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OBJECTIVES: The number of operations performed per surgeon is thought to determine the quality of carotid endarterectomy (CEA) surgery. The advent of carotid artery stenting (CAS) threatens to reduce the volume of CEA. This paper assesses CEA and the effects of the introduction of CAS service on outcomes. DESIGN: Retrospective cohort study. METHODS: Clinical data and results of CEA were reviewed retrospectively for the treatment of carotid stenosis, between January 1988 and December 2010. CEA patients were grouped into those treated before and after the introduction of CAS to our hospital in 2001. RESULTS: 757 patients underwent a CEA between 1988 and 2010. The perioperative stroke rate prior to the introduction of CAS was 4.9%, and 3.3% after stent introduction in 2001. In this latter period, 85.5% had symptomatic stenosis which suggests that the patients were not low risk. The major adverse event rate (inclusive of death and myocardial infarction) post introduction of CAS from 2001 to 2010 was 4.1%. There was no correlation between post-operative stroke/MAE and procedure volume, despite the trend of decreasing CEA numbers over time. CONCLUSION: The introduction of carotid artery stenting has led to a decrease in carotid endarterectomy volume. However, outcomes in our high risk patient population are acceptable. Therefore, CEA remains the procedure of choice for carotid artery revascularization.

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INTRODUCTION: Stercoral perforation is a rare cause of perforation. This is the first reported case where a partial eating disorder (ED) is the primary causative differential. CASE PRESENTATION: We present the case of a 17-year-old girl who presented to her local Emergency Department with a 24-h history of left-sided abdominal pain. She subsequently deteriorated and a computed tomography scan of her abdomen showed gross distension of the large bowel with a sigmoid perforation. She underwent total colectomy with end ileostomy. Histology reported stercoral perforation but normal bowel ganglia. While an inpatient she was reviewed by the Psychiatric team who were concerned she was suffering from a partial ED. CONCLUSION: This case highlights the importance of a multidisciplinary approach in optimally treating patients such as these. Aggressive medical management with involvement of a psychiatric team and dietetics addresses any underlying causative psychiatric issues and helps prevent recurrence.

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BACKGROUND: Ischaemia-reperfusion injury (I-R injury) is a recognised and potentially fatal complication following revascularisation of an ischaemic limb. Prevention of reperfusion injury is the focus of much research, but effective drug regimens have yet to be established into clinical practice. CASE REPORT: Here we present a man with prolonged, severe lower limb ischaemia, successfully treated with a novel surgical technique for preventing I-R injury. Prior to revascularisation, the common femoral vein was cannulated and the harmful venous effluent was drained. The patient made an excellent recovery, the limb was salvaged and no systemic complications were encountered.

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BACKGROUND: The United States is considering enacting a national health plan and global health care budget similar to those in other countries. There are few data on the effects of such policies on physicians and patients. METHODS: We conducted a telephone survey of 602 physicians in the United States, 507 physicians in Canada, and 519 physicians in the former West Germany from February through May 1991; the response rates were 44 percent, 49 percent, and 41 percent, respectively. Among other topics, the questionnaire included measures of satisfaction with the health care system and with medical practice. RESULTS: In the United States, 23 percent of the physicians surveyed thought the health care system worked well, as compared with 33 percent in Canada and 48 percent in West Germany. Seventy-three percent of U.S. physicians reported that patients' inability to afford necessary treatment was a serious problem, as compared with 25 percent in Canada and 15 percent in West Germany. Seventy-seven percent of West Germany physicians, 56 percent of Canadian physicians, and 54 percent of U.S. physicians said the shortage of competent nurses was a serious problem. In Canada, 50 percent of the respondents cited the lack of well-equipped medical facilities as a problem, as compared with 14 percent in the United States and 20 percent in West Germany. CONCLUSIONS: Programs of universal coverage and cost containment necessitate important trade-offs. In Canada and West Germany, physicians do not report serious problems of access to care for the poor and uninsured. In the United States, doctors do not face the limited access to sophisticated forms of medical technology that was reported in Canada or the diminished quality of some services reported in West Germany.

