Thursday, July 24, 2014

From McGill U: The ethical framing of personalized medicine

Curr Opin Allergy Clin Immunol. 2014 Jul 21. [Epub ahead of print]

The ethical framing of personalized medicine.

Author information

  • 1Centre of Genomics and Policy, McGill University, Montreal, Canada.



Personalized medicine encompasses the use of biological information such as genomics to provide tailored interventions for patients. The review explores the ethical, legal, and social issues that have emerged with personalized medicine and must be considered because of the complex nature of providing individualized care within a clinical setting.


Recent studies found that the use of personalized medicine presents challenges in multiple areas: biobanking and informed consent, confidentiality, genetic discrimination, return of results, access to treatment, clinical translation, direct-to-consumer genetic testing, emerging duties, and knowledge mobilization.


Although personalized medicine provides benefits in treating patients in a manner that is more suited to their genetic profile, there are challenges that must be discussed to ensure the protection and fair treatment of individuals. The issues concerning personalized medicine are widespread, and range from individual privacy to the stratification and discrimination of sub-populations based on ethnicity. These issues have considerable impact on the individual and society. A thorough exploration of these ethical issues may identify novel challenges as well as potential avenues for resolution.

Tuesday, July 22, 2014

Antibiotic resistance: A geo-political issue

 2014 Jul 10. doi: 10.1111/1469-0691.12767. [Epub ahead of print]

Antibiotic resistance: A geo-political issue.

Author information

  • 1World Alliance Against Antimicrobial Resistance (WAAAR).


Antibiotic resistance, associated with a lack of new antibiotics, is a major threat. Some countries have been able to contain resistance, but in most countries the numbers of antibiotic resistant bacteria continue to rise as well as antibiotic consumption in humans and animals. Antibiotic resistance is a global issue and concern all decision makers worldwide. Some actions have been undertaken in the last 15 years, in particular by the World Health Organisation (WHO), the European Centre for Diseases Prevention and Control (ECDC) and the Centre for Diseases Control and Prevention (CDC), but those actions were partial and poorly implemented, without coordination. Very recently, some important activitieshave been carried out by the WHO. Since 2009, a task force between the USA and Europe, the Trans-Atlantic Task Force on Antibiotic Resistance (TATFAR), has been working on common recommendations. At a national level some important actions were implemented, in particular in European countries and in the USA. The Chennai declaration, in India, is also a good example of a multidisciplinary and national action, which was highly political. Finally several non-governmental non-profit organisations are also very active, and have helped raising awareness on the problem of antibiotic resistance. In the future, this global issue will need political involvement and strong cooperation between countries and between international agencies.

Valuing vaccines using value of statistical life measures

 2014 Jul 18. pii: S0264-410X(14)00929-3. doi: 10.1016/j.vaccine.2014.07.003. [Epub ahead of print]

Valuing vaccines using value of statistical life measures.

Author information

  • 1Center for Disease Dynamics, Economics & Policy, 1616 P Street NW, Suite 430, Washington, DC 20036, USA; Princeton University, M43 Guyot Hall, Room 132, Princeton, NJ 08544, USA. Electronic address:
  • 2University of Washington, Department of Global Health, Ninth and Jefferson Building, 13th Floor, 908 Jefferson Street, Box 359931, Seattle, WA 98104, USA. Electronic address:
  • 3Resources for the Future, 1616 P Street NW, Suite 600, Washington, DC 20036, USA. Electronic address:
  • 4University of Bergen, Department of Medical Ethics, Department of Global Public Health and Primary Care, Kalfarveien 31, 5018 Bergen, Norway. Electronic address:


