1Washington University School of Medicine, Psychiatry, St. Louis, Missouri, United States.
Rationale: The CHRNA5-CHRNA3-CHRNB4 locus is associated with self-reported smoking behavior and also harbors the strongest genetic associations with chronic obstructive pulmonary disease (COPD) and lung cancer. Because the associations with lung disease remain after adjustment for self-reported smoking behaviors, it has been asserted that CHRNA5-CHRNA3-CHRNB4 variants increase COPD and lung cancersusceptibility independently of their effects on smoking.
Objectives: To compare the genetic associations of exhaled carbon monoxide (CO), a biomarker of current cigarette exposure, with self-reported smoking behaviors.
Methods: 1521 European-American and 247 African-American current smokers recruited into smoking cessation studies were assessed for CO at intake before smoking cessation. DNA samples were genotyped using the Illumina Omni2.5 microarray. Genetic associations with CO and smoking behaviors (cigarettes smoked per day, Fagerström test for nicotine dependence) were studied. Measurements and
Main Results: Variants in the CHRNA5-CHRNA3-CHRNB4 locus, including rs16969968, a non-synonymous variant in CHRNA5, are GWAS-significantly associated with CO (β=2.66; 95% CI=1.74,3.58; p=1.65x10-8) and this association remains strong after adjusting for smoking behavior (β=2.18; 95% CI=1.32,3.04; p=7.47x10-7). The correlation between CO and cigarettes per day (CPD) is statistically significantly lower (Z=3.43; p=6.07x10-4) in African-Americans (r=0.14; 95% CI=0.02,0.26; p=0.003) than in European-Americans (r=0.36; 95% CI=0.31,0.40; p=0.0001).
Conclusions: Exhaled carbon monoxide, a biomarker that is simple to measure, captures aspects of cigarette smoke exposure in current smokers beyond the number of cigarettes smoked per day. Behavioral measures of smoking are therefore insufficient indices of cigarette smoke exposure, suggesting that genetic associations with COPD or lung cancer that persist after adjusting for self-reported smoking behavior may still reflect genetic effects on smoking exposure.
1a Cardiopulmonary and Immunotoxicology Branch, Environmental Public Health Division , National Health and Environmental Effects Research Laboratory, Office of Research and Development, U.S. Environmental Protection Agency , Research Triangle Park , North Carolina , USA.
Studies recently showed that intratracheal (IT) instillation of Libby amphibole (LA) increases circulating acute-phase proteins (APP; α-2 macroglobulin, A2M; and α-1 acid glycoprotein, AGP) and inflammatory biomarkers (osteopontin and lipocalin) in rats. In this study, objectives were to (1) compare changes in biomarkers of rats after instillation of different naturally occurring asbestos (NOA) minerals including LA, Sumas Mountain chrysotile (SM), El Dorado Hills tremolite (ED), and Ontario ferroactinolite cleavage fragments (ON), and (2) examine biomarkers after subchronic LA or amosite inhalation exposure. Rat-respirable fractions (aerodynamic diameter approximately 2.5 μm) prepared by water elutriation were delivered via a single IT instillation at doses of 0, 0.5, and 1.5 mg/rat in male F344 rats. Nose-only inhalation exposures were performed at 0, 1, 3.3, and 10 mg/m3for LA and at 3.3 mg /m3 for amosite, 6h/d, 5 d/wk for 13 wk. Inflammation, metabolic syndrome, and cancer biomarkers were analyzed in the serum for up to 18 mo. IT instillation of some asbestos materials significantly increased serum AGP and A2M but to a varying degree (SM = LA > ON = ED). Numerical increases in interleukin (IL)-6 and osteopontin occurred in rats instilled with SM. SM and ED also elevated leptin and insulin at 15 mo, suggesting potential metabolic effects. LA inhalation tended to raise A2M at d 1 but not cytokines. Serum mesothelin appeared to elevate after 18 mo of LA inhalation. These results suggest that the lung injury induced by high levels of asbestos materials may be associated with systemic inflammatory changes and predisposition to insulin resistance.
Halifax, Nova Scotia, Dalhousie University. Electronic address: email@example.com.
