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In Holding Health Care Accountable, E. Haavi Morreim differentiates between duties of expertise and resource duties, arguing for tort liability respecting the former and contract liability respecting the latter. Though Morreim's book addresses ordinary clinical medicine, her liability scheme may also be relevant elsewhere. Focusing on disaster medicine, and especially the medical management of violent mass disasters (e.g., where terrorists have deployed weapons of mass destruction), I argue in this essay that Morreim's classification of duties still fits, but that it is difficult to hold government powers accountable for their many resource and expertise duties. This difficulty is compounded by political arrangements that foist under-funded mandates for disaster services on healthcare providers. As a result of such arrangements, hospitals and clinicians are prone to liability for expenditures and clinical interventions that are beyond their scope. This problem can be mitigated, I argue, by examining and clarifying the apparent social compact between society and healthcare.

Non-adherence to antiretroviral (ARV) regimens has been associated with HIV drug resistance. Anecdotal evidence in our client group, people living with HIV/AIDS infection in Central Sydney Area Health Service (CSAHS), suggested that non-adherence was an issue. Eighty three participants completed an anonymous questionnaire; with a 98% response rate. The mean age of respondents was 44 years with 68% over age 40 years. 68% of respondents missed doses of ARV, 54% because they forgot. 54% stated they did not report the non-adherence to their doctor. They were more likely to miss the lunch time dosage (n=49, p<0.05). The results demonstrate that non-adherence with medications is a significant issue and further research into strategies for interventions to aid adherence is required.

Moral distress is often discussed as a response to the moral dilemmas that professional and other caregivers encounter in their effort to balance competing moral principles, or to provide care in difficult cases, to difficult patients, in spite of difficult institutional requirements or policy. In this essay, a reforming ER clinician and teaching physician, offers a personal approach to moral distress. Assuming that a clinician's own foibles may sometimes contribute to another's distress, and that attempting to rationalize or subvert these foibles causes moral fatigue, he offers personal guidelines for healthcare providers--four strategies that less-than-perfect practitioners may use while striving to attain the ideal of the competent, compassionate, altruistic, calm, and wise clinician.

There is tension in bioethics between two strains of pragmatism. The most prominent strain, following John Dewey, proposes a content-rich ethos of controlled, collective moral inquiry. A second strain, descending from Charles Peirce and Josiah Royce, favors an open-ended approach where diverging moral communities evolve without extensive inter-communal oversight. This essay defends the second strain. The Deweyan approach, I argue, exhibits a problematic quasi-foundationalist character insofar as it canonizes a dubious constellation of "liberal" political values and seeks to establish these values by interposing a consensus of moral experts where genuine inter-communal dialogue, and compromise, would be more fruitful. I hold that the alternative approach of Peirce and Royce is preferable, and truer to the fundamental commitments of classical American pragmatism. Recognizing the epistemic fallibility of various content-rich moral-political formulations, Peirce and Royce hope to cultivate and sustain moral inquiry by allowing each moral community (1) to generate and test its own moral system (as long as it does so peaceably) and (2) to freely make or refuse to make collaborative arrangements with other moral communities. This approach is illustrated in a brief discussion of the Oregon Medical Experiment.

Objectives: To determine concentrations of matrix metalloproteinase (MMP)-2 and -9 in synovial fluid; and mRNA expression of MMP-1, -13, and -3; interleukin[IL]-1alpha and beta; and tumor necrosis factor (TNF)-alpha in synovial membrane and articular cartilage from horses with naturally occurring joint disease., Sample Population: Synovial fluid (n = 76), synovial membrane (59), and articular cartilage (45) from 5 clinically normal horses and 55 horses with joint disease categorized as traumatic (acute [AT] or chronic [CT]), osteochondritis dissecans (OCD), or septic (S)., Procedure: Synovial fluid gelatinase concentrations were analyzed, using zymography. Synovial membrane and articular cartilage mRNA expression for MMP-1, -3, and -13, IL-1alpha and beta, TNF-alpha, type-II collagen, and aggrecan were analyzed, using quantitative reverse transcriptase-polymerase chain reaction., Results: Synovial fluid pro-MMP-2 concentration was significantly higher in diseased joints than normal joints. Septic joints had significantly higher concentrations of pro and active MMP-9. Stromelysin-1 was expressed in > or = 80% of synovial membrane and articular cartilage samples and was strongly influenced by age. Collagenases were rarely expressed, with MMP-13 expressed only in diseased joints. Interleukin-1beta expression was significantly higher in all OCD samples and was influenced by age. Tumor necrosis factor-alpha expression was significantly higher in cartilage from joints with AT and OCD. There was no correlation between MMP or cytokines and type-II collagen or aggrecan expression., Conclusions and Clinical Relevance: Matrix metalloproteinase-2 and -3 are abundant in naturally occurring joint disease and normal joints. Interleukin-1beta and TNF-alpha may be important in the pathogenesis of OCD. Age affects MMP and IL-1beta concentrations.