Vaccines are effective tools to improve human health, but resources to pursue all vaccine-related investments are lacking. Benefit-cost and cost-effectiveness analysis are the two major methodological approaches used to assess the impact, efficiency, and distributional consequences of disease interventions, including those related to vaccinations. Childhood vaccinations can have important non-health consequences for productivity and economic well-being through multiple channels, including school attendance, physical growth, and cognitive ability. Benefit-cost analysis would capture such non-health benefits; cost-effectiveness analysis does not. Standard cost-effectiveness analysis may grossly underestimate the benefits of vaccines. A specific willingness-to-pay measure is based on the notion of the value of a statistical life (VSL), derived from trade-offs people are willing to make between fatality risk and wealth. Such methods have been used widely in the environmental and health literature to capture the broader economic benefits of improving health, but reservations remain about their acceptability. These reservations remain mainly because the methods may reflect ability to pay, and hence be discriminatory against the poor. However, willingness-to-pay methods can be made sensitive to income distribution by using appropriate income-sensitive distributional weights. Here, we describe the pros and cons of these methods and how they compare against standard cost-effectiveness analysis using pure health metrics, such as quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs), in the context of vaccine priorities. We conclude that if appropriately used, willingness-to-pay methods will not discriminate against the poor, and they can capture important non-health benefits such as financial risk protection, productivity gains, and economic wellbeing.

Changing the Conversation About Brain Death

 2014 Aug;14(8):9-14.

Changing the Conversation About Brain Death.

Author information

  • 1a Boston Children's Hospital and Harvard Medical School.


We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between "legally dead" and "legally blind" demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.

The ethics of clinical trials for cancer therapy

 2014 July-August;75(4):270-273.

The ethics of clinical trials for cancer therapy.

Author information

  • 1Division of Medical Oncology, Duke Cancer Institute; Duke Clinical Research Institute, Durham, North Carolina, USA.
  • 2Duke Cancer Institute, Durham, North Carolina, USA.


Cancer clinical trials are intended to evaluate novel interventions and to improve outcomes. Such research depends on the participation of patients seeking the best options for care. The design, conduct, and analysis of trials must therefore be grounded in an ethical framework that respects and protects the interests of clinical trial participants.

Monday, July 21, 2014

From U Montreal: Cultural Competence: A Constructivist Definition

 2014 Jul 17. pii: 1043659614541294. [Epub ahead of print]

Cultural Competence: A Constructivist Definition.

Author information

  • 1University of Montreal, Montreal, Quebec, Canada
  • 2University of Montreal, Montreal, Quebec, Canada.


In nursing education, most of the current teaching practices perpetuate an essentialist perspective of culture and make it imperative to refresh the concept of cultural competence in nursing. The purpose of this article is to propose a constructivist definition of cultural competence that stems from the conclusions of an extensive critical review of the literature on the concepts of culture, cultural competence, and cultural safety among nurses and other health professionals. The proposed constructivist definition is situated in the unitary-transformative paradigm in nursing as defined by Newman and colleagues. It makes the connection between the field of competency-based education and the nursing discipline. Cultural competence in a constructivist paradigm that is oriented toward critical, reflective practice can help us develop knowledge about the role of nurses in reducing health inequalities and lead to a comprehensive ethical reflection about the social mandate of health care professionals.

Friday, July 18, 2014

Impact of San Francisco's Toy Ordinance on Restaurants and Children's Food Purchases, 2011-2012

Prev Chronic Dis. 2014 Jul 17;11:E122. doi: 10.5888/pcd11.140026.

Impact of San Francisco's Toy Ordinance on Restaurants and Children's Food Purchases, 2011-2012.

Author information

  • 1University of Washington School of Public Health, Nutritional Sciences Program, Box 353410, Seattle, WA 98115. E-mail:
  • 2University of Washington and Seattle Children's Research Institute, Seattle, Washington.
  • 3Stanford University School of Medicine, Stanford, California.
  • 4School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona.
  • 5University of Tennessee Health Science Center, Memphis, Tennessee.



