http://www.thehastingscenter.org/uploadedFiles/Publications/Primers/integrity_pellegrino.pdf
Hastings Cent Rep. 2009;Suppl:18-20.
Physician integrity: why it is inviolable.
Pellegrino ED.
Source
Center for Clinical Bioethics at Georgetown University Medical Center, USA.
"Is the good of the patient better served when he takes charge and directs his own care, or does the erosion of trust in the physician's integrity put the patient in danger?"
Friday, October 7, 2011
PSA and libertarian paternalism
http://www.ncbi.nlm.nih.gov/pubmed/21510865
BMC Cancer. 2011 Apr 21;11:148.
Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening.
Wheeler DC, Szymanski KM, Black A, Nelson DE.
Source
Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA. dcwheels@gmail.com
Abstract
BACKGROUND:
Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence.
DISCUSSION:
Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well-informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making.
SUMMARY:
Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer.
BMC Cancer. 2011 Apr 21;11:148.
Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening.
Wheeler DC, Szymanski KM, Black A, Nelson DE.
Source
Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA. dcwheels@gmail.com
Abstract
BACKGROUND:
Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence.
DISCUSSION:
Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well-informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making.
SUMMARY:
Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer.
PSA and paternalism
http://www.ncbi.nlm.nih.gov/pubmed/20089279
J Urol. 2010 Mar;183(3):848-9. Epub 2010 Jan 20.
Paternalism, probability and prostate specific antigen.
Niederberger C.
"Describing the PSA assay in terms of odds could refocus the current public confusion over its use."
J Urol. 2010 Mar;183(3):848-9. Epub 2010 Jan 20.
Paternalism, probability and prostate specific antigen.
Niederberger C.
"Describing the PSA assay in terms of odds could refocus the current public confusion over its use."
EAU Prostate cancer guidelines-advanced disease-July 2011
http://www.ncbi.nlm.nih.gov/pubmed/21757258
Actas Urol Esp. 2011 Jul 12. [Epub ahead of print]
EAU Guidelines on Prostate Cancer. Part II: Treatment of Advanced, Relapsing, and Castration-Resistant Prostate Cancer.
[Article in English, Spanish]
Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Schmid HP, van der Kwast T, Wiegel T, Zattoni F, Heidenreich A.
Source
Departamento de Urología, Clinique Mutualiste de la Loire, Saint Etienne, Francia.
Abstract
OBJECTIVES:
Our aim is to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC).
METHODS:
The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and the levels of evidence (LEs) and/or grades of recommendation (GR) were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.
RESULTS:
Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). Although LHRH antagonists decrease testosterone without any testosterone surge, their clinical benefit remains to be determined. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation (IAD) results in equivalent oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values > 0.2 ng/ml following radical prostatectomy (RP) and > 2 ng/ml above the nadir after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT at PSA levels < 0.5 ng/ml and salvage RP or cryosurgical ablation of the prostate in radiation failures. Endorectal magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (CT) are of limited importance if the PSA is < 2.5 ng/ml; bone scans and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include screening for the metabolic syndrome and an analysis of PSA and testosterone levels. Treatment of castration-resistant prostate cancer (CRPC) includes second-line hormonal therapy, novel agents, and chemotherapy with docetaxel at 75mg/m(2) every 3 wk. Cabazitaxel as a second-line therapy for relapse after docetaxel might become a future option. Zoledronic acid and denusomab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications.
CONCLUSION:
The knowledge in the field of advanced, metastatic, and CRPC is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or online at www.uroweb.org.
Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.
Actas Urol Esp. 2011 Jul 12. [Epub ahead of print]
EAU Guidelines on Prostate Cancer. Part II: Treatment of Advanced, Relapsing, and Castration-Resistant Prostate Cancer.
[Article in English, Spanish]
Mottet N, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Schmid HP, van der Kwast T, Wiegel T, Zattoni F, Heidenreich A.
Source
Departamento de Urología, Clinique Mutualiste de la Loire, Saint Etienne, Francia.
