Tuesday, February 15, 2011

From Dana-Farber and Brigham and Women's: pulmonary embolism in cancer patients


Cancer. 2011 Feb 11. doi: 10.1002/cncr.25941. [Epub ahead of print]
Incidence of pulmonary embolism in oncologic outpatients at a tertiary cancer center.
Shinagare AB, Guo M, Hatabu H, Krajewski KM, Andriole K, Van den Abbeele AD, Dipiro PJ, Nishino M.

Department of Imaging, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
BACKGROUND: Incidence of pulmonary embolism (PE) for different cancer types in oncology outpatients is unknown. The purposes of the current study is to determine the incidence of PE in oncology outpatients and to investigate whether the incidence for PE is higher in certain cancers.

METHODS: A cohort of oncology outpatients who had imaging studies at Dana-Farber Cancer Institute, a tertiary outpatient cancer institute, from January 2004 through December 2009 was identified using research patient data registry. Radiology reports were reviewed to identify patients who developed PE. Incidences of PE in the total population and in each of 16 predefined cancer groups were calculated. Risk of PE for each cancer was compared using Fisher exact test.

RESULTS: A total of 13,783 patients was identified, of which 395 (2.87%; 95% confidence interval [CI], 2.59-3.16) developed PE. The incidence of PE was highest in the central nervous system ([CNS] 12.90%; 95% CI, 8.45-18.59), hepatobiliary (6.85%; 95% CI, 3.33-12.24), pancreatic (5.81%; 95% CI, 3.59-8.84), and upper gastrointestinal (5.81%; 95% CI, 3.96-8.20) malignancies. The risk of PE was significantly higher for CNS (P < .0001; odds ratio [OR], 5.28), pancreatic (P = .0027; OR, 2.15), upper gastrointestinal (P = .0002; OR, 2.18), and lung/pleural malignancies (P = .0028; OR, 1.45). There was significantly lower risk of PE for hematologic (incidence, 1.16%; 95% CI, 0.79-1.64; P < .0001; OR, 0.35) and breast malignancies (incidence, 1.50%; 95% CI, 1.02-2.11; P < .0001; OR, 0.47).

CONCLUSIONS: The incidence of PE in oncology outpatients in a tertiary cancer center during a 6-year period was 2.87%. CNS, pancreatic, upper gastrointestinal, and lung/pleural malignancies had a significantly higher risk for PE than other malignancies, whereas hematologic and breast malignancies had a significantly lower risk.

Cystic fibrosis: CFTR potentiators as possible therapy


Expert Opin Investig Drugs. 2011 Feb 9. [Epub ahead of print]
Cystic fibrosis transmembrane regulator potentiators as promising cystic fibrosis therapies.
Sabina Antonela A.

University of Medicine and Pharmacy ?Gr.T.Popa? Iasi, Pulmonary Disease University Hospital, Department of Internal Medicine II-Pulmonary Disease, 30 Dr I Cihac Str, 700115 Iasi, Romania +40 232 239408 ; +40 232 270918 ; sabina.antonela.antoniu@pneum.umfiasi.ro.
Introduction: Several types of mutations in the cystic fibrosis transmembrane regulator (CFTR) gene lead to abnormal CFTR protein and alterations of chloride and sodium transmembrane transportation in cystic fibrosis (CF). Some investigational compounds such as VX-770 can improve CFTR protein function. Areas covered: This paper discusses the results of a Phase II study investigating the safety and efficacy of VX-770 in patients with CF. Expert opinion: VX-770 is able to improve chloride and sodium transportation and has a good safety profile. Although such compounds have limited therapeutic targeting potential, preliminary results show great promise in the context of CF therapy.

Benefits of a Pseudomonas eradiacation protocol for Cystic Fibrosis patients


J Cyst Fibros. 2011 Feb 8. [Epub ahead of print]
Economic effects of an eradication protocol for first appearance of Pseudomonas aeruginosa in cystic fibrosis patients: 1995 vs. 2009.
Lillquist YP, Cho E, Davidson AG.

Cystic Fibrosis Clinic, BC Children's Hospital, Vancouver, BC, Canada.
BACKGROUND: Acquisition of Pseudomonas aeruginosa (Psa) and infection with mucoid strains is associated with repeated pulmonary exacerbations which often require intravenous and long-term nebulised antibiotic treatments, repeated hospitalizations and leads to a more precipitous decline in lung function. Anti-Psa antibiotic therapy early in the course of Psa infection in patients with cystic fibrosis (CF) may result in eradication of Psa and prevention or delay of colonization with the organism. From January 1995 to December 2009 our paediatric CF clinic has followed an early eradication protocol for the first appearance of Psa. In this paper we report on the economic effects after 15 years as reflected in hospitalization and antibiotic usage and cost.

METHODS: The Psa-eradication protocol includes 2 weeks of IV piperacillin and tobramycin, followed by oral ciprofloxacin for 3 weeks, and nebulised colistimethate for 6 months. The same protocol is used for newly diagnosed CF patients who grow Psa on their first visit or who grow a mucoid strain, multiresistant strain of Psa or whose Psa co-cultured with Burkholderia cepacia complex, and for patients in whom Psa recurs after initial clearance.

RESULTS: 195 Psa eradication courses were completed from 1995 to 2009 with an overall Psa clearance rate of 90%. Patients that only cultured a Psa classic (non-mucoid) strain had a clearance rate was 96.5%. The percentage of children chronically infected with Psa has declined from 44% in 1994 to 15% in 2009.Total days spent in hospital for all reasons declined by 43%; chronic Psa hospital days declined by 75%; IV and nebulised anti-Psa antibiotic costs reduced by 44%.

CONCLUSIONS: Results indicate that application of a Pseudomonas eradication protocol as described in this report has economic and resource utilization benefits in addition to clinical benefits.

Legal protections for health care providers during disasters and emergencies


J Clin Ethics. 2010 Winter;21(4):358-67.
Legal briefing: Crisis standards of care and legal protections during disasters and emergencies.
Pope TM, Palazzo MF.

Health Law Institute, Widener University School of Law, Wilmington, Deleware, USA. tmpope@widener.edu
This article outlines current safe harbors in the law for healthcare practitioners who work in a disaster setting. It reviews available legal protection in crisis situations with respect to the Emergency Medical Treatment and Labor Act (EMTALA), criminal liability, and licensure.

Med mal, punitive damages, and split recovery


Behav Sci Law. 2011 Feb 8. doi: 10.1002/bsl.968. [Epub ahead of print]
A comparison of students' and jury panelists' decision-making in split recovery cases.
Fox P, Wingrove T, Pfeifer C.

Appalachian State University, Department of Psychology, P.O. Box 32109, 222 Joyce Lawrence Ln., Boone, NC 28608, U.S.A.. foxpa@appstate.edu.

This study was designed to assess jury decision-making for 289 participants reading a medical malpractice vignette as a function of participant type (undergraduate students or jury panelists), punitive damage award apportionment (none, half, or all to the plaintiff), and compensation previously assigned to the plaintiff (low, medium, or high). We found several sample differences. Overall, jury panelists awarded more money for punitive damages. Jury panelists were also more affected by compensatory-relevant information when making punitive decisions, including assigning punitive damages and rating the fairness of the traditional apportionment scheme, where the plaintiff receives all of the money. Compared with students, more jury panelists were in favor of the plaintiff receiving the entire punitive award. Most students endorsed split recovery. The authors suggest that psycholegal research conducted solely with student samples, rather than community members, may misestimate the likely behavior of actual juries. The implications of the study for split recovery policy are also discussed.

Med mal jurors and extra-legal factors


Behav Sci Law. 2011 Feb 8. doi: 10.1002/bsl.969. [Epub ahead of print]
How reason for surgery and patient weight affect verdicts and perceptions in medical malpractice trials: A comparison of students and jurors.
Reichert J, Miller MK, Bornstein BH, Shelton HD.

