Wednesday, August 31, 2011

Allen: What health care compact means

"The health care compact initiative has united those who do not believe that the “one size fits all” federal approach will work. The compact does not decide what health care reform should look like; it changes who makes that determination — individual states rather than beltway bureaucrats."

Tuesday, August 30, 2011

From MMWR: Surveillance of violent deaths

MMWR Surveill Summ. 2011 Aug 26;60(10):1-54.
Surveillance for violent deaths --- national violent death reporting system, 16 States, 2008.
Karch DL, Logan J, Patel N; Division of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Problem/Condition: An estimated 50,000 persons die annually in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 16 U.S. states for 2008. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics. Reporting Period Covered: 2008. Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, and law enforcement reports. NVDRS data collection began in 2003 with seven states (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia) participating; six states (Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) joined in 2004, four (California, Kentucky, New Mexico, and Utah) in 2005, and two in 2010 (Ohio and Michigan) for a total of 19 states. This report includes data from 16 states that collected statewide data in 2008; data from California are not included in this report because NVDRS was implemented only in a limited number of California cities and counties rather than statewide. Ohio and Michigan are excluded because they did not begin data collection until 2010. Results: For 2008, a total of 15,755 fatal incidents involving 16,138 deaths were captured by NVDRS in the 16 states included in this report. The majority (58.7%) of deaths were suicides, followed by homicides and deaths involving legal intervention (i.e. deaths caused by police and other persons with legal authority to use deadly force, excluding legal executions) (26.4%), deaths of undetermined intent (14.5%), and unintentional firearm deaths (0.4%). Suicides occurred at higher rates among males, American Indians/Alaska Natives (AI/ANs), non-Hispanic whites, and persons aged 45--54 years. Suicides occurred most often in a house or apartment (70.6%) and involved the use of firearms (51.5%). Suicides were precipitated primarily by mental health (45.4%), intimate partner (30.9%), or physical health problems (22.6%), or by a crisis during the preceding 2 weeks (27.9%). Homicides occurred at higher rates among males and persons aged 20--24 years; rates were highest among non-Hispanic black males. The majority of homicides involved the use of a firearm (65.8%) and occurred in a house or apartment (52.5%) or on a street/highway (21.3%). Homicides were precipitated primarily by arguments (41.4%) and interpersonal conflicts (18.4%) or in conjunction with another crime (30.2%). Other manners of death and special situations or populations also are highlighted in this report. Interpretation: This report provides a detailed summary of data from NVDRS for 2008. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected adults aged <55 years, males, and certain minority populations. For homicides and suicides, relationship problems, interpersonal conflicts, mental health problems, and recent crises were among the primary precipitating factors. Because additional information might be reported subsequently as participating states update their findings, the data provided in this report are preliminary. Public Health Action: For the occurrence of violent deaths in the United States to be better understood and ultimately prevented, accurate, timely, and comprehensive surveillance data are necessary. NVDRS data can be used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths at the national, state, and local levels. The continued development and expansion of NVDRS is essential to CDC's efforts to reduce the personal, familial, and societal costs of violence. Further efforts are needed to increase the number of states participating in NVDRS, with an ultimate goal of full national representation.

BMI and length of hospital stays in Scotland

Scott Med J. 2011 Aug;56(3):135-40.
The relationship between body mass index and number of days spent in hospital in Scotland.
Wulff J, Wild SH.
Clinical Research Support Centre, Education and Research Centre, Royal Victoria Hospital, Belfast Trust, Grosvenor Road, Belfast BT12 6BA, Northern Ireland, UK.

In most countries in the Western world, more than 50% of adults are overweight or obese putting them at increased risk of hypertension, type 2 diabetes, coronary heart disease, stroke and other chronic disorders. It is not clear what impact increasing prevalence of over-weight and obesity has on hospital admissions. The objective of this study was to examine the relationship between body mass index (BMI) and number of days spent in hospital. The study was designed as a retrospective and prospective cohort study using nationally representative Health Survey data linked to NHS hospital admissions data. The study was set in Scotland. The participants were a nationally representative sample of 6968 (45%) men and 8700 (55%) women, of 16-74 years of age, living in private households whose BMI was recorded in the 1995 and 1998 Scottish Health Surveys. The outcome measure was the number of days spent in hospital between 1981 and 2004. The results showed that the proportion of participants in both normal weight (BMI 20-24.9 kg/m(2)) and over-weight (BMI 25-29.9 kg/m(2)) categories was 37%, with 21% in the obese (BMI ≥30 kg/m(2)) and 5% in the under-weight (BMI <20 kg/m(2)) categories. The median number of days spent in hospital between 1981 and 2004 was six. The odds ratios (95% confidence intervals) for spending above the median numbers of days in hospital adjusted for age, sex, socioeconomic status and behavioural factors (i.e. smoking, alcohol drinking and physical activity) were 1.29 (1.06-1.56) for the <20 kg/m(2) group, 1.00 (0.91-1.11) for the 25-29.9 kg/m(2) group and 1.24 (1.10-1.38) for the ≥30 kg/m(2) group compared with the 20-24.9 kg/m(2) group. In conclusion, extremes of BMI category identified at a single point in time are associated with spending above the median number of days in hospital over a 20-year period after adjusting for demographic, behavioural and socioeconomic exposures.

Heterothermy in growing king penguins and its fasting capacity

Nat Commun. 2011 Aug 16;2:435. doi: 10.1038/ncomms1436.
Heterothermy in growing king penguins.
Eichhorn G, Groscolas R, Le Glaunec G, Parisel C, Arnold L, Medina P, Handrich Y.
1] Université de Strasbourg, IPHC-DEPE, 23 rue Becquerel, Strasbourg 67087, France. [2] CNRS, UMR7178, Strasbourg 67037, France.

A drop in body temperature allows significant energy savings in endotherms, but facultative heterothermy is usually restricted to small animals. Here we report that king penguin chicks (Aptenodytes patagonicus), which are able to fast for up to 5 months in winter, undergo marked seasonal heterothermy during this period of general food scarcity and slow-down of growth. They also experience short-term heterothermy below 20 °C in the lower abdomen during the intense (re)feeding period in spring, induced by cold meals and adverse weather. The heterothermic response involves reductions in peripheral temperature, reductions in thermal core volume and temporal abandonment of high core temperature. Among climate variables, air temperature and wind speed show the strongest effect on body temperature, but their effect size depends on physiological state. The observed heterothermy is remarkable for such a large bird (10 kg before fasting), which may account for its unrivalled fasting capacity among birds.

PMID: 21847109 [PubMed - in process]

SEOM guidelines for pleural mesothelioma treatment

Clin Transl Oncol. 2011 Aug;13(8):569-73.
SEOM guidelines for the treatment of malignant pleural mesothelioma.
Lianes P, Remon J, Bover I, Isla D.
Servicio de Oncología Médica, Hospital de Mataró, Mataró, Barcelona, Spain.

Mesothelioma is a rare malignant tumour. Asbestos is the principal aetiological agent of malignant pleural mesothelioma (MPM) (≈80% of cases). The incidence of MPM is still increasing and will peak within the next 10 years. There are three main histological types of MPM: epithelial (≈60%), sarcomatous and mixed. There is no standard approach for patients with MPM. Surgery (radical extra-pleural pneumonectomy or pleurectomy/decortication) may be part of the initial treatment for carefully selected patients, generally combined with neoadjuvant or adjuvant chemotherapy and/or adjuvant radiotherapy, and should only be performed by experienced thoracic surgeons as part of a multidisciplinary team. Radiotherapy could be used as prophylaxis to reduce the incidence of recurrence at sites of diagnoses or therapeutic instrument insertion, in a multimodal treatment to improve locoregional control and to palliate symptoms. Based on the better compliance of neoadjuvant chemotherapy, lower rate of surgical morbidity and the possibility to select the optimal patients to be submitted to surgery, a neoadjuvant strategy is a better option than adjuvant chemotherapy, although there is no standard optimal sequence and types of treatment for multimodal therapy. In patients with no resectable disease, chemotherapy is the best option with platinum and pemetrexed or raltitrexed. At this time there is no widely approved salvage therapy.

Dram shop liability and reducing alcohol-related harms

Am J Prev Med. 2011 Sep;41(3):334-43.
Effects of dram shop liability and enhanced overservice law enforcement initiatives on excessive alcohol consumption and related harms two community guide systematic reviews.
Rammohan V, Hahn RA, Elder R, Brewer R, Fielding J, Naimi TS, Toomey TL, Chattopadhyay SK, Zometa C; Task Force on Community Preventive Services.
Community Guide Branch of the Epidemiology and Analysis Program Office, CDC, Atlanta, Georgia.

Dram shop liability holds the owner or server(s) at a bar, restaurant, or other location where a patron, adult or underage, consumed his or her last alcoholic beverage responsible for harms subsequently inflicted by the patron on others. Liability in a state can be established by case law or statute. Overservice laws prohibit the sale of alcoholic beverages to intoxicated patrons drinking in on-premises retail alcohol outlets (i.e., premises where the alcohol is consumed where purchased); enhanced enforcement of these laws is intended to ensure compliance by premises personnel. Both of these interventions are ultimately designed to promote responsible beverage service by reducing sales to intoxicated patrons, underage youth, or both. This review assesses the effectiveness of dram shop liability and the enhanced enforcement of overservice laws for preventing excessive alcohol consumption and related harms.

Studies assessing alcohol-related harms in states adopting dram shop laws were evaluated, as were studies assessing alcohol-related harms in regions with enhanced overservice enforcement. Methods previously developed for systematic reviews for the Guide to Community Preventive Services were used.

Eleven studies assessed the association of state dram shop liability with various outcomes, including all-cause motor vehicle crash deaths, alcohol-related motor vehicle crash deaths (the most common outcome assessed in the studies reviewed), alcohol consumption, and other alcohol-related harms. There was a median reduction of 6.4% (range of values 3.7% to 11.3% reduction) in alcohol-related motor vehicle fatalities associated with the presence of dram shop liability in jurisdictions where premises are licensed. Other alcohol-related outcomes also showed a reduction. Only two studies assessed the effects of enhanced enforcement initiatives on alcohol-related outcomes; findings were inconsistent, some indicating benefit and others none.

