Friday, July 29, 2011

The university called a "beer drinker's paradise" starts to deal with it.

Regarding the lack of diversity in academic medicine

Acad Med. 2011 Aug;86(8):928-931.
Commentary: The Building the Next Generation of Academic Physicians Initiative: Engaging Medical Students and Residents.
Sánchez JP, Castillo-Page L, Spencer DJ, Yehia B, Peters L, Freeman BK, Lee-Rey E.
Dr. Sánchez is past chairperson, Council of Residents, National Hispanic Medical Association, Washington, DC. Dr. Castillo-Page is senior director, Diversity Policy and Programs, Association of American Medical Colleges, Washington, DC. Mr. Spencer is co-principal investigator, Physician Researcher Initiative, Student National Medical Association, Washington, DC. Dr. Yehia is past chair, Resident and Fellow Section, American Medical Association, Chicago, Illinois. Ms. Peters is research analyst, Diversity Policy and Programs, Association of American Medical Colleges, Washington, DC. Dr. Freeman is past chair, Post-Graduate Section, National Medical Association, Silver Spring, Maryland. Dr. Lee-Rey is codirector, Hispanic Center of Excellence, Albert Einstein College of Medicine, Bronx, New York.

Data from the 2010 U.S. Census are a reminder of the diverse patient population in the United States and the growing health care needs of Americans. Academic health centers are tasked with reforming the system to expand its capacity for care and with cultivating innovation to generate the teaching, training, and research prowess needed to eliminate health disparities. At the center of this reform is enhancing the system that produces the human capital, including the physicians who care for the patients and the educators who train those physicians. Institutions and foundations have committed to the development of pipeline programs, from kindergarten through college, to create a diverse clinical workforce, but they have limited their direct promotion of diversity in the academic medicine workforce to faculty development programs. Despite faculty efforts, shortcomings in diversity persist, including a paucity of female full professors and deans, an insignificant increase in the proportion of underrepresented racial and ethnic minority faculty, and a lack of knowledge on the cultivation of the lesbian and gay faculty perspective. Furthermore, underrepresented racial and ethnic minority students in particular lose interest in academic medicine careers during medical school, and overall students lose interest in academic medicine careers during residency. The Building the Next Generation of Academic Physicians Initiative is designed to develop interest and promote achievement in pursuing academic medicine careers. This initiative is needed to increase the pool of diverse faculty down the road and elicit their perspectives to more effectively address health care disparities.

PMID: 21795902 [PubMed - as supplied by publisher]

More on so-called "patient-centered care"

J Healthc Risk Manag. 2011;31(1):32-7. doi: 10.1002/jhrm.20077.
Ethics, risk, and patient-centered care: How collaboration between clinical ethicists and risk management leads to respectful patient care.
Sine DM, Sharpe VA.
National Center for Patient Safety at the Veterans Health Administration.

Patient-centered care is driven in part by the ethical principle of autonomy and considers patients' cultural traditions, personal preferences, values, family situations, and lifestyles. Patient decision-making capacity, surrogate decision making with or in the absence of a patient's advance directive, and the right to refuse treatment are three patient-care issues that are central to the work done by both the risk manager and the clinical ethicist that have strong relevance to patient-centered care. This article discusses these three issues briefly and offers two challenging case studies involving patient-centered care that illustrate how a clinical ethics consultation may help to avert the escalation that can lead to a tort claim.

© 2011 American Society for Healthcare Risk Management of the American Hospital Association.

"Lawmakers may not realize they are becoming national jokes, but they are."

"Washington is now sullying America’s long-deserved reputation as the leading country in the world to such an extent that we are becoming a laughingstock."

"Age and Obesity Are Risk Factors for Adverse Events After Total Hip Arthroplasty."

Clin Orthop Relat Res. 2011 Jul 28. [Epub ahead of print]
Age and Obesity Are Risk Factors for Adverse Events After Total Hip Arthroplasty.
Huddleston JI, Wang Y, Uquillas C, Herndon JH, Maloney WJ.
Department of Orthopaedic Surgery, Stanford Medicine Outpatient Center, 450 Broadway Street, Mailcode 6324, Redwood City, CA, 94063, USA,

Defining the epidemiology of adverse events after THA will aid in the development of strategies to enhance perioperative care.

We identified (1) risk factors for adverse events in Medicare beneficiaries while hospitalized after THA and (2) trends in the rates of adverse events.

Data were abstracted from medical records of 1809 Medicare beneficiaries who underwent THA from 2002 to 2007. We used the hierarchical generalized linear modeling approach to assess the odds of change in adverse events over time, the association of adverse events with outcomes, and the relationship of adverse events with patient characteristics by modeling the log-odds of adverse events as a function of demographic and clinical variables adjusted for year variable.

The overall rate of adverse events was 5.8%; the 30-day mortality rate was 1.00%. Increased age, obesity, and year of procedure were risk factors for experiencing any adverse event. Annual rates of adverse events from 2002 to 2007 were 9.1%, 8.2%, 4.9%, 4.1%, 3.5%, and 3.0%, respectively. Experiencing any adverse event was associated with an increased length of stay and an increased chance of readmission but not with an increased chance of mortality. The annual rate of all adverse events decreased from 2002-2004 to 2005-2007 (odds ratio = 0.83; 95% confidence interval, 0.74-0.92).

Older and obese patients should be counseled regarding their increased risk for the development of adverse events after THA. The cause of the decline in the rate of adverse events between two time periods is unclear and warrants further investigation to confirm and identify the cause.

PMID: 21796477 [PubMed - as supplied by publisher]

From Walter Olsen-NYDailyNews: More on the nanny state in the kitchen

"If anyone's feeling an uneasy soup-stain-on-shirt-front sense of embarrassment, it should be Mayor Bloomberg's Health Department."

Read more:

"I think you'd find almost anyone who stands up to their patent rights has been called a patent troll."

"'We're at a point in the state of intellectual property where existing patents probably cover every behavior that's happening on the Internet or our mobile phones today,' says Chris Sacca, the venture capitalist. '[T]he average Silicon Valley start-up or even medium sized company, no matter how truly innovative they are, I have no doubt that aspects of what they're doing violate patents right now. And that's what's fundamentally broken about this system right now.'"

Target blood pressure in hypertensive diabetics

J Zhejiang Univ Sci B. 2011 Aug.;12(8):611-623.
Target blood pressure in diabetes patients with hypertension-What is the accumulated evidence in 2011?
Nilsson PM.
Department of Clinical Sciences, Lund University, University Hospital, S-205 02 Malmö, Sweden.
There is overwhelming evidence that hypertension is an important risk factor for both macrovascular and microvascular complications in patients with diabetes, but the problem remains to identify appropriate goals for preventive therapies. A number of guidelines (the European Society of Cardiology (ESC)/European Association for the Study of Diabetes (EASD) 2007, the Joint National Committee (JNC)-VII 2003, the American Diabetes Association (ADA) 2011) have for example advocated a blood pressure goal of less than 130/80 mmHg, but this suggestion has been challenged by findings in recent trials and meta-analyses (2011). The European Society of Hypertension (ESH) therefore recommends a systolic blood pressure goal of "well below" 140 mmHg. Based on evidence from both randomized controlled trials (hypertension optimal treatment (HOT), action in diabetes and vascular disease: preterax and diamicron MR controlled evaluation (ADVANCE), action to control cardiovascular risk in diabetes (ACCORD)) and observational studies (ongoing telmisartan alone and in combination with ramipril global endpoint trial (ONTARGET), international verapamil-trandolapril study (INVEST), treat to new targets (TNT), and the National Diabetes Register (NDR)), it has been shown that the benefit for stroke reduction remains even at lower achieved blood pressure levels, but the risk of coronary events may be uninfluenced or even increased at lower systolic blood pressure levels. In a recent meta-analysis, it was therefore concluded that the new recommended goal should be 130-135 mmHg systolic blood pressure for most patients with type 2 diabetes. Other risk factors should also be controlled with a more ambitious strategy applied in the younger patients with shorter diabetes duration, but a more cautious approach in the elderly and frail patients with a number of vascular or non-vascular co-morbidities. In patients from East Asia, such as China, the stroke risk is relatively higher than the risk of coronary events. This must also be taken into consideration for individualized goal setting in relation to total risk, for example in patients from stroke-prone families. In conclusion, the current strategy is to have a more individualized approach to risk factor control in patients with type 2 diabetes, also relevant for blood pressure control.

"Maybe because our culture has become small, we need small things to believe in."

"While some of these books contain interesting enough factoids, for the most part they mistake ubiquity for significance. Much like the Germans of Bismarck’s time and the Brooklyn hipster down the block from me, the Egyptians brewed beer! But so what?"

Returning to work after cancer in the Netherlands

J Occup Rehabil. 2011 Jul 28. [Epub ahead of print]
Return to Work After Cancer Diagnosed in 2002, 2005 and 2008.
Roelen CA, Koopmans PC, Groothoff JW, van der Klink JJ, Bültmann U.
Department of Health Sciences, University Medical Center Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlands,

Introduction Improvements in diagnosis and treatment of cancer have increased cancer survival. This study investigated the trends in return to work (RTW) after cancer. Methods All employees absent from work due to cancer diagnosed in 2002 (N = 1209), 2005 (N = 1522), and 2008 (N = 1556) were selected from an occupational health service register. Partial RTW was defined as resuming work with 50% of earnings and full RTW as resuming work with 100% of earnings. The percentages of partial and full RTW were determined 2 years after reporting sick and compared with percentages of partial and full RTW after cardiovascular disorders. The time to partial and full RTW after cancer in 2005 and 2008 was compared with the time to RTW in 2002. Results Partial RTW decreased from 85% 2 years after cancer diagnosis in 2002 to 80% in 2005 and 69% in 2008. Full RTW decreased from 80% 2 years after cancer diagnosis in 2002 to 74% in 2005 and 60% in 2008. RTW after cardiovascular disorders showed similar changes. The time to partial RTW in 2008 was longer than in 2002 after gastrointestinal cancer and lung cancer. The time to full RTW in 2008 was longer than in 2002 after breast cancer, gastrointestinal cancer and lung cancer. Conclusions In the past decade, the percentages of employees who resumed work after cancer have decreased in The Netherlands, while the time to RTW increased. Possible explanations include changes in disability policy, economic decline, and resulting decreases in work latitude and workplace accommodations.

Being clever is easy. Being original-that's something else entirely...

