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Objective To assess the effects of aromatase inhibitors in women symptomatic of pain with endometriosis.Design A systematic review of published literature.Material and methods We conducted a comprehensive literature search to identify all the published observational and randomised studies evaluating the efficacy of aromatase inhibitors on pain associated with endometriosis. A combination of keywords was used to identify the maximum number of relevant citations in MEDLINE, EMBASE, CINAHL and the Cochrane Database.Outcome Pain relief, lesion size and quality of life.Results There were eight studies (137 women) evaluating outcomes of aromatase inhibitors. In case series/reports (seven studies, 40 women), aromatase inhibitors combined with progestogens or oral contraceptive pill or gonadotrophinreleasing hormone (GnRH) analogues reduced mean pain scores and lesion size and improved quality of life. An RCT (97 women) demonstrated that aromatase inhibitors in combination with GnRH analogues significantly improved pain (P < 0.0001) compared with GnRH analogues alone together with significant improvement in multidimensional patient scores (P < 0.0001). There was no significant reduction in spine or hip-bone densities.Conclusion Aromatase inhibitors appear to have a promising effect on pain associated with endometriosis, but the strength of this inference is limited due to a dearth of the evidence available.

Media report that hospitals are closing their emergency departments (EDs) and reducing access to ED services, raising concerns that EDs are not sustainable under competition and managed care. We analyzed financial, economic, capacity, and utilization data for California EDs for 1990-2001. We found that contrary to media reports, hospitals are not abandoning the ED market. Rather, our results show a robust market, where hospitals are adding ED capacity to meet increased demand and to maintain access. Supporting economic analyses show that EDs are sustainable since they generate a sizable and growing portion of inpatient admissions, which contribute to overall economic viability.E m e r g e n c y d e pa r t m e n t s (EDs) play a critical role in the emergency medical system and the overall health care delivery system. More than 100 million visits are made to EDs each year in the United States, and more than ten million patients enter the inpatient care system through EDs. 1 Under the current U.S. approach to organization and financing, EDs are part of a largely voluntary, informal system. Hospitals decide individually whether to include an ED in their service mix and further decide how large their EDs will be.The academic literature and the media have covered access to and availability of ED services with increasing frequency. 2 There has been growing concern by some policymakers, interest groups, and the media that a voluntary ED system is not sustainable within the existing competitive, managed care-based method of payment for health care in the United States. 3 They argue that EDs are underfunded and cause hospitals to lose money and that financial pressures are forcing hospitals to close their EDs to maintain their organizational financial viability. In sum, it is argued that access to hospital emergency services is threatened. Despite the importance of the economic issues surrounding ED service availability and the degree of attention they have received in the media, there is little in the published literature to inform this debate. This paper represents an attempt to fill that gap. Study MethodsTo provide an empirical basis for understanding the economic behavior and underpinnings of the ED market, we conducted an economic analysis of EDs in California during 1990-2001. Our primary methods involved construction and analysis of a detailed hospi-H e a l t h T r a c k i n g W 4 -1 3 6 2 4 M a r c h 2 0 0 4

In response to a perceived crisis in California's emergency department (ED) capacity, Glenn Melnick and colleagues sought to construct an empirical database that could bring objective data to bear on this important issue. In this response they address some of the substantive issues raised by the authors of four preceding commentaries. These issues include the use of aggregates and averages, the omission of trauma centers, staffing shortages, and overcrowding. In their view, the paper has added reliable new information to better understand the underlying economics faced by community hospitals with EDs and how they have responded over the past decade.