According to Community Guide rules of evidence, the number and consistency of findings indicate strong evidence of the effectiveness of dram shop laws in reducing alcohol-related harms. It will be important to assess the possible effects of legal modifications to dram shop proceedings, such as the imposition of statutes of limitation, increased evidentiary requirements, and caps on recoverable amounts. According to Community Guide rules of evidence, evidence is insufficient to determine the effectiveness of enhanced enforcement of overservice laws for preventing excessive alcohol consumption and related harms.

Published by Elsevier Inc.

PMID: 21855749 [PubMed - in process]

Health care reform's individualist conception of public health

J Law Med Ethics. 2011 Sep;39(3):328-39. doi: 10.1111/j.1748-720X.2011.00603.x.
From health care reform to public health reform.
Berman ML.
Assistant Professor at New England Law - Boston and Director of the Center for Public Health and Tobacco Policy.

Even when turning its attention to public health topics such as preventive care and workplace wellness, the Affordable Care Act law embodies a highly individualistic paradigm of health. The provisions of the law implicitly assign the primary responsibility for prevention to individuals, who should be urged to make more responsible and healthier choices about what they consume and how they live. Relatively little in the law reflects the "population perspective" set forth in public health scholarship that focuses on environmental and social determinants of health. This article explores the cultural and economic factors that led Congress to embrace a highly individualist conception of public health, and it suggests how public health advocates and legal scholars might seek to reframe the public discourse surrounding preventive health issues.

© 2011 American Society of Law, Medicine & Ethics, Inc.

PMID: 21871031 [PubMed - in process]

Med Mal: Putting insurers in charge!

J Law Med Ethics. 2011 Sep;39(3):539-42. doi: 10.1111/j.1748-720X.2011.00620.x.
Improve medical malpractice law by letting health care insurers take charge.
Reinker KS, Rosenberg D.
Lawyer in Washington, D.C. Lee S. Kreindler Professor of Law at Harvard Law School, specializes in analysis and reform of tort law and the civil liability system for adjudicating mass injury cases.

This essay discusses unlimited insurance subrogation (UIS) as a means of improving the deterrence and compensation results of medical malpractice law. Under UIS, health care insureds could assign their entire potential medical malpractice claims to their first-party commercial and government insurers. UIS should improve deterrence by establishing first-party insurers as plaintiffs to confront liability insurers on the defense side, leading to more effective prosecution of meritorious claims and reducing meritless and unnecessary litigation. UIS should improve compensation outcomes by converting litigation cost- and risk- laden "tort insurance" into cheaper and enhanced first-party insurance. UIS also promises dynamic benefits through further reforms by contract between the first-party and liability insurers that would take charge of system. No UIS-related costs are apparent that would outweigh these benefits.

© 2011 American Society of Law, Medicine & Ethics, Inc.

From BYU: Corrected cancer incidence rates

J Cancer Educ. 2011 Aug 28. [Epub ahead of print]
Understanding Population-Based Site-Specific Cancer Incidence Rates in the USA.
Merrill RM, Sloan A, Novilla LB.
Department of Health Science, College of Life Sciences, Brigham Young University, Provo, UT, 84602, USA,

As compared with conventionally reported national population-based incidence rates, incidence rates better represent the "burden" of disease if they remove prevalent cases from the denominator. In order to reflect the "risk" in a disease-free population, rates should both exclude prevalent cases from the denominator and second or later diagnosed cases at the same site from the numerator. Five common cancers were evaluated through a correction method using 2005-2007 Surveillance, Epidemiology, and End Results Program data to determine the extent of difference between conventional and corrected incidence rates. These corrections lowered the incidence rates 4.0-5.8% for female breast cancer, 4.6-7.6% for melanoma, 3.0-4.0% for colorectal cancer, and 2.1-2.5% for lung and bronchus cancer. Corrected incidence rates for prostate cancer were 9.9-13.7% higher. In cancers with either high prevalence and/or high occurrence of multiple primaries at the same site, corrected population-based incidence rates are warranted.

Genomic Pathology: Challenges in Implementation

Arch Pathol Lab Med. 2011 Aug;135(8):967-8.
Genomic pathology: challenges for implementation.
Cagle PT, Dacic S, Allen TC.
PMID: 21809986 [PubMed - in process]

Tissue Factor Pathway Inhibitor Attenuates the Progression of Malignant Pleural Mesothelioma in Nude Mice

Am J Respir Cell Mol Biol. 2011 Aug 25. [Epub ahead of print]
Tissue Factor Pathway Inhibitor Attenuates the Progression of Malignant Pleural Mesothelioma in Nude Mice.
Williams L, Tucker TA, Koenig K, Allen T, Rao LV, Pendurthi U, Idell S.
Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler, Tyler, Texas, United States.

Malignant pleural mesothelioma (MPM) is a rare cancer that is refractory to current treatments. It is characterized by robust transitional fibrin deposition that is in part promoted by tumor cells. MPM cells express tissue factor (TF) and its inhibitor; tissue factor pathway inhibitor (TFPI), but their contribution to the pathogenesis of MPM has been unclear. We found that REN MPM cells fail to express TFPI. Based on the tumor growth promoting properties of TF, we hypothesized that stable transfection of TFPI into REN MPM cells would decrease their aggressiveness. We tested our hypothesis using in vitro, in vivo and ex vivo analyses. TFPI knock-in decreased proliferation, invasion and TF activity of REN cells in vitro. REN TFPI knock-in cells, empty vector and naïve controls were next injected intrapleurally in nude mice. TFPI expression significantly decreased tissue invasion, inflammation, fibrin and collagen deposition associated with tumor tissues, pleural effusions, and tumor burden. In ex vivo analyses, REN cells were cultured from the harvested tumors. TFPI over-expression was maintained in cells propagated from the TFPI knock-in tumors and attenuated activation of Factor X and tumor cell invasiveness. These analyses demonstrate that TFPI reduces the aggressiveness of MPM in vitro, in vivo and ex vivo and that the effect involves inhibition of TF procoagulant activity. These observations suggest the possibility that the TF-TFPI interaction represents a novel therapeutic target for the treatment of MPM.

From the Chronicle of Higher Education: Politics and the University

"It's no secret that public colleges are struggling with huge fiscal problems. Nor that they are facing new political pressures as legislatures and governors in Florida, Ohio, Texas, and elsewhere become more interested in issues like faculty productivity, assessment, accountability, and bottom-line budgeting."

Tuesday, August 16, 2011

CAP NewsPath Special Edition: Xenotropic Murine Leukemia Virus-related Virus (XMRV): An Update on Infectious Disease Transmission by Transfusion of Blood Products

In the '80s this was known as "warming up"

Fifteen minutes' exercise a day can boost life expectancy

"England's chief medical officer, Sally Davies, told the BBC the study would remind people there were many ways of getting exercise, 'activities like walking at a good pace or digging the garden can count too'."

Monday, August 15, 2011

Student nurses and Web-delivered education

Public Health Nurs. 2011 Jul;28(4):349-56. doi: 10.1111/j.1525-1446.2010.00933.x. Epub 2011 Feb 17.
The Impact of Web-delivered Education on Preceptor Role Self-Efficacy and Knowledge in Public Health Nurses.
Larsen R, Zahner SJ.
Ph.D., R.N., is Associate Professor, College of St. Benedict/St. John's University, St. Joseph, Minnesota Dr.P.H., R.N., is Associate Professor, University of Wisconsin-Madison, Madison, Wisconsin.

ABSTRACT Objective: Preceptors are an essential component in preparing student nurses to become practicing public health nurses. Preparation for the preceptor role is important for achieving a quality learning experience for students. This study was conducted to explore the relationship between completion of a Web-delivered preceptor education program and both knowledge of the preceptor role and self-efficacy to perform in the preceptor role.

Design and Sample: This study used a pretest-posttest, quasi-experimental design. The participants were experienced public health nurses (n=31) working in one state in the United States.

Measures: Pretest and posttest Web-delivered survey using the preceptor self-efficacy questionnaire and an instrument assessing knowledge gain.

Intervention: A Web-delivered preceptor education program tailored for public health nurses.

Results: The program was associated with improved self-efficacy scores at both the immediate and the 3-month posttest, and with increased knowledge of the preceptor role evident at the immediate posttest only. Self-efficacy scores were independent of knowledge scores. Preceptor age was not correlated with self-efficacy or knowledge scores. Nurses with higher levels of education demonstrated higher self-efficacy scores in all 3 measurements.

Conclusions: Web-delivered continuing education targeted to public health nurse preceptors is an effective method to increase confidence and knowledge for the preceptor role.

The development of clinical reasoning skills by medical students

Acad Med. 2011 Jul 21. [Epub ahead of print]
Tracking Development of Clinical Reasoning Ability Across Five Medical Schools Using a Progress Test.
Williams RG, Klamen DL, White CB, Petrusa E, Fincher RM, Whitfield CF, Shatzer JH, McCarty T, Miller BM.
Dr. Williams is J. Roland Folse Professor of Surgical Education Emeritus, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois. Dr. Klamen is associate dean for education and curriculum and professor, Department of Medical Education, Southern Illinois University School of Medicine, Springfield, Illinois. Dr. White is associate dean for faculty development and educational achievement, Medical College of Georgia School of Medicine, Augusta, Georgia. Dr. Petrusa is director, Office for Teaching and Learning in Medicine, director, Center for Outcomes Research in Education, and professor of medical education and administration, Vanderbilt School of Medicine, Nashville, Tennessee. Dr. Fincher is professor, Department of Medicine, and vice dean for academic affairs and codirector, Education Discovery Institute, Medical College of Georgia School of Medicine, Augusta, Georgia. Dr. Whitfield is associate dean for preclinical curriculum, Penn State College of Medicine, Hershey, Pennsylvania. Dr. Shatzer is director, Center for Experiential Learning and Assessment, and associate professor of medical education and administration, Vanderbilt School of Medicine, Nashville, Tennessee. Dr. McCarty is associate professor, Department of Psychiatry, and assistant dean, Simulation and Assessment, University of New Mexico School of Medicine, Albuquerque, New Mexico. Dr. Miller is senior associate dean for health sciences education, Vanderbilt School of Medicine, Nashville, Tennessee.