"When the eminent Italian critic and novelist Umberto Eco visited Johns Hopkins some decades ago, he spoke of the problem, for contemporary writers, of the 'already said': the circumstance that because Homer, for example, spoke so memorably in The Odyssey of the 'wine-dark sea' and of 'rosy-fingered Dawn,' nearly 3,000 years’ worth of poets and storytellers have had to find other images for sea and sunrise—a task that must become increasingly difficult as the repertory of possibilities is exhausted."

Thursday, July 28, 2011

From Keith Kerr and colleagues: CT screening for lung cancer in the UK

Thorax. 2011 Aug;66(8):736-7. Epub 2011 Jul 1.
CT screening for lung cancer in the UK: position statement by UKLS investigators following the NLST report.
Field JK, Baldwin D, Brain K, Devaraj A, Eisen T, Duffy SW, Hansell DM, Kerr K, Page R, Parmar M, Weller D, Williamson P, Whynes D; UKLS Team.
Department of Molecular & Clinical Cancer Medicine, University of Liverpool, 200 London Road, Liverpool L3 9TA, UK.

Background The imminent publication of a randomised controlled trial from the USA that suggests CT screening reduces mortality from lung cancer by more than 20%, may potentially lead to one of the most important developments in lung cancer care. However, there remain important questions about the applicability of the results to the UK and the clinical effectiveness of this intervention, including its feasibility and cost-effectiveness. Objective To describe the remaining questions that need to be answered by further research and to comment on the use of CT screening in the UK outside a clinical trial. Methods The detailed design process of the UKLS protocol and international discussions were used to identify the research questions that remain to be answered and to inform those who may choose to consider offering CT screening, before these questions are answered. Results A series of research imperatives have been identified and we advise that CT screening should be part of the ongoing clinical trial in the UK, currently in the pilot phase (UKLS). UKLS is randomising 4,000 individuals for the pilot and a total of 32,000 for the main study. Conclusion There remain unresolved issues with respect to CT screening for lung cancer. These include its feasibility, psychosocial and cost-effectiveness in the UK, harmonisation of CT acquisition techniques, management of suspicious screening findings, the choice of screening frequency and the selection of an appropriate risk group for the intervention. UKLS is aimed at resolving these issues.

The genetics of Kashin-Beck disease in Tibet

Arthritis Rheum. 2011 Jul 7. doi: 10.1002/art.30526. [Epub ahead of print]
Genetic variants in HLA-DRB1 gene are associated with Kashin-Beck disease in the Tibetan population.
Shi Y, Lu F, Liu X, Wang Y, Huang L, Liu X, Long W, Lv B, Zhang K, Ma S, Lin H, Cheng J, Zhou B, Hu M, Deng J, Zhu J, Hao P, Yang X, Zeng M, Wang X, Yang Z.
Sichuan Provincial Key Laboratory for Human Disease Gene Study, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China; Institute of Laboratory Medicine, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Sichuan, China.

To investigate the association between variants in HLA-DRB1 gene and Kashin-Beck disease (KBD) and selenium and iodine deficiencies in KBD in a Tibetan population.

We genotyped 14 polymorphisms around HLA-DRB1 gene and performed HLA-DRB1 allele genotyping in the discovery cohort composed of 605 patients and 393 controls and/or the replication cohort composed of 290 patients and 295 controls. Plasma selenium and iodine concentrations of 299 KBD patients and 280 controls from the same villages were measured and compared by t test.

We found four SNPs (rs6457617, rs6457620, rs9275295, and rs7745040) in the HLA-DRB1 gene locus that were significantly associated with KBD in both cohorts with combined P values from 0.0039 to 0.0006 (OR: from 1.307 to 1.402). The protective haplotype GTCC generated by the four SNPs showed significant association with KBD (P=0.0031, OR=0.77). The risk haplotype ACGT generated by the four SNPs showed significant association with KBD (P=0.0014, OR=1.40). In the HLA-DRB1 allele genotyping, the frequencies of HLA-DRB1*08 and *11 showed significant differences between KBD cases and controls (HLA-DRB1*08: OR=0.731, P=0.00564; HLA-DRB1*11: OR=0.489, P=0.000395). We also found that plasma selenium and iodine concentrations were significantly different between KBD patients and controls from the same villages (P=0.0013 and P=1.82x10(-12) , respectively).

We confirmed the role of the selenium and iodine deficiencies in the development of KBD, using, for the first time, plasma samples of the KBD patients and controls from the same villages. We established that genetic variants in the HLA-DRB1 gene significantly increase susceptibility to KBD.

Copyright © 2011 by the American College of Rheumatology.

Prehistoric Eskimos show us " the human capacity for cultural amelioration of environmental hardships is quite significant."

Am J Phys Anthropol. 2011 Jul 15. doi: 10.1002/ajpa.21556. [Epub ahead of print]
Health status among prehistoric Eskimos from Point Hope, Alaska.
Dabbs GR.
Department of Anthropology, Southern Illinois University, Carbondale, IL 62901.

Using the protocol outlined in The Backbone of History: Health and Nutrition in the Western Hemisphere (BBH) (Steckel and Rose. 2002a. The backbone of history: health and nutrition in the Western Hemisphere. Cambridge: Cambridge University Press), this project compares the Mark I Health Index (MIHI) scores of the Ipiutak (n = 76; 100BCE-500CE) and Tigara (n = 298; 1200-1700CE), two samples of North American Arctic Eskimos excavated from Point Hope, Alaska. Macroscopic examination of skeletal remains for evidence of anemia, linear enamel hypoplasias (LEH), infection, trauma, dental health, and degenerative joint disease (DJD) was conducted to assess differences in health status resulting from a major economic shift at Point Hope. These data demonstrate that despite differences in settlement pattern, economic system, and dietary composition, the MIHI scores for the Ipiutak (82.1) and Tigara (84.6) are essentially equal. However, their component scores differ considerably. The Ipiutak component scores are suggestive of increased prevalence of chronic metabolic and biomechanical stresses, represented by high prevalence of nonspecific infection and high frequencies of DJD in the hip/knee, thoracic vertebrae, and wrists. The Tigara experienced more acute stress, evidenced by higher prevalence of LEH and trauma. Comparison of overall health index scores with those published in BBH shows the MIHI score for the Ipiutak and Tigara falling just above the average for sites in the Western Hemisphere, adding support to the argument that the human capacity for cultural amelioration of environmental hardships is quite significant. Am J Phys Anthropol, 2011. © 2011 Wiley-Liss, Inc.

"Public-employee unions underestimate the magnitude of California’s unfunded retirement liability"

"Simply reducing public-pension benefits won’t solve California’s budget woes all by itself. The base rates of pay for most government workers would need to shrink, too."

Myths and realities of the Tour de France: "The myths seem infinitely preferable."

LA riot police fire rubber bullets at ravers on Hollywood Blvd

Wednesday, July 27, 2011

Ronald Coase: The Problem of Social Cost-Journal of Law and Economics, 1960

From the Washington Post: Greece's upcoming default

"The many positive aspects of the plan, Moody’s said, needed to be judged against 'the negative implications of this precedent-setting package should any country face financing challenges similar in severity to Greece’s. On balance, Moody’s says that, for creditors of such countries, the negatives will outweigh the positives.'”

Folate and colon cancer treatment

Curr Drug Metab. 2011 Jul 25. [Epub ahead of print]
The Impact of Folate Status on the Efficacy of Colorectal Cancer Treatment.
Porcelli L, Assaraf YG, Azzariti A, Paradiso A, Jansen G, Peters GJ.
Clinical Experimental Oncology Laboratory, National Cancer Institute, Bari, Italy.

Over the past three decades, numerous reports have addressed several aspects of drug resistance phenomena. However, little is known regarding the impact that dietary components and nutritional supplements have on the mechanisms of resistance that malignant cells develop to chemotherapeutic agents. The increased fortification of cereals, grains and bread with folic acid (FA) has resulted in a marked rise in folate levels in blood and tissues. Vitamin fortification that includes FA is rather commonly used by cancer patients, but FA is also used to protect against pemetrexed induced side effects in the treatment of non-small cell lung cancer and mesothelioma or that of the antifolate methotrexate in rheumatoid arthritis. Moreover, the reduced folate leucovorin (LV, 5-formyltetrahydrofolate) is also used along with 5-fluorouracil in the treatment of colorectal cancer. Likewise, LV is used to reduce toxicity of methotrexate in the treatment of leukemia. FA can also increase efficacy of unrelated regimens, containing cisplatin. Hence there is growing evidence that dietary supplements as folic acid, can mimic, intensify, or attenuate the effects of unrelated chemotherapeutic agents. The aim of this review is to highlight some new insights in the cellular and molecular mechanisms affected by folate status, leading to chemotherapy resistance, especially towards antifolates in colorectal cancer treatment. This encompasses the effect of folate status on drug export, as well as on the increased expression of mutated target enzymes involved in folate metabolism and on the augmentation of cellular folate pools that impair polyglutamylation of antifolates, ultimately affecting treatment efficacy.

From the Atlantic-Megan McCardle: the Euro:bad at the periphery?

From FT Magazine: The golden years, the silver tsunami, and Agnes the aging suit

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"'I would argue that longevity is probably the greatest achievement of human kind that has gone ignored. If you talked to anyone and said, "congratulations, you’re going live 30 to 40 years longer than your grandparents did in the 1900s", that would be seen as a bonus prize.' With a bit of ingenuity, it’s a prize worth taking."

Tuesday, July 26, 2011

From Fox News: College student health hazards

Number 8: Binge drinking:

"The lack of parents on college campuses can turn newly unleashed freshmen into binge-drinking party animals. According to a 2005 U.S. Department of Justice report, more than 90% of the alcohol consumed by people under 21 is in the form of binge drinking.
Drinking to excess is extremely dangerous and potentially fatal, and it can also lead to problems in the classroom. For every five drinks a student has per drinking occasion, his or her GPA is lowered by half a grade, according to a paper published by ImpacTeen, a research partnership at the University of Illinois at Chicago."

Richard Epstein on taxes

"Human nature what it is, most ordinary citizens will be tempted by government largesse, despite the potential losses from hamstringing the economy with higher taxes. It is for that reason that whenever there is a revenue shortfall, political forces now clamor to "tax the rich." In the end, this is a plea for steeper progressivity, which in turn cuts deeper into long-term economic growth."

From NY Times: Grad School-Why bother?

“'The information in this research,' he wrote, 'indicates that revealing one’s political and religious conservatism will, on average, negatively influence about half of the search committee one is attempting to impress.'”