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To explore the concerns of practicing physicians as a way to inform the health reform debate, the authors conducted a survey of physicians in the United States, Canada, and Germany. Survey results indicate that U.S. physicians are most likely to view affordability as the greatest barrier to access to care for their patients. However, unavailability of services and long waiting times were cited most often by Canadian physicians. German physicians did not cite access problems as frequently as Canadian physicians did; other measures of satisfaction were closer to U.S. levels, suggesting fewer trade-offs if the United States were to adopt aspects of the German health care system.

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Marketing techniques and tools, imported from the private sector, are increasingly being advocated for their potential value in crafting and disseminating effective social change strategies. This paper describes the field of social marketing as it is used to improve the health of the public. A disciplined process of strategic planning can yield promising new insights into consumer behavior and product design. But the "technology" cannot simply be transferred without some translation to reconcile differences between commercial marketing and public health.

PIP: While the administration of US President Bill Clinton is trying to reform the US health care system, less attention is being given to changing behavior. The problems caused by excessive alcohol drinking, poor diets, and the use of tobacco products and other harmful substances often tend to be more related to a country's health status than are acute, short-lived illnesses. Private sector-derived marketing techniques and tools are increasingly being used to create and disseminate effective social change strategies. The authors describe how social marketing can be used to improve public health. They draw from information obtained from major textbooks, conference proceedings, telephone interviews with more than 30 practitioners and scholars in the field, and data on the application of social marketing in maternal and child health and nutrition in developing countries, family planning in developing countries, the anti-smoking campaign in the US, cardiovascular disease risk reduction, and substance abuse prevention among adolescents. Sections consider the historical convergence of marketing and health promotion; the essential elements of a social marketing approach to health; lessons learned from applications of social marketing to health; and limitations, caveats, and issues for the future.

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Faced by a worsening economy and a powerful public mandate to decrease taxes and non-defense government expenditures, many are calling for additional cuts in spending for Medicaid-a large, not very popular program that pays for the medical care of many of the nation's poor. Available evidence suggests that Medicaid has been far more valuable than is commonly realized: It serves a broad cross-section of the American people, its adoption coincides with major improvements in the health of Americans, and its costs per recipient are about the same as the costs of care per person for all Americans of similar age. Not widely recognized is the program's importance to the financial well-being (if not the very survival) of any major teaching hospitals and the majority of nursing homes in this country. Public and professional awareness of the accomplishments of this program may be a crucial factor in determining whether the cuts will spare many of the gains in access to medical care that have been made during the past two decades. If we do not wish to reduce needed medical services to the poor, health-care institutions and health professionals will have to cooperate with each other and with the government in developing less costly ways of delivering high-quality care.

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The United States enters the 1980s beset with serious economic problems. The picture currently projected from long-term economic forecasts supplemented by national opinion polls for the early to mid-1980s suggests a downturn in our nation's economy and a sharp decrease in monies available for further growth or improvements in America's medical care system. These prospects have serious implications for many of America's most important health care institutions, their health professionals, and how plan for the future.

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There is a growing conviction that medical technologies are major contributors to escalating costs, and regulating them is generally viewed as the least contentious way to control expenses in the 1980's. Five forms of technology control are being discussed or developed. All aim to reduce costs by controlling big, expensive technologies in the class of computed tomographic (CT) scanning. We present evidence that technologies such as the CT scanner account for far less of the growth in medical expenditures than do the collective expenses of thousands of small tests and procedures. Furthermore, we suggest that each strategy for controlling large technology involves substantial practical and conceptual problems that would severely limit its effectiveness. We thus suggest a shift away from attempts to harness the big technologies, and toward incentives to encourage the more discerning use of all technologies. To this end, we propose changes in physician reimbursement and education and expanded insurance incentives to encourage physicians and hospitals to be more selective in the use of technology.

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