Grant Sawyer Center for Justice Studies, Mail Stop 313, University of Nevada, Reno, Reno, NV, 89557, U.S.A.. jreichert@crda.unr.edu.
Jurors' decision-making processes are often influenced by extra-legal factors, including judgments of defendants and plaintiffs. Two studies comparing the decisions of university students with those of community jurors sought to determine if extra-legal factors such as individual differences (including identity as a student or juror participant), the reason for surgery (medically necessary vs. elective), the type of surgery (e.g., gastric bypass, nasal reconstruction) or weight of the patient influenced jurors' decisions and perceptions in medical malpractice suits, such that participants would hold negative perceptions of overweight patients or patients who undergo elective surgeries. Results indicate that students and jurors differ in perceptions of the patient's injury and perceptions of risk, which explains some of the variance in liability verdicts. Students were more likely to find doctors liable, but also were more likely to assign responsibility to patients than were jurors. Patients who had undergone elective surgery were seen as more responsible for their situation - and their doctors were assigned less responsibility - than those who had undergone a medically necessary surgery. Tests of weight bias showed that jurors found overweight patients less responsible for their situation than patients of normal weight, but students showed the opposite pattern. Theoretical explanations are explored and implications discussed.

Health promotion by hospitals


Health Care Manage Rev. 2011 Feb 10. [Epub ahead of print]
Hospitals' health promotion services in their communities: Findings from a literature review.
Olden PC, Hoffman KE.

Peter C. Olden, PhD, MHA, is Professor of Health Administration, University of Scranton, PA. E-mail: oldenp1@scranton.edu. Keith E. Hoffman, MHA, BS, is Operations Analyst, Westchester Medical Center, Valhalla, NY.
BACKGROUND: Hospitals have long had an important role in the health of communities and the nation. Health promotion (HP) has gained attention in American health and will become more important with the 2010 health reform legislation. Many U.S. hospitals provide HP services in their communities, and hospital leaders are accountable for HP.

PURPOSES: This article uses a systematic review of research literature to answer three questions about U.S. hospitals' HP services in their communities: (a) What are the characteristics of hospitals that offer HP services? (b) What are the reasons that hospitals offer HP services? And (c) what are the implementation processes hospitals use to offer HP services?

METHODOLOGY/APPROACH: Authors used search criteria and found 255 articles published between 1985 and 2009. Inclusion/exclusion criteria were applied to screen and select articles, and 25 articles were kept and reviewed. Authors independently completed a standard data extraction form for each article, combined and reconciled their data, and created a database of findings.

FINDINGS: Hospital size was positively associated with HP, as were participation in systems, alliances, and networks. Communities' median income, existing HP, population younger than 65 years, population above poverty, and employment levels were positively related to hospitals' HP. Relationships with hospital ownership, managed care, and competition were less clear. External norms, HP diffusion, and mimetic behavior were reasons for hospitals' HP; community benefit laws were less important. To implement HP, hospitals applied management methods, shared resources, collaborated with community organizations, and used a variety of HP methods.

PRACTICE IMPLICATIONS: Collaboration and linkages with other organizations enable hospitals to expand HP. Hospitals should apply management methods (not just HP methods) to effectively offer HP services. Support for small hospitals' HP is needed.

German guidelines for surgery to treat obesity


Int J Colorectal Dis. 2011 Feb 12. [Epub ahead of print]
Evidence-based German guidelines for surgery for obesity.
Runkel N, Colombo-Benkmann M, Hüttl TP, Tigges H, Mann O, Flade-Kuthe R, Shang E, Susewind M, Wolff S, Wunder R, Wirth A, Winckler K, Weimann A, de Zwaan M, Sauerland S.

Deutsche Gesellschaft für Allgemein- und Viseralchirurgie (DGAV), Klinik für Allgemein-, Visceral- und Kinderchirurgie, Vöhrenbacherstr. 15, 78050, Villingen-Schwenningen, Germany, avc@sbk-vs.de.
BACKGROUND: The young field of obesity surgery (bariatric surgery) in Germany expands as a consequence of the rapid increase of overweight and obesity. New surgical methods, minimal access techniques, and the enormous increase of scientific studies and evidence, all contribute to the success of bariatric surgery, which is the only realistic chance of permanent weight loss and regression of secondary diseases in many cases.

METHODS: A systematic literature review, classification of evidence, graded recommendations, and interdisciplinary consensus.

RESULTS: Obesity surgery is an integral component of the multimodal treatment of obesity, which consists of multidisciplinary evaluation and preparation, conservative and surgical treatment elements, and a life-long follow-up. The guideline confirms the body mass index (BMI)-based spectrum of indications (BMI > 40 kg/m(2) or >35 kg/m(2) with secondary diseases) and extends it through elimination of all age restrictions (>18 years and <60 years) and most of the contraindications. Precondition for surgery is the failure of a structured conservative program of 6-12 months or the expected futility of it. Type II diabetes mellitus becomes an independent indication criterion for BMI < 35 kg/m(2) (metabolic surgery). The standard techniques are gastric balloon, gastric banding, gastric bypass, gastric sleeve, and biliopancreatic diversion. The choice of procedure is based on profound knowledge of results, long-term effects, complications, and patient-specific circumstances. The after-care should be structured and organized long term.

CONCLUSION: The S3-guidelines contain evidence-based recommendations for the indication, selection of procedure, technique, and follow-up. Patient care should improve after implementation of these guidelines in clinical practice. Compliance by decision makers and health insurers is warranted.

Exercise, quality of life, and lung cancer


Lung Cancer. 2011 Feb 11. [Epub ahead of print]
Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: A systematic review.
Granger CL, McDonald CF, Berney S, Chao C, Denehy L.

Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Level 1, 200 Berkeley Street, Parkville 3052, Victoria, Australia.
CONTEXT: The role of exercise intervention for patients with Non-small cell lung cancer (NSCLC) has not been systematically reviewed to date.

OBJECTIVE: To identify, evaluate and synthesize the evidence examining (1) the effect of exercise intervention on exercise capacity, health related quality of life (HRQoL), physical activity levels, cancer symptoms and mortality for patients with NSCLC; and (2) the safety and feasibility of exercise intervention for a population with NSCLC.

DATA SOURCES: A systematic review of articles using the electronic databases MEDLINE (1950-2010), CINAHL (1982-2010), EMBASE (1980-2010), TRIP (1997-2010), Science Direct (1994-2010), PubMed (1949-2010), Cochrane Library (2010), Expanded Academic ASAP (1994-2010), Meditext Informit (1995-2010), PEDRO (1999-2010) and DARE (2010). Additional studies were identified by manually cross referencing all full text reports and personal files were searched. No publication date restrictions were imposed.

STUDY SELECTION: Randomised controlled trials (RCTs), case-control studies and case series assessing exercise intervention to improve exercise capacity, HRQoL, level of daily physical activity, cancer symptoms or mortality of patients with NSCLC were included. Only articles available in English and published in a peer reviewed journal were included.

DATA EXTRACTION: A data collection form was developed by one reviewer and data extracted. Data extraction was cross checked by a second reviewer.

DATA SYNTHESIS: 16 studies on 13 unique patient groups totalling 675 patients with NSCLC met the inclusion criteria. The majority of studies were case series (n=9) and two RCTs were included. Studies exercising participants pre-operatively reported improvements in exercise capacity but no change in HRQoL immediately post exercise intervention. Studies exercising participants post-treatment (surgery, chemotherapy or radiotherapy) demonstrated improvements in exercise capacity but conflicting results with respect to the impact on HRQoL immediately post exercise intervention. Heterogeneity among studies was observed and a meta-analysis was deemed inappropriate. PRISMA guidelines were followed in reporting this systematic review.

CONCLUSION: Exercise intervention for patients with NSCLC is safe before and after cancer treatment. Interventions pre-operatively or post-cancer treatment are associated with positive benefits on exercise capacity, symptoms and some domains of HRQoL. The majority of studies are small case series therefore results should be viewed with caution until larger RCTs are completed. Further research is required to establish the effect of exercise during and after cancer treatment and in the advanced stage of disease, the optimum type of exercise training and the optimum setting for delivery.

Monday, February 14, 2011

Revised Diabetes Knowledge Scale


Diabet Med. 2011 Mar;28(3):306-10.
Modification and validation of the Revised Diabetes Knowledge Scale.
Collins GS, Mughal S, Barnett AH, Fitzgerald J, Lloyd CE.