"If you were a conservative undergraduate, would you risk spending at least four years in graduate school in the hope of getting a job offer from a committee dominated by people who don’t share your views?"

Monday, July 25, 2011

All your tweets are belong to us.

From Jon Reed & colleagues: the recurrent nevus phenomenon

From BBC: Moody's give Greece the lowest rating of any country it rates in the world

"The downgrade means Moody's has followed its counterpart Standard & Poor's in giving Greece the lowest rating of any country it rates in the world, falling below Cuba and Ecuador."

"Austerity measures demanded by Greece's European partners and the International Monetary Fund remain highly unpopular among many of the country's voters, and face continuing street protests."

From University of Chicago: 2 genetic variations predict second cancers after radiation for children with Hodgkin lymphoma

"This finding means we can better identify children who are most susceptible to radiation-induced cancers before treatment begins and modify their care to prevent this serious long-term complication," said Kenan Onel, MD, PhD, associate professor of pediatrics and senior author of the study. "Luckily our options for Hodgkin's are broad enough that we can find ways to control the initial disease without relying on radiation therapy."

The Euro Endgame: "Buying time is the name of the game."

"Well, that is the plan (at the time of writing), complete with a hint of Ponzi, a dash of Micawber, and dire warnings of what the alternative might be."

From USC: Stroke declines as cause of death

Stroke. 2011 Jul 21. [Epub ahead of print]
Stroke Declines From Third to Fourth Leading Cause of Death in the United States: Historical Perspective and Challenges Ahead.
Towfighi A, Saver JL.
From the Division of Stroke and Critical Care, Department of Neurology, University of Southern California, Los Angeles, CA; the Department of Neurology, Rancho Los Amigos National Rehabilitation Center, Downey, CA; and the Department of Neurology and Stroke Center, University of California at Los Angeles, Los Angeles, CA.
Stroke recently declined from the third to the fourth leading cause of death in the United States, its first rank transition among sources of American mortality in nearly 75 years.

This is a narrative review supplemented by new analyses of Centers for Disease Control and Prevention National Vital Statistics Reports from 1931 to 2008.

Historically, stroke transitioned from the second to the third leading cause of death in the United States in 1937, but stroke death rates were essentially stable from 1930 to 1960. Then a long, great decline began, moderate in the 1960s, precipitous in the 1970s and 1980s, and moderate again in the 1990s and 2000s. By 2008, age-adjusted annual death rates from stroke were three fourths less than the historic 1931 to 1960 norm (40.6 versus 175.0 per 100 000). Total actual stroke deaths in the United States declined from a high of 214 000 in 1973 to 134 000 in 2008. Improved stroke prevention, through control of hypertension, hyperlipidemia, and tobacco, contributed most greatly to the mortality decline with a lesser but still substantial contribution of improved acute stroke care. Persisting challenges include race-ethnicity, sex, and geographic disparities in stroke mortality; the burden of stroke disability; the expanding obesity epidemic and aging of the US population; and the epidemic of cerebrovascular disease in low- and middle-income countries worldwide.

The recent rank decline of stroke among leading causes of American death is testament to a half century of societal progress in cerebrovascular disease prevention and acute care. Renewed commitments are needed to preserve and broaden this historic achievement.

Nina Easton: "The longer a worker is unemployed, the farther he or she falls behind in sellable skills in a fast-paced global economy."

"All three executives spoke at an Atlantic magazine-sponsored jobs forum last week that exposed a stark disconnect between the jobs that are available—and the increasingly rusty skill-sets of those who are unemployed, especially for long periods of time. People have 'no idea what skills they should have to find a job,' says Bock."

BMI, obesity, and diabetes: a 45-year follow-up study

Diabetes Care. 2011 Jul 20. [Epub ahead of print]
Changes in BMI, Duration of Overweight and Obesity, and Glucose Metabolism: 45 years of follow-up of a birth cohort.
Power C, Thomas C.
MRC Centre of Epidemiology for Child Health, University College London Institute of Child Health, London, England.
OBJECTIVE Long-term implications of childhood obesity and BMI change over the life course for risk of type 2 diabetes remain uncertain. The objective was to establish whether there are effects on adult glucose metabolism of 1) sensitive periods of BMI gain or 2) long duration of overweight and obesity. RESEARCH DESIGN AND METHODS Participants in the 1958 British birth cohort with child to adult BMI and glycosylated hemoglobin (HbA(1c)) at 45 years (n = 7,855). RESULTS Prevalence of type 2 diabetes or HbA(1c) ≥7 was 2%. BMI gains in child- and adulthood were associated with higher HbA(1c): for every SD of 5-year BMI increase from 0 to 7 years, there was a 75% (95% CI 1.42-2.16) increased risk of HbA(1c) ≥7, increasing to a 4.7-fold (3.12-7.00) risk for the interval 23-33 years. Associations for BMI gain in adulthood were related to attained BMI but were independent for the longer period birth (or 7 years) to 45 years. Duration of obesity was also associated with HbA(1c); compared with the never obese, those with childhood onset had a 23.9-fold risk (13.5-42.1) of HbA(1c) ≥7%; odds ratios were 16.0 (10.6-24.2) and 2.99 (1.77-5.03), respectively, for young and midadulthood onset. Similar trends by onset age were found in mean HbA(1c) levels and for onset of overweight. Those with the earliest age of onset had higher BMI and waist circumference at 45 years, which markedly explained the associations for onset age and HbA(1c). CONCLUSIONS Excessive BMI gain across the life span and earlier onset of overweight/obesity are associated with impaired glucose metabolism, in part through attained adult BMI.

Water woes in the Green Mountain State

"For now, the state has appointed a panel to examine ways of going ahead with the phase-out without running afoul of workplace rules and practical considerations. Among them: whether it would cost more to re-install water fountains in buildings than to keep buying bottled water."

From Businessweek: Cyber weapons

"To deal with the Code War, which amounts to a constant state of threat, governments and companies can always try to develop their own technology. As with smart bombs, fighter jets, and other real-world countermeasures, though, it’s often easier to buy than build. 'The hacking industry is way ahead in terms of being able to deploy something like a massive botnet,' says Amichai Shulman, chief technology officer at Imperva, a security specialist. 'If a nation wants to launch an attack that distributes some kind of malware, it makes more sense for them to just rent an existing botnet.'”

COPD genetics

Allergol Int. 2011 Jul 25. [Epub ahead of print]
Genetics of COPD.
Nakamura H.
Department of Medicine, Tokyo Electric Power Company Hospital, Tokyo, Japan.

Previous family studies suggested that genetic variation contributes to COPD susceptibility. The only gene proven to influence COPD susceptibility is SERPINA1, encoding α1-antitrypsin. Most studies on COPD candidate genes except SERPINA1, have not been consistently replicated. However, longitudinal studies of decline in lung function, meta-analyses of candidate gene studies, and family-based linkage analyses suggested that variants in EPHX1, GST, MMP12, TGFB1, and SERPINE2 were associated with susceptibility to COPD. A genome-wide association (GWA) study has recently demonstrated that CHRNA3/5 in 15q25 was associated with COPD compared with control smokers. It was of interest that the CHRNA3/5 locus was associated with nicotine dependence and lung cancer as well. The associations of HHIP on 4q31 and FAM13A on 4q22 with COPD were also suggested in GWA studies. Another GWA study has shown that BICD1 in 12p11 was associated with the presence or absence of emphysema. Although every genetic study on COPD has some limitations including heterogeneity in smoking behaviors and comorbidities, it has contributed to the progress in elucidating the pathogenesis of COPD. Future studies will make us understand the mechanisms underlying the polygenic disease, leading to the development of a specific treatment for each phenotype.

Friday, July 22, 2011

"The attempt to impose fiscal union on all Europe will bring its demise."

"Monetary union, always unworkable, has set in train a European disaster
The eurozone is edging closer to doomed fiscal union. But sceptics shouldn't celebrate, as the chaos will reach Britain too"

From Tax Prof Blog: ABA Responds to Sen. Grassley's Concerns About Law School Accreditation

"When I met Lenin …my most vivid impressions were of bigotry and Mongolian cruelty."

Killing With Kindness: What’s Wrong With Benevolence: Happiness, Private Property, and the Limits of Enlightenment, by David Stove

From Marc Ladanyi and colleagues: Lung cancer and acquired resistance to molecular therapy

Clin Cancer Res. 2011 Jul 20. [Epub ahead of print]
New Strategies in Overcoming Acquired Resistance to EGFR Tyrosine Kinase Inhibitors in Lung Cancer.
Oxnard GR, Arcila ME, Chmielecki J, Ladanyi M, Miller VA, Pao W.
Medical Oncology, Dana-Farber Cancer Institute.

The management of non-small cell lung cancer (NSCLC) has been transformed by the observation that lung adenocarcinomas harboring mutations in EGFR are uniquely sensitive to EGFR tyrosine kinase inhibitors (TKIs). In these patients, acquired resistance to EGFR-TKI develops after a median of 10-14 months, at which time the current standard practice is to switch to conventional cytotoxic chemotherapy. Several possible mechanisms for acquired resistance have been identified, the most common being the development of an EGFR T790M gate-keeper mutation in over 50% of cases. In this review, we discuss recent advances in the understanding of acquired TKI resistance in EGFR-mutant lung cancer and review therapeutic progress with second generation TKIs and combinations of targeted therapies.

Do cancer treatment research trials match the real world?

Ann Surg. 2011 Jul 19. [Epub ahead of print]
Cancer Trials versus the Real World in the United States.
Al-Refaie WB, Vickers SM, Zhong W, Parsons H, Rothenberger D, Habermann EB.
From the Department of Surgery, University of Minnesota and Minneapolis Veteran Affairs Medical Center, Minneapolis, Minnesota.

Federal policies have been implemented to mitigate underenrollment in cancer trials in the United States. We sought to identify patterns and predictors of enrollment patterns to cancer trials in a contemporary era using a real world setting.

The 2001-2008 California Cancer Registry was used to determine patterns and predictors of enrollment in clinical trials for stage 0 to IV solid organ malignant tumors. Multivariate techniques were used to identify predictors of enrollment in cancer protocols, controlling for covariates.

Less than a percent (0.64%) of patients enrolled in clinical trials (1566 of 244,528). Black patients were less likely than whites to enroll in trials (0.48% vs 0.67%, P < 0.05). On multivariate analysis, older persons (>65 years), early stage cancer, and those with lung or gastrointestinal cancers were less likely to be enrolled in cancer trials. Results were consistent when evaluated among only nonbreast cancer protocols. Though approaching significance, black, underinsured, and uninsured patients showed trends toward underenrollment.