The purpose of the present paper was to measure the variation in mantle planning in Australia and New Zealand. A chest X-ray (CXR) of a patient in the supine position with a neck node marked by wire was sent to every radiation oncologist in Australia and New Zealand. They were to mark on the CXR the lung blocks that they would use to treat this patient, assuming that the patient had stage IA Hodgkin's disease. These marks were compared with a small sample of radiologists who were asked to define the mediastinum on the same CXR. Radiation oncologists were also asked to complete a short questionnaire about other modifications to their treatment fields and their experience with this technique. One hundred and six films were sent out and 44 radiation oncologists replied. There was a maximum variation in the placement of their lung blocks of 6 cm. Half of the lung blocks were within a 2-cm range. One respondent said they would not use a mantle field to treat this patient. Mediastinal coverage was inadequate in at least 50% of cases. There was a very large variation in mantle field planning practices within Australia and New Zealand. For this reason Australasian Radiation Oncology Lymphoma Group has produced consensus guidelines for mantle block design. These are appended to the present paper.

Objective: To evaluate the outcome of horses with large fragments of the extensor process of the distal phalanx that were removed by use of arthrotomy., Design: Retrospective study., Animals: 14 horses with large fragments of the extensor process of the distal phalanx., Procedure: Medical records for horses with large fragments of the extensor process that were removed by use of arthrotomy were reviewed. Data retrieved from medical records included signalment, use of horse, affected limb, lameness history, lameness examination findings, radiographic findings, surgical technique, and outcome. Follow-up evaluation was obtained by telephone interview., Results: Most affected horses were < 5 years old and had a history of chronic lameness. Lameness grade ranged from 1/5 to 4/5. Fragments involved 20 to 45% of the dorsopalmar articular surface of the distal phalanx. Eight of 14 horses had a successful outcome. Outcome was not associated with age, duration or severity of lameness, or fragment size., Conclusions and Clinical Relevance: Despite involvement of a large portion of the articular surface and use of arthrotomy, joint instability and permanent soft tissue injury was not a problem in most horses. Outcome may be improved by selection of horses with lameness of < 2 years' duration and careful management after surgery. A fair prognosis may be anticipated for removal of large fragments of the extensor process via arthrotomy.

Objective: To report the history, clinical findings, and outcome of horses with idiopathic focal eosinophilic enteritis associated with acute small intestinal obstruction., Study Design: Retrospective study., Animals: Six horses with idiopathic focal eosinophilic enteritis., Methods: Retrospective review of medical records of horses with idiopathic focal eosinophilic enteritis, with acute abdominal pain and small intestinal obstruction, associated with a focal region of eosinophilic enteritis of unknown cause. Information retrieved from the medical records included signalment, physical examination, laboratory findings, surgical procedure, histologic diagnosis, and postoperative management. Outcome was determined by telephone communication with owners., Results: Six horses met the selection criteria. Horses had persistent pain, distended small intestine, and nasogastric reflux. Idiopathic focal eosinophilic enteritis lesions associated with a small intestinal obstruction were treated surgically by intestinal resection and anastomosis or wedge resection. There were no observed complications associated with extension of the disease from the lesion site. Five horses were alive at follow-up 5 to 60 months after surgery., Conclusions: Although the cause of these focal eosinophilic enteritis lesions is unknown, the long-term outcome after lesion resection was favorable., Clinical Relevance: Small intestinal obstruction associated with a focal eosinophilic enteritis lesion may be a cause of acute abdominal pain in horses. Horses apparently have a good prognosis after lesion resection.

Objective: To determine relative amounts of mRNA expression of aggrecan, type-II collagen, matrix metalloproteinase (MMP) 1, and MMP3 in articular cartilage and synovial membrane samples from healthy equine joints and joints with osteoarthritis (OA) and to compare results of Northern blot hybridization with results of a reverse transcriptase-polymerase chain reaction (RT-PCR) assay., Sample Population: Articular cartilage samples from 8 pairs of joints (1 with OA and 1 healthy) from 6 horses and synovial membrane samples from 6 pairs of joints from 5 horses., Procedure: RNA was extracted from samples by use of a modified Trizol procedure. Northern blot hybridization and the RT-PCR assay were performed; results were quantitated by use of glyceraldehyde 3-phosphate dehydrogenase as an internal standard., Results: Articular cartilage samples from joints with mild or moderate OA yielded less total RNA than samples from joints with severe OA. Northern blot hybridization indicated that type-II collagen mRNA expression in articular cartilage samples from joints with OA was significantly greater than expression in samples from healthy joints. The RT-PCR assay identified low levels of MMP3 mRNA expression in 4 of 8 sets of articular cartilage samples and 4 of 6 sets of synovial membrane samples, whereas Northern blot hybridization identified MMP3 mRNA expression in only 1 of 6 sets of articular cartilage samples and 1 of 6 sets of synovial membrane samples., Conclusions: A RT-PCR assay is more sensitive than Northern blot hybridization for detection of MMP3 mRNA expression in articular cartilage and synovial membrane and requires smaller samples.

In this article, sources of error that are likely involved when alternative medical traditions are assessed from the standpoint of orthodox biomedicine are discussed. These sources include (1) biomedicine's implicit reductive materialism (manifested in its negative orientation toward placebo effects), (2) a related bias against ritual, and (3) cultural barriers to the construction of externally valid protocols. To overcome these biases, investigators must attend to ritualistic elements in alternative treatments and should recruit patients from appropriate cultural groups. Collaborative research may be the key. Benefits of collaborative research include (1) increased mutual respect and integration between culturally distinct groups and practices, (2) increased understanding and use of sophisticated techniques of empirical analysis among practitioners from the alternative traditions, (3) increased appropriation of the therapeutic benefits of ritual, and (4) enhanced overall benefit for patients of all cultural backgrounds.

Objective: The purpose of this study was to compare bone healing induced by equine demineralized bone matrix (DBM) to autogenous cancellous bone graft (ACB) or no graft (control) in a rib-defect model in horses., Study Design: The osteogenic properties of ACB and DBM were evaluated in bilateral 19-mm circular defects created in the outer cortex of the 6th and 8th ribs of each horse., Animals or Sample Population: Eight mature horses., Methods: Three rib defects in each horse were randomly treated with each of the 3 treatment groups, and the fourth rib defect received a random treatment. Rib sections, including the defects, were harvested 56 days after implantation and examined for bone mineral density, percent ash and calcium and graded for signs of radiographic and histological healing., Results: All ribs were fractured at the defect site and were classified as nonunion fractures 56 days after implantation. There were no significant differences among groups in bone mineral density and signs of radiographic or histological healing. There was an increased volume of bone in control and ACB-treated sites compared with DBM-treated sites. Rib defects treated with ACB were significantly higher in percent ash and calcium than those treated with DBM. DBM elicited no inflammatory reaction, and remodeling occurred around the periphery and within vascular channels of the decalcified particles., Conclusion: DBM particles remodel from the periphery, which may explain the significantly lower percent ash, calcium, and bone when compared with ACB, because 2- to 4-microL pieces of DBM may act as space-occupying masses until completely mineralized. There was no evidence of enhanced healing associated with the use of DBM in this model., Clinical Relevance: Particles of 2 to 4 mm DBM should not be used as an aid to fracture repair because particles of this size interfere with normal mineralization. However, our model of nonunion fracture healing may be useful in future studies.

Objective: To determine response of interleukin-1alpha (IL-1alpha)-conditioned equine articular cartilage explants to insulin-like growth factor-1 (IGF-1). Sample Population-Cartilage from the trochlea and condyles of the femur of a clinically normal 4-year-old horse., Procedure: Effects of IGF-1 (0 to 500 ng/ml) after addition of IL-1alpha were evaluated by assessing matrix responses, using a sulfated glycosaminoglycan (GAG) assay, matrix 35SO4 GAG incorporation, and release of GAG. Mitogenic response was assessed by 3H-thymidine incorporation into DNA and fluorometric assay of total DNA concentration., Results: Human recombinant IL-1alpha (40 ng/ml) increased the amount of labeled GAG released and decreased labeled and total GAG remaining in explants, and IL-1alpha decreased mitogenic response. Addition of IGF-1 counteracted effects seen with IL-1alpha alone. In general, IGF-1 decreased total and labeled GAG released into the medium, compared with IL-1alpha-treated explants (positive-control sample). Values for these variables did not differ significantly from those for negative-control explants. A significant increase in total and newly synthesized GAG in the explants at termination of the experiment was observed with 500 ng of IGF-1/ml. Labeled GAG remaining in explants was greater with treatment at 50 ng of IGF-1/ml, compared with treatment with IL-1alpha alone. Concentrations of 200 ng of IGF-1/ml abolished actions of IL-1alpha and restored DNA synthesis to values similar to those of negative-control explants., Conclusions and Clinical Relevance: IGF-1 at 500 ng/ml was best at overcoming detrimental effects associated with IL-1alpha in in vitro explants. These beneficial effects may be useful in horses with osteoarthritis.

Purpose: To assess, in a multi-institutional setting, the impact on relapse, survival, and toxicity of adding two cycles of intravenous methotrexate to cranial irradiation for immunocompetent patients with primary CNS lymphoma., Patients and Methods: Forty-six patients with a median age of 58 years and Eastern Cooperative Oncology Group performance status 0 to 3 were entered onto this phase II study. The protocol consisted of methotrexate 1 g/m(2) on days 1 and 8 followed by cranial irradiation on day 15. A whole-brain dose of 45 Gy was followed by a boost of 5.4 Gy. Intrathecal chemotherapy and spinal irradiation were given only to patients for whom cytologic examination of CSF was positive for CNS lymphoma. The median follow-up time was 36 months, with a minimum potential follow-up of 12 months., Results: Median survival was 33 months, with 2-year probability of survival 62% +/- 15% (95% confidence interval). Twenty patients have relapsed. The predominant site of relapse was the brain. Neither performance status nor age was found to influence survival. Six patients developed a dementing illness at a median of 16 months after treatment, and three of these died as a consequence., Conclusion: A brief course of intravenous methotrexate before cranial irradiation is associated with 2-year and median survival rates superior to those reported for radiotherapy alone and similar to more intensive combined-modality regimens. Neurotoxicity remains an important competing risk for these patients.

Objective: To evaluate the effect of arthroscopic subchondral bone microfracture on healing of large chondral defects in horses., Study Design: Short- (4 months) and long-term (12 months) in vivo experimental chondral defect model., Animals: 10 horses, aged 2 to 5 years., Methods: Each horse had a 1 cm2 full-thickness chondral defect created in both radial carpal bones and both medial femoral condyles. One carpus and one femoral condyle of each horse had the subchondral bone plate under the defect perforated using an orthopedic awl. All horses were exercised, five horses were evaluated after 4 months and five horses after 12 months. Gross, histologic, and histomorphometric examination of defect sites and repair tissues was performed, as was collagen typing of the repair tissue., Results: On gross observation a greater volume of repair tissue filled treated defects (74%) compared with control defects (45%). Histomorphometry confirmed more repair tissue filling treated defects, but no difference in the relative amounts of different tissue types was observed. There was an increased percentage of type II collagen in treated defects compared with control defects and evidence of earlier bone remodeling as documented by changes in porosity., Conclusions: In full-thickness chondral defects in exercised horses, treatment with subchondral bone microfracture increased the tissue volume in the defects and the percentage of type II collagen in the tissue filling the defects when compared to nontreated defects., Clinical Relevance: No negative effects of the microfracture technique were observed and some of the beneficial effects are the basis for recommending its use in patients cases with exposed subchondral bone.

Objective: To determine effects of intra-articularly administered 6alpha-methylprednisolone acetate (MPA) in exercised horses with carpal osteochondral fragmentation., Animals: 18 horses: 3 groups of 6 each., Procedure: An osteochondral (chip) fragment was created in 1 randomly chosen middle carpal joint of each horse. Polyionic fluid (PF) was injected into both middle carpal joints of horses in the control group. In horses of the MPA-control group, MPA was injected into the middle carpal joint without an osteochondral fragment; a similar volume of PF was injected into the contralateral middle carpal joint. In the MPA-treated group of horses, 100 mg of MPA was injected into the middle carpal joint containing the osteochondral fragment; a similar volume of PF was injected into the contralateral joint. Injections were administered on postsurgical days 14 and 28, and horses were exercised on a high-speed treadmill for 8 weeks, starting on postsurgical day 15., Results: Clinical improvement in degree of lameness was not associated with MPA administration. Joints that contained an osteochondral fragment and were treated with MPA had lower prostaglandin E2 concentration in synovial fluid, and lower scores for intimal hyperplasia and vascularity in synovial membrane, compared with PF-treated joints. However, articular cartilage erosion and morphologic lesions suggested possible deleterious effect of intra-articular MPA administration., Conclusions: Some beneficial effects of MPA administration on synovial fluid and synovial membrane were identified; however, the deleterious findings contrast with those associated with triamcinolone acetonide used in a similar model, but agree with other results of MPA administration in normal and abnormal joints.

Objective: To determine the outcome of horses after arthroscopic removal of abaxial fracture fragments of the proximal sesamoid bone and association of fracture grade with outcome., Design: Retrospective study., Animals: 47 horses., Procedure: Information obtained from dorsopalmar and dorsoplantar radiographic views of metacarpophalangeal and metatarsophalangeal joints was used to classify fractures as grade 1 (< 15 mm long), grade 2 (15 to 25 mm long), and grade 3 (> 25 mm long) and type 1 (abaxial) and type 2 (apical-abaxial). Outcome was determined by whether the horse returned to its intended use, raced in the same class or higher (racehorses), or performed satisfactorily (nonracehorses). Number of starts, performance index, and money earned were also used to evaluate performance of racehorses., Results: Follow-up information was obtained for 41 horses (35 racehorses, 6 nonracehorses). Twenty-five racehorses were able to return to racing (16 in the same class, 9 in a lower class). All 6 nonracehorses were able to return to performance at the same level. Horses with small fracture fragments or fractures involving the abaxial aspect of the proximal sesamoid bone only had a more favorable outcome, compared with horses with large or apical-abaxial fractures., Clinical Implications: Overall, horses with abaxial fractures of the proximal sesamoid bone have a favorable prognosis for return to racing, but only a fair prognosis for return to racing in the same class, after arthroscopic removal of fracture fragments. Successful results can be expected for nonracehorses.

practice nurses need clinical supervision to help them keep abreast of their expanding primary care role. Ali Farquharson, Gail Trotter and Sheila Nimmo report on a project that set out to provide a support model.

Background: Morphologic analysis of malignant renal tumors of childhood and adolescence has resulted in the identification of a variety of tumor types with characteristic histology and clinical behavior. The authors report a case of renal sarcoma in a 19-year-old male that differs in morphology from the various established categories of primitive renal tumors., Methods: Sections taken from the nephrectomy specimen were stained by routine methods and by immunohistochemistry for stromal and epithelial markers, and for proliferation markers. In addition, ultrastructural studies were undertaken., Results: The tumor, which the authors termed cystic embryonal sarcoma, was comprised of poorly differentiated malignant mesenchyme in a myxoid stroma. Numerous epithelial-lined cysts were present. The distribution of the cysts and proliferation kinetics of cyst-lining epithelial cells suggested that they were derived from entrapped renal tubules. The tumor showed early recurrence postoperatively and after aggressive chemotherapy. The pathologic features and clinical behavior of the tumor resemble those of 2 previously reported cases and an additional 25 cases from the files of the National Wilms' Tumor Study Pathology Center., Conclusions: The clinical and histologic features of cystic embryonal sarcoma differ from those of other renal tumors of childhood and adolescence, and the tumor appears to be a novel form of renal malignancy.

Objectives: To clone equine interleukin 1 receptor antagonist (IL-1ra) and determine its full-length cDNA sequence., Procedure: A cDNA library derived from lipopolysaccharide-stimulated equine monocytes was screened by means of plaque hybridization to radiolabeled equine IL-1ra DNA probes generated by means of the polymerase chain reaction. The cDNA nucleotide sequence for equine IL-1ra was determined by use of the dideoxy chain termination technique, analyzed by use of computer software for sequence characteristics, and compared with sequences reported for IL-1ra of other species., Results: The cDNA of equine IL-1ra was 1,614 base pairs in length with an ORF encoding a peptide of 177 amino acids with a predicted molecular mass of 20.427 kd. Similarity between the amino acid sequence of equine IL-1ra and sequences for human, murine, rat, and lapine IL-1ra was 76%. Similarity between sequence for equine IL-1ra and sequences for equine interleukin-1 alpha and equine interleukin-1 beta were 22.6 and 24.6%, respectively., Conclusion: Comparison of the sequence for equine IL-1ra with sequences for IL-1ra of other species indicated a high degree of conservation., Clinical Relevance: Results establish a basis for studying the roles of interleukin-1 in healthy and diseased joints in horses.

Objectives: To clone equine interleukin 1 alpha (IL-1 alpha) and equine interleukin 1 beta (IL-1 beta) and determine their full-length cDNA sequences., Procedures: The mRNA isolated from lipopolysaccharide-stimulated cultured equine monocytes was reverse transcribed, and a cDNA library was constructed in a lambda phage. The cDNA library was screened by means of plaque hybridization with radiolabeled human IL-1 alpha and IL-1 beta cDNA probes. The cDNA nucleotide sequences for equine IL-1 alpha and equine IL-1 beta were determined by use of the dideoxy chain termination technique. The cDNA sequences were analyzed, using computer software, for sequence characteristics and compared with sequences reported for other species., Results: The cDNA for equine IL-1 alpha was 1,728 base pairs in length with an ORF encoding a peptide of 270 amino acids with a predicted molecular mass of 30.823 kd. The cDNA for equine IL-1 beta was 1,473 base pairs in length with an ORF encoding a peptide of 268 amino acids with a predicted molecular mass of 30.342 kd. Similarity between amino acid sequence of equine IL-1 alpha and sequences for IL-1 alpha of other species ranged from 62.5 to 82.2%; similarity between amino acid sequence of equine IL-1 beta and sequences for IL-1 beta of other species ranged from 62.5 to 82.2%; similarity between amino acid sequences of equine IL-1 alpha and equine IL-1 beta was 26%., Conclusions and Clinical Relevance: Results establish a basis for studying the roles of interleukin 1 in healthy and diseased joints in horses.

