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The plaintiffs, physicians and women seeking abortions, challenged licensing regulations imposed by the state of Illinois on abortion clinics. The Court found the following requirements to place unconstitutional burdens on a woman's right to obtain an abortion: 1) that separate licenses be obtained for facilities devoted primarily to performing first trimester abortions; 2) that a physician who was to perform an abortion also perform a pregnancy test, even if such a test had already been performed by another physician; 3) that persons undergoing abortions be given counseling which includes a discussion of alternatives, a description of procedures, and an explanation of risks and possible complications; 4) that physicians providing preabortion counseling not be involved financially in the woman's decision; 5) that facilities performing abortions comply with the physical plant and staffing provisions of the Illinois Ambulatory Surgery Treatment Center Act; and 6) "certificate of need" proceeding requirements of the Health Facilities Planning Act. In 1988, other US Courts reached the following decisions with respect to the licensing of abortion clinics: 1) a building inspector had violated the right of privacy of women to obtain abortions by classing an outpatient abortion clinic as a hospital, thereby forcing it to obtain a special-use permit to operate in the zone where it was to be sited (P.L.S. Partners, Women's Medical Center of Rhode Island, Inc. vs. City of Cranston, US District Court, D. Rhode Island, 28 June 1988 [696 F.Supp. 788]) and 2) a physician who is prevented from operating an abortion clinic by unconstitutional zoning ordinances can bring a personal civil rights action under federal law for monetary damages, and those who enacted the ordinances are not absolutely immune from liability if the purpose of the ordinances was to single out an individual and treat that individual differently from others (Haskell vs. Washington Township, United States Court of Appeals, Sixth Circuit, 20 December 1988 [864 F.2d 1266]).
The conviction of two former Roger Williams Medical Center executives in Rhode Island is sure to keep up the heat for more vigorous oversight of hospitals. Robert Urciuoli and Frances Driscoll were both convicted of fraud. "It's not to say that directors should be running these organizations," says attorney Patrick Coffey, left. "But it is their function to hire qualified people (who) won't ever tarnish the reputation of their institution".
BACKGROUND: The availability of sensitive assays for plasma HIV viral load and the trend toward earlier and more aggressive treatment of HIV infection has led to the inappropriate use of these assays as primary tools for the diagnosis of acute HIV infection. OBJECTIVE: To describe limitations in the use of plasma viral load testing for the diagnosis of HIV infection. DESIGN: Case series. SETTING: Academic medical centers in Providence, Rhode Island, and Worcester, Massachusetts. PATIENTS: Three persons in whom HIV infection was falsely diagnosed by plasma viral load testing. MEASUREMENTS: Laboratory measures and clinical outcomes. RESULTS: Two cases of false-positive results obtained by using branched-chain DNA plasma viral load assays and one case of a false-positive result obtained by using reverse transcriptase-polymerase chain reaction plasma viral load assay are reported. All three plasma viral load tests yielded positive results with low values (1254 copies/mL, 1574 copies/mL, and 1300 copies/mL). Infection with HIV was initially diagnosed in all three patients, but each patient subsequently tested negative by HIV-1 enzyme-linked immunosorbent assay and repeated plasma viral load testing. CONCLUSION: Physicians should exercise caution when using plasma viral load assays to detect primary HIV infection, particularly when the pretest probability of infection is low.
Methicillin-resistant Staphylococcus aureus (MRSA) has been an endemic nosocomial pathogen at the VA medical center (VAMC) in Providence, Rhode Island since 1981. From 1985 to 1987, more than 30% of all unique S aureus isolates were methicillin resistant. To evaluate the frequency of acquisition of MRSA isolates by healthcare workers, we compared the antimicrobial susceptibility patterns, multilocus enzyme genotypes and plasmid profiles of isolates recovered from nasal and hand cultures from VAMC nurses and house staff on rotation at the VAMC with those of clinical isolates from patients at the VAMC and four other affiliated hospitals. Fifty-six percent of ward nurses cultured (n = 112) were colonized with S aureus, of which 65% was methicillin resistant. Six isolates of MRSA were identified on the initial culturing of house staff (n = 65); 16 MRSA isolates were recovered at the end of a four-week rotation (p less than .02). Phenotypic and genotypic analyses demonstrated that numerous distinct MRSA strains were recovered in the study period. The incidence of MRSA among clinical isolates at the VAMC and affiliated institutions was remarkably constant throughout the three-year study period. Moreover, despite regularly sharing resident physicians, interns and medical students, MRSA isolates were commonly recovered at the other university-affiliated hospitals. Our study failed to reveal evidence of significant interhospital transmission of MRSA isolates by healthcare workers. While healthcare workers may contribute to the dissemination of MRSA within institutions, they appear to be less important in spreading MRSA between institutions.
Ovarian cancer is the leading cause of death from gynecologic maligancy among women in the United States. In 1997, there were nearly 27,000 ovarian cancer cases with over 14,000 deaths. Recent attempts at early detection of ovarian cancer have been aimed at the identification of biomarkers that would indicate an underlining malignant process or reflect the biological behavior of the tumor. Our previous studies revealed that chromosome 8 copy number abnormality, especially trisomy, is common in several cancers. Archival tissues from 24 cases of papillary serous ovarian carcinoma (10 stage I and 14 stage III) were analyzed by fluorescence in situ hybridization (FISH) with a chromosome 8-specific alpha-satellite probe (Oncor, Gaithersburg, MD). The analysis was done according to standard protocols of the Lifespan Academic Medical Center Cytogenetics Laboratory at Rhode Island Hospital. Twenty-one of 24 cases (87.5%) were found to be trisomic for chromosome 8, if a cutoff point of >/=15% cells with three signals is adopted. Overall, 80% of stage I and 93% of stage III tumors had trisomy 8. This study confirms the presence of a high frequency of trisomy 8 in both early and late stages of the disease and suggests that trisomy 8 may be an early event in the multistep process leading to ovarian cancer. It is of interest to note that a higher frequency of trisomy 8 was found in a higher stage of disease, consistent with our previous results on breast cancer. Thus, additional FISH studies of ovarian tumors for chromosome 8 copy number assessment may be warranted.