In addition to profoundly low overall cancer trial accrual, vast underrepresentation by age, cancer stage, and site continue to exist. The generalizability of these trials to a real world perspective remains an open question. Physicians, payers, the National Cancer Institute, and other stakeholders need to develop broader cancer trials to benefit the millions of patients with cancer in the United States.

Chemical exposure and lung cancer

J Environ Public Health. 2011;2011:463701. Epub 2011 Jul 10.
Association between Six Environmental Chemicals and Lung Cancer Incidence in the United States.
Luo J, Hendryx M, Ducatman A.
Department of Community Medicine, School of Medicine, West Virginia University, P.O. Box 9190, Morgantown, WV 26506, USA.

Background. An increased risk of lung cancer has been observed at exposure to certain industrial chemicals in occupational settings; however, less is known about their carcinogenic potential to the general population when those agents are released into the environment. Methods. We used the Toxics Release Inventory (TRI) database and Surveillance, Epidemiology, and End Results (SEER) data to conduct an ecological study at the county level. We used multiple linear regression to assess the association of age-adjusted lung cancer incidence with the quantities of on-site air and water releases of six selected industrial chemicals including arsenic, 1,3 butadiene, cadmium, chromium, formaldehyde, and nickel after controlling for other risk variables. Results. Overall, we observed a significantly increased risk of lung cancer incidence associated with releases of chromium, formaldehyde, and nickel. The links were present for both males and females. Significant effects were present in nonmetropolitan but not metropolitan counties. Releases of arsenic, 1,3 butadiene, and cadmium were reported by small numbers of facilities, and no relationships to lung cancer incidence were detected. Conclusions. Our results suggest that environmental exposure to chromium, formaldehyde, and nickel from TRI sites may increase population risk of lung cancer. These findings need to be confirmed in individual-level studies, but in congruence with the precautionary principle in environmental science, support prudent efforts to limit release of these agents into the environment.

Thursday, July 21, 2011

"Europe, whole and free, is sailing through freezing waters..."

"'Europe is in its most severe crisis in 50 years,' Joschka Fischer, the former German foreign minister, told me. 'What appears to be a sovereign debt crisis is really a political crisis. We don't have the institutions or the political will or the leaders willing to do what is necessary. We're talking about the success or failure of the whole project of Europe since World War II, and everywhere there is a lack of political leadership.'''

From Columbia: Regarding patients' appropriate radiation doses

Radiology. 2011 Jul 19. [Epub ahead of print]
Impact of Reduced Patient Life Expectancy on Potential Cancer Risks from Radiologic Imaging.
Brenner DJ, Shuryak I, Einstein AJ.
Center for Radiological Research and Departments of Medicine and Radiology, College of Physicians and Surgeons, Columbia University Medical Center, 630 W 168th St, VC-11-235, New York, NY 10032.

Purpose: To quantify the effect of reduced life expectancy on cancer risk by comparing estimated lifetime risks of lung cancer attributable to radiation from commonly used computed tomographic (CT) examinations in patients with and those without cancer or cardiac disease. Materials and Methods: With the use of clinically determined life tables, reductions in radiation-attributable lung cancer risks were estimated for coronary CT angiographic examinations in patients with multivessel coronary artery disease who underwent coronary artery bypass graft (CABG) surgery and for surveillance CT examinations in patients treated for colon cancer. Statistical uncertainties were estimated for the risk ratios in patients who underwent CABG surgery and patients with colon cancer versus the general population. Results: Patients with decreased life expectancy had decreased radiation-associated cancer risks. For example, for a 70-year-old patient with colon cancer, the estimated reduction in lifetime radiation-associated lung cancer risk was approximately 92% for stage IV disease, versus 8% for stage 0 or I disease. For a patient who had been treated with CABG surgery, the estimated reduction in lifetime radiation-associated lung cancer risk was approximately 57% for a 55-year-old patient, versus 12% for a 75-year-old patient. Conclusion: The importance of radiation exposure in determining optimal imaging usage is much reduced for patients with markedly reduced life expectancies: Imaging justification and optimization criteria for patients with substantially reduced life expectancies should not necessarily be the same as for those with normal life expectancies. © RSNA, 2011.

Steakhouse Syndrome: Not what you might think

World J Gastrointest Endosc. 2011 May 16;3(5):101-4.
Steakhouse syndrome causing large esophageal ulcer and stenosis.
Enomoto S, Nakazawa K, Ueda K, Mori Y, Maeda Y, Shingaki N, Maekita T, Ota U, Oka M, Ichinose M.
Shotaro Enomoto, Kazuki Ueda, Yoshiyuki Mori, Yoshimasa Maeda, Naoki Shingaki, Takao Maekita, Masashi Oka, Masao Ichinose, Department of Gastroenterology, School of Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama 641-0012, Japan.

A 66-year-old man developed dysphagia during dinner and was evaluated 2 d later in our hospital because of persistent symptoms. Upper gastrointestinal endoscopy showed no impacted food, but advanced esophageal cancer was suspected based on the presence in the upper esophagus of a large irregular ulcerative lesion with a thick white coating and stenosis. Further imaging studies were performed to evaluate for metastases, revealing circumferential esophageal wall thickening and findings suggestive of lung and mediastinal lymph node metastases. However, dysphagia symptoms and the esophageal ulcer improved after hospital admission, and histopathological examination of the esophageal mucosa revealed only nonspecific inflammation. At the time of symptom onset, the patient had been eating stewed beef tendon (Gyusuji nikomi in Japanese) without chewing well. Esophageal ulceration due to steakhouse syndrome was therefore diagnosed. The lung lesion was a primary lung cancer that was surgically resected. Although rare, steakhouse syndrome can cause large esophageal ulceration and stenosis, so care must be taken to distinguish this from esophageal cancer.

Early lung cancers: segmentectomy vs lobectomy

Surg Today. 2011 Aug;41(8):1062-6. Epub 2011 Jul 20.
How many pathological T1N0M0 non-small cell lung cancers can be completely resected in one segment? Special reference to high-resolution computed tomography findings.
Horinouchi H, Nomori H, Nakayama T, Kohno M, Izumi Y, Watanabe M, Kawamura M.
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.

Although segmentectomy is attempted for small non-small cell lung cancer (NSCLC) tumors, no reports have so far described how many of these tumors can be candidates for a successful resection by single segmentectomy.

In all, 135 patients with peripheral p-T1N0M0 NSCLC were examined. The tumors were classified into five groups divided by every 0.5-cm increase in size. Tumor locations were classified into two groups - limited to within one segment and extended beyond one segment - based on the identification of whether pulmonary vessels and the bronchi were involved in the tumors on high-resolution computed tomography. Differences in the proportion of tumors limited within one segment between tumors smaller and larger than each class of tumor size were assessed.

The tumor sizes were 0-1.0 cm in 8 tumors, 1.1-1.5 cm in 27, 1.6-2.0 cm in 35, 2.1-2.5 cm in 34, and 2.6-3.0 cm in 31 tumors. Of these 135 tumors, 92 (65%) were limited to one segment, whereas 48 (35%) had extended beyond one segment. When the tumor size was less than 30 mm, the proportion of tumor limited within one segment did not show any significant difference depending on the size of the tumor.

More than one-third of p-T1N0M0 NSCLC tumors extended beyond one segment, irrespective of size. It is therefore noteworthy that resection of up to two segments or lobectomy should be undertaken for prevention of local recurrence in patients with p-T1N0M0 peripheral NSCLC.

"The land that invented democracy used it to perfect the art of living at the expense of others"

"Why the E.U. extended credit to a nation whose governments have been in a chronic state of default since the country gained independence from the Ottoman Empire in 1832 is a fitting subject for a News of the World expose. Perhaps they were being advised by Fannie Mae."

From The New Atlantis: Why Bother with Marshall McLuhan?

"Much of what McLuhan wrote came an instant too soon, and perhaps that’s the best reason to read him, infuriating and confusing though that experience may be."

Tuesday, July 19, 2011

Bird longevity, bird muscles, and bird BMR

J Comp Physiol B. 2011 Jul 16. [Epub ahead of print]
Metabolic rate and membrane fatty acid composition in birds: a comparison between long-living parrots and short-living fowl.
Montgomery MK, Hulbert AJ, Buttemer WA.
Diabetes & Obesity Program, Garvan Institute of Medical Research, Darlinghurst, NSW, 2010, Australia,

Both basal metabolic rate (BMR) and maximum lifespan potential (MLSP) vary with body size in mammals and birds and it has been suggested that these are mediated through size-related variation in membrane fatty acid composition. Whereas the physical properties of membrane fatty acids affect the activity of membrane proteins and, indirectly, an animal's BMR, it is the susceptibility of those fatty acids to peroxidation which influence MLSP. Although there is a correlation between body size and MLSP, there is considerable MLSP variation independent of body size. For example, among bird families, Galliformes (fowl) are relatively short-living and Psittaciformes (parrots) are unusually long-living, with some parrot species reaching maximum lifespans of more than 100 years. We determined BMR and tissue phospholipid fatty acid composition in seven tissues from three species of parrots with an average MLSP of 27 years and from two species of quails with an average MLSP of 5.5 years. We also characterised mitochondrial phospholipids in two of these tissues. Neither BMR nor membrane susceptibility to peroxidation corresponded with differences in MLSP among the birds we measured. We did find that (1) all birds had lower n-3 polyunsaturated fatty acid content in mitochondrial membranes compared to those of the corresponding tissue, and that (2) irrespective of reliance on flight for locomotion, both pectoral and leg muscle had an almost identical membrane fatty acid composition in all birds.

From Am J Respir Crit Care Med: Cystic Fibrosis respiratory exacerbations

Am J Respir Crit Care Med. 2011 Jul 15;184(2):278.
Location and duration of treatment of cystic fibrosis respiratory exacerbations.
Schechter MS, Wagener J, Konstan MW, Morgan W.

Using EMR to identify comorbidity in lung cancer patients

J Cancer Epidemiol. 2011;2011:983271. Epub 2011 May 2.
Evaluation of the Reliability of Electronic Medical Record Data in Identifying Comorbid Conditions among Patients with Advanced Non-Small Cell Lung Cancer.
Muehlenbein CE, Hoverman JR, Gruschkus SK, Forsyth M, Chen C, Lopez W, Lawson A, Hartnett HJ, Pohl G.
Lilly Corporate Center, Eli Lilly and Company, Indianapolis, IN 46285, USA.