Centre for Statistics in Medicine, University of Oxford, Oxford Birmingham Heartlands Hospital, Birmingham, UK University of Michigan, Ann Arbor, MI, USA Faculty of Health and Social Care, The Open University, Milton Keynes, UK.
Diabet. Med. 28, 306-310 (2011) ABSTRACT: Objectives  To develop a simplified true/false response format of the Revised Diabetes Knowledge Scale and assess scaling assumptions, reliability and validity of the binary response format (the Simplified Diabetes Knowledge Scale) and compare with a multiple-choice version. Methods  Ninety-nine respondents attending an outpatient clinic completed the multiple-choice version of the Revised Diabetes Knowledge Scale and the simplified version of the Revised Diabetes Knowledge Scale. The response patterns and psychometric properties of both questionnaires were assessed in order to test the construct validity of the simplified version. Results  The mean age of the respondents was 57 years (range 21-83 years) and 64% were men. Respondents attained an average score of 65% on the Simplified Diabetes Knowledge Scale, compared with 62% on the Revised Diabetes Knowledge Scale. Overall, the Simplified Diabetes Knowledge Scale appeared to be somewhat easier to complete compared with the Revised Diabetes Knowledge Scale, as indicated by the number of missing responses. Conclusions  The Simplified Diabetes Knowledge Scale provides researchers with a brief and simple diabetes knowledge questionnaire with favourable psychometric properties. The scale may require further updating to include other items relevant to diabetes education. This simplified version will now undergo translation and validation for use among minority ethnic groups resident in the UK.

Sleep disturbances in cancer patients


Support Care Cancer. 2011 Feb 11. [Epub ahead of print]
Characteristics and correlates of sleep disturbances in cancer patients.
Phillips KM, Jim HS, Donovan KA, Pinder-Schenck MC, Jacobsen PB.

Department of Health Outcomes and Behavior, Moffitt Cancer Center and Research Institute, Magnolia Drive, MRC-PSY, Tampa, FL, 33612, USA, Kristin.Phillips@Moffitt.org.
PURPOSE: Few studies of sleep disturbances in cancer patients have focused on the period before chemotherapy starts. Understanding sleep disturbances in this period is important since early intervention has the potential to reduce the severity or chronicity of these problems. The present study sought to characterize sleep disturbances in this period, examine if they could be predicted by demographic, clinical, or lifestyle factors, and identify their relationship to fatigue, depression, and physical and mental well-being.

METHODS: Patients (N = 288) with breast cancer (32%), lung cancer (32%), or other cancers (36%) about to begin chemotherapy completed self-report measures assessing demographic and lifestyle characteristics, sleep, fatigue, depression, and quality of life.

RESULTS: Twenty-six percent of patients rated their sleep quality as fairly or very bad. Poorer overall sleep was significantly predicted by less education, more medical comorbidities, previous radiotherapy, less physical activity, and current tobacco use, but these variables accounted for only 7% of the variability in sleep disturbances. After controlling for significant relationships with depression and fatigue, sleep disturbances explained significant variability in physical well-being but not mental well-being.

CONCLUSIONS: Sleep disturbances are common before the start of chemotherapy and contribute to poorer physical well-being independent of fatigue and depression. Demographic, clinical, and lifestyle variables had limited value in predicting sleep disturbances. However, depression and fatigue were highly correlated with sleep. Future research should seek to identify common etiological factors (e.g., cytokine production) and implement longitudinal designs to examine temporal relationships among these three symptoms in cancer patients.

Clinical review of asbestos-related disease


Intern Med J. 2011 Feb 10. doi: 10.1111/j.1445-5994.2011.02451.x. [Epub ahead of print]
Clinical Review: Asbestos-related Disease.
Jamrozik E, de Klerk N, Musk A.

Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia Telethon Institute for Child Health Research & Centre for Child Health Research, University of Western Australia, Perth, Western Australia School of Population Health, University of Western Australia, Perth, Western Australia.
Inhalation of airborne asbestos fibres causes several diseases. These include asbestosis, lung cancer, malignant mesothelioma as well as pleural effusion, discrete (plaques) or diffuse benign pleural fibrosis and rolled atelectasis. The lag time between exposure and the development of disease may be many decades, thus the health risks of asbestos continue to be relevant despite bans on the use of asbestos and improvements in safety regulations for those who are still exposed. Asbestos was mined and used extensively in Australia for over 100 years and Australia is now experiencing part of a worldwide epidemic of asbestos related disease. This review provides insight into the history and epidemiology of asbestos related disease in Australia and discusses relevant clinical aspects in their diagnosis and management. The past and current medico legal aspects of asbestos as well as currently evolving areas of research and future projections are summarised.

Friday, February 11, 2011

Breast cancer in Ugandan women: younger patients, more aggressive disease


Arch Pathol Lab Med. 2011 Feb;135(2):194-9.
Breast carcinoma in Uganda: microscopic study and receptor profile of 45 cases.
Roy I, Othieno E.

Abstract Context.-Histologic and receptor data on breast carcinoma in Uganda are scarce. Estrogen receptor status is not routinely available. Breast cancer blocks from Uganda were studied in Montreal, Canada, and clinical correlations subsequently discussed in Kampala, Uganda. Objective.-To correlate histologic features (tumor type, histologic grade), receptor profile (estrogen receptor, progesterone receptor, and HER2/neu), and age in Ugandan women. Design.-Pathology reports for 2000-2004 from Nsambya Hospital, reporting invasive breast carcinoma, provided 45 microscopically confirmed cases. Results.-Seventy-three percent of patients were 50 years or younger. Histologic types were invasive ductal carcinoma (78%) and "good" prognosis types (11%). Overall 40% were grade 3, but 48% of invasive ductal carcinomas were grade 3. Estrogen receptor was positive in 60% overall and in 51% of invasive ductal carcinomas. HER2/neu was overexpressed in 11%; 36% were "triple" negative (estrogen receptor, progesterone receptor, HER2/neu negative). Conclusions.-Breast carcinoma in Ugandan women presents at a younger age and is histologically and by receptor profile more aggressive than carcinoma in Caucasian women.

Telepathology in developing countries


The Future of Telepathology for the Developing World
Charles L. Hitchcock, MD, PhD
Arch Pathol Lab Med. 2011;135:211–214

Physician shortages are acute in developing countries,
where disease burden is the greatest and resources for
health care are very limited. A lack of pathologists in these
countries has lead to delays in diagnosis and misdiagnoses
that adversely affect patient care and survival. The
introduction of telepathology into countries with limited
resources for health care is but one of multiple approaches
that can be used to alleviate the problem.
Telepathology is the electronic transmission of digital
images that can be used for education and diagnostic
consultation. A basic system consists of a microscope with
a mounted digital camera linked to a computer. The ability
to produce histologic slides, to repair and maintain
equipment, and to provide training are also needed for
the successful use of this technology.
iPath is a Web-based, open platform, software application which was developed at the University of Basel,
Switzerland, for telepathology and which brings together
pathologists from around the world to provide telepathology support for diagnostic consultation and provides
education to centers with limited resources. The use of
virtual-slide technology to provide a digital image of an
entire glass slide is another technology for diagnostic
consultation and pathology education. This technology
requires more costly resources to support it, which may
limit its utility in many areas. Telepathology can generate
collections of digital images and virtual slides needed for
training indigenous pathologists in their countries to
become self-sufficient. Thus, the long-term goal of this
technology is to improve patient care and survival.

Pathology in Afghanistan


Wednesday, February 9, 2011

Are routine CT screenings after heart transplantation necessary?


Eur J Radiol. 2011 Feb 5. [Epub ahead of print]
Utility of screening computed tomography of chest, abdomen and pelvis in patients after heart transplantation.
Dasari TW, Pavlovic-Surjancev B, Dusek L, Patel N, Heroux AL.

Cardiology/Heart Failure and Heart Transplant Program, Loyola University Medical Center, Maywood, IL 60153, USA.
INTRODUCTION: Malignancy is a late cause of mortality in heart transplant recipients. It is unknown if screening computed tomography scan would lead to early detection of such malignancies or serious vascular anomalies post heart transplantation.

METHODS: This is a single center observational study of patients undergoing surveillance computed tomography of chest, abdomen and pelvis atleast 5 years after transplantation. Abnormal findings, included pulmonary nodules, lymphadenopathy and intra-thoracic and intra-abdominal masses and vascular anomalies such as abdominal aortic aneurysm. The clinical follow up of each of these major abnormal findings is summarized.

RESULTS: A total of 63 patients underwent computed tomography scan of chest, abdomen and pelvis at least 5 years after transplantation. Of these, 54 (86%) were male and 9 (14%) were female. Mean age was 52±9.2 years. Computed tomography revealed 1 lung cancer (squamous cell) only. Non specific pulmonary nodules were seen in 6 patients (9.5%). The most common incidental finding was abdominal aortic aneurysms (N=6 (9.5%)), which necessitated follow up computed tomography (N=5) or surgery (N=1). Mean time to detection of abdominal aortic aneurysms from transplantation was 14.6±4.2 years. Mean age at the time of detection of abdominal aortic aneurysms was 74.5±3.2 years.