In this article I report on an investigation of the pharmaceutical industry's influence in medical education. Findings are based on fifty semi-structured interviews with medical students in the United States and Canada conducted between 2010 and 2013. Participant responses support the survey-based literature demonstrating that there is clear and pervasive influence of the pharmaceutical industry in medical education. They also challenge the theory that medical students feel entitled to industry gifts and uncritically accept industry presence. I investigate how medical students who are critical of the pharmaceutical industry negotiate its presence in the course of their medical education. Findings suggest that these participants do not simply absorb industry presence, but interpret it and respond in complex ways. Participants were uncomfortable with industry influence throughout their medical training and found multifaceted ways to resist. They struggled with power relations in medical training and the prevailing notion that industry presence is a normal part of medical education. I argue that this pervasive norm of industry presence is located in neoliberal structural transformations within and outside both education and medicine. The idea that industry presence is normal and inevitable represents a challenge for students who are critical of industry.
Over the past decade, the medical education literature has recognized the need to develop a culture that nurtures wellbeing and resilience in students. However, the introduction of or increase in student fees precipitated a shift in higher education policies toward a consumer model of education. Importantly, it has altered the expectations of students and promoted a sense of "entitlement", rather than "striving" for something where success is not guaranteed. This model is consistent with materialism and status, and removed from intrinsic goals that are associated with mental and physical wellbeing. This article challenges medical educators to reconsider the current context of student learning and realign it with the graduate attributes needed to be a competent and responsible medical practitioner by enabling students to develop the 3Rs of resilience, responsibility and resolve. We propose that brave decisions and actions must be made by medical educators to provide students with opportunities to learn independence, self-management, and self-regulation and guarantee their role in helping medical students become resilient and responsible doctors of tomorrow.
1University Medical Center Leiden, Leiden, The Netherlands.
According to the first publication in 1993 by Rauscher et al. [Nature 1993;365:611], the Mozart effect implies the enhancement of reasoning skills solving spatial problems in normal subjects after listening to Mozart's piano sonata K 448. A further evaluation of this effect has raised the question whether there is a link between music-generated emotions and a higher level of cognitive abilities by mere listening. Positron emission tomography and functional magnetic resonance imaging have revealed that listening to pleasurable music activates cortical and subcortical cerebral areas where emotions are processed. These neurobiological effects of music suggest that auditory stimulation evokes emotions linked to heightened arousal and result in temporarily enhanced performance in many cognitive domains. Music therapy applies this arousal in a clinical setting as it may offer benefits to patients by diverting their attention from unpleasant experiences and future interventions. It has been applied in the context of various important clinical conditions such as cardiovascular disorders, cancer pain, epilepsy, depression and dementia. Furthermore, music may modulate the immune response, among other things, evidenced by increasing the activity of natural killer cells, lymphocytes and interferon-γ, which is an interesting feature as many diseases are related to a misbalanced immune system. Many of these clinical studies, however, suffer from methodological inadequacies. Nevertheless, at present, there is moderate but not altogether convincing evidence that listening to known and liked music helps to decrease the burden of a disease and enhances the immune system by modifying stress.
1Iran University of Medical Sciences, Iran firstname.lastname@example.org.
2Queensland University of Technology, Australia.
Healthcare professionals' use of social media platforms, such as blogs, wikis, and social networking web sites has grown considerably in recent years. However, few studies have explored the perspectives and experiences of physicians in adopting social media in healthcare. This article aims to identify the potential benefits and challenges of adopting social media by physicians and demonstrates this by presenting findings from a survey conducted with physicians. A qualitative survey design was employed to achieve the research goal. Semi-structured interviews were conducted with 24 physicians from around the world who were active users of social media. The data were analyzed using the thematic analysis approach. The study revealed six main reasons and six major challenges for physicians adopting social media. The main reasons to join social media were as follows: staying connected with colleagues, reaching out and networking with the wider community, sharing knowledge, engaging in continued medical education, benchmarking, and branding. The main challenges of adopting social media by physicians were also as follows: maintaining confidentiality, lack of active participation, finding time, lack of trust, workplace acceptance and support, and information anarchy. By revealing the main benefits as well as the challenges of adopting social media by physicians, the study provides an opportunity for healthcare professionals to better understand the scope and impact of social media in healthcare, and assists them to adopt and harness social media effectively, and maximize the benefits for the specific needs of the clinical community.
1Duke Cancer Institute, Duke University Medical Center and Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina. Electronic address: email@example.com.
2Division of Geriatric Medicine, University of North Carolina, Chapel Hill, North Carolina.
3Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
4Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
5Palliative Care Program, Division of Hospital Medicine, University of California, San Francisco, California.
6Center for Aging, Health and Humanities, George Washington University, Washington, DC, USA.
7Duke Cancer Institute, Duke University Medical Center and Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina.