In 2011, San Francisco passed the first citywide ordinance to improve the nutritional standards of children's meals sold at restaurants by preventing the giving away of free toys or other incentives with meals unless nutritional criteria were met. This study examined the impact of the Healthy Food Incentives Ordinance at ordinance-affected restaurants on restaurant response (eg, toy-distribution practices, change in children's menus), and the energy and nutrient content of all orders and children's-meal-only orders purchased for children aged 0 through 12 years.


Restaurant responses were examined from January 2010 through March 2012. Parent-caregiver/child dyads (n = 762) who were restaurant customers were surveyed at 2 points before and 1 seasonally matched point after ordinance enactment at Chain A and B restaurants (n = 30) in 2011 and 2012.


Both restaurant chains responded to the ordinance by selling toys separately from children's meals, but neither changed their menus to meet ordinance-specified nutrition criteria. Among children for whom children's meals were purchased, significant decreases in kilocalories, sodium, and fat per order were likely due to changes in children's side dishes and beverages at Chain A.


Although the changes at Chain A did not appear to be directly in response to the ordinance, the transition to a more healthful beverage and default side dish was consistent with the intent of the ordinance. Study results underscore the importance of policy wording, support the concept that more healthful defaults may be a powerful approach for improving dietary intake, and suggest that public policies may contribute to positive restaurant changes.

From Andy Churg and colleagues: Respiratory Bronchiolitis With Fibrosis–Interstitial Lung Disease: A New Form of Smoking-Induced Interstitial Lung Disease

Andrew ChurgMDRebecca HallMDAnaMaria BilawichMD
From the Departments of Pathology (Dr Churg) and Radiology (Drs Hall and Bilawich), Vancouver General Hospital, Vancouver, British Columbia, Canada.
The recent pathology literature has described a new form of localized interstitial fibrosis associated with heavy cigarette smoking. This lesion has been referred to by various names, including respiratory bronchiolitis–interstitial lung disease with fibrosis,1 airspace enlargement with fibrosis,2 and smoking-related interstitial fibrosis.3 We have suggested that, to avoid confusion with other forms of smoking-related interstitial lung disease (ILD), the lesion be referred to as respiratory bronchiolitis with fibrosis (RBF).4 Most importantly, we have found that this pathologic abnormality often has a distinctive high-resolution computed tomography (HRCT) correlate, such that in many cases RBF should be diagnosable on the basis of imaging.4 The purpose of this short piece is to suggest how RBF fits into the general category of smoking-related ILD, and particularly to compare it with two possibly related forms of accepted smoking-related ILDs: respiratory bronchiolitis–interstitial lung disease (RBILD) and desquamative interstitial pneumonia (DIP).

Treatment strategies for idiopathic interstitial pneumonias

 2014 Jul 16. [Epub ahead of print]

Treatment strategies for idiopathic interstitial pneumonias.

Author information

  • 1Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom.



With recent changes in diagnostic algorithms in idiopathic pulmonary fibrosis (IPF) guidelines and treatment advances in IPF, it is now necessary to reappraise the way in which clinicians should formulate treatment strategies in the idiopathic interstitial pneumonias.


The idiopathic interstitial pneumonias can usefully be subdivided into the following categories: first, definite IPF, second, probable IPF with major differential diagnoses of fibrotic nonspecific interstitial pneumonia and chronic hypersensitivity pneumonitis and third, apparently idiopathic interstitial pneumonias other than IPF. In definite IPF, the therapeutic landscape has irrevocably changed with the identification of robust treatment effects with pirfenidone and nintedanib, consisting of the prevention of approximately 50% of disease progression (as judged by serial forced vital capacity trends). In probable IPF, generally equating with high resolution computed tomography findings of 'possible usual interstitial pneumonia' and the nonperformance of a diagnostic surgical biopsy, management is based on multidisciplinary evaluation, integrating all available information, with a final 'working diagnosis' made for treatment purposes. In other idiopathic interstitial pneumonias and their major differentials, removal of potential triggers and immunomodulation remain the cornerstones of therapy, with treatment goals usefully designated using a disease behaviour classification. In mild disease, an initial policy of observation is often appropriate.