CONCLUSION: Screening computed tomography scan in patients 5 years from transplantation revealed only one malignancy but lead to increased detection of abdominal aortic aneurysms. Thus the utility is low in terms of detection of malignancy. Based on this study we do not recommend routine computed tomography post heart transplantation.

Addition of ABT-751 to pemetrexed does not improve outcome in unselected patients with recurrent NSCLC


J Clin Oncol. 2011 Feb 7. [Epub ahead of print]
Phase I/II Study of Pemetrexed With or Without ABT-751 in Advanced or Metastatic Non-Small-Cell Lung Cancer.
Rudin CM, Mauer A, Smakal M, Juergens R, Spelda S, Wertheim M, Coates A, McKeegan E, Ansell P, Zhou X, Qian J, Pradhan R, Dowell B, Krivoshik A, Gordon G.

Johns Hopkins University, Baltimore, MD; Creticos Cancer Center; Abbott Laboratories, Chicago, IL; Oblastni Nemocnice Pribam, Pribam; Masaryk Memorial Cancer Institute, Brno, Czech Republic; and the Hematology Oncology Associates of the Treasure Coast, Port St Lucie, FL.
PURPOSE ABT-751 is an antimitotic and vascular disrupting agent with potent preclinical anticancer activity. We conducted a phase I and randomized double-blind phase II study of pemetrexed with ABT-751 or placebo in patients with recurrent advanced or metastatic non-small-cell lung cancer (NSCLC). METHODS One hundred seventy-one patients received intravenous pemetrexed 500 mg/m(2) day 1 and oral ABT-751 or placebo days 1 to 14 of 21-day cycles. The primary end point was progression-free survival (PFS). Secondary end point included overall survival (OS); pharmacokinetic and pharmacodynamic parameters were also analyzed. Results The recommended phase II dose of ABT-751 with pemetrexed is 200 mg. Fatigue, constipation, anemia, nausea, and diarrhea were the most common toxicities in both study arms. No pharmacokinetic interactions were observed. Median PFS in the ABT-751 arm was 2.3 months versus 1.9 for placebo (P = .819, log-rank) for the intention-to-treat population. However, differences in PFS (P = .112, log-rank) and OS (P = .034, log-rank; median 3.3 v 8.1 months) favoring ABT-751 were seen in the squamous NSCLC subgroup. Baseline circulating tumor cell concentrations were predictive of improved OS (P = .013). Changes from baseline of greater than 20% in plasma levels of placenta growth factor (P = .056), squamous cell carcinoma antigen (P = .03), and cytokeratin 19 fragment antigen 21-1 (P = .01) were markers best associated with improved OS. CONCLUSION Addition of ABT-751 to pemetrexed is well-tolerated, but does not improve outcome in unselected patients with recurrent NSCLC. ABT-751 may have therapeutic potential in squamous NSCLC. Exploratory cellular and molecular analyses in this study identified biomarkers that may correlate with survival.

Tuesday, February 8, 2011

More about NSAIDs and prostate cancer risk. Results in this study are "modest"


PLoS One. 2011 Jan 28;6(1):e16412.
Use of non-steroidal anti-inflammatory drugs and prostate cancer risk: a population-based nested case-control study.
Mahmud SM, Franco EL, Turner D, Platt RW, Beck P, Skarsgard D, Tonita J, Sharpe C, Aprikian AG.

Department of Oncology, McGill University, Montreal, Canada.
BACKGROUND: Despite strong laboratory evidence that non-steroidal anti-inflammatory drugs (NSAIDs) could prevent prostate cancer, epidemiological studies have so far reported conflicting results. Most studies were limited by lack of information on dosage and duration of use of the different classes of NSAIDs.

METHODS: We conducted a nested case-control study using data from Saskatchewan Prescription Drug Plan (SPDP) and Cancer Registry to examine the effects of dose and duration of use of five classes of NSAIDs on prostate cancer risk. Cases (N = 9,007) were men aged ≥40 years diagnosed with prostatic carcinoma between 1985 and 2000, and were matched to four controls on age and duration of SPDP membership. Detailed histories of exposure to prescription NSAIDs and other drugs were obtained from the SPDP.

RESULTS: Any use of propionates (e.g., ibuprofen, naproxen) was associated with a modest reduction in prostate cancer risk (Odds ratio = 0.90; 95%CI 0.84-0.95), whereas use of other NSAIDs was not. In particular, we did not observe the hypothesized inverse association with aspirin use (1.01; 0.95-1.07). There was no clear evidence of dose-response or duration-response relationships for any of the examined NSAID classes.

CONCLUSIONS: Our findings suggest modest benefits of at least some NSAIDs in reducing prostate cancer risk.

From Harvard: Social networking and attitudes toward diabetes


J Community Health. 2011 Feb 6. [Epub ahead of print]
The Influence of Social Networks on Patients' Attitudes Toward Type II Diabetes.
Mani N, Caiola E, Fortuna RJ.

Harvard Medical School, Massachusetts General Hospital and MGH Revere Health Care Center, 300 Ocean Ave, Revere, MA, 02151, USA, nmani1@partners.org.
Social networks are increasingly recognized as important determinants of many chronic diseases, yet little data exist regarding the influence of social networks on diabetes. We surveyed diabetic patients to determine how social networks affect their overall level of concern regarding diabetes and its complications. We adapted a previously published instrument and surveyed 240 diabetic patients at two primary care practices. Patients recorded the number of family and friends who had diabetes and rated their level of concern about diabetes on a scale of 0% (no concern) to 100% (extremely concerned). Our primary outcome variable was patients' level of concern (<75% or ≥75%). We developed logistic regression models to determine the effect of disease burden in patients' social networks on expressed level of concern about diabetes. We received 154 surveys (64% response rate). We found that for each additional family member with diabetes, patients expressed a greater level of concern about diabetes (AOR 1.5; 95% CI 1.2-2.0) and its potential complications (AOR 1.4; 95% CI 1.1-1.7). Similarly, patients with an increased number of friends with diabetes expressed greater concern about diabetes (AOR 1.5; 95% CI 1.2-1.9) and its complications (AOR 1.3; 95% CI 1.1-1.7). Patients with a higher prevalence of diabetes within their social networks expressed greater concern about diabetes and diabetic complications. Determining disease burden within patients' social networks may allow physicians to better understand patients' perspectives on their disease and ultimately help them achieve meaningful behavioral change.

Molecular therapies for lung cancer are here. Now is the time to seriously address their cost.


J Med Econ. 2011 Feb 2. [Epub ahead of print]
Budget impact of erlotinib for maintenance therapy in advanced non-small cell lung cancer.
Carlson JJ, Wong WB, Veenstra DL, Reyes C.

University of Washington, Pharmaceutical Outcomes Research and Policy Program, Seattle, WA, USA.
Abstract Objective: Assess the budgetary impact of adding erlotinib for maintenance therapy (MTx) in advanced non-small cell lung cancer (NSCLC) from a US health plan perspective. Methods: A budget impact model was developed to analyze the costs (drug, administration, adverse events) associated with adding erlotinib MTx to a hypothetical 500,000 member US health plan. Treatment durations and dosing were derived from randomized controlled trials, FDA labeling, and National Comprehensive Cancer Network guidelines. Treatment patterns and assumptions were based on market research data, the SEER registry, and published literature. Cost data were obtained from Centers for Medicare and Medicaid Services payment rates and a drug pricing database. Sensitivity analyses were conducted to assess uncertainty. Results: Overall health plan expenditures increased by $0.010 per member per month (PMPM). The main driver of additional cost was the erlotinib drug cost (?$66,000) with the administration ($464) and side-effect ($47) costs being relatively modest. One-way sensitivity analyses showed that the results were most sensitive to the proportion of members receiving MTx; however, the PMPM did not exceed $0.013. Conclusions: The overall budget impact to a health plan of expanding the use of erlotinib from the 2nd/3rd-line advanced NSCLC setting to include the maintenance setting was relatively small. This was primarily due to the proportion of patients who would receive erlotinib MTx, the low cost of side-effects and minimal cost of drug administration. Additional research may be warranted to estimate the relative clinical and economic impacts of erlotinib MTx versus alternative MTx treatments.

Does it matter who owns the hospital where one is treated?


J Health Care Finance. 2010 Winter;37(2):56-80.
Inpatient cancer treatment: an analysis of financial and nonfinancial performance measures by hospital-ownership type.
Newton AN, Ewer SR.