Little is known about the acquisition of clinical reasoning skills in medical school, the development of clinical reasoning over the medical curriculum as a whole, and the impact of various curricular methodologies on these skills. This study investigated (1) whether there are differences in clinical reasoning skills between learners at different years of medical school, and (2) whether there are differences in performance between students at schools with various curricular methodologies.

Students (n = 2,394) who had completed zero to three years of medical school at five U.S. medical schools participated in a cross-sectional study in 2008. Students took the same diagnostic pattern recognition (DPR) and clinical data interpretation (CDI) tests. Percent correct scores were used to determine performance differences. Data from all schools and students at all levels were aggregated for further analysis.

Student performance increased substantially as a result of each year of training. Gains in DPR and CDI performance during the third year of medical school were not as great as in previous years across the five schools. CDI performance and performance gains were lower than DPR performance and gains. Performance gains attributable to training at each of the participating medical schools were more similar than different.

Years of training accounted for most of the variation in DPR and CDI performance. As a rule, students at higher training levels performed better on both tests, though the expected larger gains during the third year of medical school did not materialize.

Can we adequately train physicians under the current resident duty-hour restrictions?

J Surg Educ. 2011 Sep-Oct;68(5):387-92. Epub 2011 May 26.
Strategies to accommodate resident work-hour restrictions: impact on surgical education.
Freiburg C, James T, Ashikaga T, Moalem J, Cherr G.
University of Vermont, Burlington, Vermont.

The introduction of duty-hour restrictions has impacted surgical training. Several strategies were introduced by training programs in response to these restrictions. The purpose of this study was to assess the various strategies employed by residency programs to comply with work-hour restrictions with respect to the impact on the quality of surgical education.

A national survey was developed and distributed to resident members of the Resident and Associate Society of the American College of Surgeons in all accredited residency programs across North America. Questions in the survey addressed 10 separate accommodation strategies used by training programs to adhere to resident work-hour restrictions. Resident respondents completed a 5-point Likert scale rating each strategy according to its impact on surgical education (detrimental, not very helpful, neutral, somewhat helpful, and very helpful).

A total of 599 (9.7%) responses were received from 6186 members of the Resident Associate Society. The use of health information technology (IT), nurse practitioners, and physician assistants were most highly rated. Hiring clinical fellows, establishing nonteaching services, and shift-work scheduling were the three most poorly rated accommodations to work-hour restrictions with respect to resident education.

Hospital IT and nonphysician care providers were rated by residents to optimize surgical education in the current work-hour limitation environment. We infer that strategies which lead to increased efficiency and redistribution of resident workload allow surgical trainees to spend more time on activities perceived to have higher educational value.

From JAMA: Prevention of torture and care of survivors

JAMA. 1993 Aug 4;270(5):606-11.
Prevention of torture and care of survivors. An integrated approach.
Başoğlu M.
Institute of Psychiatry, University of London, England.

An analysis of the 1992 Amnesty International report demonstrates the nature and global distribution of reports of human rights violations. Systematic torture was reported in 93 of 204 countries. Reports of torture were more common from regions affected by political unrest, including mass demonstrations, riots, outbreaks of violence, killings, coup attempts, civil war, armed tribal conflict, rebellions, and conflicts with various opposition groups demanding social and political reform. These observations suggest that effective measures against torture require a multilevel analysis of underlying social, political, cultural, and psychological factors. Effective care of survivors of organized violence and torture is an indispensable component of the human rights struggle and needs more scientific attention. An integrated approach involving both preventive efforts and care of survivors can promote the human rights cause.

The Bombay blood group

Mymensingh Med J. 2011 Jul;20(3):536-40.
The bombay blood group: are we out of risk?
Dipta TF, Hossain AZ.
Dr Tashmim Farhana Dipta, Associate Professor and Head, Department of Transfusion Medicine, BIRDEM and Ibrahim Medical College, Shahbagh, Dhaka, Bangladesh.
The Bombay blood group is a rare blood group, phenotypes of this group lacking H antigen on the red cell membrane and have anti-H in the serum. It fails to express any A, B or H antigen on their red cells or other tissues. The existence of a human H/h genetic polymorphism was first established by Bhende et al. As first discovery in Bombay (Mumbai), in India in 1952, so the name of this rare blood group is known as Bombay blood group. People having Bombay phenotype are mostly confined to the Southeast Asia. Around 179 persons in India with a frequency of 1 in 10,000 have "Bombay Blood group". A high level of consanguinity present among the parents of the Bombay phenotype. The classic Bombay phenotype has been reported in those of Indian descendent. It is quite rare in Caucasian with an incidence of 1 in 250,000. As because in our country there is routine practice of "only forward or cell type grouping" using finger prick method by voluntary blood donors organization and various blood banks; so there is tremendous chance of misinterpretation or unexploration of this Bombay blood group. When misdiagnosed, this Bombay group can cause fatal haemolytic transfusion reaction. For this reason our suggestion is to incorporate "routine serum typing or reverse grouping confirmation" along with 'O' cell control in reverse grouping procedure in every Transfusion Medicine Department or Blood Bank or Blood Donor Centers and this practice should be mandatory to reduce the risk of fatal haemolytic transfusion reaction. In this view we will highlight the incidence, molecular biology and clinical significance of this rare and fatal blood group.

Testing for latent TB infection: improving performance measures

Jt Comm J Qual Patient Saf. 2011 Jul;37(7):309-16.
The need for performance measures on testing for latent tuberculosis infection in primary care.
Tschampl C, Bernardo J, Garvey T, Garnick D.
The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, USA.

BACKGROUND: The millions of people living in the United States with latent tuberculosis infection (LTBI) represent a reservoir of potentially active tuberculosis (TB) disease. When LTBI is left to activate, the consequences may include intense suffering, permanent disability, and high economic costs for patients, their caretakers, and society at large as TB spreads. The introduction of performance measures would improve accountability for quality of care and to reduce disparities, especially if the measures are group-targeted.

PERFORMANCE MEASURES PROPOSAL: One National Quality Forum-endorsed measure (#0408) calculates the rate of TB screening in persons with HIV. Using the measure as a model, a set of performance measures is proposed. Denominators will include all persons in a given high-risk category, and numerators will include those persons from the denominators with LTBI test results. National guidelines informed appropriate exclusions.

IMPLEMENTATION CHALLENGES AND SOLUTIONS: Challenges to implementation include lack of TB knowledge among primary care providers, potential for overwhelming already burdened schedules, and stigma associated with TB. However, the new measures, along with publication of educational resources, would raise clinicians' awareness. Short checklists and electronic supports would minimize time pressures. The routinization of screening would help reduce stigma. Finally, new federal funding and political will for electronic health records would facilitate data collection and impact assessment.

CONCLUSIONS: TB sits at the crossroads of health and economic inequity and is a huge public health problem. The proposed performance measures will address a neglected secondary prevention opportunity and will be consistent with national priorities and health reform.

First time DUI offenders and their social networks

Traffic Inj Prev. 2011 Aug;12(4):306-11.
A Descriptive Analysis of the Social Context of Drinking Among First-Time DUI Offenders.
Beck KH, Ahmed A, Farkas ZA.
a University of Maryland School of Public Health , Department of Behavioral and Community Health , College Park , Maryland.

Objective: To understand the role of social context in contributing to the incidence of alcohol-impaired driving.

Methods: Telephone interviews were conducted with 161 individuals who received a first-time DUI citation. They were predominantly white (70%), male (62%) and 21 to 45 years of age (62%). They were paid $25 for their participation. Questions were asked about their social network, the social context in which they typically drink, the specific location and circumstances where they were drinking at the time of their citation, risky driving behaviors, in the last month as well as the number of traffic tickets they received and crashes they have been involved in since they started to drive.

Results: Two reliable social contexts of drinking were identified through principle components factors analysis: emotional pain and social facilitation. Analyses of variance showed that drinking in a context of emotional pain (eg, to deal with depression, stress) was related to drinking alone at this location and driving when they know they have had too much to drink. Drinking in a context of social facilitation (eg, with friends, to be sociable) was related to drinking more frequently and with others (versus alone) at this location. Social facilitation was also positively related to driving over the speed limit and running a red light/stop sign.

Conclusions: The social context of drinking is important for understanding the social network of drinking drivers, because most (86%) said that someone from their social network was with them at this drinking location. The need to understand how significant others influence the context of drinking as well as the likelihood of impaired driving is critical for program development. These results suggest that different types of interventions are needed for offenders depending on their social context of drinking.

Should cancer patients get Vitamin D supplements?

Oncologist. 2011 Aug 11. [Epub ahead of print]
Prognostic Role of Vitamin D Status and Efficacy of Vitamin D Supplementation in Cancer Patients: A Systematic Review.
Buttigliero C, Monagheddu C, Petroni P, Saini A, Dogliotti L, Ciccone G, Berruti A.
University of Turin, Medical Oncology, San Luigi Hospital, Orbassano, Italy;

Abstract Background. Whether or not hypovitaminosis D can influence the prognosis of cancer patients and whether or not vitamin D (vitD) supplementation improves outcome remain controversial.

Design. Studies evaluating the prognostic role of vitD and vitD receptor (VDR) in cancer patients and trials evaluating the efficacy of vitD administration on patient outcome were identified by a search of MEDLINE, EMBASE, ISI Web of Knowledge, and the Cochrane Library through June 2010.

Results. Twenty-five studies were included. A negative prognostic role for low serum vitD level was observed in five cohort studies including patients with breast cancer (one study), colon cancer (two studies), prostate cancer (one study), and melanoma (one study), but not in two studies on non-small cell lung cancer and one study on breast cancer. Three of four studies showed that VDR(+) tumors carry a better prognosis than VDR(-) tumors, whereas VDR polymorphisms were significantly associated with prognosis in five of 10 studies. A significant interaction between serum vitD level and VDR polymorphism was observed in one study. Three randomized trials involving advanced prostate cancer patients explored the prognostic role of vitD supplementation. A meta-analysis of these trials showed no effect on survival (pooled risk ratio, 1.07; 95% confidence interval, CI, 0.93-1.23), with strong heterogeneity among studies.