Abstract
OBJECTIVES:
Our aim is to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the treatment of advanced, relapsing, and castration-resistant prostate cancer (CRPC).
METHODS:
The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and the levels of evidence (LEs) and/or grades of recommendation (GR) were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.
RESULTS:
Luteinising hormone-releasing hormone (LHRH) agonists are the standard of care in metastatic prostate cancer (PCa). Although LHRH antagonists decrease testosterone without any testosterone surge, their clinical benefit remains to be determined. Complete androgen blockade has a small survival benefit of about 5%. Intermittent androgen deprivation (IAD) results in equivalent oncologic efficacy when compared with continuous androgen-deprivation therapy (ADT) in well-selected populations. In locally advanced and metastatic PCa, early ADT does not result in a significant survival advantage when compared with delayed ADT. Relapse after local therapy is defined by prostate-specific antigen (PSA) values > 0.2 ng/ml following radical prostatectomy (RP) and > 2 ng/ml above the nadir after radiation therapy (RT). Therapy for PSA relapse after RP includes salvage RT at PSA levels < 0.5 ng/ml and salvage RP or cryosurgical ablation of the prostate in radiation failures. Endorectal magnetic resonance imaging and 11C-choline positron emission tomography/computed tomography (CT) are of limited importance if the PSA is < 2.5 ng/ml; bone scans and CT can be omitted unless PSA is >20 ng/ml. Follow-up after ADT should include screening for the metabolic syndrome and an analysis of PSA and testosterone levels. Treatment of castration-resistant prostate cancer (CRPC) includes second-line hormonal therapy, novel agents, and chemotherapy with docetaxel at 75mg/m(2) every 3 wk. Cabazitaxel as a second-line therapy for relapse after docetaxel might become a future option. Zoledronic acid and denusomab can be used in men with CRPC and osseous metastases to prevent skeletal-related complications.
CONCLUSION:
The knowledge in the field of advanced, metastatic, and CRPC is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice. A full version is available at the EAU office or online at www.uroweb.org.
Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.
EAU Prostate cancer guidelines-localized disease-Oct 2011
http://www.ncbi.nlm.nih.gov/pubmed/21757259
Actas Urol Esp. 2011 Oct;35(9):501-514. Epub 2011 Jul 14.
EAU Guidelines on Prostate Cancer. P5art I: Screening, Diagnosis, and Treatment of Clinically Localised Disease.
[Article in English, Spanish]
Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Mottet N, Schmid HP, van der Kwast T, Wiegel T, Zattoni F.
Source
Departamento de Urología, Universidad RWTH Aachen, Aachen, Alemania.
Abstract
OBJECTIVE:
Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).
METHODS:
The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.
RESULTS:
A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.
CONCLUSIONS:
The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.
Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.
Actas Urol Esp. 2011 Oct;35(9):501-514. Epub 2011 Jul 14.
EAU Guidelines on Prostate Cancer. P5art I: Screening, Diagnosis, and Treatment of Clinically Localised Disease.
[Article in English, Spanish]
Heidenreich A, Bellmunt J, Bolla M, Joniau S, Mason M, Matveev V, Mottet N, Schmid HP, van der Kwast T, Wiegel T, Zattoni F.
Source
Departamento de Urología, Universidad RWTH Aachen, Aachen, Alemania.
Abstract
OBJECTIVE:
Our aim was to present a summary of the 2010 version of the European Association of Urology (EAU) guidelines on the screening, diagnosis, and treatment of clinically localised cancer of the prostate (PCa).
METHODS:
The working panel performed a literature review of the new data emerging from 2007 to 2010. The guidelines were updated, and level of evidence and grade of recommendation were added to the text based on a systematic review of the literature, which included a search of online databases and bibliographic reviews.