Seasonal presentation of skin cancers has been previously described, but the seasonal presentation of keratoacanthomas is less well documented. Pathology reports and dermatology clinic visits were examined from the Roger Williams Medical Center, the major dermatopathology service in Rhode Island, U.S.A., from 1990 to 1992. Seasonal presentation was defined as the ratio of keratoacanthomas during the summer months (June-September) to the number diagnosed during the winter months (December-March). A peak incidence of keratoacanthomas was noted in the summer and early autumn months. The summer/winter ratio (1-38) was statistically significant (P = 0.002). The summer/winter ratio of office visits was smaller at 1.12, but also significant (P < 0.001). There appears to be a seasonal presentation of keratoacanthoma in southern New England. This suggests that ultraviolet radiation has an acute effect on the development of keratoacanthoma.
Adolescence is a developmental stage characterized by excessive risk-taking behavior that produces adverse health effects, typically in the form of injury. At issue is whether adolescent suicide attempters and injured adolescent motor vehicle drivers constitute a common risk group and are differentiated by the response of the emergency medical care system and by case disposition. Data originated in the medical records of a Rhode Island (USA) trauma center. The two study groups were not distinguished by religious preference, socioeconomic status or timing of the injury incident, but differed significantly by gender, race, emergency vehicle use, hospital admission rates, and seasonal injury patterns. Alcohol and drug involvement was examined, but serious data deficiencies were noted.
OBJECTIVE: To establish a model based on risk factor analysis to guide selective axillary lymph node dissection in patients with T1a and T1b breast cancers. DESIGN: Retrospective review to determine histopathologic features and patient demographic profiles that may influence the incidence of nodal metastases. SETTING: Primary care and referral centers in Rhode Island and Massachusetts. PATIENTS: Women with invasive breast cancers with nodal status reported to the statewide tumor registry, the Hospital Association of Rhode Island, and the tumor registry at Baystate Medical Center, Springfield, Mass, between January 1984 and December 1995. There were 12030 patients with breast cancer reported; 2185 (18%) of these had tumors 1 cm or less in diameter. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Axillary node metastases. RESULTS: The nodal status of 377 patients with T1a tumors and 1808 patients with T1b tumors was studied. Seventy-five percent had axillary dissections, and 16% were found to have nodal metastases. Thirty-one percent (29/93) of patients younger than 40 years had positive nodes compared with 15% (241/1546) of older patients (P = .001). The T1a tumors had fewer metastases than the T1b tumors did (11% vs 17%; P = .02). Nuclear grade was available in 49% of cases. Nuclear grades 2 and 3 were associated with nodal involvement twice as often as grade 1 tumors were (P = .002). Patients with no poor prognostic factors had a 7% or less chance of nodal involvement, while patients with all 3 poor prognostic indicators had a 33.5% chance of nodal involvement. CONCLUSIONS: Selective nodal dissection may be possible through risk factor analysis. Prospective registration of complete histopathologic information will allow more comprehensive analysis and may further enhance the selective treatment of patients with minimally invasive breast cancer.
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BACKGROUND: Routine axillary dissection in patients with invasive small breast cancer remains controversial. We previously reported a model for predicting nodal involvement in patients with T1a or T1b breast cancer that may guide the practice of selective nodal dissection. The objective of this study was to determine whether the prognosticators that predict nodal metastases also predict survival. STUDY DESIGN: This study is a retrospective review of 2,153 women with small invasive breast cancer (< or = 1 cm) diagnosed between January 1984 and December 1995. Cases were identified from a statewide tumor registry, the Hospital Association of Rhode Island, and the tumor registry at Baystate Medical Center in Massachusetts. The impact on survival of patient age (< or = 40 versus > 40 years), nodal status (positive versus negative), tumor size (T1a versus T1b), and tumor grade (1 versus 2 or 3) were analyzed. Breast cancer-specific survival (BCSS) was analyzed using the Kaplan-Meier method and the proportional hazards regression method. RESULTS: There were 388 patients with tumors 0.5 cm or less (T1a) and 1,765 with tumors 0.6-1.0 cm (T1b). Nodal status was known in 68% of cases (1,461 of 2,153), and tumor grade was recorded in 42% of cases (902 of 2,153). In univariate analysis, age, grade, and nodal status were significant in their association with BCSS. Tumor size did not influence BCSS among patients with small invasive tumors. Women older than 40 years had superior survival compared with younger women (93% versus 78% at 5 years; p = 0.01). Similarly, women with low grade (1) tumors did better than those with higher grade (2 or 3) tumors (98% versus 88% at 5 years; p = 0.03). The 5-year BCSS was 96% versus 78% for node-negative versus node-positive disease, and the 10-year BCSS was 91% versus 62% (p = 0.001). In the multivariate analysis, age and nodal status remained firmly associated with survival, although grade lost its significance. CONCLUSIONS: Small tumor size does not affect survival. Although risk profiles for nodal involvement can be constructed to help guide the practice of selective axillary lymphadenectomy in patients with small invasive breast cancers, these factors cannot serve as a surrogate to nodal status in establishing patient prognosis. Nodal status remains the most powerful determinant of survival in breast cancer patients, even those with very small tumors.
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