Conclusion. Hypovitaminosis D seems to be associated with a worse prognosis in some cancers, but vitD supplementation failed to demonstrate a benefit in prostate cancer patients. The currently available evidence is insufficient to recommend vitD supplementation in cancer patients in clinical practice.

Friday, August 12, 2011

From the Daily Caller: College as a 4-year TSA line

"...[Y]our tuition and tax dollars are funding an ever-growing army of bureaucrats that police everything from free speech to dating. Administrators now outnumber faculty on our nation’s campuses, and even students’ innermost thoughts are subject to their oversight. Each year, the college experience gets closer to that of a TSA line at the airport — but one that you have to live in for four years."

Read more:

From Reuters: Appeals court rules against Obama healthcare law

"This economic mandate represents a wholly novel and potentially unbounded assertion of congressional authority: the ability to compel Americans to purchase an expensive health insurance product they have elected not to buy, and to make them re-purchase that insurance product every month for their entire lives," a divided three-judge panel said.

America's future? Spain's "fast track" cancer program: 37 days from lung cancer detection to initial treatment!

"Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009)."

Br J Cancer. 2011 Aug 9. doi: 10.1038/bjc.2011.308. [Epub ahead of print]
Implementing a Cancer Fast-track Programme between primary and specialised care in Catalonia (Spain): a mixed methods study.
Prades J, Espinàs JA, Font R, Argimon JM, Borràs JM.
1] Catalonian Cancer Plan, Duran i Reynals Hospital, Av. Gran Via de l'Hospitalet 199-203, Hospitalet de Llobregat, Barcelona 08908, Spain [2] Clinical Sciences Department, Bellvitge Biomedical Research Institute (Institut d'Investigació Biomèdica de Bellvitge - IDIBELL), University of Barcelona, Av. Gran Via de l'Hospitalet 199-203, Hospitalet de Llobregat, Barcelona 08908, Spain.

Background:The Cancer Fast-track Programme's aim was to reduce the time that elapsed between well-founded suspicion of breast, colorectal and lung cancer and the start of initial treatment in Catalonia (Spain). We sought to analyse its implementation and overall effectiveness.

Methods:A quantitative analysis of the programme was performed using data generated by the hospitals on the basis of seven fast-track monitoring indicators for the period 2006-2009. In addition, we conducted a qualitative study, based on 83 semistructured interviews with primary and specialised health professionals and health administrators, to obtain their perception of the programme's implementation.

Results:About half of all new patients with breast, lung or colorectal cancer were diagnosed via the fast track, though the cancer detection rate declined across the period. Mean time from detection of suspected cancer in primary care to start of initial treatment was 32 days for breast, 30 for colorectal and 37 for lung cancer (2009). Professionals associated with the implementation of the programme showed that general practitioners faced with suspicion of cancer had changed their conduct with the aim of preventing lags. Furthermore, hospitals were found to have pursued three specific implementation strategies (top-down, consensus-based and participatory), which made for the cohesion and sustainability of the circuits.

Conclusion:The programme has contributed to speeding up diagnostic assessment and treatment of patients with suspicion of cancer, and to clarifying the patient pathway between primary and specialised care.

British Journal of Cancer advance online publication, 9 August 2011; doi:10.1038/bjc.2011.308

From JAMA: Sleep-disordered breathing and cognitive impairment

JAMA. 2011 Aug 10;306(6):613-9.
Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women.
Yaffe K, Laffan AM, Harrison SL, Redline S, Spira AP, Ensrud KE, Ancoli-Israel S, Stone KL.
Department of Psychiatry, University of California, San Francisco, San Francisco, CA 94121, USA.

Sleep-disordered breathing (characterized by recurrent arousals from sleep and intermittent hypoxemia) is common among older adults. Cross-sectional studies have linked sleep-disordered breathing to poor cognition; however, it remains unclear whether sleep-disordered breathing precedes cognitive impairment in older adults.

To determine the prospective relationship between sleep-disordered breathing and cognitive impairment and to investigate potential mechanisms of this association.

Prospective sleep and cognition study of 298 women without dementia (mean [SD] age: 82.3 [3.2] years) who had overnight polysomnography measured between January 2002 and April 2004 in a substudy of the Study of Osteoporotic Fractures. Sleep-disordered breathing was defined as an apnea-hypopnea index of 15 or more events per hour of sleep. Multivariate logistic regression was used to determine the independent association of sleep-disordered breathing with risk of mild cognitive impairment or dementia, adjusting for age, race, body mass index, education level, smoking status, presence of diabetes, presence of hypertension, medication use (antidepressants, benzodiazepines, or nonbenzodiazepine anxiolytics), and baseline cognitive scores. Measures of hypoxia, sleep fragmentation, and sleep duration were investigated as underlying mechanisms for this relationship.

Adjudicated cognitive status (normal, dementia, or mild cognitive impairment) based on data collected between November 2006 and September 2008.

Compared with the 193 women without sleep-disordered breathing, the 105 women (35.2%) with sleep-disordered breathing were more likely to develop mild cognitive impairment or dementia (31.1% [n = 60] vs 44.8% [n = 47]; adjusted odds ratio [AOR], 1.85; 95% confidence interval [CI], 1.11-3.08). Elevated oxygen desaturation index (≥15 events/hour) and high percentage of sleep time (>7%) in apnea or hypopnea (both measures of disordered breathing) were associated with risk of developing mild cognitive impairment or dementia (AOR, 1.71 [95% CI, 1.04-2.83] and AOR, 2.04 [95% CI, 1.10-3.78], respectively). Measures of sleep fragmentation (arousal index and wake after sleep onset) or sleep duration (total sleep time) were not associated with risk of cognitive impairment.

Among older women, those with sleep-disordered breathing compared with those without sleep-disordered breathing had an increased risk of developing cognitive impairment.

From Mello/Harvard: "Worker's comp" for medical injuries

Issue Brief (Commonw Fund). 2011 Jul;14:1-18.
Administrative compensation for medical injuries: lessons from three foreign systems.
Mello MM, Kachalia A, Studdert DM.
Harvard School of Public Health, USA.

The United States requires patients injured by medical negligence to seek compensation through lawsuits, an approach that has drawbacks related to fairness, cost, and impact on medical care. Several countries, including New Zealand, Sweden, and Denmark, have replaced litigation with administrative compensation systems for patients who experience an avoidable medical injury. Sometimes called "no-fault" systems, such schemes enable patients to file claims for compensation without using an attorney. A governmental or private adjudicating organization uses neutral medical experts to evaluate claims of injury and does not require patients to prove that health care providers were negligent in order to receive compensation. Information from claims is used to analyze opportunities for patient safety improvement. The systems have successfully limited liability costs while improving injured patients' access to compensation. American policymakers may find many of the elements of these countries' systems to be transferable to demonstration projects in the U.S.

From Roger Moorhouse, a historian and author, whose interest in the story of Peter the Wild Boy is the result of a misspent childhood

"In the summer of 1725 a peculiar youth was found in the forest of Hertswold near Hameln in northern Germany. Aged about 12, he walked on all fours and fed on grass and leaves. ‘A naked, brownish, blackhaired creature’, he would run up trees when approached and could utter no intelligible sound. The latest in a long line of feral children – in turn celebrated, shunned and cursed through the ages – ‘The Wild Boy of Hameln’ would be the first to achieve real fame."

From U Toronto: The paracrinology of tubal ectopic pregnancy

Mol Cell Endocrinol. 2011 Jul 30. [Epub ahead of print]
The paracrinology of tubal ectopic pregnancy.
Shaw JL, Horne AW.
Department of Laboratory Medicine and Pathobiology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada M5S 1A8.

As part of successful human reproduction, the Fallopian tube must provide a suitable environment for pre-implantation development of the embryo and for efficient transport of the embryo to the uterus for implantation. These functions are coordinated by paracrine interactions between tubal epithelial, smooth muscle and immune cells and the cells of the developing embryo. Alterations in these signals can lead to a tubal microenvironment encouraging of embryo implantation and to dysregulated tubal motility, ultimately resulting in inappropriate and early implantation of the embryo in the Fallopian tube. Here, we highlight novel and emerging concepts in tubal physiology and pathobiology, such as the induction of a receptive phenotype within the Fallopian tube, leading to ectopic implantation. Chlamydia trachomatis infection is a risk factor for tubal ectopic pregnancy. Activation of toll-like receptor 2 (TLR-2) in the Fallopian tube epithelium, by C. trachomatis has recently been demonstrated, leading to the dysregulation of factors involved in implantation and smooth muscle contractility, such as prokineticins (PROK), activin A and interleukin 1 (IL-1). The Fallopian tube has also recently been shown to harbour a unique population of immune cells, compared to the endometrium. In addition, the complement of immune cells in the Fallopian tube has been reported to be altered in Fallopian tube from women with ectopic pregnancy. There are increasing data suggesting that vascularisation of the Fallopian tube, by the embryo during ectopic pregnancy, differs from that initiated in the uterus during normal pregnancy. This too, is likely the result of paracrine signals between the embryo and the tubal microenvironment.

Thursday, August 11, 2011

Anticipatory ex ante moral hazard and the effect of medicare on prevention

Health Econ. 2011 Sep;20(9):1056-72. doi: 10.1002/hec.1778.
Anticipatory ex ante moral hazard and the effect of medicare on prevention.
de Preux LB.
Centre for Health Economics, University of York, York, UK; Centre for Economic Performance, London School of Economics and Political Science, London, UK.