Palliative medicine must prioritize the routine assessment of the quality of clinical care we provide. This includes regular assessment, analysis, and reporting of data on quality. Assessment of quality informs opportunities for improvement and demonstrates to our peers and ourselves the value of our efforts. In fact, continuous messaging of the value of palliative care services is needed to sustain our discipline; this requires regularly evaluating the quality of our care. As the reimbursement mechanisms for health care in the United States shift from fee-for-service to fee-for-value models, palliative care will be expected to report robust data on quality of care. We must move beyond demonstrating to our constituents (including patients and referrers), "here is what we do," and increase the focus on "this is how well we do it" and "let's see how we can do it better." It is incumbent on palliative care professionals to lead these efforts. This involves developing standardized methods to collect data without adding additional burden, comparing and sharing our experiences to promote discipline-wide quality assessment and improvement initiatives, and demonstrating our intentions for quality improvement on the clinical frontline.
Between January 2009 and October 2013, 49 states and the District of Columbia passed laws focusing on mitigating the consequences of traumatic brain injuries (TBIs) in organized youth sports. Using historical, contextual, and empirical methods, this Article describes the content, goals, and structure of youth sports TBI laws, while hypothesizing about their underlying legislative logic and long-term public health consequences. The Article's empirical evidence suggests two key findings: first, that a dominant interest group, the National Football League, helped to define the problem and its associated solutions for the vast majority of states, thus curving the legislative story are in favor of its policy prescriptions; second, that existing youth sports TBI laws are focused on secondary, not primary, prevention, and may thus shift attention away from more comprehensive solutions. Finally, the Article explains why such state laws will likely fail to substantially resolve the larger untackled problem--significantly reducing the overall rate and number of TBIs in youth sports. After explaining why existing state youth sports TBI laws fail to accomplish this broader goal, the Article queries whether alternative policy or public health measures might offer more robust solutions.
1Centre of Genomics and Policy, McGill University, Montreal, Canada.
PURPOSE OF REVIEW:
Personalized medicine encompasses the use of biological information such as genomics to provide tailored interventions for patients. The review explores the ethical, legal, and social issues that have emerged with personalized medicine and must be considered because of the complex nature of providing individualized care within a clinical setting.
Recent studies found that the use of personalized medicine presents challenges in multiple areas: biobanking and informed consent, confidentiality, genetic discrimination, return of results, access to treatment, clinical translation, direct-to-consumer genetic testing, emerging duties, and knowledge mobilization.
Although personalized medicine provides benefits in treating patients in a manner that is more suited to their genetic profile, there are challenges that must be discussed to ensure the protection and fair treatment of individuals. The issues concerning personalized medicine are widespread, and range from individual privacy to the stratification and discrimination of sub-populations based on ethnicity. These issues have considerable impact on the individual and society. A thorough exploration of these ethical issues may identify novel challenges as well as potential avenues for resolution.
1World Alliance Against Antimicrobial Resistance (WAAAR).
Antibiotic resistance, associated with a lack of new antibiotics, is a major threat. Some countries have been able to contain resistance, but in most countries the numbers of antibiotic resistant bacteria continue to rise as well as antibiotic consumption in humans and animals. Antibiotic resistance is a global issue and concern all decision makers worldwide. Some actions have been undertaken in the last 15 years, in particular by the World Health Organisation (WHO), the European Centre for Diseases Prevention and Control (ECDC) and the Centre for Diseases Control and Prevention (CDC), but those actions were partial and poorly implemented, without coordination. Very recently, some important activitieshave been carried out by the WHO. Since 2009, a task force between the USA and Europe, the Trans-Atlantic Task Force on Antibiotic Resistance (TATFAR), has been working on common recommendations. At a national level some important actions were implemented, in particular in European countries and in the USA. The Chennai declaration, in India, is also a good example of a multidisciplinary and national action, which was highly political. Finally several non-governmental non-profit organisations are also very active, and have helped raising awareness on the problem of antibiotic resistance. In the future, this global issue will need political involvement and strong cooperation between countries and between international agencies.
1Center for Disease Dynamics, Economics & Policy, 1616 P Street NW, Suite 430, Washington, DC 20036, USA; Princeton University, M43 Guyot Hall, Room 132, Princeton, NJ 08544, USA. Electronic address: Ramanan@cddep.org.
2University of Washington, Department of Global Health, Ninth and Jefferson Building, 13th Floor, 908 Jefferson Street, Box 359931, Seattle, WA 98104, USA. Electronic address: firstname.lastname@example.org.
3Resources for the Future, 1616 P Street NW, Suite 600, Washington, DC 20036, USA. Electronic address: email@example.com.
