Band 95, Heft 11

Although cigarette smoking is a declining trend in the United States, the amount of cigarettes consumed by the American public is the same today as in 1964. The role of cigarette smoking in many disease processes is publicly well known, and smoking cessation has been proved to reduce risk for some diseases, but the various methods of cessation are often met with a high rate of treatment failure or relapse. In this study, the short-term efficacy of nicotine-replacement therapy by way of the transdermal patch system was evaluated in 110 patients in a family practice setting. Patches were tapered from 21 mg of nicotine to 14 mg to 7 mg, each for 30 days. Subjects wore one patch for every 24 hours and were instructed not to smoke. Telephone follow-up was used at 2 to 3 weeks to check smoking status and inquire for side effects, and further follow-up of those who had completed the 3-month program was initiated 6 months after the program began. Nineteen patients never filled the prescription, and six were lost to follow-up. Of the 85 who finished the program, 35% were still not smoking at 6 months after the study began. The other 65% had relapsed. Side effects were mild and were mainly related to skin irritation at the patch site and abnormal dreams. Combinations of this cessation method with physician counseling and other behavioral methods should improve the success rate of this encouraging treatment.

Each year, more than 1 million children and adolescents begin smoking, and an average of 24% of high school students report smoking, despite existing laws that prohibit the sale of tobacco to minors. In this study, the authors observed an 11-year-old boy attempt to purchase cigarettes at 57 retail establishments in western Pennsylvania to determine if the existing laws do, indeed, limit children's access to buy cigarettes. This study took place between August 15, 1993, and October 2, 1993. The establishments included convenience stores, gas stations, liquor distributors, and restaurants. One of the researchers entered each establishment to look for the posting of the state law prohibiting the sale of cigarettes to minors after their underage subject had requested cigarettes from the salesclerks. The researcher also inquired of the salesclerks if they were aware of the state law. In 30 of the 57 attempts (53%), the 11-year old student would have been able to purchase cigarettes. Of these attempts, 53% would have sold them on his first request, while 47% would have sold them to him if he indicated that the cigarettes were for his dad. Only 3 of the 57 establishments (5.2%) posted the law, and 54 of the 57 clerks (95%) were aware of the cigarette law.

Mter reviewing the history of antitrust legislation and established zones of safety for providers and the application of antitrust laws to the healthcare industry in two earlier installments, the authors explore the consequences of the vigorous application of antitrust laws to physician networking, with an emphasis on rural communities. They review common exemptions to antitrust laws that maintain the uneven distribution of power in the evolving healthcare market. Acknowledging the tenuous ground that providers hold in the struggle for control of the healthcare industry, the authors argue for greater consideration of the unique circumstances and barriers that tend to prohibit the formation of strong, physician-sponsored, integrated healthcare networks. The authors have tested the climate for relief from the antitrust enforcement agencies in Washington, DC, and have found no easing of antitrust legislation forthcoming. However, following the resolution of several antitrust cases in recent months, barriers to physician-led organizations appear to be lessening. The authors close with a review of several strategies to minimize the risk of antitrust challenges.

Twenty years after placement of a Mentor bladder pacemaker, a 38-year-old woman with spina bifida cystica still has controlled detrusor contraction and complete bladder emptying. The varied treatment modalities for this difficult group of patients has included electronic bladder stimulation. Although no longer commonly used, electronic bladder stimulation has shown long-term efficiency in this patient.