This paper extends the ex ante moral hazard model to allow healthy lifestyles to reduce the probability of illness in future periods, so that current preventive behaviour may be affected by anticipated changes in future insurance coverage. In the United States, Medicare is offered to almost all the population at the age of 65. We use nine waves of the US Health and Retirement Study to compare lifestyles before and after 65 of those insured and not insured pre 65. The double-robust approach, which combines propensity score and regression, is used to compare trends in lifestyle (physical activity, smoking, drinking) of the two groups before and after receiving Medicare, using both difference-in-differences and difference-in-differences-in-differences. There is no clear effect of the receipt of Medicare or its anticipation on alcohol consumption nor smoking behaviour, but the previously uninsured do reduce physical activity just before receiving Medicare. Copyright © 2011 John Wiley & Sons, Ltd.

Copyright © 2011 John Wiley & Sons, Ltd.

From American Journal of Drug and Alcohol Abuse: Relationship between civic/political involvement and health

Am J Drug Alcohol Abuse. 2011 Aug 8. [Epub ahead of print]
Associations between Political/Civic Participation and HIV Drug Injection Risk.
Mino M, Deren S, Kang SY, Guarino H.
National Development and Research Institutes, Inc ., New York, NY.

Background: Participating in civic activities has been found to be related to positive health outcomes.

Objective: This study examines associations between injection drug use health variables (sharing paraphernalia, using shooting galleries) and political/civic engagement (identifying with any political party, attention paid to politics and being registered to vote).

Methods: Participants (N = 162) were recruited at 6 New York City (NYC) methadone programs as part of an HIV intervention (86% male). Results: In the bivariate analysis, being registered to vote and political party identification were related to lower paraphernalia sharing; higher levels of attention paid to politics were associated with lower shooting gallery use. In the multivariate analysis, political party identification was associated with lower paraphernalia sharing and higher levels of attention paid to politics was related to lower shooting gallery use.

Conclusions: Findings suggest that maintaining connections with mainstream civic activities can be related to reduced health risks, including HIV risk behaviors. Scientific Significance: This study contributes to understanding the relationships between involvement in civic/political participation and health, an area in which few studies have been conducted.

From Milan: Erdheim Chester disease-imaging and therapy

Clin Nucl Med. 2011 Aug;36(8):704-6.
Erdheim-chester disease: imaging-guided therapeutic approach.
Della Torre E, Dagna L, Mapelli P, Mellone R, Grazia Sabbadini M.
From the *Università Vita-Salute San Raffaele, School of Medicine, San Raffaele Scientific Institute, Milan, Italy; Departments of †Medicine and Clinical Immunology, and ‡Nuclear Medicine, San Raffaele Scientific Institute, Milan, Italy; §Università Milano Bicocca, Milan, Italy; and ¶Department of Radiology, San Raffaele Scientific Institute, Milan, Italy.

Erdheim-Chester disease (ECD) is a rare form of systemic non-Langerhans cell histiocytosis with characteristic bone involvement. However, extraskeletal involvement occurs in approximately half of the patients. Because of its protean findings, the diagnosis of ECD is often delayed; thus, a clinical suspicion may prompt specific imaging studies to recognize suggestive signs of organ involvement. In this study, a case of a patient with ECD with representative progressive multisystemic involvement has been reported; although the final diagnosis was confirmed by histologic analysis, imaging studies with almost pathognomonic findings guided the diagnostic process and prompted different therapeutic approaches according to the localization of the disease.

PMID: 21716027 [PubMed - in process]

From St. Georges Hospital, London: Update on lung cancer screening in Europe and America

Eur Radiol. 2011 Aug 10. [Epub ahead of print]
European and North American lung cancer screening experience and implications for pulmonary nodule management.
Nair A, Hansell DM.
Department of Radiology, St Georges Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK,

The potential for low dose computed tomography (LDCT) to act as an effective tool in screening for lung cancer is currently the subject of several randomised control trials. It has recently been given prominence by interim results released by the North American National Lung Screening Trial (NLST). Several other trials assessing LDCT as a screening tool are currently underway in Europe, and are due to report their final results in the next few years. These include the NELSON, DLSCT, DANTE, ITALUNG, MILD and LUSI trials. Although slow to instigate a trial of its own, the UK Lung Screen (UKLS) trial will shortly commence. The knowledge gained from the newer trials has mostly reinforced and refined previous concepts that have formed the basis of existing nodule management guidelines. This article takes the opportunity to summarise the main aspects and initial results of the trials presently underway, assess the status of current collaborative efforts and the scope for future collaboration, and analyse observations from these studies that may usefully inform the management of the indeterminate pulmonary nodule. Key Points • Low dose CT screening for lung cancer is promising. • The effect of LDCT screening on mortality is still uncertain. • Several European randomised controlled trials for LDCT are underway. • The trials vary in methodology but most compare LDCT to no screening. • Preliminary results have reinforced existing nodule management concepts.

Gender and occupational burnout

Int Arch Occup Environ Health. 2011 Jun 18. [Epub ahead of print]
Exploring within- and between-gender differences in burnout: 8 different occupational groups.
Innstrand ST, Langballe EM, Falkum E, Aasland OG.
Research Centre for Health Promotion and Resources HiST/NTNU, Department of Social Work and Health Sciences, Norwegian University of Science and Technology, 7491, Trondheim, Norway,

The aim of this study was to examine gender differences in burnout within and between occupations using latent mean analysis.

Burnout was measured using the Oldenburg Burnout Inventory (OLBI), designed to assess the two sub-dimension exhaustion and disengagement. Men and women from eight different occupational groups in Norway were investigated: lawyers, physicians, nurses, teachers, church ministers, bus drivers and people working in advertising and information technology (n = 4,965). The average age was 42 years (SD 10.8), and 50.5% of the respondents were female. Within- and between-gender differences were examined by multi-group latent mean analysis by means of LISREL.

Significant latent mean differences in the two dimensions of burnout between men and women were demonstrated. In general, the analyses indicate that overall, women report more exhaustion, but not more disengagement, than men. However, separate analyses indicate that the gender differences vary across occupational groups, especially for the disengagement dimension. Within-gender analyses suggest an approximately similar burnout profile across occupational groups for men and women.

Despite gender equality in society in general, and inconclusive findings in previous studies on gender differences in burnout, women in this study seem to experience slightly higher burnout levels than men. Occupational differences found in the burnout profiles indicate that some professions may be more prone to burnout than others. For the occupational groups most at risk, more research is needed to disclose potential organizational factors that may make these workers more prone to burnout than others.

From the Journal of Pediatric Nursing: Electronic aggression and flash mobs

"Flash mobs can be a public health hazard. Flash mobs occur when adolescents broadcast impromptu events via online social networks or mobile devices. Densely populated cities are ideal targets for flash mobs because there is the potential for more participants and more witnesses to events (Chung, 2010). Often, people are injured, and multiple law enforcement officials are needed for crowd control. Pediatric nurses can impact mob mentality by offsetting teen “follower mentality.” School nurses are uniquely positioned to educate the youth about the dangers of electronic aggression and develop programs to strengthen teens' skills of assertiveness, communication, conflict management, and decision making. Through combined efforts with the community, pediatric nurses may be able to do some “trampling” of their own in regard to media and violence, thereby protecting our greatest resource of all—the next generation."

From the Guardian: Britain's riots, young people, and state responsibility

"The biggest problem our country has faced over the last two decades is that everyone thinks the government should do everything. Personal responsibility and community responsibility have been replaced by state responsibility. If the riots have shown us anything, it is that this approach does not work."

From Higher education's bubble has burst

"Not only are the returns poor, but the quality of the product is poor (as in the case of new-construction quality in the housing boom). According to the authors of Academically Adrift: Limited Learning on College Campuses, 45 percent of students make no gains in their critical reasoning and thinking skills, as well as writing ability, after two years in college. More than one out of three college seniors were no better at writing and thinking than they were when they first arrived at their campuses."

Wednesday, August 10, 2011

Music helps you keep your exercise pace going. We needed a study for that?

Hum Mov Sci. 2011 Aug 3. [Epub ahead of print]
An investigation of stride interval stationarity while listening to music or viewing television.
Sejdić E, Jeffery R, Vanden Kroonenberg A, Chau T.
Department of Electrical and Computer Engineering, University of Pittsburgh, Pittsburgh, PA, USA; Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.

In recent years, there has been considerable interest in the effects of auditory and visual distractions on pedestrian ambulation. A fundamental temporal characteristic of ambulation is the temporal fluctuation of the stride interval. In this paper, we investigate the stationarity of stride interval time series when people are exposed to different forms of auditory and visual distractions. An increase in nonstationary behavior may be suggestive of divided attention and more frequent central modulation of locomotion, both of which may have ramifications on pedestrian vigilance and responsiveness to environmental perturbations. One group of fifteen able-bodied (6 females) young adult participants completed a music protocol (overground walking with and without music). A second group of fifteen (7 females) did a television protocol (treadmill walking while watching TV with and without sound). Three walking trials, each 15min in duration, were performed at each participant's comfortable walking speed, with force sensitive resistors under the heel of each foot. Using the reverse arrangements test, the vast majority of time series were nonstationary, with a time-varying mean as the principal source of nonstationarity. Furthermore, the television trial with sound had the greatest number of nonstationarities followed by overground walking while listening to music. We discuss the possibility that these conditions measurably affect gait dynamics through a subconscious synchronization to external rhythms or a cyclic distraction followed by a period of increased conscious correction of gait timing. Our findings suggest that the regulation of stride timing is particularly susceptible to constant, time-evolving auditory stimuli, but that normal pacing can be restored quickly upon stimulus withdrawal. These kinds of sensory distractions should thus be carefully considered in studies of pedestrian ambulation.

From U Pittsburgh: Advance care planning and cognitive impairment

Am J Geriatr Psychiatry. 2011 Aug;19(8):712-20.
Incidence and predictors of advance care planning among persons with cognitive impairment.
Garand L, Dew MA, Lingler JH, Dekosky ST.
From the Departments of Health and Community Systems (LG), Psychiatry (MAD, JHL, STD), Psychology (MAD), Epidemiology (MAD, STD), and Biostatistics (MAD, JHL, STD), University of Pittsburgh; and Alzheimer Disease Research Center (MAD, JHL, STD), Pittsburgh, PA.