University of Oklahoma, Division of Finance, USA. anewton@ou.edu
This study uses longitudinal data of inpatient treatment from the Agency for Healthcare Research and Quality's (AHRQ's) Healthcare Cost and Utilization Project (HCUP) to examine the differences in historical trends and build future projections of charges, costs, and lengths of stay (LOS) for inpatient treatment of four of the most prevalent cancer types: breast, colon, lung, and prostate. We stratify our data by hospital ownership type and for the aforementioned four major cancer types. We use the Kruskal Wallis (nonparametric ANOVA) Test and time series models to analyze variance and build projections, respectively, for mean charges per discharge, mean costs per discharge, mean LOS per discharge, mean charges per day, and mean costs per day. We find that significant differences exist in both the mean charges per discharge and mean charges per day for breast, colon, lung, and prostate cancers and in the mean LOS per discharge for breast cancer. Additionally, we find that both mean charges and mean costs are forecast to continue increasing while mean LOS are forecast to continue decreasing over the forecast period 2008 to 2012. The methodologies we employ may be used by individual hospital systems, and by health care policy-makers, for various financial planning purposes. Future studies could examine additional financial and nonfinancial variables for these and other cancer types, test for geographic disparities, or focus on procedural-level hospital measures.

Lung cancer: age cannot be a surrogate for poor outcome


Maturitas. 2011 Feb 2. [Epub ahead of print]
Management of non-small-cell lung cancer in the older adult.
Vanderwalde A, Pal SK, Reckamp KL.

Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, 1500 East Duarte Road, Duarte, CA 91010, United States.
The treatment of older adults with non-small cell lung cancer (NSCLC) poses special challenges for the clinician. Older adults are more likely to have decreased functional reserve which might limit their ability to undergo surgery or receive chemotherapy. Additionally, age is associated with increased number of co-morbid medical conditions that could be exacerbated by treatment and could predispose to poor outcome. It is unclear how these propensities affect the efficacy and safety of therapy in older patients with NSCLC, as the elderly are an understudied population and there are limited data in older adults in most trials evaluating therapy in lung cancer. As the number of trials of older adults increases, however, it is becoming more evident that age alone cannot be used as a surrogate for poor outcome. Various studies have shown that older adults are able to benefit from surgery or chemotherapy when correct patient selection is used. Most chemotherapeutic regimens have similar efficacy in older and younger patients, and while some toxicity rates are higher in older patients, with appropriate prophylaxis and supportive care older adults are generally able to tolerate most chemotherapy regimens, even in combinations. Proper selection of candidates for aggressive therapy is important, and identification of issues that might limit ability to complete treatment or benefit from treatment is essential, and can be accomplished through the use of a comprehensive geriatric assessment. This article serves as a review of the available evidence in the evaluation, treatment, and support of the older adult with cancer.

Stats on cancer deaths globally. In developing countries, breast, lung, and cervical cancer kill many women


CA Cancer J Clin. 2011 Feb 4. [Epub ahead of print]
Global cancer statistics.
Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D.

Vice President, Surveillance Research, American Cancer Society, Atlanta, GA.
The global burden of cancer continues to increase largely because of the aging and growth of the world population alongside an increasing adoption of cancer-causing behaviors, particularly smoking, in economically developing countries. Based on the GLOBOCAN 2008 estimates, about 12.7 million cancer cases and 7.6 million cancer deaths are estimated to have occurred in 2008; of these, 56% of the cases and 64% of the deaths occurred in the economically developing world. Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death among females, accounting for 23% of the total cancer cases and 14% of the cancer deaths. Lung cancer is the leading cancer site in males, comprising 17% of the total new cancer cases and 23% of the total cancer deaths. Breast cancer is now also the leading cause of cancer death among females in economically developing countries, a shift from the previous decade during which the most common cause of cancer death was cervical cancer. Further, the mortality burden for lung cancer among females in developing countries is as high as the burden for cervical cancer, with each accounting for 11% of the total female cancer deaths. Although overall cancer incidence rates in the developing world are half those seen in the developed world in both sexes, the overall cancer mortality rates are generally similar. Cancer survival tends to be poorer in developing countries, most likely because of a combination of a late stage at diagnosis and limited access to timely and standard treatment. A substantial proportion of the worldwide burden of cancer could be prevented through the application of existing cancer control knowledge and by implementing programs for tobacco control, vaccination (for liver and cervical cancers), and early detection and treatment, as well as public health campaigns promoting physical activity and a healthier dietary intake. Clinicians, public health professionals, and policy makers can play an active role in accelerating the application of such interventions globally.

From Harvard: An update on the use of hormone therapy with menopausal patients


J Clin Endocrinol Metab. 2011 Feb;96(2):255-64.
Update in hormone therapy use in menopause.
Taylor HS, Manson JE.

Division of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02215. jmanson@rics.bwh.harvard.edu.
The original report from the Women's Health Initiative (WHI) changed our understanding of the benefits and risks of hormone therapy. Since that time, reanalysis of the WHI and additional data from other studies have further refined these concepts. Here we provide an update on recent advances in the field. Menopausal hormone therapy continues to have a clinical role in the management of vasomotor symptoms. However, our understanding of the role of hormones in cardiovascular disease and breast cancer continues to evolve. Further analyses of the effect of age and proximity to menopause at the time of initiation of therapy, duration of treatment, dose, route of administration, and the persistence of risks and benefits after stopping hormone therapy are described. In addition, recent data have emerged suggesting that there may be a link between hormone therapy and cancers of the lung and ovary. Finally, we discuss new advances in hormone therapy that will likely lead to a more favorable benefit-to-risk ratio, enabling safer effective menopausal symptom relief.

Lung cancer surgery in octogenarians: in this study, over 1/3 exhibited 5-year survival


Interact Cardiovasc Thorac Surg. 2011 Feb 5. [Epub ahead of print]
Surgical treatment of non-small cell lung cancer in octogenarians.
Fanucchi O, Ambrogi MC, Dini P, Lucchi M, Melfi F, Davini F, Mussi A.

Department of Cardiac Thoracic and Vascular Surgery, University of Pisa, Pisa, Italy.
As the European population ages, surgeons are regularly faced with octogenarians with resectable early stage non-small cell lung cancer (NSCLC). We compared our experience with those reported in the literature to comprehend the feasibility, outcomes and lessons learned regarding surgical treatment. We reviewed octogenarians who underwent lung resection for NSCLC in the past nine years in our Department. The purpose of this paper is to retrospectively analyse postoperative surgical and oncological outcomes of our series, trying to find possible correlations between mortality, morbidity, survival and preoperative oncological and functional assessment, surgical approach and extent of resection. Eighty-two patients (M/F=63/19), with a mean age 81.0 years (range 80-87 years) underwent lung resection for NSCLC: 63 lobectomies, one inferior bilobectomy, three segmentectomies, and 15 wedge resections. There were two perioperative deaths (2.4%). The overall complication rate was 30.0%, with a major complication rate of 2.5%. Actuarial cancer-related survival rates at one, three and five years were 90%, 44% and 36%, respectively, with a statistically-significant correlation with pathological stage. Octogenarians may benefit from surgical treatment of NSCLC with an acceptable morbidity and mortality rate, if an accurate preoperative selection is pursued.

From Mayo: Curing late stage colorectal cancer? It would be a remarkable achievement. This certainly requires additional studies.


Curr Oncol Rep. 2011 Feb 5. [Epub ahead of print]
Curable Metastatic Colorectal Cancer.
Eadens MJ, Grothey A.

Department of Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA, Eadens.Matthew@mayo.edu.
In the United States and Europe, colorectal cancer (CRC) is the third most common malignancy and the second leading cause of cancer-related death for men and women. In the course of their disease, many patients will present with metastasis, with the liver and lung being the most common locations. Untreated metastatic disease carries a poor prognosis. However, cure is still possible for selected patients with stage IV CRC. Surgical resection provides the best chance for cure, and chemotherapy can be a valuable adjunct when given in a (neo-)adjuvant fashion or as conversion therapy to downsize initially unresectable tumors. For unresectable metastases, alternative treatment options include radiofrequency ablation and hepatic artery infusion. Additional local therapies are being explored, including chemoembolization, radioembolization, and stereotactic body radiation therapy. Prospective randomized trials are needed to further clarify the roles of these novel treatment options in the clinician's repertoire for metastatic CRC.