The striking recent treatment effects reported in IPF will have major management implications in the idiopathic interstitial pneumonia in general, whenever IPF is in the differential diagnosis.

Preventing Childhood Obesity: What Are We Doing Right?

 2014 Jul 17:e1-e5. [Epub ahead of print]

Preventing Childhood Obesity: What Are We Doing Right?

Author information

  • 1At the time of this work, Thomas A. Farley and Deborah Dowell were with the New York City Department of Health and Mental Hygiene, New York, NY.


After decades of increases, the prevalence of childhood obesity has declined in the past decade in New York City, as measured in children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and public school students, with the greatest reductions occurring in the youngest children. Possible explanations were changes in demographics; WIC, day care, and school food policies; citywide obesity prevention policies, media messages; and family and community food consumption. Although the decreases cannot be attributed to any one cause, the most plausible explanation is changes in food consumption at home, prompted by media messages and reinforced by school and child care center policy changes. Continued media messages and policy changes are needed to sustain these improvements and extend them to other age groups. 

Potential Effects of California's New Vaccine Exemption Law on the Prevalence and Clustering of Exemptions

 2014 Jul 17:e1-e4. [Epub ahead of print]

Potential Effects of California's New Vaccine Exemption Law on the Prevalence and Clustering of Exemptions.

Author information

  • 1Malia Jones is with the Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles. Alison Buttenheim is with the School of Nursing and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia.


Exemptions from childhood immunizations required for school entry have continued to increase among California kindergartners, and exemptions show spatial clustering within the state. A 2014 change in California's school-entry vaccine exemption law requires parents filing for an exemption to submit signed documents from a health care provider. However, the evidence presented here suggests that the policy change will probably not be sufficient to reverse the growing trend in vaccine refusals. 

Pathologizing Suffering and the Pursuit of a Peaceful Death

 2014 Jul 17:1-14. [Epub ahead of print]

Pathologizing Suffering and the Pursuit of a Peaceful Death.


The specialty of psychiatry has a long-standing, virtually monolithic view that a desire to die, even a desire for a hastened death among the terminally ill, is a manifestation of mental illness. Recently, psychiatry has made significant inroads into hospice and palliative care, and in doing so brings with it the conviction that dying patients who seek to end their suffering by asserting control over the time and manner of their inevitable death should be provided with psychotherapeutic measures rather than having their expressed wishes respected as though their desire for an earlier death were the rational choice of someone with decisional capacity. This article reviews and critiques this approach from the perspective of recent clinical data indicating that patients who secure and utilize a lethal prescription are generally exercising an autonomous choice unencumbered by clinical depression or other forms of incapacitating mental illness.

Dignity and the Ownership and Use of Body Parts

 2014 Jul 17:1-14. [Epub ahead of print]

Dignity and the Ownership and Use of Body Parts.


Property-based models of the ownership of body parts are common. They are inadequate. They fail to deal satisfactorily with many important problems, and even when they do work, they rely on ideas that have to be derived from deeper, usually unacknowledged principles. This article proposes that the parent principle is always human dignity, and that one will get more satisfactory answers if one interrogates the older, wiser parent instead of the younger, callow offspring. But human dignity has a credibility problem. It is often seen as hopelessly amorphous or incurably theological. These accusations are often just. But a more thorough exegesis exculpates dignity and gives it its proper place at the fountainhead of bioethics. Dignity is objective human thriving. Thriving considerations can and should be applied to dead people as well as live ones. To use dignity properly, the unit of bioethical analysis needs to be the whole transaction rather than (for instance) the doctor-patient relationship. The dignity interests of all the stakeholders are assessed in a sort of utilitarianism. Its use in relation to body part ownership is demonstrated. Article 8(1) of the European Convention of Human Rights endorses and mandates this approach.