4University of Bergen, Department of Medical Ethics, Department of Global Public Health and Primary Care, Kalfarveien 31, 5018 Bergen, Norway. Electronic address: Ole.Norheim@igs.uib.no.
Vaccines are effective tools to improve human health, but resources to pursue all vaccine-related investments are lacking. Benefit-cost and cost-effectiveness analysis are the two major methodological approaches used to assess the impact, efficiency, and distributional consequences of disease interventions, including those related to vaccinations. Childhood vaccinations can have important non-health consequences for productivity and economic well-being through multiple channels, including school attendance, physical growth, and cognitive ability. Benefit-cost analysis would capture such non-health benefits; cost-effectiveness analysis does not. Standard cost-effectiveness analysis may grossly underestimate the benefits of vaccines. A specific willingness-to-pay measure is based on the notion of the value of a statistical life (VSL), derived from trade-offs people are willing to make between fatality risk and wealth. Such methods have been used widely in the environmental and health literature to capture the broader economic benefits of improving health, but reservations remain about their acceptability. These reservations remain mainly because the methods may reflect ability to pay, and hence be discriminatory against the poor. However, willingness-to-pay methods can be made sensitive to income distribution by using appropriate income-sensitive distributional weights. Here, we describe the pros and cons of these methods and how they compare against standard cost-effectiveness analysis using pure health metrics, such as quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs), in the context of vaccine priorities. We conclude that if appropriately used, willingness-to-pay methods will not discriminate against the poor, and they can capture important non-health benefits such as financial risk protection, productivity gains, and economic wellbeing.
1a Boston Children's Hospital and Harvard Medical School.
We seek to change the conversation about brain death by highlighting the distinction between brain death as a biological concept versus brain death as a legal status. The fact that brain death does not cohere with any biologically plausible definition of death has been known for decades. Nevertheless, this fact has not threatened the acceptance of brain death as a legal status that permits individuals to be treated as if they are dead. The similarities between "legally dead" and "legally blind" demonstrate how we may legitimately choose bright-line legal definitions that do not cohere with biological reality. Not only does this distinction bring conceptual coherence to the conversation about brain death, but it has practical implications as well. Once brain death is recognized as a social construction not grounded in biological reality, we create the possibility of changing the social construction in ways that may better serve both organ donors and recipients alike.
1Division of Medical Oncology, Duke Cancer Institute; Duke Clinical Research Institute, Durham, North Carolina, USA.
2Duke Cancer Institute, Durham, North Carolina, USA. firstname.lastname@example.org.
Cancer clinical trials are intended to evaluate novel interventions and to improve outcomes. Such research depends on the participation of patients seeking the best options for care. The design, conduct, and analysis of trials must therefore be grounded in an ethical framework that respects and protects the interests of clinical trial participants.
1University of Montreal, Montreal, Quebec, Canada email@example.com.
2University of Montreal, Montreal, Quebec, Canada.
In nursing education, most of the current teaching practices perpetuate an essentialist perspective of culture and make it imperative to refresh the concept of cultural competence in nursing. The purpose of this article is to propose a constructivist definition of cultural competence that stems from the conclusions of an extensive critical review of the literature on the concepts of culture, cultural competence, and cultural safety among nurses and other health professionals. The proposed constructivist definition is situated in the unitary-transformative paradigm in nursing as defined by Newman and colleagues. It makes the connection between the field of competency-based education and the nursing discipline. Cultural competence in a constructivist paradigm that is oriented toward critical, reflective practice can help us develop knowledge about the role of nurses in reducing health inequalities and lead to a comprehensive ethical reflection about the social mandate of health care professionals.
1University of Washington School of Public Health, Nutritional Sciences Program, Box 353410, Seattle, WA 98115. E-mail: firstname.lastname@example.org.
2University of Washington and Seattle Children's Research Institute, Seattle, Washington.
3Stanford University School of Medicine, Stanford, California.
4School of Nutrition and Health Promotion, Arizona State University, Phoenix, Arizona.
5University of Tennessee Health Science Center, Memphis, Tennessee.
In 2011, San Francisco passed the first citywide ordinance to improve the nutritional standards of children's meals sold at restaurants by preventing the giving away of free toys or other incentives with meals unless nutritional criteria were met. This study examined the impact of the Healthy Food Incentives Ordinance at ordinance-affected restaurants on restaurant response (eg, toy-distribution practices, change in children's menus), and the energy and nutrient content of all orders and children's-meal-only orders purchased for children aged 0 through 12 years.
Restaurant responses were examined from January 2010 through March 2012. Parent-caregiver/child dyads (n = 762) who were restaurant customers were surveyed at 2 points before and 1 seasonally matched point after ordinance enactment at Chain A and B restaurants (n = 30) in 2011 and 2012.
Both restaurant chains responded to the ordinance by selling toys separately from children's meals, but neither changed their menus to meet ordinance-specified nutrition criteria. Among children for whom children's meals were purchased, significant decreases in kilocalories, sodium, and fat per order were likely due to changes in children's side dishes and beverages at Chain A.
Although the changes at Chain A did not appear to be directly in response to the ordinance, the transition to a more healthful beverage and default side dish was consistent with the intent of the ordinance. Study results underscore the importance of policy wording, support the concept that more healthful defaults may be a powerful approach for improving dietary intake, and suggest that public policies may contribute to positive restaurant changes.
Andrew Churg, Rebecca Hall, AnaMaria Bilawich, (2014) Respiratory Bronchiolitis With Fibrosis–Interstitial Lung Disease: A New Form of Smoking-Induced Interstitial Lung Disease. Archives of Pathology & Laboratory Medicine In-Press.
From the Departments of Pathology (Dr Churg) and Radiology (Drs Hall and Bilawich), Vancouver General Hospital, Vancouver, British Columbia, Canada.
The recent pathology literature has described a new form of localized interstitial fibrosis associated with heavy cigarette smoking. This lesion has been referred to by various names, including respiratory bronchiolitis–interstitial lung disease with fibrosis,1 airspace enlargement with fibrosis,2 and smoking-related interstitial fibrosis.3 We have suggested that, to avoid confusion with other forms of smoking-related interstitial lung disease (ILD), the lesion be referred to as respiratory bronchiolitis with fibrosis (RBF).4 Most importantly, we have found that this pathologic abnormality often has a distinctive high-resolution computed tomography (HRCT) correlate, such that in many cases RBF should be diagnosable on the basis of imaging.4 The purpose of this short piece is to suggest how RBF fits into the general category of smoking-related ILD, and particularly to compare it with two possibly related forms of accepted smoking-related ILDs: respiratory bronchiolitis–interstitial lung disease (RBILD) and desquamative interstitial pneumonia (DIP).
1Interstitial Lung Disease Unit, Royal Brompton Hospital, London, United Kingdom.
PURPOSE OF REVIEW:
With recent changes in diagnostic algorithms in idiopathic pulmonary fibrosis (IPF) guidelines and treatment advances in IPF, it is now necessary to reappraise the way in which clinicians should formulate treatment strategies in the idiopathic interstitial pneumonias.
The idiopathic interstitial pneumonias can usefully be subdivided into the following categories: first, definite IPF, second, probable IPF with major differential diagnoses of fibrotic nonspecific interstitial pneumonia and chronic hypersensitivity pneumonitis and third, apparently idiopathic interstitial pneumonias other than IPF. In definite IPF, the therapeutic landscape has irrevocably changed with the identification of robust treatment effects with pirfenidone and nintedanib, consisting of the prevention of approximately 50% of disease progression (as judged by serial forced vital capacity trends). In probable IPF, generally equating with high resolution computed tomography findings of 'possible usual interstitial pneumonia' and the nonperformance of a diagnostic surgical biopsy, management is based on multidisciplinary evaluation, integrating all available information, with a final 'working diagnosis' made for treatment purposes. In other idiopathic interstitial pneumonias and their major differentials, removal of potential triggers and immunomodulation remain the cornerstones of therapy, with treatment goals usefully designated using a disease behaviour classification. In mild disease, an initial policy of observation is often appropriate.
The striking recent treatment effects reported in IPF will have major management implications in the idiopathic interstitial pneumonia in general, whenever IPF is in the differential diagnosis.
1At the time of this work, Thomas A. Farley and Deborah Dowell were with the New York City Department of Health and Mental Hygiene, New York, NY.
After decades of increases, the prevalence of childhood obesity has declined in the past decade in New York City, as measured in children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and public school students, with the greatest reductions occurring in the youngest children. Possible explanations were changes in demographics; WIC, day care, and school food policies; citywide obesity prevention policies, media messages; and family and community food consumption. Although the decreases cannot be attributed to any one cause, the most plausible explanation is changes in food consumption at home, prompted by media messages and reinforced by school and child care center policy changes. Continued media messages and policy changes are needed to sustain these improvements and extend them to other age groups.