RESULTS:
A full version is available at the EAU office or Web site (www.uroweb.org). Current evidence is insufficient to warrant widespread population-based screening by prostate-specific antigen (PSA) for PCa. A systematic prostate biopsy under ultrasound guidance and local anaesthesia is the preferred diagnostic method. Active surveillance represents a viable option in men with low-risk PCa and a long life expectancy. PSA doubling time in < 3 yr or a biopsy progression indicates the need for active intervention. In men with locally advanced PCa in whom local therapy is not mandatory, watchful waiting (WW) is a treatment alternative to androgen-deprivation therapy (ADT) with equivalent oncologic efficacy. Active treatment is mostly recommended for patients with localised disease and a long life expectancy with radical prostatectomy (RP) shown to be superior to WW in a prospective randomised trial. Nerve-sparing RP represents the approach of choice in organ-confined disease; neoadjuvant androgen deprivation demonstrates no improvement of outcome variables. Radiation therapy should be performed with at least 74Gy and 78Gy in low-risk and intermediate/high-risk PCa, respectively. For locally advanced disease, adjuvant ADT for 3 yr results in superior disease-specific and overall survival rates and represents the treatment of choice. Follow-up after local therapy is largely based on PSA, and a disease-specific history with imaging is indicated only when symptoms occur.
CONCLUSIONS:
The knowledge in the field of PCa is rapidly changing. These EAU guidelines on PCa summarise the most recent findings and put them into clinical practice.
Copyright © 2011 AEU. Published by Elsevier Espana. All rights reserved.
From King's College London: The politics of prostate screening
http://www.ncbi.nlm.nih.gov/pubmed/21812794
Sociol Health Illn. 2011 Aug 3. doi: 10.1111/j.1467-9566.2011.01385.x. [Epub ahead of print]
Resisting the screening imperative: patienthood, populations and politics in prostate cancer detection technologies for the UK.
Faulkner A.
Source
Department of Political Economy, King's College London.
Abstract
The introduction of mass screening programmes in the UK has been controversial. It is instructive to examine medical conditions for which screening has been actively considered but not introduced, such as prostate cancer. Incidence of the disease has escalated during the last 20 years, partly due to the upsurge in use of PSA (prostate-specific antigen) detection technology. The controversy is moving into a new phase, associated with the development of new molecular genetic biomarkers and tests derived from genome-association studies. The paper outlines the most recent scientific and technological developments for the three types of detection technology - PSA, genetic, and genomic. Applying concepts of risk, technology governance and technology expectations, it is shown that central public health governance actors continue to resist the tidal wave of new technologies through a variety of increasingly diverse governance modes. In the case of PSA, a governance trend moving beyond 'responsibilisation' to citizen rights is shown, whereas in the case of genetic tests and genomic risk profiling, state public health agencies are shown to be engaging in a form of technology expectation management, as it responds to a new marketplace of private commercial testing and mediatised science-based visions of future healthcare.
© 2011 The Author. Sociology of Health & Illness © 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
Sociol Health Illn. 2011 Aug 3. doi: 10.1111/j.1467-9566.2011.01385.x. [Epub ahead of print]
Resisting the screening imperative: patienthood, populations and politics in prostate cancer detection technologies for the UK.
Faulkner A.
Source
Department of Political Economy, King's College London.
Abstract
The introduction of mass screening programmes in the UK has been controversial. It is instructive to examine medical conditions for which screening has been actively considered but not introduced, such as prostate cancer. Incidence of the disease has escalated during the last 20 years, partly due to the upsurge in use of PSA (prostate-specific antigen) detection technology. The controversy is moving into a new phase, associated with the development of new molecular genetic biomarkers and tests derived from genome-association studies. The paper outlines the most recent scientific and technological developments for the three types of detection technology - PSA, genetic, and genomic. Applying concepts of risk, technology governance and technology expectations, it is shown that central public health governance actors continue to resist the tidal wave of new technologies through a variety of increasingly diverse governance modes. In the case of PSA, a governance trend moving beyond 'responsibilisation' to citizen rights is shown, whereas in the case of genetic tests and genomic risk profiling, state public health agencies are shown to be engaging in a form of technology expectation management, as it responds to a new marketplace of private commercial testing and mediatised science-based visions of future healthcare.
© 2011 The Author. Sociology of Health & Illness © 2011 Foundation for the Sociology of Health & