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To position themselves for optimal use of health information technology through goals such as electronic health records and the eventual transition to a national health information infrastructure, providers need to make better decisions regarding the use of their existing systems.

Authors summarize preliminary results from the first round of a two-round modified Delphi study called "Facing the Uncertain Future." Health care experts were asked to comment on the status of the health care industry in 1994 when the study began and their predictions for change by 1999. Major findings based on the 580 responses received include: (1) the continued movement of the U.S. health care industry from a primarily private insurance industry to one in which medical groups and hospitals will be members of integrated delivery systems/networks (IDS/N); (2) the increasing dominance of the components of IDS/Ns in 1999 (components are defined as: medical practices, system hospitals, managed care organizations and IDS/Ns); and (3) the potential effects of IDS/Ns on the health care industry, including: increases in cost effectiveness, quality of administrative management and the quality of physician leadership, as well as decreases in availability of advanced medical technology and the duplication of ancillary services, facilities and equipment. The study is being conducted jointly by the Medical Group Management Association and Texas Tech University with funding from Abbott Laboratories.

The costs of medical care and lost productivity associated with migraine headache impose an economic burden on society. Knowledge of the costs that can be attributed to migraine would provide a basis for evaluating alternative diagnosis and treatment strategies. The most widely used approaches to analyzing the cost of illness analysis are the willingness-to-pay and human capital methods. Using these as a framework, all recent published studies (from 1980 to the present) relevant to the economic cost of migraine were reviewed. The literature reviewed demonstrates that the economic burden of migraine headache is substantial. To estimate the cost of migraine to society more precisely, data are needed on incidence and prevalence among carefully selected samples representative of the underlying population. Use of medical care must be expressed as units of specific types of services rendered over known periods. Health insurance coverage, an important determinant of access to care, should also be known. Absenteeism and work losses must be linked to occupation and earnings levels.

CRAHCA serves as a broad-based research resource for the study of medical practice management. In their article, Steven S. Lazarus, Ph.D., associate executive director, and Anna M. Bergström, research director, outline many of the projects undertaken by the Center in its 20 years and some of the significant publications and findings that have resulted from them.

We studied a tumor of the oral mucosa that initially appeared as an intraepithelial carcinoma, and then progressed after one year to invasive squamous carcinoma and after eight years to basal-cell carcinoma (BCC) with admixture of basosquamous and squamous carcinomas. This tumor, which originated from basal cells, reflects the ability of these cells to produce neoplasms that range from those consisting of least-mature elements (basal cells) to mature ones (squamous cells), with intermediary types that contain both elements (basosquamous carcinoma). These transformations imply that BCCs can arise from the basal layer of skin and oral mucosa and that the terms BCC, basosquamous carcinoma, and squamous carcinoma are descriptive rather than of histogenetic significance.

An electron microscopic study was undertaken of the protein release mechanism within myeloma cells showing a very high degree of protein production. Smooth surfaced vesicles (50 millimicrons) were seen to originate from the outer margin of the perinuclear cistern. Similar vesicles were also associated with distended Golgi sacs. Possible function of these vesicles could not be determined. Coated vesicles (60 millimicrons) originated as evaginations from endoplasmic reticulum in the transitional region. They were present throughout the cytoplasm and were seen to fuse with the cell membrane discharging an electron dense material. These vesicles are, therefore, thought to transport protein from the rough endoplasmic reticulum and discharge it at the cell surface.

We report here 3 cases of adenocarcinoma of the small bowel complicating Crohn's disease ("Crohn's carcinoma"). In 2 cases, the adenocarcinoma was discovered in the first attack of enteritis. In only one other case in the literature, a similar presentation was described. A review of 59 reported cases of adenocarcinoma of small bowel in Crohn's disease, together with these 3 cases reveals that: (a) the cancer develops at a younger age than in carcinoma de novo; (b) there is no difference in incidence of carcinoma in the first, second, and third decades after the onset of symptoms of Crohn's disease; (c) in 73% of cases, the neoplasm rose in the ileum; (d) in all but 1 case it developed in inflamed segments of bowel; (e) in 31% of cases the cancer developed in a bypassed segment of bowel. This analysis clearly demonstrates that "Crohn's carcinoma" is a complication in Crohn's disease and not a chance coexistence of two diseases in the same patient.

A paratesticular tumour by light microscopy showed large amounts of partly hyalinized collagenous stroma, spindle shaped fibroblast-like cells, pleomorphic cells with foamy cytoplasm, multinucleated tumour type giant cells and lipid inclusions. By light microscopy, there was a problem as to whether the tumour should be classified with the liposarcomas or with the fibrous histiocytic group. Ultrastructurally, spindle shaped cells resembled fibroblasts and, in a few cells, intracellular collagen fibres were seen. Histochemical studies revealed the presence of mannose-rich glycoprotein which is characteristic for collagen producing cells, but frequently these cells also showed numerous lipid inclusion. The foamy cytoplasmic areas of pleomorphic cells were shown to consist of dilated ergastoplasmic sacs and large vacuoles lined by smooth endoplasmic reticulum negating the possibility that these cells were of histiocytic origin. This is supported further by the dearth of lysosomes and absence of lysozyme (muramidase) in the tumour cells. The presence of numerous lipid inclusions in many of the tumour cells, which are otherwise ultrastructurally similar to fibroblast, suggests that these cells represent precursors of lipoblasts. The above findings taken together allowed the tumour to be categorized as a sclerosing liposarcoma.

An ultrastructural and histochemical analysis was made of a lesion identified by light microscopy as a non-ossifying fibroma of bone. A histogenetic sequence was traced from spindle-shaped fibroblast-like cells to multivacuolated lipoblasts with abundant glycogen. These lipid-laden cells showed remarkable similarity to some cells of a well differentiated liposarcoma. Others have interpreted the lipid-containing cells of non-ossifying fibroma as representing fibroblasts which have imbibed or synthesized lipid or lipid-laden macrophages. Our studies demonstrate that this tumour consists of primitive mesenchymal cells with partial maturation to early lipoblasts, suggesting its classification as a benign lipoblastoma of bone.

A solitary tumor which by light microscopy was calssified as a neurofibroma was found by electron microscopic study to be composed of parallel, elongate cells with collagen rich intervening matrix. The cells showed thin, polar cytoplasmic processes which extended long distances, frequent junctional complexes between cell processes, numerous surface vesicles, and either no or fragmented and variable basement membrane. Perineurial cells from small peripheral nerves of skin were demonstrated to have similar morphologic characteristics as the tumor cells. The present study, together with previous ultrastructural findings, indicate that benign peripheral nerve sheath tumors should be placed in at least three categories: Schwannoma, neurofibroma and perineurioma.

The ambulance service is an important component in the emergency medical system of a community. The availability of performance information on several aspects of the ambulance system may improve ambulance management. The location of new ambulance stations, selection of the destination hospital for urgent cases, scheduling of crew changes, and evaluation of crew performance can be approached through an examination of existing data. Management use of such an information system by the Victorian Civil Ambulance Service in Melbourne, Australia is included in the discussion.

Since rehabilitation services are generally not available on a local basis to rural communities, a rural service delivery approach, the Coordinated Ambulatory Rehabilitation Evaluation Services (CARES) Project, was established. The program demonstrated a local rural rehabilitation capability based on primary care physicians, a local hospital, and nonphysician rehabilitation providers working cooperatively with a rehabilitation specialty hospital 640km away. Service delivery profiles of the hospital and local teams were compared for pediatric and adult clinics. The project was successfully implemented with 281 patients seen in their local areas.