Monday, February 7, 2011

From Yale: More state attorney general involvement to combat obesity--potential solution or expanding the nanny state?


Am J Public Health. 2011 Jan 13. [Epub ahead of print]
Advancing Public Health Obesity Policy Through State Attorneys General.
Pomeranz JL, Brownell KD.

Yale University.
Obesity in the United States exacts a heavy health and financial toll, requiring new approaches to address this public health crisis. State attorneys general have been underutilized in efforts to formulate and implement food and obesity policy solutions. Their authority lies at the intersection of law and public policy, creating unique opportunities unavailable to other officials and government entities. Attorneys general have a broad range of authority over matters specifically relevant to obesity and nutrition policy, including parens patriae (parent of the country) authority, protecting consumer interests, enacting and supporting rules and regulations, working together across states, engaging in consumer education, and drafting opinions and amicus briefs. Significant room exists for greater attorney general involvement in formulating and championing solutions to public health problems such as obesity.

Diabetes: MRI assessment of accelerated cognitive decline


Diabetes Metab Res Rev. 2011 Feb;27(2):195-202. doi: 10.1002/dmrr.1163.
Accelerated cognitive decline in patients with type 2 diabetes: MRI correlates and risk factors.
Reijmer YD, van den Berg E, de Bresser J, Kessels RP, Kappelle LJ, Algra A, Biessels GJ; on behalf of the Utrecht Diabetic Encephalopathy Study Group.

Department of Neurology, Rudolf Magnus Institute of Neurosciences, University Medical Center, Utrecht, The Netherlands. y.d.reijmer@umcutrecht.nl.
BACKGROUND: Type 2 diabetes mellitus is associated with an increased risk of cognitive decline and dementia. We examined brain imaging correlates and vascular and metabolic risk factors of accelerated cognitive decline in patients with type 2 diabetes.

METHODS: Cognitive functioning and brain volume as well as metabolic and vascular risk factors were assessed twice in 68 patients with no dementia with type 2 diabetes with a 4-year interval. Thirty-eight control participants served as a reference group. Volumetric measurements of the total brain, lateral ventricles and white-matter hyperintensities were performed on 1.5T magnetic resonance imaging scans. A regression-based index score was calculated on the basis of the reference group to assess changes in cognitive performance over time, adjusted for age, sex and estimated intelligence quotient. Brain volumes were compared between patients with and without accelerated cognitive decline. Logistic regression analyses were used to identify baseline risk factors for accelerated cognitive decline within the diabetes group.

RESULTS: Accelerated cognitive decline was found in 17 (25%) patients with type 2 diabetes and was associated with a greater increase in ventricular volume [mean difference (95% confidence interval): 0.23% (0.08-0.38); p = 0.003] and white-matter hyperintensities volume [0.16% (0.05-0.27); p = 0.006] over the 4-year period. There were no specific vascular or metabolic risk factors associated with accelerated cognitive decline.

CONCLUSIONS: Accelerated cognitive decline in patients with type 2 diabetes was associated with progressive changes on brain magnetic resonance imaging, comprising both vascular damage and global atrophy. Exploration of vascular and metabolic risk factors revealed no specific determinants of accelerated cognitive decline.

More on disclosure of medical errors


J Med Ethics. 2011 Feb 2. [Epub ahead of print]
To lie or not to lie: resident physician attitudes about the use of deception in clinical practice.
Everett JP, Walters CA, Stottlemyer DL, Knight CA, Oppenberg AA, Orr RD.

Loma Linda University, California, Loma Linda, CA, USA.
Background Physicians face competing values of truth-telling and beneficence when deception may be employed in patient care. The purposes of this study were to assess resident physicians' attitudes towards lying, explore lie types and reported reasons for lying. Method After obtaining institutional review board review (OSR# 58013) and receiving exempt status, posts written by Loma Linda University resident physicians in response to forum questions in required online courses were collected from 2002 to 2007. Responses were blinded and manually coded by two investigators using NVivo software. Qualitative and quantitative analyses of the data were performed with links to various attributes. A 95% binomial proportion CI was used to analyse the attribute data. Results The study found that the majority of residents (90.3%) would disclose the truth about medical errors. Similarly, many residents (55.7%) would disclose the truth regarding unanticipated events, especially if the error was serious enough to result in a malpractice suit (74.7%). However, many residents (40.9%) would not reveal a near miss event because they believe it has no impact on patient health. Some residents (47.3%) would deceive the insurance company for additional patient benefits. Of those willing to lie, only a small group (4.2%) gave self-serving reasons. Conclusions This study demonstrates that the ethical issues related to deception that trouble attending physicians also exist at the resident physician level. Residents primarily lie for altruistic reasons and rarely for egoistic or self-serving purposes that may or may not result in harm to patients, insurance companies and/or physicians themselves.

From Spain: Cystic fibrosis patient bone density and physical activity


Chest. 2011 Feb 3. [Epub ahead of print]
"Bone health, daily physical activity and exercise tolerance in cystic fibrosis patients"
Tejero García S, Giráldez-Sánchez MA, Cejudo Ramos P, Quintana Gallego E, Fernández FJ, García Jiménez R, Cano Luis P, Gómez de Terreros I.

Medical Doctor in Sport Medicine. Trauma and Orthopaedic Surgery of the "Virgen del Rocío" Hospital. Sevilla. Spain.

BACKGROUND: Daily physical activity (PA) may be an excellent tool for the maintenance of bone health in patients with cystic fibrosis (CF). The aim of this study was to analyze the possible association between physical capacity and activity, and bone mineral density (BMD), in young adults with CF. A secondary goal was to evaluate vertebral fractures in this population.

METHODS: A cross-sectional study was conducted in 50 CF patients, who were clinically stable and older than 16 years old but not being lung transplant recipient. PA was quantified using a portable motion monitor (BodyMedia Fit Armband). Cardiopulmonary exercise test (CPET), and 6-minute walk test (6MWT) assessed exercise capacity. BMD was obtained from dual energy X-ray absorptiometry (DXA) of the lumbar column, hip and whole body. To analyze vertebral fractures and deformity, we performed the Genant and Cobb methods.

RESULTS: Daily PA time at low (3-4.8 METs) and moderate (4.8-7.2 METs) intensity was correlated with Z-Score BMD of the lumbar column (r=0.36, p<0.01 and r=0.59, p<0.001, respectively), the neck of femur (r=0.51, p<0.001 and r=0.72, p<0.001), and the total hip (r=0.54, p<0.001 and r=0.74, p<0.001). PA, BMI, age and sex were found to be predictors of BMD. Vertebral fractures correlated with kyphosis (r=0.42, p=0.02), but not with BMD. Mild and severely affected patients differed in vertebral fracture rate and kyphosis prevalence (p=0.002 and p=0.013, respectively).

CONCLUSIONS: The most active patients with better exercise capacity had higher BMD. Those with more affected pulmonary function had greater prevalence of vertebral fractures and dorsal kyphosis.

NCI/NIH study: No association between HPV & lung cancer


J Natl Cancer Inst. 2011 Feb 3. [Epub ahead of print]
Assessment of Human Papillomavirus in Lung Tumor Tissue.
Koshiol J, Rotunno M, Gillison ML, Van Doorn LJ, Chaturvedi AK, Tarantini L, Song H, Quint WG, Struijk L, Goldstein AM, Hildesheim A, Taylor PR, Wacholder S, Bertazzi PA, Landi MT, Caporaso NE.