Objective: Various methods have been used to quantify [35S] sulfate incorporation into proteoglycans and separate this from unincorporated [35S] sulfate. The methods currently used have not been compared for accuracy or precision, ease of completion and relative economics. This experiment evaluated and compared cetylpyridinium chloride (CPC) precipitation, potassium acetate (KAc) precipitation, rapid filtration, modified dye-binding (AB) technique to molecular weight exclusion chromatography (PD-10) as techniques to quantitate chondrocyte proteoglycan metabolism., Methods: Each of the first three techniques was compared to the PD-10 technique as a 'gold standard' based on this technique's accuracy, precision and repeatability in molecular weight exclusion utilizing sieve chromatography. Articular cartilage was harvested, cultured and labeled with [35S] sulfate in a routine manner. Seventeen samples were processed and each was analyzed by the four different methodologies. Linear regression analysis was used to predict the linear relationship of PD-10 chromatography to the other methods (CPC, KAc, and AB) in the amount of proteoglycan synthesis in a pulse chase experiment., Results: The KAc and AB methods had a significant linear relationship to the PD-10 method but the CPC did not. The AB technique was much easier than the KAc method to complete although the relative economics were similar per sample, when capital equipment costs were not considered., Conclusions: Either the KAc or AB methods compared favorably to the PD-10 method, although the AB procedure was much easier, and was more precise and more accurate. The CPC method did not compare favorably to the PD-10 method in precision or accuracy although it was easier and cost effective.

This essay examines the nature of service in medicine and the relationship between service and profit. "Customer service medicine" is identified with the interrelated views that 1) profit is or ought to be healthcare's fundamental concern and 2) the quality of medical service corresponds to the degree to which it produces a feeling of approval in patients. This position is contrasted with the more traditional "beneficence model," which holds that 1) service ought to be healthcare's fundamental concern and 2) the proper criterion of quality medical service is the alleviation, mitigation, or prevention of the human suffering that occasions illness. Five shortcomings in the customer service model are identified: 1) customer service advocates often appeal to an unsound "efficiency argument"; 2) the prioritization of profit over service will vitiate patients' legitimate trust in healthcare; 3) the prioritization of profit converts medicine from a "practice" into an "instrumental activity"; 4) the prioritization of profit countervails the values of continuity and thoroughness; and 5) the notion of service as customer satisfaction derives more from the exigencies of turning a profit than from an analysis of sick persons' needs.

To determine the effects of osteochondral fragmentation and intra-articular corticosteroid treatment on dynamics of bone remodelling and fragility, 12 horses each had a unilateral, 8 mm osteochondral fragment created in the distal aspect of one radiocarpal bone. Six of the horses were treated in the fragmented joint, and the other 6 were treated in the nonfragmented joint with 12 mg of triamcinolone acetonide (TA) 14 and 28 days after surgery. All horses were exercised on a high-speed treadmill starting 15 days, and ending 72 days after surgery. Horses treated with TA in the fragmented joints were significantly less lame than those treated in the nonfragmented joints. Third carpal bones from joints with fragments showed significantly more vascularity, single labelled surface, total labelled surface and mineralising surface in subchondral and subjacent trabecular bone. Trends were also seen towards higher vascular canal volume and osteochondral junction remodelling sites in third carpal bones from fragmented joints. No significant differences were seen in microdamage density or size between fragmented and nonfragmented joints. No significant influence of TA treatment was seen on any parameter measured. The results from this study show that osteochondral fragmentation induces significant changes in remodelling of opposing bones, and that the administration of corticosteroids into joints with fragmentation does not significantly alter bone remodelling or fragility.

Objective: To evaluate the effects of arthroscopic surgery, osteochondral fragmentation, and treatment with IV administered hyaluronate on histologic, histochemical, and biochemical measurements within the carpal joints of horses., Animals: 12 clinically normal horses, 2 to 7 years of age., Procedure: Horses had an osteochondral fragment created at the distal aspect of the radiocarpal bone of 1 randomly chosen middle carpal joint to simulate osteochondral fragmentation. Horses were treated with 40 mg of hyaluronate or saline solution (placebo) intravenously once a week for 3 consecutive weeks (days 13, 20, and 27 after surgery). Treadmill exercise proceeded 5 days per week beginning 15 days, and ending 72 days, after surgery. Clinical evaluations were performed at the beginning and end of the study. Synovial fluid samples were obtained aseptically from both middle carpal joints on days 0, 13, 20, 27, 34, and 72 after surgery, and total protein, inflammatory cell, hyaluronate, glycosaminoglycan, and prostaglandin E2 concentrations were measured in each sample. All horses were euthanatized on day 72. Synovial membrane and articular cartilage were obtained for histologic evaluation. Articular cartilage samples were also obtained aseptically for determining glycosaminoglycan content and chondrocyte synthetic rate for glycosaminoglycans., Results: Horses treated with hyaluronate intravenously had lower lameness scores (were less lame), significantly better synovial membrane histologic scores, and significantly lower concentrations of total protein and prostaglandin E2 within synovial fluid 72 days after surgery, compared with placebo-treated horses. Treatment with intravenously administered hyaluronate had no significant effects on glycosaminoglycan content, synthetic rate or morphologic scoring in articular cartilage, or other synovial fluid measurements., Conclusion: Intravenously administered hyaluronate appears to alleviate signs of lameness by interacting with synoviocytes, and by decreasing production and release of inflammatory mediators.

