Client/server power attracts healthcare markets.

Client/server architecture has become the darling of I/S professionals. The intelligence is spread among several processors, creating enormous flexibility. But are C/S systems easier, cheaper and faster than the good old mainframe? Not quite yet.

Primary renal candidiasis associated with a penile prosthesis in a diabetic man.

Infectious complications of penile prostheses are unusual even in diabetic patients, and generally involve Staphylococcus or gram-negative enteric organisms. This paper presents a diabetic patient who developed fatal, primary renal candidiasis associated with an infected penile prosthesis. He is the fourth patient we have seen with refractory nausea and vomiting associated with a cryptic urinary infection. Invasive Candida should always be considered in a diabetic patient with evidence of a urinary tract infection.

Tracheal carcinoma presenting as a thyroid cyst.

A patient was seen with a thyroid cyst. Fine- and core-needle biopsies revealed no evidence of tumor. A thyroid cyst lined by malignant squamous cells was found at surgery. Invasive squamous carcinoma was found to arise in adjacent trachea. The thyroid gland was normal except for inflammatory changes. Aspiration biopsies of thyroid cysts may be misleading, especially when hemorrhagic; sclerosis should be performed with caution.

Cervical lipomas masquerading as thyroid nodules.

Masses in the thyroid gland can usually be distinguished from other anterior cervical masses by history, physical examination, and scintigraphic and ultrasonographic examination. We describe four cases of lipomas masquerading as thyroid nodules in which finding from these examinations were consistent with solid thyroid nodules. Computed tomography can distinguish fat from thyroid tissue density, thus avoiding the use of thyroid hormone suppression or the need for urgent surgery.

Algorithm-directed care by nonphysician practitioners in a pediatric population. Part II. Clinical outcomes, patient satisfaction, and costs of care.

We compared outcome and cost of care for 2234 pediatric patients with upper respiratory tract infections cared for by nonphysician practitioners and 304 similar patients cared for by pediatricians. We found no significant differences (p greater than 0.05) between nonphysician practitioners' patients and pediatricians' patients in the status of the original symptoms, the number of patients reporting new symptoms, the number of return visits, or the reasons for return visits. Approximately 93 per cent of both groups had no complaints about their care. Medication costs were higher for Pamosists than pediatricians, but lower labor costs caused Pamosist care to be 15.5 per cent ($2.64) less expensive than pediatrician care in this setting, even when the costs of Pamosist audit by computer were included. Through use of clinical algorithms with computer audit, relatively untrained nonphysician practitioners can deliver safe, cost-effective health care to pediatric patients with upper respiratory infections.

Algorithm-directed care by nonphysician practitioners in a pediatric population: Part I. Adherence to algorithm logic and reproducibility of nonphysician practitioner data-gathering behavior.

The ability of quickly trained nonphysician practitioners to care for pediatric patients with upper respiratory tract infections (URIs) was evaluated in 3802 patients. These nonphysician practitioners (Army Pamosists) used an explicit treatment protocol and computerized audit of protocol adherence. Pamosists omitted protocol-suggested plans in 3.7 per cent of cases and ordered unnecessary treatment plans in 1.7 per cent of cases. They did not obtain a suggested MD consultation in 6.2 per cent of the cases. Agreement between Pamosists and pediatricians on data and management decisions (PM-MD study) was then compared with agreement on the same variables between pairs of a group of five pediatricians who saw a separate but comparable group of 103 pediatric URI patients (MD-MD study). The Pamosists demonstrated good (77 to 89 per cent) overall agreement with pediatricians, and the amounts of agreement between Pamosists and pediatricians in the PM-MD study did not generally differ significantly (p greater than 0.05) from the agreement on the same variables between pairs of pediatricians in the MD-MD study.

A versatile closed circuit.

A versatile closed circuit with new features is described. It may be used in a totally closed manner, without continuous gas inflow. As gas is absorbed from the circuit, it is replaced through a demand valve. Facilities for continuous gas input and use of a ventilator are included, and one control converts it to a non-rebreathing circuit. The circuit has excellent mechanical characteristics in all modes, and has been used extensively in routine clinical practice.

A laboratory investigation of a multigas monitor for anaesthesia (EMMA).

A new volatile anaesthetic gas analyser (EMMA) was tested in the laboratory. It was shown to have an accurate, linear response, with minimal zero drift and to be almost unaffected by carrier gases. It is a versatile and sensitive machine with a fast response time indicating that it might be used for breath-by-breath monitoring. The EMMA is a useful new anaesthetic gas analyser than should find widespread clinical usage.