "If you've seen one managed care plan you've seen one managed care plan." The alphabet soup of managed care includes IPA (independent practice association), HMO (health maintenance organization), PPO (preferred provider organization), POS (point-of-service plan), PGP (prepaid group practice), and the beat goes on.The principles and practices of managed care are hardly new. The first group practice in

BACKGROUND: We present our experience with an as yet undescribed type of intentionally ingested metallic foreign body that was specially designed to arrest in its passage and cause perforation of the gastrointestinal tract. The two halves of a standard paper clip are tied crosswise with a rubber band, forming an elastic "cross." With its branches squeezed to lie parallel, the cross is wrapped into a small strip of paper and ingested. After being released from its wrapper, the branches of the cross spring back to their original position and cause perforation of the bowel wall. DESIGN: Case series. SETTING: University hospital, Bulgaria. PATIENTS: Five male prisoners from the same jail undergoing laparotomy for foreign body removal during 1 week in January 1994. INTERVENTIONS: Laparotomy, removal of the foreign bodies through incisions of the bowel wall, immediate restoration of the gastrointestinal tract continuity, and peritoneal lavage and drainage. OUTCOME MEASURES: Morbidity and mortality. RESULTS: Two of the patients were initially observed but subsequently underwent surgery for perforations of the gastrointestinal tract. Three of the patients underwent immediate operative treatment. There were 20 total crosses ingested; all foreign objects impacted and perforated the stomach (50%), first duodenal portion (25%), and fourth duodenal portion (20%). There was no morbidity or mortality among the five patients treated. CONCLUSIONS: Because ingested crosses that have been released from their wrappers never move distally, the only definitive solution is to operate early.(Arch Surg. 1996;131:166-169)

Two years ago, Kellogg Speed1 reported sixty-seven cases of fracture of the femur in children in which he evaluated the relative results of treatment by cast, extension with the leg supported on the bed, and continuous extension with the leg elevated and supported by an over-head frame. His results decidedly favored the method last named. Burdick and Siris2 also presented a paper advocating overhead continuous traction in treatment of fractures of the femur in children.The material presented in this paper is the result of the study of seventy-five children with fractured femur who were treated on the joint service of Dr. George G. Davis and myself at the Cook County Hospital between Jan. 1, 1922, and June 1, 1923. The ages of the children varied from 1 year to 11 years. Table 1 shows the occurrence of the fractures according to ages.All but three of these

In the studies here recounted, three different aspects of the problems involved in the development of bone are discussed, as indicated in the title. All three studies are closely interwoven and cannot be considered separately without much needless repetition and reduplication. Consideration is given each aspect in its proper relation to various portions of the work to be described, and they must be considered collectively for a proper elucidation of the problems discussed and for an interpretation of the results of the work which has been accomplished.The process of the transport of calcium salts in the body and their deposition in bone have already been discussed in previous papers. But a much more thorough, detailed and minute study has now been made of the process of calcification of the cartilaginous and bony matrix of the skeleton, and the results obtained are embodied in this paper. It is to be

CONGENITAL DISLOCATIONS CONGENITAL DISLOCATIONS OF THE HIP. OPEN OPERATION. —Galloway1 describes in detail his operation for the reduction of congenital dislocation of the hip, which he has been strongly advocating since the publication of his paper in 1920. Sherman, many years previously, advised a somewhat similar attack, but we believe that before his death he grew somewhat less enthusiastic concerning the method. Galloway says that the operation has been further developed and improved (since his paper of 1920) until now the results in young children are so uniformly satisfactory that he no longer approaches these cases with a feeling of dread or uncertainty, but with confidence that the treatment is simple, safe and practically certain to result satisfactorily. He considers the closed method of Denucé successful, but unfavorable when compared to the open method, because of the greater length of time required to attain the desired result. Galloway does

The subject of suppurative pericarditis has been thoroughly presented, the literature reviewed, and records brought up to date in the recent papers of Peterson,1 Winslow and Shipley,2 and Williamson.3 Including the following reports, there are now 133 cases on record in which operation has been performed. Many unreported cases undoubtedly exist. In the discussion which followed the presentation of Peterson's paper before the Congress of Thoracic Surgeons in New York, the possibility of a posterior approach for drainage of the pericardium was mentioned. To demonstrate the plausibility of this method of approach in certain instances, the following cases are recorded. REPORT OF CASES Case 1.—History.—Sun Chan Chun, a Chinese soldier, aged 19, was admitted to the surgical service of the Peking Union Medical College on Dec. 17, 1925, four days after having been shot in the left axilla. The missile, a rifle bullet, was retained, and the roentgenelogic examination

Nodules of tissue indistinguishable microscopically from pancreas have been observed by many investigators and have been discussed at length, deservedly, in numerous papers. Not only is such a phenomenon of considerable interest, but it presents a fundamental pathologic problem. In many of the papers that have appeared, not only have hypotheses which are untenable in the present state of knowledge been proposed, but even patently inaccurate observations have been made. In addition, certain relevant features of considerable import in the determination of the nature of these masses have been overlooked. HISTORICAL DATA The earliest record of the occurrence of pancreatic tissue in the stomach which is available to us is that of Zenker, published in 1861. He referred to a previous note by Klob in 1859, and to some observations in lower animals by Leydig (1857).Wagner (1862) and Gegenbauer (1863) reported other cases, and a few further reports appeared,