The objective of this study was to determine the effects of intra-articularly administered triamcinolone acetonide (TA) in exercised equine athletes with carpal osteochondral fragmentation. Eighteen horses were randomly assigned to each of 3 groups. An osteochondral chip fragment was created in one randomly chosen intercarpal joint of each horse. Both intercarpal joints in the placebo control group (CNT) horses were injected with intra-articular administration (IA) of polyionic fluid. Both joints in the TA control group (TA CNT) horses were treated with 12 mg of TA in the intercarpal joint without an osteochondral fragment, and the opposite intercarpal joint was injected with a similar volume of polyionic fluid. The TA treated group (TA TX) horses were treated with 12 mg of TA in the joint that contained the osteochondral fragment and the opposite intercarpal joint was injected with a similar volume of polyionic fluid. All horses were treated IA on days 13 and 27 after surgery and exercised on a high speed treadmill for 6 weeks starting on Day 14. Horses in the TA TX group were significantly less lame than horses in the CNT and TA CNT groups. Horses in either TA CNT or TA TX groups had lower total protein, and higher hyaluronan, and glycosaminoglycan concentrations in synovial fluid than did those in the CNT group. Synovial membrane collected from subjects in TA CNT and TA TX groups had significantly less inflammatory cell infiltration, subintimal hyperplasia and subintimal fibrosis compared to the CNT group. Articular cartilage histomorphological parameters were significantly better from the TA CNT and TA TX groups compared to the CNT group. In conclusions, results from this study support favourable effects of TA on degree of clinically detectable lameness, and on synovial fluid, synovial membrane, and articular cartilage morphological parameters, both with direct intra-articular administration and remote site administration as compared to placebo treatment. The clinical use of IA administered TA in horses may be therapeutically beneficial in selected cases of osteochondral fragmentation and osteoarthritis.

Objective: The purpose of this study was to determine whether detection of bacterial contamination of ventral midline incisions was predictive of postoperative incisional complications in horses undergoing exploratory celiotomy for colic., Study Design: Prospective study., Animal or Sample Population: Horses that had ventral median celiotomies for colic at Colorado State University between May 1, 1991 and April 30, 1993 were studied prospectively. Complete information was obtained on 66 horses., Methods: Bacterial cultures were obtained from ventral midline incisions at surgery. Information regarding the type of surgery performed (celiotomy vs celiotomy plus enterotomy or enterectomy), preoperative total nucleated cells and presence of a left shift, postoperative fever (> 38.5 degrees C), incisional drainage, incisional herniation, and outcome were obtained from medical records. Additional information concerning incisional drainage, herniation, and survival was obtained at a minimum of 18 months after surgery., Results: Examination of odds ratio (ORs) and confidence intervals (CIs) revealed that a celiotomy plus enterotomy or enterectomy was positively, but not significantly, associated (OR > 1) with positive culture results, presence of incisional drainage and incisional herniation. A significant association between incisional drainage and hernia formation was found; odds of incisional herniation were 62.5 times greater in horses that had incisional drainage. Incisional drainage and herniation were negatively associated with patient survival. The later association was significant (OR = 0.18, P = .04)., Conclusions: This study indicated that detection of bacterial contamination at incisional closure by the swab culture technique was not beneficial in the prediction of postoperative incisional problems in horses undergoing colic surgery. Incisional drainage or infection appeared to be associated with hernia formation., Clinical Relevance: Immediate treatment of incisional drainage or method to prevent incisional infections may decrease hernia formation.

Objectives: To assess the results and toxicity of a regimen of combined chemotherapy and radiotherapy for patients with non-AIDS-related primary central nervous system lymphoma., Design: Prospective assessment of patients treated with intravenous methotrexate followed by cranial irradiation between 1 January 1991 and 31 July 1995., Patients and Setting: Patients attending nine Australian and New Zealand centres who were eligible and gave informed consent., Main Outcome Measures: Probability of survival at two years, and acute toxicity., Results: Twenty-four patients were treated. Their probability of survival at two years was 70% (95% confidence interval [CI], 45%-95%). The acute toxicity of the regimen was minimal in most cases, but one patient died of treatment-related neutropenia and subsequent sepsis. Two patients showed progression of pre-existing short term memory disturbance, without evidence of recurrent lymphoma., Conclusions: Combined-modality therapy improves survival in patients with non-AIDS-related primary central nervous system lymphoma, at least in the short term, relative to radiotherapy alone. The combined regimen resulted in only moderate treatment-related morbidity. Longer follow-up is required for a more accurate estimate of late effects and long-term survival prospects.

