Circumcision-Barrie et al. rDImNA 275The attitude of the medical profession in this country against circumcision has hardened in recent years, so much so that sincere and reasonable requests by the parents are sometimes turned down, which may cause distress and result in the mother canvassing other doctors or hospitals in search of a willing surgeon. The parents' desire for their baby to be circumcised may be based on firmly held beliefs concerning hygiene, national or religious convictions, or a desire for conformity among the males of the family. Our policy in such cases is to perform the operation if the parents still request it after a frank discussion of the medical viewpoint. SummaryA technique for circumcising the newborn, using a plastic bell to protect the glans, which also acts as a guide to the amount of prepuce to be removed, is described. Case 1A 33-year-old housewife developed pleuritic pain in February 1961. A month later she felt tired and ill, with pains in the limbs, and had become pale and very dyspnoeic. On admission to a local hospital in May she was febrile and the tip of the spleen was just palpable. A moderate normochromic anaemia was present (Hb 7.1 g./100 ml.) with a small number of red-cell and white-cell precursors in the peripheral blood. The total white-cell count and platelet count were normal. All investigations, including blood urea, liverfunction tests, blood culture, and a search for L.E. cells were negative. No definite diagnosis was reached.Prednisolone, penicillin, and blood transfusions were given. She improved and was discharged home on a reduced steroid dosage. Five days later, however, she was readmitted with epistaxis, purpura, vomiting, and pain in the left arm. The haemoglobin level had fallen to 4.9 -g./100 ml. Steroid therapy was continued and she was transfused repeatedly. Four weeks later, when she was transferred to the Royal Infirmary, Manchester, there was still extensive purpura. In spite of the blood she had received the haemoglobin was still only 7.6 g./100 ml. The platelet count had fallen to 40,000/c.mm., and the leucocytes numbered 18,000/c.mm. There was still a leucoerythroblastic peripheral blood picture.All investigations remained negative. A sternal marrow specimen was unhelpful. However, a radiological skeletal survey revealed multiple osteolytic foci indicating widespread tumour involvement. She continued to receive steroids and blood transfusions ; in addition, intravenous nitrogen mustard therapy-2 x 6 mg. Trillekamin (trimustine hydrochloride)-was given. There was no response; her condition deteriorated and 14 days later she died.Pathology.-Necropsy confirmed the presence of haemorrhagic and partly necrotic tumour tissue in the upper end of the femora, humeri (with a pathological fracture through a deposit in the proximal left humerus), thoracic vertebrae, and throughout the rib cage. Tumour deposits were also present in the liver, spleen, right ovary, and right atrium. The lymph nodes were not involved.None of these tumour deposits could be conf...
Background The physician shortage in the United States (US) continues to become more apparent. We aimed to evaluate the relationship between the US physician distribution from 2012-2019 by specialty at the state/regional level relative to the corresponding population growth. Methods US matched residents and practicing physicians from 2012-2019 were extracted from the National Resident Matching Program and Association of American Medical College databases, respectively. Residents and practicing physicians were divided by geographic regions (West, Midwest, South, Northeast), states, and specialties (anesthesiology, emergency medicine, family medicine, general surgery (GS), internal medicine, obstetrics/gynecology and pediatrics). Results Entering residents and physicians increased across 7 specialties from 2012-2019 with the exception of GS, which showed .2% decrease in practicing physicians. GS experienced decreases in entering residents in all US regions except the South. All specialties showed a decrease in the people-per-physician (PPP) except GS and pediatrics, which had a 4.1% and 71.3% increase, respectively. EM showed the largest growth overall, both in entering residents and overall workforce. Conclusion GS experienced slow growth of residents, decreases in practicing physicians and workforce overall, and an increase in PPP from 2012-2019. Our findings suggest that current population growth rate is exceeding the rate of physicians entering the field of GS and highlights the need for interventions to promote the recruitment of GS residents and retainment of attending physicians, particularly for rural areas. Future research to measure surgeon distribution in relation to patient outcomes and the efficacy of recent policy to address shortages can help define additional interventions to address physician shortages moving forward.
The Care Continuum and Health Outcomes Project is part of a national initiative to build an outcomes management approach in health care. This paper examines the baseline performance of the study : In 1995-96, 7154
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