Background. Traditional methods for identifying comorbidity data in EMRs have relied primarily on costly and time-consuming manual chart review. The purpose of this study was to validate a strategy of electronically searching EMR data to identify comorbidities among cancer patients. Methods. Advanced stage NSCLC patients (N = 2,513) who received chemotherapy from 7/1/2006 to 6/30/2008 were identified using iKnowMed, US Oncology's proprietary oncology-specific EMR system. EMR data were searched for documentation of comorbidities common to advanced stage cancer patients. The search was conducted by a series of programmatic queries on standardized information including concomitant illnesses, patient history, review of systems, and diagnoses other than cancer. The validity of the comorbidity information that we derived from the EMR search was compared to the chart review gold standard in a random sample of 450 patients for whom the EMR search yielded no indication of comorbidities. Negative predictive values were calculated. Results. The overall prevalence of comorbidities of 22%. Overall negative predictive value was 0.92 in the 450 patients randomly sampled patients (36 of 450 were found to have evidence of comorbidities on chart review). Conclusion. Results of this study suggest that efficient queries/text searches of EMR data may provide reliable data on comorbid conditions among cancer patients.

From Byron York: Lose the battle; win the war?

"'The biggest problem the president has right now is that he is trying to make his arguments with an anemic economy and staggering deficits,' says the Republican involved in the fight. 'He's saying, "I've got an economic plan," and they're responding, "You mean like the last one?"'

Republicans know they're losing the message battle, but in the end, they are convinced that they'll win the war."

Read more at the Washington Examiner:

"Genetic engineers have invented a new way to quickly, precisely and thoroughly rewrite the genome of living bacteria."

"James Collins of Boston University says the paper represents an important advance for synthetic biology. 'The team shows it is possible to introduce in a rational way large-scale changes in the genome of an organism. They have very cleverly swapped one punctuation mark with another punctuation mark, which opens up the possibility of rewriting the genome wholesale.'"

Richard Epstein on the debt limit

"The current trajectory of taxation, regulation, deficits, and expenditures is unsustainable."

Been to the opera lately?

"In The Opera Fanatic: Ethnography of an Obsession, Claudio E. Benzecry identifies four distinct types of the obsessed attendee: There’s the hero, who believes he is keeping the opera house open and the art itself alive and vital. There’s the addict, who is willing to sacrifice his families, friends, lovers, money, and sanity to attend multiple performances of the same opera, to listen to the records and attend lectures and travel to distant theaters. There’s the nostalgic, for whom everything was better when it was sung by Maria Callas, or Joan Sutherland, or back in 1965, or back when people took pride in knowing about opera. Then there’s the pilgrim, the devoted subject who treats the opera house as a religious temple."

Monday, July 18, 2011


"'Does your dog love you?' The answer is yes: probably even more than you think."

In Defence of Dogs by John Bradshaw – review
John Bradshaw calls for a new understanding of our canine friends

Sunday, July 17, 2011

"When people say they love writing, they usually mean they love having written.)"

"So yes, he can write a book. But why would he want to? Why, in fact, would anyone want to?"

TB blood tests "dangerous"

"Widely used blood tests to detect tuberculosis are "dangerous" to patients because they are unreliable and can produce wrong results, the World Health Organization warned Sunday."

Saturday, July 16, 2011

The Unselfish Gene

"Like biology, however, the discipline of economics has changed over the years. In 2009, Elinor Ostrom was awarded the Nobel Prize in economics for showing how commons can—and do—sustain themselves for centuries as well-functioning systems. The most striking example is in Spain, where thousands of farmers have been managing their access to water through self-regulated irrigation districts for more than five centuries."

Dartmouth and drinking

"Thirst for drinking-related news still not quenched? Read on for more hysteria in Hanover."

Less academics, more narcissism

"California’s budget crisis has reduced the University of California to near-penury, claim its spokesmen. “Our campuses and the UC Office of the President already have cut to the bone,” the university system’s vice president for budget and capital resources warned earlier this month, in advance of this week’s meeting of the university’s regents. Well, not exactly to the bone. Even as UC campuses jettison entire degree programs and lose faculty to competing universities, one fiefdom has remained virtually sacrosanct: the diversity machine."

Friday, July 15, 2011

Dr. John Lukeman, again, thank you. Rest in peace

John M. Lukeman, M.D. ,96, passed away in Houston, Texas on July 14, 2011, in his home. He was born in New York City, New York, on October 19, 1914, to Samuel and Bella Lukeman.
Dr. Lukeman was a very loving and caring person that will be missed by everyone that knew him especially his friends and family. He proudly served in the United States Army for 26 years and retired from Ft. Sam Houston/ Brook Army Medical Center, with the rank of Colonel. Dr. Lukeman served in Germany, and in the Pacific Theater, specifically Japan, assisting and treating the burn victims of Hiroshima. In his civilian career, he practiced medicine at M. D. Anderson Cancer Center and retired as the Chief of Pathology. He was inducted into the Thomas Jefferson Alumni Society for practicing medicine for over 50 years.
A Funeral Service will be held at Memorial Oaks Funeral Home, 13001 Katy Freeway, Houston, Texas, 77079, Sunday, July 17, 2011, at 12:30 p.m. Interment will follow at Memorial Oaks Cemetery.
In lieu of flowers, donations can be made to M.D. Anderson Cancer Center.

Perceptions of weakness and ageing in older adults

Int J Older People Nurs. 2011 Jun 30. doi: 10.1111/j.1748-3743.2011.00280.x. [Epub ahead of print]
Older adults' perceptions of weakness and ageing.
Rush KL, Watts WE, Stanbury J.
Associate Professor, School of Nursing, University of British Columbia Okanagan, Kelowna, BC, CanadaClinical Instructor, College of Nursing, University of Saskatchewan, Saskatoon, SK, CanadaInstructor, School of Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada.

rush k.l., watts w.e. & stanbury j. (2011) Older adults' perceptions of weakness and ageing. International Journal of Older People Nursing00, 000-000 doi: 10.1111/j.1748-3743.2011.00280.x Background.  Age-related weakness, or sarcopenia, has been related to functional disability, falls, frailty and mortality. Although it is one of the most common symptoms older adults link to their functional abilities, to date, no studies have explored older adults' perceptions of weakness and its association with ageing. Aims and objectives.  To understand the meaning of weakness for older adults' and their perceptions of its association with ageing. Designs.  A qualitative descriptive design involved in-depth interviews with 13 community-dwelling older adults. Results.  Weakness was described primarily in two ways: (i) inability and (ii) inward turning. The extreme of weakness, as giving up and giving in, which older adults applied to others, not themselves, prompted them to engage in several efforts at staying strong. These included motivating self-talk, achieving balance, keeping busy and active, and self-validating as a strong person. Older adults' perceptions of the association between weakness and ageing were variable and characterized by considerable ambiguity. Implications for practice.  Nurses must be alert to both the visible and subtler dimensions of weakness. It is important to engage older adults in active strategies that enhance muscle strength while capitalizing on their self-motivating and validating efforts at staying strong.

ALK-rearranged lung cancers

Am J Surg Pathol. 2011 Aug;35(8):1226-1234.
Comprehensive Histologic Analysis of ALK-Rearranged Lung Carcinomas.
Yoshida A, Tsuta K, Nakamura H, Kohno T, Takahashi F, Asamura H, Sekine I, Fukayama M, Shibata T, Furuta K, Tsuda H.
*Pathology and Clinical Laboratory Division ∥Division of Thoracic Surgery ¶Division of Thoracic Oncology, National Cancer Center Hospital †Department of Pathology, The University of Tokyo ‡Division of Genome Biology ♯Division of Cancer Genomics, Center for Medical Genomics, National Cancer Center Research Institute §Department of Clinical Medicine (Biostatistics), School of Pharmacy, Kitasato University, Tokyo, Japan.

A subset (1% to 5%) of non-small-cell lung carcinomas harbors the EML4-ALK fusion gene. Data from previous studies on the histomorphology of ALK-rearranged lung cancer are inconsistent, and the specific histologic parameters that characterize this subset and how accurately such parameters predict underlying ALK abnormality remain uncertain. To answer these questions, we performed a comprehensive histologic analysis of 54 surgically resected, extensively sampled ALK-rearranged lung carcinomas and compared them with 100 consecutive resections of ALK-wild-type lung cancers. All 54 cases showed at least a focal adenocarcinoma component, and 3 and 2 cases had additional squamous and sarcomatoid differentiation, respectively. Solid or acinar growth pattern, cribriform structure, presence of mucous cells (signet-ring cells or goblet cells), abundant extracellular mucus, lack of lepidic growth, and lack of significant nuclear pleomorphism were more common in ALK-positive cancers. Two recognizable constellations of findings, a solid signet-ring cell pattern and a mucinous cribriform pattern, were present at least focally in the majority (78%) of ALK-positive tumors, but were rare (1%) in ALK-negative tumors. Multivariate analysis showed that a combination of these 2 patterns was the most powerful histologic indicator of ALK rearrangement. Characteristic histologies were present both in primary sites and in metastases. Thus, histologic findings may help to identify cases for ALK testing. However, none of the histologic parameters were completely sensitive or specific to ALK rearrangement, and histomorphology should not replace confirmatory molecular or immunohistochemical studies. ALK-positive cancers commonly showed coexpression of thyroid transcription factor-1 and p63, and its significance is currently unclear.

From MD Anderson: Battling lung cancer!

Cancer Prev Res (Phila). 2011 Jul;4(7):962-72.
The BATTLE to Personalize Lung Cancer Prevention through Reverse Migration.
Gold KA, Kim ES, Lee JJ, Wistuba II, Farhangfar CJ, Hong WK.
Division of Cancer Medicine, Unit 421, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030.

Agents can enter clinical development for cancer prevention either initially or after previous development for a different indication, such as arthritis, with both approaches consuming many years of development before an agent is fully evaluated for cancer prevention. We propose the following, third approach: reverse migration, that is, importing agents, targets, and study designs to personalize interventions and concepts developed in advanced cancer to the setting of cancer prevention. Importing these "ready-made" features from therapy will allow reverse migration to streamline preventive agent development. We recently reported the Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination (BATTLE) trial of personalized lung cancer therapy and now propose the reverse migration development of personalized lung cancer prevention based on the BATTLE model. Cancer Prev Res; 4(7); 962-72. ©2011 AACR.