Affiliations of authors: Division of Cancer Epidemiology and Genetics, NCI/NIH/DHHS, Bethesda, MD (JK, MR, AKC, AMG, AH, PRT, SW, MTL, NEC); Department of Internal Medicine, Ohio State University Comprehensive Cancer Center-James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH (MLG, HS); DDL Diagnostic Laboratory, Voorburg, the Netherlands (L-JVD, WGVQ, LS); EPOCA Research Center, Department of Occupational and Environmental Health, Università degli Studi di Milano, Milan, Italy (LT, PAB); Epidemiology Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy (LT, PAB).
Background Lung cancer kills more than 1 million people worldwide each year. Whereas several human papillomavirus (HPV)-associated cancers have been identified, the role of HPV in lung carcinogenesis remains controversial. Methods We selected 450 lung cancer patients from an Italian population-based case-control study, the Environment and Genetics in Lung Cancer Etiology. These patients were selected from those with an adequate number of unstained tissue sections and included all those who had never smoked and a random sample of the remaining patients. We used real-time polymerase chain reaction (PCR) to test specimens from these patients for HPV DNA, specifically for E6 gene sequences from HPV16 and E7 gene sequences from HPV18. We also tested a subset of 92 specimens from all never-smokers and a random selection of smokers for additional HPV types by a PCR-based test for at least 54 mucosal HPV genotypes. DNA was extracted from ethanol- or formalin-fixed paraffin-embedded tumor tissue under strict PCR clean conditions. The prevalence of HPV in tumor tissue was investigated. Results Specimens from 399 of 450 patients had adequate DNA for analysis. Most patients were current (220 patients or 48.9%) smokers, and 92 patients (20.4%) were women. When HPV16 and HPV18 type-specific primers were used, two specimens were positive for HPV16 at low copy number but were negative on additional type-specific HPV16 testing. Neither these specimens nor the others examined for a broad range of HPV types were positive for any HPV type. Conclusions When DNA contamination was avoided and state-of-the-art highly sensitive HPV DNA detection assays were used, we found no evidence that HPV was associated with lung cancer in a representative Western population. Our results provide the strongest evidence to date to rule out a role for HPV in lung carcinogenesis in Western populations.

Eat your veggies!


Cancer. 2011 Feb 15;117(4):658. doi: 10.1002/cncr.25964.
A diverse vegetable diet may decrease lung cancer risk for smokers.
Printz C.

Friday, February 4, 2011

Not surprising: Comorbidities in COPD patients increases costs


Respir Res. 2011 Jan 13;12(1):7.
Determinants of elevated healthcare utilization in patients with COPD.
Simon-Tuval T, Scharf SM, Maimon N, Bernhard-Scharf BJ, Reuveni H, Tarasiuk A.

Department of Health Systems Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University, Beer-Sheva, Israel. simont@bgu.ac.il.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) imparts a substantial economic burden on western health systems. Our objective was to analyze the determinants of elevated healthcare utilization among patients with COPD in a single-payer health system.

METHODS: Three-hundred eighty-nine adults with COPD were matched 1:3 to controls by age, gender and area of residency. Total healthcare cost 5 years prior recruitment and presence of comorbidities were obtained from a computerized database. Health related quality of life (HRQoL) indices were obtained using validated questionnaires among a subsample of 177 patients.

RESULTS: Healthcare utilization was 3.4-fold higher among COPD patients compared with controls (p < 0.001). The "most-costly" upper 25% of COPD patients (n = 98) consumed 63% of all costs. Multivariate analysis revealed that independent determinants of being in the "most costly" group were (OR; 95% CI): age-adjusted Charlson Comorbidity Index (1.09; 1.01 - 1.2), history of: myocardial infarct (2.87; 1.5 - 5.5), congestive heart failure (3.52; 1.9 - 6.4), mild liver disease (3.83; 1.3 - 11.2) and diabetes (2.02; 1.1 - 3.6). Bivariate analysis revealed that cost increased as HRQoL declined and severity of airflow obstruction increased but these were not independent determinants in a multivariate analysis.

CONCLUSION: Comorbidity burden determines elevated utilization for COPD patients. Decision makers should prioritize scarce health care resources to a better care management of the "most costly" patients.

From University of Chicago-Asthma inhaler misuse


J Gen Intern Med. 2011 Jan 20. [Epub ahead of print]
Misuse of Respiratory Inhalers in Hospitalized Patients with Asthma or COPD.
Press VG, Arora VM, Shah LM, Lewis SL, Ivy K, Charbeneau J, Badlani S, Naurekas E, Mazurek A, Krishnan JA.

Department of Medicine, University of Chicago, Instructor, Section of Hospital Medicine, Chicago, IL, 60637, USA, vpress@medicine.bsd.uchicago.edu.
BACKGROUND: Patients are asked to assume greater responsibility for care, including use of medications, during transitions from hospital to home. Unfortunately, medications dispensed via respiratory inhalers to patients with asthma or chronic obstructive pulmonary disease (COPD) can be difficult to use.

OBJECTIVES: To examine rates of inhaler misuse and to determine if patients with asthma or COPD differed in their ability to learn how to use inhalers correctly.

DESIGN: A cross-sectional and pre/post intervention study at two urban academic hospitals.

PARTICIPANTS: Hospitalized patients with asthma or COPD.

INTERVENTION: A subset of participants received instruction about the correct use of respiratory inhalers.

MAIN MEASURES: Use of metered dose inhaler (MDI) and Diskus® devices was assessed using checklists. Misuse and mastery of each device were defined as <75% and 100% of steps correct, respectively. Insufficient vision was defined as worse than 20/50 in both eyes. Less-than adequate health literacy was defined as a score of <23/36 on The Short Test of Functional Health Literacy in Adults (S-TOFHLA).

KEY RESULTS: One-hundred participants were enrolled (COPD n = 40; asthma n = 60). Overall, misuse was common (86% MDI, 71% Diskus®), and rates of inhaler misuse for participants with COPD versus asthma were similar. Participants with COPD versus asthma were twice as likely to have insufficient vision (43% vs. 20%, p = 0.02) and three-times as likely to have less-than- adequate health literacy (61% vs. 19%, p = 0.001). Participants with insufficient vision were more likely to misuse Diskus® devices (95% vs. 61%, p = 0.004). All participants (100%) were able to achieve mastery for both MDI and Diskus® devices.

CONCLUSIONS: Inhaler misuse is common, but correctable in hospitalized patients with COPD or asthma. Hospitals should implement a program to assess and teach appropriate inhaler technique that can overcome barriers to patient self-management, including insufficient vision, during transitions from hospital to home.

Weather cold? Watch out for stroke


Stroke. 2011 Jan 27. [Epub ahead of print]
Innovative Approaches Helpful to Enhance Knowledge on Weather-Related Stroke Events Over a Wide Geographical Area and a Large Population.
Morabito M, Crisci A, Vallorani R, Modesti PA, Gensini GF, Orlandini S.

From the Interdepartmental Centre of Bioclimatology, University of Florence, Firenze, Italy; the Institute of Biometeorology, National Research Council, Firenze, Italy; Clinica Medica and Cardiologia, University of Florence, Firenze, Italy; and Don Carlo Gnocchi Foundation, Centro S. Maria agli Ulivi, Onlus IRCCS, Pozzolatico, Italy.
BACKGROUND AND PURPOSE: Results on the effect of weather on stroke occurrences are still confusing and controversial. The aim of this study was to retrospectively investigate in Tuscany (central Italy) the weather-related stroke events through the use of an innovative source of weather data (Reanalysis) together with an original statistical approach to quantify the prompt/delayed health effects of both cold and heat exposures.

METHODS: Daily stroke hospitalizations and meteorologic data from the Reanalysis 2 Achieve were obtained for the period 1997 to 2007. Generalized linear and additive models and an innovative modeling approach, the constrained segmented distributed lag model, were applied.

RESULTS: Both daily averages and day-to-day changes of air temperature and geopotential height (a measure that approximates the mean surface pressure) were selected as independent predictors of all stroke occurrences. In particular, a 5°C temperature decrease was associated with 16.5% increase of primary intracerebral hemorrhage of people ≥65 years of age. A general short-term cold effect on hospitalizations limited to 1 week after exposure was observed and, for the first time, a clear harvesting effect (deficit of hospitalization) for cold-related primary intracerebral hemorrhage was described. Day-to-day changes of meteorologic parameters disclosed characteristic U- and J-shaped relationships with stroke occurrences.

CONCLUSIONS: Thanks to the intrinsic characteristic of Reanalysis, these results might simply be implemented in an operative forecast system regarding weather-related stroke events with the aim to develop preventive health plans.

Thursday, February 3, 2011

Med mal issues in China


Leg Med (Tokyo). 2011 Jan 24. [Epub ahead of print]
China's criminal penalty for medical malpractice: Too lenient or not?
Zhu S, Li L, Li Y.