This paper deals with some of the anatomic and physiologic peculiarities which govern the operative treatment of certain lesions of the contents of the anterior cranial fossae, and includes a description of a method of exposing the latter. It is not intended to be in itself a complete survey of the field; many practical points have been recorded by other surgeons, and reference will be made to these in the appropriate places. Details concerning the various types of lesions are best assembled in papers which are confined to a particular type; because many such studies are now available, it may be not unprofitable to revert now and then to a regional outlook, by attempting to combine in broad outline an account of the surgical difficulties which are the sum, or perhaps even the product, of lesion and site. Although much of what follows may be already familiar to individual surgeons,

Of the many technical methods employed in the study of gastrointestinal motility, none fully escapes criticism. Objections commonly fall into three groups: The animal is, as a rule, anesthetized; a certain amount of trauma is usually entailed, and, finally, the methods of recording are to a certain degree deceptive and misleading in that intestinal activity is either visibly perceived or recorded as a volumetric change in the lumen. In this paper a new method and its application will be presented. While all the objections are not overcome, especially in regard to trauma, the method possesses distinct advantages over any other in use at present. The experiments are conducted on unanesthetized animals; the action of both muscular coats is individually recorded, and, finally, it is possible to apply stimuli to the mucosa in a manner simulating the passage of normal fecal contents.The paper will be presented in two parts, the

In the past few years a number of papers dealing with the question of nonspecific inflammatory lesions in the gastro-intestinal tract have appeared. Some of the papers dealt with the subject at length. Others reported only a few cases with comments. A great deal remains to be clarified, especially regarding the early phases of the disease. More specific information is needed relating to (1) prognosis as to life, (2) incidence of recurrence even after radical surgical intervention, and (3) the end-results in cases of the early stages noted at operation, in which no resection or other intestinal procedure is done. Criteria for clinical diagnosis must be established, as it becomes more obvious daily that the condition is not uncommon and must surely be noted from time to time in the routine experience of the general practitioner. He must be prepared to recognize the syndrome or at least the possibilities thereof.

Injection into varicose veins of the lower extremities has become the most popular and is undoubtedly the best method of treatment in most cases. In a previous paper by Garside and one of us (Ochsner)1 and in a previous paper by us2 the results of histologic studies of the effects of intravenous injection of twenty-nine sclerosing solutions are reported in detail. In each of those papers attention was called to the fact that the endothelium was partially or completely destroyed by an effective thrombosis-producing agent, and mention was made of the fact that such destruction was essential for the precipitation of a thrombus. In our last paper2 we also showed that the effect of some sclerosing agents was not only the destruction of the intima but also at times the production of coagulation necrosis of the media. The intima, when sufficiently injured, disappeared so that it was

ONE SIDE-RESULT of the application of surgical treatment to neoplasm of the esophagus has been to bring the benign lesions into sharper focus. The conditions of the esophagus presented in this paper are collected from the case records of the last 10 years of the private practice of one of us (H. L. T.) and from the Los Angeles General Hospital. The conditions include leucoplakia, broncho-esophageal fistula, spontaneous perforation, benign esophageal stenosis, esophagitis, and peptic ulcer of the esophagus. The benign tumors of the esophagus are the subject of another paper. It is believed that the cases reported here illustrate the practical problems of diagnosis and treatment by surgical means. LEUCOPLAKIA It is our belief that any consideration of benign pathologic conditions of the esophagus must necessarily include leucoplakia. This is because the condition is encountered so frequently in symptomatic and asymptomatic esophageal disease. As is well known, leucoplakia is

THE PURPOSE of this paper is to illustrate the marked increase in intracranial pressure that occurs after radical operations on the neck and the methods used in an attempt to overcome this abnormality.The most acceptable therapy for cancer of the head and neck is wide surgical excision. Radical neck dissection involves removal of the superficial and deep cervical structures, including the sternocleidomastoid muscle, the external and internal jugular veins and the entire block of tissue containing the superficial and deep cervical lymphatic vessels. This procedure, therefore, requires the removal of the internal jugular vein from the base of the skull to the base of the neck. That such is the accepted practice is indicated by several papers and communications.1The cases herein analyzed involve 11 patients who were operated on in the above-mentioned method for cancer of the head and/or neck. The individual diagnoses are indicated in Table

IN A PREVIOUS paper, we reported a series of patients who, within a few days after trauma or surgery not related to the stomach, developed serious complications of their pre-existing peptic ulcers. Stimulated by these cases, we started a study of the relationship of such trauma and surgery to gastric secretion.In our first paper,1 we presented data showing that after duodenorrhaphy for acutely perforated duodenal ulcers, gastric secretion attained high concentrations of acids by 8 to 12 hours and maintained acid levels for the following 12 to 24 hours which were comparable to those found in a group of patients with active duodenal ulcers. No preoperative controls were available in these patients presented in the first paper.In the present paper, we are presenting additional clinical and laboratory data on both ulcer and nonulcer patients with preoperative and postoperative control studies. GENERAL OBSERVATIONS EFFECT OF NONSPECIFIC OPERATIONS ON