From Memorial Sloan-Kettering: Personalized medicine

Hum Genet. 2011 Jul;130(1):3-14. Epub 2011 Jun 26.
Personalized medicine: new genomics, old lessons.
Offit K.
Clinical Genetics Service, Department of Medicine, Program in Cancer Biology and Genetics, Sloan-Kettering Institute, Memorial Sloan-Kettering Cancer Center, New York, NY, 10021, USA,

Personalized medicine uses traditional, as well as emerging concepts of the genetic and environmental basis of disease to individualize prevention, diagnosis and treatment. Personalized genomics plays a vital, but not exclusive role in this evolving model of personalized medicine. The distinctions between genetic and genomic medicine are more quantitative than qualitative. Personalized genomics builds on principles established by the integration of genetics into medical practice. Principles shared by genetic and genomic aspects of medicine, include the use of variants as markers for diagnosis, prognosis, prevention, as well as targets for treatment, the use of clinically validated variants that may not be functionally characterized, the segregation of these variants in non-Mendelian as well as Mendelian patterns, the role of gene-environment interactions, the dependence on evidence for clinical utility, the critical translational role of behavioral science, and common ethical considerations. During the current period of transition from investigation to practice, consumers should be protected from harms of premature translation of research findings, while encouraging the innovative and cost-effective application of those genomic discoveries that improve personalized medical care.

Personalized lung cancer prevention

Cancer Prev Res (Phila). 2011 Jul;4(7):949-53.
The dawn of a revolution in personalized lung cancer prevention.
Khuri FR.
FACP, Chair, Department of Hematology and Medical Oncology, Deputy Director, Winship Cancer Institute, Emory University School of Medicine, 1365 C Clifton Road, NE, Atlanta, GA 30322.

Lung cancer prevention and early detection, which have fallen on hard times for more than the past 20 years, seem to have turned a corner toward better times ahead. Exciting new results of randomized controlled trials that targeted the arachidonic acid pathway, including a celecoxib trial reported by Mao and colleagues in this issue of the journal (beginning on page 984) and a trial of the prostacyclin analog iloprost, complement recently reported 20%-30% lung cancer mortality reductions, either with aspirin in targeting the arachidonic acid pathway or with computed tomography screening. The new results show encouraging activity personalized to former smokers and/or people expressing predictive biomarkers. These trials and technological advances in molecular profiling and imaging herald substantial clinical advances on the horizon of this field. Cancer Prev Res; 4(7); 949-53. ©2011 AACR.

What are intellectuals good for?

"The need for specialized empirical intellectuals who can clarify technical problems for the public does indeed overshadow the other roles that intellectuals might take on, and the experience of residing in a republic that often resembles an oligarchy or an empire can be, for American intellectuals, horribly disorienting. To respond with essays and reviews is, to say the least, awkward. But that turns out not to matter as much as one might think. The grace and integrity and sympathy required of the good citizen must be learned, and we cannot afford to neglect any opportunity for that education."

Thursday, July 14, 2011

From Duke: High resolution CT scan evaluation of diffuse cystic lung disease

AJR Am J Roentgenol. 2011 Jun;196(6):1305-11.
Diffuse cystic lung disease at high-resolution CT.
Seaman DM, Meyer CA, Gilman MD, McCormack FX.
Department of Radiology, Duke University Medical Center, Box 3808 DUMC, Durham, NC 27710, USA.
OBJECTIVE: This article will illustrate and describe the spectrum of diseases associated with air cysts at high-resolution CT (HRCT). CONCLUSION: HRCT is an important modality in the evaluation of interstitial lung disease to include cystic lung disease. Although most commonly associated with lymphangioleiomyomatosis or Langerhans cell histiocytosis, cystic lung disease is increasingly being recognized as a feature of other entities. Awareness of the spectrum of HRCT findings associated with these diseases may help the trained observer narrow the differential diagnosis.

The use of sleeve lobectomy for peripheral lung cancers with intralobar nodal metastases invading the bronchus

Gen Thorac Cardiovasc Surg. 2011 Jul;59(7):515-7. Epub 2011 Jul 14.
Extended sleeve lobectomy for interlobar lymph node metastasis invading the bronchus from peripheral lung cancer.
Tsubochi H, Kanai Y, Tezuka K, Watanabe Y, Koyama S, Nakano T, Isogami K, Endo S.
Department of General Thoracic Surgery, Saitama Medical Center, Jichi Medical School, 1-847 Amanuma-cho, Saitama, 330-8503, Japan,
Although extended sleeve lobectomy has been used as an alternative to pneumonectomy for the treatment of centrally located lung cancer, the validity of this surgical procedure is unclear in patients with peripheral lung cancer with interlobar lymph node metastasis invading the bronchus. We herein report four patients with peripheral lung cancer in the left lower lobe who underwent extended sleeve lobectomy consequent to interlobar lymph node metastasis. The tumor and metastasized lymph node was extirpated en bloc with division of the main bronchus and upper division bronchus, and those bronchi were anastomosed using the telescope method. All patients were doing well without recurrence. Extended sleeve lobectomy may be applicable to patients with peripheral lung cancer with interlobar lymph node metastasis invading the bronchus to avoid pneumonectomy.

From MD Anderson: Disparities in symptom burden in lung cancer patients

Cancer. 2011 Jul 12. doi: 10.1002/cncr.26312. [Epub ahead of print]
Early referral to supportive care specialists for symptom burden in lung cancer patients: A Comparison of Non-Hispanic Whites, Hispanics, and Non-Hispanic Blacks.
Reyes-Gibby CC, Anderson KO, Shete S, Bruera E, Yennurajalingam S.
Department of Epidemiology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.
Effective management of symptoms in cancer patients requires early intervention. This study assessed whether the timing of referral to the Supportive Care Center (SCC) and symptom burden outcome varied by race or ethnicity in lung cancer patients who had been seen at a tertiary cancer center.

Non-Hispanic white (n = 752), Hispanic (n = 111), and non-Hispanic black (n = 117) patients with nonsmall cell lung cancer comprised this sample. Data on sociodemographic factors, stage of disease, comorbid conditions, and symptom severity (pain, depressed mood, fatigue) served as potential predictor variables.

Whereas the mean time (15 months; median = 7 months) from initial presentation at the cancer center to referral to the SCC did not vary by race or ethnicity, we found that Hispanics and non-Hispanic blacks had higher symptom burden when they first presented at the cancer center than non-Hispanic whites. Severe pain, depressed mood, and fatigue were significant predictors for early referral (<7 months) of non-Hispanic whites, but only severe fatigue (P <.05) was predictive of early referral for Hispanics and non-Hispanic blacks. Furthermore, while the proportion of non-Hispanic white patients reporting severe pain, depressed mood, and fatigue significantly decreased (P <.001) at first follow-up visit after referral to the SCC; among Hispanics, improvement was only observed for depressed mood. No improvement in any of these symptoms was observed for non-Hispanic blacks.

Whereas the timing of referral to supportive services did not vary by race, disparities in symptom burden outcomes persisted. Additional studies are needed to validate our findings. Cancer 2011;. © 2011 American Cancer Society.

From the Annals of Emergency Medicine: Tort reform

Ann Emerg Med. 2011 Jul;58(1):111.
Reform of tort law.

From JAMA: On health care reform and incentives

JAMA. 2011 Jul 13;306(2):204-5.
Realigning incentives to achieve health care reform.
Coller BS.

Wednesday, July 13, 2011

Tuesday, July 12, 2011

From the LA Times: Smoking, pregnancy, and birth defects,0,5221073.story

"The last major interest group opposing rational teacher evaluation had bowed to the inevitable."

From Royal Brompton Hospital: Good review of organizing pneumonia on HRCT

Eur Radiol. 2011 Jul 10. [Epub ahead of print]
Organizing pneumonia: a kaleidoscope of concepts and morphologies.
Roberton BJ, Hansell DM.
Department of Radiology, Royal Brompton Hospital, Sydney Street, London, SW36NP, UK.
The basic histopathological pattern of organizing pneumonia (OP) is well recognized, but the contexts in which it is encountered continue to increase. In parallel with an appreciation of new causes and associations of OP, an understanding of OP in the spectrum of lung injury and repair has evolved. There is an increasing array of HRCT manifestations of OP, some of which have only recently been described. This article concentrates on new concepts surrounding OP and highlights newly described imaging patterns.

Research integrity. Still a problem.

Proc (Bayl Univ Med Cent). 2011 Jul;24(3):224-6.
Unraveling the conflicts to preserve research integrity.
Chapman BJ.
Baylor Research Institute, Dallas, Texas.
PMID: 21738296 [PubMed - in process]

From Ignacio Wistuba and colleagues: Gene expression signatures and lung cancer prognosis

Clin Cancer Res. 2011 Jul 8. [Epub ahead of print]
Robust Gene Expression Signature from Formalin-Fixed Paraffin-Embedded Samples Predicts Prognosis of Non-Small-Cell Lung Cancer Patients.
Xie Y, Xiao G, Coombes K, Behrens C, Solis LM, Raso MG, Girard L, Erickson HS, Roth JA, Heymach JV, Moran C, Danenberg KD, Minna JD, Wistuba II.
Clinical Sciences, University of Texas Southwesten Medical Center.

The requirement of frozen tissues for microarray experiments limits the clinical usage of genome-wide expression profiling using microarray technology. The goal of this study is to test the feasibility of developing lung cancer prognosis gene signatures using genome-wide expression profiling of formalin-fixed paraffin-embedded (FFPE) samples, which are widely available and provide a valuable rich source for studying the association of molecular changes in cancer and associated clinical outcomes.

We randomly selected 100 Non-Small-Cell lung cancer (NSCLC) FFPE samples with annotated clinical information from the UT-Lung SPORE Tissue Bank. We micro dissected tumor area from FFPE specimens, and used Affymetrix U133 plus 2.0 arrays to attain gene expression data. After strict quality control and analysis procedures, a supervised principal component analysis was used to develop a robust prognosis signature for NSCLC. Three independent published microarray data sets were used to validate the prognosis model.

This study demonstrated that the robust gene signature derived from genome-wide expression profiling of FFPE samples is strongly associated with lung cancer clinical outcomes, can be used to refine the prognosis for stage I lung cancer patients and the prognostic signature is independent of clinical variables. This signature was validated in several independent studies and was refined to a 59-gene lung cancer prognosis signature.

We conclude that genome-wide profiling of FFPE lung cancer samples can identify a set of genes whose expression level provides prognostic information across different platforms and studies, which will allow its application in clinical settings.

Can Antarctic sponge bacteria help control a common Cystic Fibrosis-related infection?