: Persons with mild cognitive impairment (MCI) and Alzheimer disease (AD) are at heightened risk for future decisional incapacity. We sought to characterize advance care planning (ACP) rates over time in individuals who had no advance directives (living will or durable power of attorney) in place when they initially presented for a cognitive evaluation.

: Retrospective analysis of data that had been prospectively collected.

: Alzheimer's Disease Research Center memory disorders clinic.

: Persons (N = 127) with a diagnosis of MCI or early AD (n = 72) or moderate to severe AD (n = 55) and no advance directives upon initial presentation for a cognitive evaluation.

: Extraction of responses to items pertaining to ACP assessed during annual semistructured interviews.

: By 5 years of follow-up, 39% of the sample had initiated ACP, with little difference by baseline diagnosis. Younger subjects (younger than 65 years) were significantly more likely to initiate advance directives (43%) than older subjects (37%). This age effect was more pronounced in men than in women as well as in married subjects, those with a family history of dementia, those with no depressive disorder, and subjects with moderate to severe AD (versus those with MCI or early AD) at baseline.

: Only a minority of subjects initiated ACP. The findings suggest the need for interventions aimed at enhancing ACP completion rates, particularly among older adults with cognitive impairment, since these individuals may have a time-limited opportunity to plan for future medical, financial, and other major life decisions.

PMID: 21785291 [PubMed - in process] PMCID: PMC3145957 [Available on 2012/8/1]

Gynecologists, robot-assisted surgery, and medical malpractice

J Minim Invasive Gynecol. 2011 Jul-Aug;18(4):512-5.
Medicolegal review of liability risks for gynecologists stemming from lack of training in robot-assisted surgery.
Lee YL, Kilic GS, Phelps JY.
School of Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas.

The advances in robot-assisted surgery in gynecology evolved after most practicing gynecologists had already completed residency training. Postgraduate training in new technology for gynecologists in practice is limited. Therefore, gynecologists with insufficient training who perform robot-assisted surgery may potentially be at risk for liability. In addition to the traditional medical negligence claims, plaintiff attorneys are seeking causes of actions for lack of informed consent and negligent credentialing. Thus, it is essential that gynecologists be aware of these potential liability claims that arise in a robot-assisted malpractice suit. This commentary provides an overview of the current medicolegal liability risks originating from lack of training in robotic surgery and seeks to raise awareness of the implications involved in these claims. A better understanding of the doctrine of informed consent and seeking assistance of proctors or experienced co-surgeons early in robotics training are likely to reduce the liability risks for gynecologic surgeons.

Copyright © 2011 AAGL. Published by Elsevier Inc. All rights reserved.

From Thorax: Results of a phase IIa study of VX-809 in adult Cystic Fibrosis patients

Thorax. 2011 Aug 8. [Epub ahead of print]
Results of a phase IIa study of VX-809, an investigational CFTR corrector compound, in subjects with cystic fibrosis homozygous for the F508del-CFTR mutation.
Clancy JP, Rowe SM, Accurso FJ, Aitken ML, Amin RS, Ashlock MA, Ballmann M, Boyle MP, Bronsveld I, Campbell PW, Deboeck K, Donaldson SH, Dorkin HL, Dunitz JM, Durie PR, Jain M, Leonard A, McCoy KS, Moss RB, Pilewski JM, Rosenbluth DB, Rubenstein RC, Schechter MS, Botfield M, Ordoñez CL, Spencer-Green GT, Vernillet L, Wisseh S, Yen K, Konstan MW.
Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

Background VX-809, a cystic fibrosis transmembrane conductance regulator (CFTR) modulator, has been shown to increase the cell surface density of functional F508del-CFTR in vitro.

Methods A randomised, double-blind, placebo-controlled study evaluated the safety, tolerability and pharmacodynamics of VX-809 in adult patients with cystic fibrosis (n=89) who were homozygous for the F508del-CFTR mutation. Subjects were randomised to one of four VX-809 28 day dose groups (25, 50, 100 and 200 mg) or matching placebo.

Results The type and incidence of adverse events were similar among VX-809- and placebo-treated subjects. Respiratory events were the most commonly reported and led to discontinuation by one subject in each active treatment arm. Pharmacokinetic data supported a once-daily oral dosing regimen. Pharmacodynamic data suggested that VX-809 improved CFTR function in at least one organ (sweat gland). VX-809 reduced elevated sweat chloride values in a dose-dependent manner (p=0.0013) that was statistically significant in the 100 and 200 mg dose groups. There was no statistically significant improvement in CFTR function in the nasal epithelium as measured by nasal potential difference, nor were there statistically significant changes in lung function or patient-reported outcomes. No maturation of immature F508del-CFTR was detected in the subgroup that provided rectal biopsy specimens.

Conclusions In this study, VX-809 had a similar adverse event profile to placebo for 28 days in F508del-CFTR homozygous patients, and demonstrated biological activity with positive impact on CFTR function in the sweat gland. Additional data are needed to determine how improvements detected in CFTR function secondary to VX-809 in the sweat gland relate to those measurable in the respiratory tract and to long-term measures of clinical benefit. Clinical trial number NCT00865904.

Sarcopenic obesity

Clin Geriatr Med. 2011 Aug;27(3):401-21.
Sarcopenia and obesity.
Waters DL, Baumgartner RN.
Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand.

Four body composition phenotypes exist in older adults: normal, sarcopenic, obese, and a combination of sarcopenic and obese. There is no consensus, however, on the definitions and classifications of these phenotypes and their etiology and consequences continue to be debated. The lack of standard definitions, particularly for sarcopenia and sarcopenic obesity, creates challenges for determining prevalence across different populations. The etiology of these phenotypes is multifactorial with complex covariate relationships. This review focuses on the current literature addressing the classification, prevalence, etiology, and correlates of sarcopenia, obesity, and the combination of sarcopenia and obesity, referred to as sarcopenic obesity.

Copyright © 2011 Elsevier Inc. All rights reserved.

From Pediatrics: Infant health outcomes with homeless pregnant women

Pediatrics. 2011 Aug 8. [Epub ahead of print]
Health Behaviors and Infant Health Outcomes in Homeless Pregnant Women in The United States.
Richards R, Merrill RM, Baksh L.
Department of Nutrition, Dietetics and Food Science, Brigham Young University, Provo, Utah

Objective: To describe selected demographics; maternal health behaviors before, during, and after pregnancy; and infant health outcomes among homeless women in the United States. Patients and Methods: Analyses are based on Pregnancy Risk Assessment Monitoring System data from 31 participating states from 2000 to 2007 that were linked to birth certificate data, which contain demographic and medical information collected through the state's vital records system. Responses were then weighted to be representative of all women who gave birth in each state during that year. Assessment of these data takes into account the complex sampling designs employed by the states. Results: Four percent of women reported homelessness within 12 months before pregnancy, with the highest percentage in Illinois, followed by Oregon and Washington. Homeless women were younger, unmarried, uninsured, less educated, less likely to initiate and sustain breastfeeding, and had less prenatal care and well-visits. They were also more likely to be black, Hispanic, smoke cigarettes, be underweight or have class III obesity, and not take preconception multivitamins. Infants had lower birth weights, a longer hospital stay, and were more likely to receive neonatal intensive care. Conclusions: In this study we provide additional insight into homelessness in the perinatal period and provide information on ways to direct interventions aimed at improving the health of homeless mothers and infants. Additional research is needed to determine factors that influence pregnancy weight gain and infant feeding practices among homeless women and how this affects infant health.

From Investor's Business Daily: One reason college tuition costs are so high

"College students and their families have struggled to pay for the rising cost of tuition, a cost that has been driven in part by swelling administrative expenses. Over a 20-year period, the growth in administrative personnel at institutions of higher education has outpaced the growth in both faculty and student enrollment."

"One reason administration at public institutions has grown faster may be that bureaucracies tend to expand their staff and programs over time, regardless of need."

Federal health care dollars: Apparently not in Kansas anymore, Toto

"WASHINGTON, Aug 9 (Reuters) - Kansas became on Tuesday the second U.S. state to return a large federal grant meant to help it create a prototype health insurance exchange as part of the Obama administration's healthcare overhaul.

Republican Governor Sam Brownback said the state would give back the $31.5 million it received from the U.S. Department of Health and Human Services to become an early leader, along with six other states, in establishing health insurance exchanges that other local government could use as a model."

Tuesday, August 9, 2011

From Jim Musser and colleagues: Rapidly Progressive, Fatal, Inhalation Anthraxlike Infection in a Human

Rapidly Progressive, Fatal, Inhalation Anthraxlike Infection in a Human Case Report, Pathogen Genome Sequencing, Pathology, and Coordinated Response
Angela M. Wright, MD; Stephen B. Beres, PhD; Erin N. Consamus, MD; S. Wesley Long, MD, PhD; Anthony R. Flores, MD, PhD; Roberto Barrios, MD; G. Stefan Richter, PhD; So-Young Oh, PhD; Gabriella Garufi, PhD; Hannah Maier, BS; Ashley L. Drews, MD; Kathryn E. Stockbauer, PhD; Patricia Cernoch, MT; Olaf Schneewind, MD, PhD; Randall J. Olsen, MD, PhD; James M. Musser, MD, PhD

Context.—Ten years ago, a bioterrorism event involving Bacillus anthracis spores captured the nation’s interest, stimulated extensive new research on this pathogen, and heightened concern about illegitimate release of infectious agents. Sporadic reports have described rare, fulminant, and sometimes fatal cases of pneumonia in humans and nonhuman primates caused by strains of Bacillus cereus, a species closely related to Bacillus anthracis.

Objectives.—To describe and investigate a case of rapidly progressive, fatal, anthraxlike pneumonia and the overwhelming infection caused by a Bacillus species of uncertain provenance in a patient residing in rural Texas.