Why Physicians Should Not Be Involved in Hostile Interrogations

 2014 Jul 17:1-9. [Epub ahead of print]

Why Physicians Should Not Be Involved in Hostile Interrogations.


The purpose of this article is to provide a moral foundation for Heilig's argument (published in the same issue) that physician participation in torture is a violation of medical ethics. The argument needs a moral foundation because it is unconventional by the standards of academic biomedical ethics. There is little about the "principles of bioethics", the nature of medicine, the physician-patient relationship, the physician's "social role," or the like. Instead, Heilig rests his argument primarily on the AMA's Code of Ethics (and international equivalents)-what most bioethicists tend to treat as mere custom, etiquette, law, or statements of opinion (when they do not ignore it altogether). This article explains why the AMA Code of Ethics can set the standard for ethical conduct for physicians-given a certain understanding of "ethics" and "profession" largely absent from biomedical ethics but common in professional ethics generally. The article also responds to six likely objections.

The Ethical Imperative to Think about Thinking

 2014 Jul 17:1-11. [Epub ahead of print]

The Ethical Imperative to Think about Thinking.


While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty.

Wednesday, July 16, 2014

West African Ebola: "This outbreak is unprecedented for many reasons..."

Assistant Professor of Africana Studies Donna Patterson Emphasizes Global Nature of Public Health

The ongoing West African Ebola epidemic is officially the most deadly on record, and the number of infected persons is steadily rising. Donna Patterson, assistant professor of Africana studies, writes and teaches about Africa and global health issues and has been traveling to the region most affected by the outbreak for almost 20 years. She reflects on why we should be paying close attention to the outbreak. 

She writes:
This outbreak is unprecedented for many reasons: the speed and sustained pattern of infection, its existence in some high-density settings, and its emergence in the West African subregion. It arrived without any forewarning and within a matter of two weeks 80 cases were confirmed. By late May, it seemed as if the epidemic would subside like previous cases but in June, cases and deaths spiked and the disease began to take hold in new areas.

 - See more at:

Nicotine reduction as an increase in the unit price of cigarettes: A behavioral economics approach

 2014 Jul 12. pii: S0091-7435(14)00246-1. doi: 10.1016/j.ypmed.2014.07.005. [Epub ahead of print]

Nicotine reduction as an increase in the unit price of cigarettes: A behavioral economics approach.

Author information

  • 1Department of Psychology, University of Pittsburgh. Electronic address:
  • 2Department of Psychology, University of Pittsburgh; Department of Neuroscience, University of Pittsburgh.
  • 3Department of Psychiatry, University of Minnesota.
  • 4Department of Psychology, University of Pittsburgh. Electronic address:


Urgent action is needed to reduce the harm caused by smoking. Product standards that reduce the addictiveness of cigarettes are now possible both in the U.S. and in countries party to the Framework Convention on Tobacco Control. Specifically, standards that required substantially reduced nicotine content in cigarettes could enable cessation in smokers and prevent future smoking among current non-smokers. Behavioral economics uses principles from the field of microeconomics to characterize how consumption of a reinforcer changes as a function of the unit price of that reinforcer (unit price=cost / reinforcer magnitude). A nicotine reduction policy might be considered an increase in the unit price of nicotine because smokers are paying more per unit of nicotine. This perspective allows principles from behavioral economics to be applied to nicotine reduction research questions, including how nicotine consumption, smoking behavior, use of other tobacco products, and use of other drugs of abuse are likely to be affected. This paper reviews the utility of this approach and evaluates the notion that a reduction in nicotine content is equivalent to a reduction in the reinforcement value of smoking-an assumption made by the unit price approach.