Biotechnol Adv. 2011 Jun 29. [Epub ahead of print]
Sponge-associated microbial Antarctic communities exhibiting antimicrobial activity against Burkholderia cepacia complex bacteria.
Papaleo MC, Fondi M, Maida I, Perrin E, Lo Giudice A, Michaud L, Mangano S, Bartolucci G, Romoli R, Fani R.
Laboratory of Microbial and Molecular Evolution, Dept of Evolutionary Biology, University of Florence, via Romana 17-19, I-50125 Firenze, Italy.

The aerobic heterotrophic bacterial communities isolated from three different Antarctic sponge species were analyzed for their ability to produce antimicrobial compounds active toward Cystic Fibrosis opportunistic pathogens belonging to the Burkholderia cepacia complex (Bcc). The phylogenetic analysis performed on the 16S rRNA genes affiliated the 140 bacterial strains analyzed to 15 genera. Just three of them (Psychrobacter, Pseudoalteromonas and Arthrobacter) were shared by the three sponges. The further Random Amplified Polymorphic DNA analysis allowed to demonstrate that microbial communities are highly sponge-specific and a very low degree of genus/species/strain sharing was detected. Data obtained revealed that most of these sponge-associated Antarctic bacteria and belonging to different genera were able to completely inhibit the growth of bacteria belonging to the Bcc. On the other hand, the same Antarctic strains did not have any effect on the growth of other pathogenic bacteria, strongly suggesting that the inhibition is specific for Bcc bacteria. Moreover, the antimicrobial compounds synthesized by the most active Antarctic bacteria are very likely Volatile Organic Compounds (VOCs), a finding that was confirmed by the SPME-GC-MS technique, which revealed the production of a large set of VOCs by a representative set of Antarctic bacteria. The synthesis of these VOCs appeared to be related neither to the presence of pks genes nor the presence of plasmid molecules. The whole body of data obtained in this work indicates that sponge-associated bacteria represent an untapped source for the identification of new antimicrobial compounds and are paving the way for the discovery of new drugs that can be efficiently and successfully used for the treatment of CF infections.

From UNC-Charlotte: Diabetes and binge eating disorder in bariatric surgery candidates

Eat Behav. 2011 Aug;12(3):175-81. Epub 2011 Apr 21.
A comparative analysis of Type 2 diabetes and binge eating disorder in a bariatric sample.
Webb JB, Applegate KL, Grant JP.
UNC Charlotte Department of Psychology, 9201 University City Blvd., Charlotte, NC 28223, USA.

An emerging literature has illuminated an important link between Type 2 diabetes mellitus (DM) and binge eating disorder (BED) within obese cohorts. However, prior work has not examined this relationship specifically in a weight loss surgery (WLS) sample or fully explored potential psychosocial factors associated with this co-occurrence. Therefore, the present investigation sought to identify socio-demographic (i.e. age, education, BMI, ethnicity, gender, age of obesity onset) and psychological (i.e. depressive symptoms, hedonic hunger/food locus of control beliefs, severity of binge eating-related cognitions) correlates of the co-occurrence of Type 2 DM and BED among bariatric surgery candidates. An archival sample of 488 patients seeking surgical treatment for clinical obesity completed a standard battery of pre-operative psychosocial measures. The presence of BED was evaluated using a semi-structured clinical interview based on the DSM-IV TR (APA, 2000) and was further corroborated by responses on the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R; Spitzer, Yanovski, & Marcus, 1993). Results indicated that 8.2% of the sample was classified as having both Type 2 DM and BED concurrently. A multivariate logistic regression model revealed that in addition to other psychological (e.g., binge eating-related cognitions, hedonic hunger) and demographic variables (i.e. male gender), African American ethnicity (OR=3.3: 1.41-7.73) was a particularly robust indicator of comorbid status. Findings support and extend previous health disparity research urging greater attention to the needs of traditionally underserved, at-risk populations seeking treatment for obesity complicated by dysregulated eating and metabolism. Additionally, these preliminary results underscore the relevance of considering the potential benefits of providing quality comprehensive pre- and post-operative psychological care among bariatric patients towards optimizing both short- and long-term health and well-being.

From Mayo: Weight loss counseling among lower socioeconomic women

J Community Health. 2011 Jul 9. [Epub ahead of print]
Who is Counseled to Lose Weight? Survey Results and Anthropometric Data from 3,149 Lower Socioeconomic Women.
Breitkopf CR, Egginton JS, Naessens JM, Montori VM, Jatoi A.
Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA.

Because obesity is a grave public health concern, this study examined the percentage of disadvantaged women who recalled ever having received weight loss advice from a healthcare provider and factors associated with such advice. This study was part of a 5-clinic, cervical cancer prevention trial. Patients not immediately post-partum completed a Spanish/English survey; height and weight were also obtained. Of the 3,149 respondents (response rate 83%), 2,138 (68%) were overweight or obese (body mass index (BMI) ≥ 25); 94% reported a household income of <$35,000/year; 69% were Hispanic; 10% non-Hispanic black; and 40% completed the survey in Spanish. Only one-third reported ever having been told to lose weight. Based on BMI, these rates were 15% in the 25-29.9 range (overweight); 34% within 30-34.9; 57% within 35-39.9; and 73% ≥ 40. In univariate analyses, among overweight women, diabetes or English-speaking was associated with weight loss advice. In multivariate analyses, being older, more educated, and diabetic were associated with such advice. 48% of non-Hispanic whites, 31% of non-Hispanic blacks, and 29% of Hispanic had a home scale. Among disadvantaged women, obesity alone does not determine who recalls weight loss advice. Language barriers and lack of a home scale merit further study to address obesity.

From WSJ: Law schools--Throwing out decades of tradition. That'll do the trick.

"Looking to attract employers' attention, some law schools are throwing out decades of tradition by replacing textbook courses with classes that teach more practical skills."

Monday, July 11, 2011

CAP/ASCO recommendations for ER/PgR/HER2 testing in breast cancer patients

NewsPath: New CAP/ASCO Recommendations for ER/PgR and HER2 Testing in Breast Cancer

Feedback loops change human behavior; new technology makes change quicker

"Provide people with information about their actions in real time (or something close to it), then give them an opportunity to change those actions, pushing them toward better behaviors. Action, information, reaction. It’s the operating principle behind a home thermostat, which fires the furnace to maintain a specific temperature, or the consumption display in a Toyota Prius, which tends to turn drivers into so-called hypermilers trying to wring every last mile from the gas tank. But the simplicity of feedback loops is deceptive. They are in fact powerful tools that can help people change bad behavior patterns, even those that seem intractable. Just as important, they can be used to encourage good habits, turning progress itself into a reward. In other words, feedback loops change human behavior. And thanks to an explosion of new technology, the opportunity to put them into action in nearly every part of our lives is quickly becoming a reality."

From Tax Prof Blog: Number of lawyers increase while legal jobs decline

"Number of Legal Jobs Continue to Shrink, Number of Lawyers Continue to Rise

American Lawyer, June Jobs Report: Legal Industry Continues to Shrink:
The legal industry shed 2,600 jobs this month, according to the U.S. Bureau of Labor Statistics' June employment report, which the agency released Friday. It was the fourth month this year during which the legal sector saw jobs decline. ...
The downward trend comes at a time when the number of lawyers across the country continues to expand, according to the ABA’s 2011 National Lawyer Population Survey. The report indicates that only five states -- Arkansas, Hawaii, Massachusetts, Oklahoma and Utah -- experienced drops in their lawyer populations from 2010 to 2011."

mTOR and its role in lung cancer

Int J Clin Exp Pathol. 2011 Jun 20;4(5):476-95. Epub 2011 Jun 14.
Mammalian target of rapamycin: a central node of complex signaling cascades.
Dobashi Y, Watanabe Y, Miwa C, Suzuki S, Koyama S.
Department of Pathology, Respiratory Medicine Saitama, Japan.

The mammalian target of rapamycin (mTOR) is a serine/threonine kinase that regulates cell growth and metabolism in response to diverse external stimuli. In the presence of mitogenic stimuli, mTOR transduces signals that activate the translational machinery and promote cell growth. mTOR functions as a central node in a complex net of signaling pathways that are involved both in normal physiological, as well as pathogenic events. mTOR signaling occurs in concert with upstream Akt and tuberous sclerosis complex (TSC) and several downstream effectors. During the past few decades, the mTOR-mediated pathway has been shown to promote tumorigenesis through the coordinated phosphorylation of proteins that directly regulate cell-cycle progression and metabolism, as well as transcription factors that regulate the expression of genes involved in the oncogenic processes. The importance of mTOR signaling in oncology is now widely accepted, and agents that selectively target mTOR have been developed as anti-cancer drugs. In this review, we highlight the past research on mTOR, including clinical and pathological analyses, and describe its molecular mechanisms of signaling, and its roles in the physiology and pathology of human diseases, particularly, lung carcinomas. We also discuss strategies that might lead to more effective clinical treatments of several diseases by targeting mTOR.

Obesity and knee pain in women

Arthritis Care Res (Hoboken). 2011 Jul 7. doi: 10.1002/acr.20546. [Epub ahead of print]
Obesity predicts knee pain over 14 years in women, independent of radiographic changes.
Goulston LM, Kiran A, Javaid MK, Soni A, White KM, Hart DJ, Spector TD, Arden NK.
MRC Lifecourse Epidemiology Unit, University of Southampton.

To examine longitudinal patterns in body mass index (BMI) over 14 years and its association with knee pain in the Chingford Study.

594 women with BMI data from clinic visits at year 1, 5, 10 and 15 were studied. Year 15 (Y15) knee pain was assessed by questionnaire. Associations between BMI over 14 years and Y15 knee pain were examined using logistic regression.

BMI significantly increased from Y1 to Y15 (p<0.0005) with median (IQR) of 24.5 kg/m(2) (22.5, 27.2) and 26.5 kg/m(2) (23.9, 30.1) respectively. At Y15, 45.1% had knee pain. A greater BMI at Y1 (OR = 1.34, 95% CI 1.05 - 1.69), at Y15 (OR = 1.34, 1.10 - 1.61) and change in BMI over 15 years (OR = 1.40, 1.00 - 1.93) were significant predictors of Y15 knee pain (p<0.05). BMI change was associated with bilateral (OR = 1.61, 1.05 - 1.76), p = 0.024, but not unilateral knee pain (OR = 1.22, 0.73 - 1.76), p = 0.298. The association between BMI change and knee pain was independent of radiographic knee osteoarthritis (RKOA). The strength of association between BMI and Y15 knee pain was similar during follow-up measurements.