Design.—We characterized the genome of the causative strain within days of its recovery from antemortem cultures using next-generation sequencing and performed immunohistochemistry on tissues obtained at autopsy with antibodies directed against virulence proteins of B anthracis and B cereus

Results.—We discovered that the infection was caused by a previously unknown strain of B cereus that was closely related to, but genetically distinct from, B anthracis. The strain contains a plasmid similar to pXO1, a genetic element encoding anthrax toxin and other known virulence
factors. Immunohistochemistry demonstrated that several homologs of B anthracis virulence proteins were made in infected tissues, likely contributing to the patient’s death.
Conclusions.—Rapid genome sequence analysis permitted us to genetically define this strain, rule out the likelihood of bioterrorism, and contribute effectively to the institutional response to this event. Our experience strongly reinforced the critical value of deploying a wellintegrated, anatomic, clinical, and genomic strategy to respond rapidly to a potential emerging, infectious threat to public health.

Challenges to marketing retail health clinics

Health Mark Q. 2011 Jul-Sep;28(3):270-85.
Marketing retail health clinics: challenges and controversies arising from a health care innovation.
Williams CA, Khanfar NM, Harrington C, Loudon D.
a College of Pharmacy , Nova Southeastern University , Fort Lauderdale , Florida.

Since their founding in 2000, retail-based health care clinics, also called convenient care clinics, have flourished but continue to generate controversy. This article examines the literature with respect to the industry's background, establishment of industry standards, types of services offered, marketing of retail health clinics, industry growth with new target markets, and patient demographics. It also examines the growing relationship with insurers and third-party payers, quality-of-care concerns by medical associations, and legal regulations and their potential impact on industry growth nationwide.

PMID: 21815743 [PubMed - in process]

From Germany: Teaching patient safety to medical students

GMS Z Med Ausbild. 2011;28(1):Doc12. Epub 2011 Feb 4.
Pilot project "Patient-Safety" in Medical Education.
Rosentreter M, Groß D, Schäfer G.
RWTH Aachen, Medizinische Fakultät, Institut für Geschichte, Theorie und Ethik der Medizin, Aachen, Deutschland.

Since the summer term 2009 the study project "Patientensicherheit - Der klinische Umgang mit Patienten- und Eingriffsverwechslungen sowie Medikationsfehlern" (Patient Safety - the clinical handling of patients - and mistaking of procedures as well as medication errors) is offered within the Modellstudiengang Medizin. Seminars on patient safety in Germany so far mainly address trained doctors and health economists. In contrast, this study project on patient safety should at an early stage contribute to a "culture of discussing and preventing mistakes" - an aspect that is little established in clinical medicine, but also in medical training. For this purpose, a broad variety of courses was developed, which - relying on problem-oriented learning - enables the students to analyse so-called adverse events (AE) and develop adequate prevention measures on the basis of the insights gained by this analysis. Therefore, theoretical lessons are complemented by discussing prototypical clinical cases. These discussions are moderated by experienced clinicians. After completing the seminar, students showed a significant increase (comparison of means) in the self-assessed qualifications "Wissen zu Patientensicherheit" (Knowledge of Patient Safety) and "Wahrnehmung von Risikosituationen" (Appreciation of Risk Situations). All in all, the students rated their training success with a grade of 1.5 (good).

PMID: 21818227 [PubMed - as supplied by publisher]

From Vanderbilt: Real-time surveillance to reduce medication errors

Jt Comm J Qual Patient Saf. 2011 Jul;37(7):326-32.
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.
Waitman LR, Phillips IE, McCoy AB, Danciu I, Halpenny RM, Nelsen CL, Johnson DC, Starmer JM, Peterson JF.
Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.

High-alert medications are frequently responsible for adverse drug events and present significant hazards to inpatients, despite technical improvements in the way they are ordered, dispensed, and administered.

A real-time surveillance application was designed and implemented to enable pharmacy review of high-alert medication orders to complement existing computerized provider order entry and integrated clinical decision support systems in a tertiary care hospital. The surveillance tool integrated real-time data from multiple clinical systems and applied logical criteria to highlight potentially high-risk scenarios. Use of the surveillance system for adult inpatients was analyzed for warfarin, heparin and enoxaparin, and aminoglycoside antibiotics.

Among 28,929 hospitalizations during the study period, patients eligible to appear on a dashboard included 2224 exposed to warfarin, 8383 to heparin or enoxaparin, and 893 to aminoglycosides. Clinical pharmacists reviewed the warfarin and aminoglycoside dashboards during 100% of the days in the study period-and the heparinlenoxaparin dashboard during 71% of the days. Displayed alert conditions ranged from common events, such as 55% of patients receiving aminoglycosides were missing a baseline creatinine, to rare events, such as 0.1% of patients exposed to heparin were given a bolus greater than 10,000 units. On the basis of interpharmacist communication and electronic medical record notes recorded within the dashboards, interventions to prevent further patient harm were frequent.

Even in an environment with sophisticated computerized provider order entry and clinical decision support systems, real-time pharmacy surveillance of high-alert medications provides an important platform for intercepting medication errors and optimizing therapy.

From Chest: more on accountability for medical error

Chest. 2011 Aug;140(2):519-26.
Accountability for medical error: moving beyond blame to advocacy.
Bell SK, Delbanco T, Anderson-Shaw L, McDonald TB, Gallagher TH.
Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis St, LMOB-GB, Boston, MA 02215.

Accountability in medicine, once assigned primarily to individual doctors, is today increasingly shared by groups of health-care providers. Because patient safety experts emphasize that most errors are caused not by individual providers, but rather by system breakdowns in complex health-care teams, individual doctors are left to wonder where their accountability lies. Increasingly, teams deliver care. But patients and doctors alike still think of accountability in individual terms, and the law often measures it that way. Drawing on an example of delayed lung cancer diagnosis, we describe the mismatch between how we view errors (systems) and how we apportion blame (individuals). We discuss "collective accountability," suggesting that this construct may offer a way to balance a "just culture" and a doctor's specific responsibilities within the framework of team delivery of care. The concept of collective accountability requires doctors to adopt transparent behaviors, learn new skills for improving team performance, and participate in institutional safety initiatives to evaluate errors and implement plans for preventing recurrences. It also means that institutions need to prioritize team training, develop robust, nonpunitive reporting systems, support clinicians after adverse events and medical error, and develop ways to compensate patients who are harmed by errors. A conceptual leap to collective accountability may help overcome longstanding professional and societal norms that not only reinforce individual blame and impede patient safety but may also leave the patient and family without a true advocate.

From Stanford: Benefit or burden?: sending patients with nonresectable lung cancer to the ICU

Chest. 2011 Aug;140(2):558.
Benefit or burden?: sending patients with nonresectable lung cancer to the ICU.
Chooljian DM, Liu V.
JD, Stanford University School of Medicine, Division of Pulmonary and Critical Care Medicine, 300 Pasteur Dr, Room H3143, Stanford, CA

Wow: "29% do not receive guideline recommended chemotherapy treatment"

Lung Cancer. 2011 Aug 2. [Epub ahead of print]
Factors associated with adherence to chemotherapy guidelines in patients with non-small cell lung cancer.
Salloum RG, Smith TJ, Jensen GA, Lafata JE.
Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Center for Health Services Research, Henry Ford Health System, Detroit, MI 48202, USA.

Evidence-based guidelines recommend chemotherapy for medically fit patients with stages II-IV non-small cell lung cancer (NSCLC). Adherence to chemotherapy guidelines has rarely been studied among large populations, mainly because performance status (PS), a key component in assessing chemotherapy appropriateness, is missing from claims-based datasets. Among a large cohort of patients with known PS, we describe first line chemotherapy use relative to guideline recommendations and identify patient factors associated with guideline concordant use.

Insured patients, ages 50+, with stages II-IV NSCLC between 2000 and 2007 were identified via tumor registry (n=406). Chart abstracted PS, automated medical claims, Census tract information, and travel distance were linked to tumor registry data. Chemotherapy was considered appropriate for patients with PS 0-2. Multivariate logit models were fit to evaluate patient characteristics associated with chemotherapy over- and under-use per guideline recommendations. Tests of statistical significance were two sided.

Overall compliance with first line chemotherapy guidelines was 71%. Significant (p<0.05) predictors of chemotherapy underuse (19%) included increasing age (odds ratio [OR], 1.09), higher income (OR, 1.02), diagnosed before 2003 (OR, 2.05), and vehicle access (OR, 6.96) in the patient's neighborhood. Significant predictors of chemotherapy overuse (10%) included decreasing age (OR, 0.92), diagnosed after 2003 (OR, 3.24), and higher income (OR, 1.05) in the patient's neighborhood. Among NSCLC patients 29% do not receive guideline recommended chemotherapy treatment missing opportunities for cure or beneficial palliation, or receiving chemotherapy with more risk of harm than benefit. Care concordant with guidelines is influenced by age, economic considerations such as income and transportation barriers.

Spain's public health perspective on treating patients with metastatic lung cancer

Clin Lung Cancer. 2011 Aug 2. [Epub ahead of print]
Costs and Ethical Issues Related to First-Line Treatment of Metastatic Non-Small-Cell Lung Cancer: Considerations From a Public Healthcare System Perspective.
Bosch-Barrera J, Quer N, Brunet J.
Department of Medical Oncology, Catalan Institute of Oncology, Doctor Josep Trueta University Hospital, Girona, Spain.

Metastatic non-small-cell lung cancer is generally not considered to be curable, and the overall 5-year survival rate is less than 1%. Despite this poor prognosis, palliative chemotherapy can increase time and quality of life in the advanced-disease setting. New chemotherapy treatments and targeted therapies are available for this stage of disease, but their high costs are an important issue. In this perspective article, we discuss the hospital costs of antitumor drug administration and the ethical principles involved, the roles of drug agencies and oncologists, and relevant current research on these topics. These considerations have been examined from the perspective of a national public healthcare system.

Copyright © 2011. Published by Elsevier Inc.

From Memorial Sloan-Kettering: Cancer and BRAF

Curr Top Microbiol Immunol. 2011 Aug 5. [Epub ahead of print]
Targeting Oncogenic BRAF in Human Cancer.
Pratilas CA, Xing F, Solit DB.
Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA.