The second Female Labor Camp, Labor Reeducation Branch Bureau, Chongqing Municipal Bureau of Justice, Chongqing, China.
Although China had greatly improved its health and medical system, the contradiction between arduous medical tasks and insufficient health resources has not been fundamentally resolved. This contradiction raised a large number of legal issues in medical industry. Literatures about these issues are usually published in legal journal, and are not easy accessible to clinicians. We thus provide clinicians a brief introduction to the legal liability of medical malpractice, and describe the debate about the punishment setting of China's medical malpractice crime in detail. Considering the complexity and humanitarian nature of medical practice, legislators set a relative lenient punishment system for medical malpractice crime. But the "aggravating" supporter argued that, judging from criminal jurisprudence, only serious irresponsible medical personnel might face criminal penalty, so severe penalty was not conflict with the humanitarian nature of medical work. They also deemed that, too lenient penalties of this crime had broken the internal harmony of Criminal Law, and violated the basic principles of law. The opponents believed that: although the statutory penalty for medical malpractice crime seemed lenient, the declared sentence was more severe than surrounding areas. And, too severe penalties would not only aggravate the shortage of Chinese medical personnel, but also deteriorate the unbalanced physician-patient relationship. So, they did not agree enhancing the penalty of medical malpractice crime. We propose to add disqualification to the punishment setting of medical malpractice crime, reform the health system more thoroughly. We also hope Chinese governments could encourage medicolegal research. And, from the viewpoint of risk management in health care, we emphasize the role of Medical Professional Liability Insurance system as a powerful tool to prevent medical malpractice.

From MD Anderson: Symptom assessment in lung cancer patients


Oncologist. 2011 Feb 1. [Epub ahead of print]
Measuring the Symptom Burden of Lung Cancer: The Validity and Utility of the Lung Cancer Module of the M. D. Anderson Symptom Inventory.
Mendoza TR, Wang XS, Lu C, Palos GR, Liao Z, Mobley GM, Kapoor S, Cleeland CS.

Departments of Symptom Research (Unit 1450).
Abstract We conducted a study to establish the psychometric properties of a module of the M. D. Anderson Symptom Inventory (MDASI) developed specifically for patients with lung cancer (MDASI-LC). The MDASI measures 13 common "core" symptoms of cancer and its treatment. The MDASI-LC includes the 13 core MDASI symptom items and three lung cancer-specific items: coughing, constipation, and sore throat. MDASI-LC items were administered to three cohorts of patients with lung cancer undergoing either chemotherapy or chemoradiotherapy. Known-group validity and criterion (concurrent) validity of the MDASI-LC were evaluated using the Eastern Cooperative Oncology Group performance status and the 12-item Short-Form Health Survey. The internal consistency and test-retest reliability of the module were adequate, with Cronbach coefficient α-values of 0.83 or higher for all module items and subscales. The sensitivity of the MDASI-LC to changes in patient performance status (disease progression) and to continuing cancer treatment (effects of treatment) was established. Cognitive debriefing of a subset of participants provided evidence for content validity and indicated that the MDASI core items and three additional lung cancer-specific items were clear, relevant to patients, and easy to understand; only two patients suggested additional symptom items. As expected, the item "sore throat" was sensitive only for patients receiving chemoradiotherapy. The MDASI-LC is a valid, reliable, and sensitive symptom-assessment instrument whose use can enhance clinical studies of symptom status in patients with lung cancer and epidemiological and prevalence studies of symptom severity across various cancer types.

From University of Turin, Italy: Lifestyle contributions to obesity and hyperglycemia


Int J Obes (Lond). 2011 Feb 1. [Epub ahead of print]
Contributors to the obesity and hyperglycemia epidemics. A prospective study in a population-based cohort.
Bo S, Ciccone G, Durazzo M, Ghinamo L, Villois P, Canil S, Gambino R, Cassader M, Gentile L, Cavallo-Perin P.

Department of Internal Medicine, University of Turin, Turin, Italy.
Objective:Relatively unexplored contributors to the obesity and diabetes epidemics may include sleep restriction, increased house temperature (HT), television watching (TW), consumption of restaurant meals (RMs), use of air conditioning (AC) and use of antidepressant/antipsychotic drugs (ADs).

Design and Subjects:In a population-based cohort (n=1597), we investigated the possible association among these conditions, and obesity or hyperglycemia incidence at 6-year follow-up. Subjects with obesity (n=315) or hyperglycemia (n=618) at baseline were excluded, respectively, 1282 and 979 individuals were therefore analyzed.

Results:At follow-up, 103/1282 became obese; these subjects showed significantly higher body mass index, waist circumference, saturated fat intake, RM frequency, TW hours, HT, AC and AD use, and lower fiber intake, metabolic equivalent of activity in h per week (METS) and sleep hours at baseline. In a multiple logistic regression model, METS (odds ratio=0.94; 95% confidence interval (CI) 0.91-0.98), RMs (odds ratio=1.47 per meal per week; 1.21-1.79), being in the third tertile of HT (odds ratio=2.06; 1.02-4.16) and hours of sleep (odds ratio=0.70 per h; 0.57-0.86) were associated with incident obesity. Subjects who developed hyperglycemia (n=174/979; 17.8%) had higher saturated fat intake, RM frequency, TW hours, HT, AC and AD use at baseline and lower METS and fiber intake. In a multiple logistic regression model, fiber intake (odds ratio=0.97 for each g per day; 0.95-0.99), RM (1.49 per meal per week; 1.26-1.75) and being in the third tertile of HT (odds ratio=1.95; 1.17-3.26) were independently associated with incident hyperglycemia.

Conclusions:Lifestyle contributors to the obesity and hyperglycemia epidemics may be regular consumption of RM, sleep restriction and higher HT, suggesting potential adjunctive non-pharmacological preventive strategies for the obesity and hyperglycemia epidemics.



Curr Cardiol Rev. 2010 Feb;6(1):54-61.
Sleep duration as a risk factor for cardiovascular disease- a review of the recent literature.
Nagai M, Hoshide S, Kario K.

Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Yakushiji, Shimotsuke, Tochigi, Japan.
Sleep loss is a common condition in developed countries, with evidence showing that people in Western countries are sleeping on average only 6.8 hour (hr) per night, 1.5 hr less than a century ago. Although the effects of sleep deprivation on our organs have been obscure, recent epidemiological studies have revealed relationships between sleep deprivation and hypertension (HT), coronary heart disease (CHD), and diabetes mellitus (DM). This review article summarizes the literature on these relationships. Because sleep deprivation increases sympathetic nervous system activity, this increased activity serves as a common pathophysiology for HT and DM. Adequate sleep duration may be important for preventing cardiovascular diseases in modern society.

From Yale Med-Pregnancy in cystic fibrosis patients


Clin Chest Med. 2011 Mar;32(1):111-20.
Pregnancy in cystic fibrosis.
McArdle JR.

Section of Pulmonary & Critical Care Medicine, Yale University School of Medicine, 333 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
The challenges posed by cystic fibrosis (CF), including poor nutrition and progressive lung function decline, may pose problems for pregnancy for both mother and child. A multidisciplinary team of providers is optimal to help address the variety of issues that might arise in such a pregnancy. Careful attention to maternal weight gain, pulmonary function and exacerbations, and screening for gestational diabetes is necessary. Pregnancies among women with CF are associated with more frequent use of intravenous antibiotics and hospitalization than is seen in nonpregnant CF women. This article reviews maternal and fetal outcomes for CF in pregnancy.

Dealing with conflicts of interest in medicine


Am J Bioeth. 2011 Jan;11(1):33-4.
Taking a lesson from the lawyers: defining and addressing conflict of interest.
Morreim EH.

University of Tennessee Health Science Center.
PMID: 21240805 [PubMed - in process]

The new lung adenocarcinoma classification system


J Thorac Oncol. 2011 Feb;6(2):244-85.
International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma.
Travis WD, Brambilla E, Noguchi M, Nicholson AG, Geisinger KR, Yatabe Y, Beer DG, Powell CA, Riely GJ, Van Schil PE, Garg K, Austin JH, Asamura H, Rusch VW, Hirsch FR, Scagliotti G, Mitsudomi T, Huber RM, Ishikawa Y, Jett J, Sanchez-Cespedes M, Sculier JP, Takahashi T, Tsuboi M, Vansteenkiste J, Wistuba I, Yang PC, Aberle D, Brambilla C, Flieder D, Franklin W, Gazdar A, Gould M, Hasleton P, Henderson D, Johnson B, Johnson D, Kerr K, Kuriyama K, Lee JS, Miller VA, Petersen I, Roggli V, Rosell R, Saijo N, Thunnissen E, Tsao M, Yankelewitz D.

Lung cancer histology in an emerging molecular age: more important that ever


Med Health R I. 2010 Oct;93(10):317-9.
The evolving role of histology in the treatment of non-small cell lung cancer.
Rana N, Khurshid H.

Boston University School of Medicine, Division of Hematology and Oncology, Roger Williams Medical Center, USA.
PMID: 21284271 [PubMed - in process]