CAP Archives: Alterations in the Expression of p53, KLF4, and p21 in Neuroendocrine Lung Tumors

José Manuel Naranjo GómezMD, PhD; Jose Fernando Val BernalMD, PhD; Pilar García ArranzMD; Servando LazuénFernándezMD; Jose Javier Gómez RomanMD, PhD
From the Departments of Thoracic Surgery (Dr Naranjo Gómez) and Pathology (Drs Val Bernal, García Arranz, Lazuén Fernández, and Gómez Roman), Hospital Universitario Marqués de Valdecilla, Santander, Spain.
Context.—Neuroendocrine lung neoplasms are a heterogeneous group of tumors with different clinical behavior and prognosis.
Objectives.—To evaluate the expression of p53, KLF4, and p21 in neuroendocrine lung neoplasms and to analyze the influence that expression has on the prognosis of those tumors.
Design.—All neuroendocrine lung neoplasms (N = 109) resected in our institution were reviewed, with the collection of histologic slides and paraffin blocks of 47 typical carcinoids (43%), 9 atypical carcinoids (8%), 35 large cell neuroendocrine carcinomas (32%), and 18 small cell lung carcinomas (17%), as well as 10 tumorlets (100%). Four tissue microarrays were performed. Follow-up was assessed in all cases (119 of 119; 100%).
Results.—p53 protein immunostaining results were negative in both the tumorlets and typical carcinoids and were overexpressed in 11% (1 of 9) of the atypical carcinoids and in 68% (36 of 53) of the carcinomas. KLF4 results were positive in all tumorlets (10 of 10; 100%), 32% (15 of 47) of the typical carcinoids, 44% (4 of 9) of the atypical carcinoids, and 62% (33 of 53) of the carcinomas. p21 expression did not differ among the groups. The lack of KLF4 and p21 expression was associated with an accumulation of aggressive features in typical carcinoids (P = .04 and P = .004, respectively, Fisher exact test).
Conclusions.—p53, KLF4, and p21 showed altered expression patterns in pulmonary neuroendocrine neoplasms. Lack of KLF4 and p21 expression was associated with accumulation of aggressive features in typical carcinoids.

CAP Archives: Significance of Proximal Margin Involvement in Low-Grade Appendiceal Mucinous Neoplasms

Thomas ArnasonMDMichal KamionekMDMichelle YangMDRhonda K. YantissMDJoseph MisdrajiMD
Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston (Drs Arnason, Kamionek, and Misdraji)
Division of Anatomical Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada (Dr Arnason)
Department of Pathology, University of Massachusetts Memorial Medical Center, Worcester (Dr Yang); and
Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York (Dr Yantiss). Dr Kamionek is now located at the Carolinas Pathology Group, Carolinas Medical Center, Charlotte, North Carolina.
Context.— Appendiceal adenomas and low-grade appendiceal mucinous neoplasms (LAMNs) confined to the appendix are cured by appendectomy. However, involvement of the proximal margin raises concern for residual disease. Some patients with a positive margin at appendectomy undergo cecal resection to eliminate a perceived risk for tumor recurrence or dissemination, although that likelihood is assumed rather than demonstrated.
Objective.— To determine whether involvement of the proximal appendiceal resection margin by adenoma or LAMN is a risk factor for local development of recurrence or pseudomyxoma peritonei.
Design.— Appendiceal adenomas and LAMNs confined to the appendix were considered for the study if they showed neoplasia or dissecting mucin at the proximal margin. The presence or absence of residual tumor in cecal resections was determined. Follow-up data were obtained from clinical records.
Results.— 16 patients (14 female, 2 male) with LAMN (n = 15) or adenoma (n = 1) and an involved proximal resection margin were identified, including 9 with neoplastic epithelium within the lumen and 7 with acellular mucin in the appendiceal wall at the margin. Six patients underwent cecal resection and the others were nonsurgically followed. No cecal resection had residual neoplasia. No patient developed recurrence or pseudomyxoma peritonei (mean follow-up, 4.7 years).
Conclusions.— In patients with LAMNs confined to the appendix, involvement of the appendectomy margin by neoplastic epithelium or acellular mucin does not predict recurrence of disease, even without further surgery. A conservative approach to managing these patients can be justified.