Over 14 years, a higher BMI predicts Y15 knee pain in women, independently of RKOA. When adjusted, the association was significant in bilateral, not unilateral, knee pain suggesting alternative pathological mechanisms may exist. The longitudinal effect of BMI on Y15 knee pain is equally important at any time point, which may assist reducing the knee pain population burden.

On whether the PPACA is extreme government takeover of health care or not

J Health Polit Policy Law. 2011 Jun;36(3):373.
Political significance of reform.
[No authors listed]

The terms used to describe the Patient Protection and Affordable Care Act (ACA) of 2010 seem so polemical and exaggerated - private takeover, socialized medicine, Obamacare, death panels - that many questions arise. Is this reform truly historic? Is it a big-bang reform or classic American incrementalism, building slowly and persistently on the existing system? Are there clear historical roots in this reform, and are there parts of the ACA that will potentially take the United States in a new direction? These are the questions addressed by the essays in this section. James A. Morone provides a broad historical look and shows us how social insurance, Lockean liberalism, a broken Congress, and our need for a neo-Progressive technical fix have shaped the U.S. health care system and this particular reform. Kimberly J. Morgan and Andrea Louise Campbell explain how the ACA is yet another example of the American penchant for delegated governance. Although technical feasibility and efficiency are often used to explain this preference, Morgan and Campbell show how classic liberal views for minimal government and interest-group mobilization are at the root of our reliance on delegation. Marie Gottschalk helps us understand why Democrats abandoned the movement for a single-payer system in lieu of a public option. She examines why this approach failed, as well as its costs and implications. In a response to the hyperbolic descriptions above, I then demonstrate how the ACA is neither extreme government takeover nor private privilege but is consistent with an established pattern of building up the U.S. health care state through investments in private provision and infrastructure, then hiding such investments from view. Finally, as a seasoned health policy analyst and herself a political player, Judith Feder considers the political and policy significance of the ACA in light of the long-term struggle to enact health care reform in the United States.

From J Am Board Fam Med: on the Physician-Patient Relationship

J Am Board Fam Med. 2011 Jul-Aug;24(4):463-8.
Having and being a personal physician: vision of the pisacano scholars.
Devoe JE, Nordin T, Kelly K, Duane M, Lesko S, Saccocio SC, Lesser LI.
Department of Family Medicine, Oregon Health and Science University, Portland.
Having a strong relationship with a personal physician can improve patient health outcomes. Yet achieving and sustaining this type of patient-physician relationship is often not possible in the current American health care system. Pisacano scholars and alumni, a group of young physician leaders supported by the American Board of Family Medicine, gathered for a 2-day symposium in June 2010 to explore the meaning of personal doctoring and its importance to our work as family physicians. Using the techniques of appreciative inquiry, the group discussed three questions: What is it like to have a personal physician? What is it like to be a personal physician? and, What are some feasible next steps toward making this possible? Symposium participants concluded that achieving the ideal patient-physician relationship for all patients and physicians would involve extensive alterations to the current health care system beyond what is outlined in the 2010 Patient Protection and Affordable Care Act. However, in the context of current health reform efforts, individual physicians, researchers, and policy makers must not lose sight of the importance of the patient-physician relationship and should continue to take concrete steps on an individual and system level to move us closer to this ideal.

GI reflux and lung fibrosis

Pulm Med. 2011;2011:634613. Epub 2010 Dec 9.
Gastroesophageal reflux and idiopathic pulmonary fibrosis: a review.
Fahim A, Crooks M, Hart SP.
Division of Cardiovascular and Respiratory Studies, Castle Hill Hospital, Castle Road, Cottingham HU16 5JQ, UK.

The histological counterpart of idiopathic pulmonary fibrosis is usual interstitial pneumonia, in which areas of fibrosis of various ages are interspersed with normal lung. This pattern could be explained by repeated episodes of lung injury followed by abnormal wound healing responses. The cause of the initiating alveolar epithelial injury is unknown, but postulated mechanisms include immunological, microbial, or chemical injury, including aspirated gastric refluxate. Reflux is promoted by low basal pressure in the lower oesophageal sphincter and frequent relaxations, potentiated by hiatus hernia or oesophageal dysmotility. In susceptible individuals, repeated microaspiration of gastric refluxate may contribute to the pathogenesis of IPF. Microaspiration of nonacid or gaseous refluxate is poorly detected by current tests for gastroesophageal reflux which were developed for investigating oesophageal symptoms. Further studies using pharyngeal pH probes, high-resolution impedance manometry, and measurement of pepsin in the lung should clarify the impact of reflux and microaspiration in the pathogenesis of IPF.

Friday, July 8, 2011

ACOs. Too big,, vitally fail! (By the way, where's the patient input?)

Health Aff (Millwood). 2011 Jul;30(7):1250-5.
The accountable care organization: whatever its growing pains, the concept is too vitally important to fail.
Crosson FJ.

The success of health reform efforts will depend, in part, on creating new and better ways to organize, deliver, and pay for health care. Increasingly central to this idea is the accountable care organization model proposed for Medicare and a slightly different model for commercial health care. But these new health care delivery and payment models face considerable skepticism. Can Medicare succeed with accountable care organizations if physicians can't determine whether patients are in the organization or not? Will commercial hospitals use their clout to create accountable care organizations, leaving physician practices in a weaker position? This article answers those and other criticisms of the developing accountable care organization movement. If the concept fails, the nation may face indiscriminate cuts to health care payments, with resulting reductions in access, service, and quality.

Lung cancer: Better imaging for more effective radiotherapy

Phys Med Biol. 2011 Jul 6;56(15):4701-4713. [Epub ahead of print]
Toward efficient biomechanical-based deformable image registration of lungs for image-guided radiotherapy.
Al-Mayah A, Moseley J, Velec M, Brock K.
Radiation Medicine Program, Princess Margaret Hospital, University Health Network and the University of Toronto, Toronto, Ontario, Canada.
Both accuracy and efficiency are critical for the implementation of biomechanical model-based deformable registration in clinical practice. The focus of this investigation is to evaluate the potential of improving the efficiency of the deformable image registration of the human lungs without loss of accuracy. Three-dimensional finite element models have been developed using image data of 14 lung cancer patients. Each model consists of two lungs, tumor and external body. Sliding of the lungs inside the chest cavity is modeled using a frictionless surface-based contact model. The effect of the type of element, finite deformation and elasticity on the accuracy and computing time is investigated. Linear and quadrilateral tetrahedral elements are used with linear and nonlinear geometric analysis. Two types of material properties are applied namely: elastic and hyperelastic. The accuracy of each of the four models is examined using a number of anatomical landmarks representing the vessels bifurcation points distributed across the lungs. The registration error is not significantly affected by the element type or linearity of analysis, with an average vector error of around 2.8 mm. The displacement differences between linear and nonlinear analysis methods are calculated for all lungs nodes and a maximum value of 3.6 mm is found in one of the nodes near the entrance of the bronchial tree into the lungs. The 95 percentile of displacement difference ranges between 0.4 and 0.8 mm. However, the time required for the analysis is reduced from 95 min in the quadratic elements nonlinear geometry model to 3.4 min in the linear element linear geometry model. Therefore using linear tetrahedral elements with linear elastic materials and linear geometry is preferable for modeling the breathing motion of lungs for image-guided radiotherapy applications.

From the Atlantic and Megan McCardle: Medicaid and wellbeing. Next question, even bigger: How much does Medicine in general improve wellbeing?

"As for lower mortality--economist-speak for 'confirms that Medicaid does, indeed, save lives', the authors didn't find any such thing. I quote: 'Panel A shows that we do not detect any statistically significant improvement in survival probability.' Mortality and related metrics such as life-expectancy is the easiest thing to measure--we can all pretty much agree on who is dead, and that death is generally pretty bad. It's also, for obvious reasons, the easiest emotional appeal for proponents of a program."

From Investor's Business Daily: About that government spending problem...

"'Constructive meetings' between GOP leaders and the White House should ring the alarm bells. In May, the budget deal to avoid a government shutdown, with a promise of $38.5 billion in spending cuts, was soon found by the Congressional Budget Office to boost spending by $3.2 billion over the rest of the current fiscal year."

From Arts & Letters Daily: Procrastination among writers!

"I am aware that there are writers who successfully avoid ever having to write at all. Whatever creative energies they may possess have been completely absorbed by displacement activities."

From Reuters: A dozen states have obesity rates above 30%

Mississippi most obese state, Colorado least

"Today, the state with the lowest adult obesity rate would have had the highest rate in 1995."

Thursday, July 7, 2011

From NCI: MicroRNA and Small Cell Lung Cancer

PLoS One. 2011;6(6):e21300. Epub 2011 Jun 22.
MicroRNA Expression and Clinical Outcome of Small Cell Lung Cancer.
Lee JH, Voortman J, Dingemans AM, Voeller DM, Pham T, Wang Y, Giaccone G.
Medical Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, United States of America.
The role of microRNAs in small-cell lung carcinoma (SCLC) is largely unknown. miR-34a is known as a p53 regulated tumor suppressor microRNA in many cancer types. However, its therapeutic implication has never been studied in SCLC, a cancer type with frequent dysfunction of p53. We investigated the expression of a panel of 7 microRNAs (miR-21, miR-29b, miR-34a/b/c, miR-155, and let-7a) in 31 SCLC tumors, 14 SCLC cell lines, and 26 NSCLC cell lines. We observed significantly lower miR-21, miR-29b, and miR-34a expression in SCLC cell lines than in NSCLC cell lines. The expression of the 7 microRNAs was unrelated to SCLC patients' clinical characteristics and was neither prognostic in term of overall survival or progression-free survival nor predictive of treatment response. Overexpression or downregulation of miR-34a did not influence SCLC cell viability. The expression of these 7 microRNAs also did not predict in vitro sensitivity to cisplatin or etoposide in SCLC cell lines. Overexpression or downregulation of miR-34a did not influence sensitivity to cisplatin or etoposide in SCLC cell lines. In contrast to downregulation of the miR-34a target genes cMET and Axl by overexpression of miR-34a in NSCLC cell lines, the intrinsic expression of cMET and Axl was low in SCLC cell lines and was not influenced by overexpression of miR-34a. Our results suggest that the expression of the 7 selected microRNAs are not prognostic in SCLC patients, and miR-34a is unrelated to the malignant behavior of SCLC cells and is unlikely to be a therapeutic target.