Objective: To evaluate the effects of a commercially defined, serum-free medium additive on equine articular cartilage explants, compared with effects of serum-free and serum-supplemented media., Animals: Articular cartilage from a 3-year-old, mixed breed horse euthanatized for reasons other than musculoskeletal disease or sepsis., Procedure: Media were changed every 48 hours, and the glycosaminoglycan (GAG) content was determined in media collected at each time point. Glycosaminoglycan synthesis by explant chondrocytes, and residual GAG content of articular cartilage (as a measure of explant GAG loss) were determined at the end of the study (day 8)., Results: Articular cartilage explants in serum-free medium and the commercial supplemented medium had significantly lower GAG synthesis and GAG content than did those incubated in serum-supplemented medium. There were no significant differences in GAG synthesis and content between serum-free and commercial supplemented medium groups. When comparing medium GAG content for all treatment groups, the GAG content in serum-free medium on day 8 was significantly greater than that in commercial supplemented medium, but significant differences were not evident in percentage of release of GAG (as an indicator of GAG degradation) among all 3 treatment groups., Conclusions: Commercial supplemented medium had effects on articular cartilage matrix GAG loss into medium equal to those of serum-supplemented medium (eg, both lost articular cartilage explant GAG to a similar degree). However, residual articular cartilage GAG content was higher in serum-supplemented medium, as was GAG synthesis. Commercial supplemented medium appears to either lack the proper ingredients to maintain steady-state GAG synthesis, or lacks proper concentrations of these ingredients.

Surgical procedures completed under arthroscopic guidance have become commonplace in many equine practices and have largely replaced surgery using arthrotomy incisions. With a limited amount of equipment, numerous diagnostic and surgical procedures can be completed. Surgeons need to become familiar with regional and intraarticular (intrasynovial) anatomy to ensure that proper surgical approaches are used, access to the lesion will be realized, and potential complications will be minimized. Specialized motorized instruments and surgical lasers are now available and may be useful in the treatment of selected clinical cases.

Purpose: To review the Australasian results of Stage I and IIA Infradiaphragmatic Hodgkin's Disease (IHD) treated solely by irradiation., Methods and Materials: Eligible patients had IHD only and were treated by irradiation with curative intent over the period of 1969 to 1988. Ten radiation oncology centres from within Australia and New Zealand were surveyed for patient, tumour and treatment variables. Disease free rates, survival and complications were analysed., Results: 106 patients with IHD were studied. The average potential follow up was 9.4 years. The male to female ratio was 3.3:1. The median age was 37.5 years. Histological subgroups were as follows; lymphocyte predominant 43%, mixed cellularity 21%, lymphocyte depleted 5%, nodular sclerosing 27% and unclassifiable 4%. Fifty nine patients had laparotomy of which 22 (37%) were positive for tumour. Nine laparotomies were performed for diagnosis and the remainder for staging. One patient was up-staged by laparotomy and three were down-staged. Sixty-eight patients presented with inguinal disease alone, five with abdominal disease alone, 19 with two sites of involvement and 12 with inguinal, pelvic and abdominal disease. In two patients the site was unknown. There was no correlation between site of involvement, age, sex or histological subtype. Forty seven cases were clinically staged (CS) as follows: CS IA-23, CS IIA-24. The other 59 were pathologically staged (PS) as follows: PS IA-37, PS IB-1, PS IIA-21. Treatment consisted of involved field alone (16), inverted Y (68), inverted Y and spleen (13), para-aortic irradiation only (3), or total nodal irradiation (6). Mean dose was 37 Gy. There were 30 recurrences to give an acturial 10-year disease-free rate of 70%. In multivariate analysis lower number of tumour sites, lymphocyte predominant histology and higher dose were all significantly correlated with higher disease free rates. Eight patients died of Hodgkin's disease and 19 of other causes. The 10-year overall survival rate was 71%. Older age and higher number of disease sites were significantly correlated with shorter survival. Fourteen of 30 relapses may have been avoidable by the use of total nodal irradiation. In particular ten of 21 patients with abdominal disease relapsed in nodal sites which would have been covered by total nodal irradiation., Conclusions: The rate of control in IHD could perhaps be improved by avoiding involved field irradiation or by aggressive therapy with total nodal irradiation or combined modality chemo-irradiation in Stage II disease. Staging laparotomy does not appear to be indicated.