Tuesday, July 15, 2014

Clinical presentation of sarcoidosis and diagnostic work-up

Semin Respir Crit Care Med. 2014 Jun;35(3):336-51. doi: 10.1055/s-0034-1381229. Epub 2014 Jul 9.

Clinical presentation of sarcoidosis and diagnostic work-up.

Author information

  • 1Pneumology Department, Avicenne Universitary Hospital, Bobigny, France.
  • 2Histology and Cytology Department, Tenon Universitary Hospital, Paris, France.
  • 3Pathology Department, Avicenne Universitary Hospital, Bobigny, France.
  • 4Université Paris 13, Sorbonne Paris Cité, EA 2363, Hypoxie et poumon, Bobigny, France.
  • 5Nuclear Medicine Department, Avicenne Universitary Hospital, Bobigny, France.


Sarcoidosis is a systemic disease of unknown cause characterized by the formation of immune granulomas which most often involve the lung and the lymphatic system. Sarcoidosis may encompass numerous different clinical presentations. Typical presentations often prompt a rapid diagnosis while in 25 to 50% of cases, diverse and less typical presentations may lead to delayed diagnosis. The mediastinopulmonary sphere is involved in 85 to 95% of cases, associated with extrapulmonary localizations in half of cases while extrapulmonary localizations without lung involvement may be seen in 5 to 15% of cases. Bilateral hilar lymphadenopathy is the most typical sign at chest radiography. Computed tomography (CT) is essential face for atypical manifestations of the disease to avoid confusion with differential diagnoses and, sometimes, comorbidities. CT typically evidences diffuse pulmonary perilymphatic micronodules, with a perilobular and fissural distribution and upper and posterior predominance, even when an atypical CT pattern is predominant. CT allows deciphering pulmonary lesions in cases of pulmonary fibrosis, pulmonary hypertension, and airflow limitation. Pulmonary function tests generally correlate with the overall disease process. Forced vital capacity is the simplest and most accurate parameter to reflect the impact of pulmonary sarcoidosis. Cardiopulmonary exercise testing helps in understanding the mechanism behind dyspnea of uncertainorigin. Endoscopic transbronchial needle aspiration is an extra tool to support diagnosis in addition to more classical biopsy means. Bronchoalveolar lavage (BAL) may be used for individual patients while it is not really decisive for the diagnosis of sarcoidosis for most patients. Diagnosis relies on compatible clinical and radiological presentation, evidence of noncaseating granulomas and exclusion of other diseases with a similar presentation or histology. The probability of diagnosis at presentation is variable from case to case and may often be reinforced with time. Some investigations are mandatory at diagnosis to assess organ involvement and disease activity. However, there are important variations in diagnostic work-up due to diverse expressions of sarcoidosis and differences in clinical practices among physicians.

From Wake Forest: Use of St. John's Wort in Potentially Dangerous Combinations

 2014 Jul;20(7):578-9. doi: 10.1089/acm.2013.0216. Epub 2014 Jun 23.

Use of St. John's Wort in Potentially Dangerous Combinations.

Author information

  • 11 Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine , Winston-Salem, NC.


Objectives: The objective of this study was to assess how often St. John's wort (SJW) is prescribed with medications that may interact dangerously with it. 
Design: The study design was a retrospective analysis of nationally representative data from the National Ambulatory Medical Care Survey. Settings: The study setting was U.S. nonfederal outpatient physician offices. Subjects: Those prescribed SJW between 1993 and 2010 were the subjects. Outcome Measures: The outcome measures were medications co-prescribed with SJW. 
Results: Twenty-eight percent (28%) of SJW visits involved a drug that has potentially dangerous interaction with SJW. These included selective serotonin reuptake inhibitors, benzodiazepines, warfarin, statins, verapamil, digoxin, and oral contraceptives. 
Conclusions: SJW is frequently used in potentially dangerous combinations. Physicians should be aware of these common interactions and warn patients appropriately.