Mitogen Activated Protein Kinase (MAPK) pathway activation is a frequent event in human cancer and is often the result of activating mutations in the BRAF and RAS oncogenes. BRAF missense mutations, the vast majority of which are V600E, occur in approximately 8% of human tumors. These kinase domain mutations, which are non-overlapping in distribution with RAS mutations, are observed most frequently in melanoma but are also common in tumors arising in the colon, thyroid, lung, and other sites. Supporting its classification as an oncogene, (V600E)BRAF stimulates ERK signaling, induces proliferation, and is capable of promoting transformation. Given the frequent occurrence of BRAF mutations in human cancer and the continued requirement for BRAF activity in the tumors in which it is mutated, efforts are underway to develop targeted inhibitors of BRAF and its downstream effectors. These agents offer the possibility of greater efficacy and less toxicity than the systemic therapies currently available for tumors driven by activating mutations of MAPK pathway components. Early clinical results with the BRAF-selective inhibitors PLX4032 and GSK2118436 suggest that this strategy will prove successful in a select group of patients whose tumors are driven by oncogenic BRAF.

Circulating tumor cells and lung cancer

Lung Cancer. 2011 Aug 3. [Epub ahead of print]
Circulating tumor cell detection in advanced non-small cell lung cancer patients by multi-marker QPCR analysis.
Devriese LA, Bosma AJ, van de Heuvel MM, Heemsbergen W, Voest EE, Schellens JH.
Division of Experimental Therapy, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands; Department of Clinical Pharmacology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.

The aim of this study was to explore circulating tumor cell (CTC) detection in advanced non-small cell lung cancer (NSCLC). CTCs may not only serve as a prognostic marker in selected tumor types, but may also be useful as pharmacodynamic marker in drug development.

Fourty-six advanced NSCLC patients and fourty-six healthy controls were included in the study and 8.0ml of peripheral blood was obtained from each of the participants. Immunomagnetic bead enrichment for cells expressing epithelial cell adhesion molecule (EpCAM) was performed, followed by multi-marker quantitative real-time PCR of a panel of marker genes: cytokeratin 7 (CK7), cytokeratin 19 (CK19), human epithelial glycoprotein (EGP) and fibronectin 1 (FN1). Using quadratic discriminant analysis (QDA), expression values were combined into a single score, which indicated CTC-positivity or -negativity. Test characteristics were assessed using receiver operating characteristic (ROC) curve analysis.

ROC curve analysis showed capability of discrimination between advanced NSCLC patients and healthy controls (area=0.712; 95% CI 0.606-0.819; P<0.001). A cut-off minimizing overall misclassification for QDA-positivity reached a sensitivity of 46% (95% CI 31-61) and a specificity of 93% (95% CI 82-99).

In this exploratory study, an assay was developed for discriminating CTCs in peripheral blood samples of advanced NSCLC patients from healthy controls. The assay demonstrated an acceptable sensitivity in combination with good specificity. Further validation studies should take place in NSCLC patients and a matched control group.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

From U Mich: Molecular predictors of prognosis in lung cancer

Ann Surg Oncol. 2011 Aug 6. [Epub ahead of print]
Molecular Predictors of Prognosis in Lung Cancer.
Lin J, Beer DG.
Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA.

Lung carcinoma is the leading cause of cancer mortality worldwide. Currently, cancer staging and prognosis are determined using histopathology and clinical factors such as lymph node status. However, even the earliest stage of non-small cell lung carcinoma has a widely varying prognosis. In this review, the evolution and refinement of molecular predictors of prognosis in lung carcinoma are described.

From MD Anderson: Validation of the Royal Marsden Hospital prognostic score

Cancer. 2011 Aug 5. doi: 10.1002/cncr.26413. [Epub ahead of print]
Validation of the royal marsden hospital prognostic score in patients treated in the phase I clinical trials program at the MD Anderson Cancer Center.
Garrido-Laguna I, Janku F, Vaklavas C, Falchook GS, Fu S, Hong DS, Naing A, Tsimberidou AM, Wen S, Kurzrock R.
Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program), The University of Texas MD Anderson Cancer Center, Houston, Texas.

The authors validated the Royal Marsden Hospital (RMH) prognostic score in patients with advanced lung, pancreatic, and head and neck cancers who were enrolled on phase 1 trials in the MD Anderson Cancer Center Phase I Clinical Trials Program.

The RMH score uses albumin (≥3.5 g/dL vs <3.5 g/dL), lactate dehydrogenase (less than or equal to the upper limit of normal [≤ULN] vs >ULN), and the number of metastatic sites (≤2 sites vs ≥3 sites) to predict patient survival in phase 1 trials. The authors of this report retrospectively reviewed the outcomes of 229 consecutive patients with lung, pancreatic, and head and neck tumors who were treated on 57 phase 1 trials.

Two hundred twenty-nine consecutive patients with lung cancer (N = 85), pancreatic cancer (N = 83), and head and neck tumors (N = 61) were treated. The median patient age was 60 years (range, 26-85 years), and 63% of the patients were men. Patients with a good RMH prognostic score (0-1) at baseline had a longer median survival than patients with a poor prognostic score (2-3; 33.9 weeks vs 21.1 weeks; P < .0001). The RMH score was an independent variable that predicted survival in multivariate analysis. Other independent variables that predicted better survival were hemoglobin level (≥10.5 g/dL), Eastern Cooperative Oncology Group performance status (0-1), and tumor type. Patients who were treated on first-in-human trials did not fare worse compared with those who were not treated on first-in-human trials.

For patients with lung, pancreatic, and head and neck tumors who were treated on phase 1 trials, survival was predicted accurately by the RMH prognostic score. Cancer 2011;. © 2011 American Cancer Society.

Copyright © 2011 American Cancer Society.

Thursday, August 4, 2011

Just 60%?

"Of the new generation of smartphone users, 60% of teenagers classed themselves as "highly addicted" to their device, compared to 37% of adults."

From Johns Hopkins: HPV infection in men and women

Future Microbiol. 2011 Jul;6:739-45.
Male foreskin and oncogenic human papillomavirus infection in men and their female partners.
Tobian AA, Gray RH.
Department of Population, Family & Reproductive Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA; Department of Pathology, Johns Hopkins University, Carnegie 667, 600 N. Wolfe St, Baltimore, MD 21287, USA.

Persistent high-risk human papillomavirus (HR-HPV) infection causes cervical cancer, the third leading cause of cancer mortality in women worldwide. High rates of HR-HPV and cervical cancer occur in sub-Saharan Africa and are exacerbated by the HIV epidemic, making prevention of HR-HPV and HIV priorities. Male circumcision reduces HIV acquisition in men. As presented in this article, randomized controlled trial data also demonstrate that male circumcision reduces penile HR-HPV infection in both HIV-negative and -positive men. Male circumcision of HIV-negative men also reduces the prevalence and incidence of HR-HPV infections in their female partners. However, male circumcision of HIV-positive men has no effect on HR-HPV infection in their female partners. These data demonstrate that male circumcision is most effective prior to sexual debut, and the presence of the male foreskin facilitates HIV and HR-HPV infection in men and their female partners. Additional studies that utilize the foreskin mucosa obtained at the time of male circumcision are needed to assess the mucosal microenvironment in HIV and HR-HPV coinfections to develop additional preventive and therapeutic approaches.

Spirit-hosts in Madagascar and healing. Time for peer-reviewed double blind studies.

Anthropol Med. 2011 Aug;18(2):231-43.
Healing words: becoming a spirit-host in Madagascar.
Mack J.
a University of East Anglia , Norwich NR4 7TJ , UK.

In discussion of healing processes in sub-Saharan Africa, emphasis is characteristically placed on the role of performance. Yet in spirit mediumship, speech is also an important element in therapeutic practices. In Madagascar, the spirits (tromba) are often of exotic origins (frequently in time as well as space) and the language used is likewise exotic. A complex of techniques of enchantment is employed: amongst them, music, changes of dress, the burning of perfumes and incense, rum, putting matches in the mouth, or the use of herbal medicines. Sometimes artefacts, such as - in the case discussed - a large model ship, are employed. Although the setting is shrine-like, the techniques are at once both dynamic and eclectic, collapsing time and space into a single embodied moment when the spirit speaks through the vehicle of the medium. Such 'spirit-speech' is itself empowered and empowering, cathartic and curative.

From Helsinki U: Fallopian tube carcinoma-an occupational disease?

Int J Cancer. 2011 Jul 29. doi: 10.1002/ijc.26337. [Epub ahead of print]
Occupation and risk of primary fallopian tube carcinoma in nordic countries.
Riska A, Martinsen J, Kjaerheim K, Lynge E, Sparen P, Tryggvadottir L, Weiderpass E, Pukkala E.
Department of Obstetrics and Gynaecology, Helsinki University Central Hospital, Helsinki, Finland.

The aetiology of primary Fallopian tube carcinoma (PFTC) is poorly understood. Occupational exposures may contribute to PFTC risk. We studied incidence of PFTC in occupational categories in the Nordic female population aged 30-64 years during the 1960, 1970, 1980/1981 and/or 1990 censuses in Denmark, Finland, Iceland, Norway and Sweden. Standardized incidence ratios (SIRs) for the years following inclusion in the study up to 2005 were calculated for 53 occupations; the expected numbers of cases were based on PFTC incidence in the national populations. Altogether 2206 PFTC cases were detected during follow up via data linkages with the Nordic cancer registries. Significantly increased risks of PFTC were observed for smelting workers (SIR 3.99, 95% confidence interval 1.46-8.68,Obs=6), artistic workers (2.64, 1.44-4.43,Obs=14), hairdressers (2.18, 1.41-3.22,Obs=25), packers (1.62, 1.11-2.29,Obs=32), nurses (1.49, 1.14- 1.92,Obs=60), shop workers (1.25, 1.07-1.46,Obs=159) and clerical workers (1.20, 1.07-1.35,Obs=271) and these sustained over times and different Nordic countries. There was a non-significant increased risk for PFTC among welders, printers, painters and chemical process workers. The risk was significantly and consistently low for women working in farming (0.68, 0.47-0.95,Obs=34) and among economically inactive women (0.88, 0.82-0.94,Obs=833). The possible role of occupational exposures to the PFTC risks found in this study must be further evaluated in studies with a possibility to adjust for possible confounding factors, such as reproductive and life-style factors, which was not possible in our study.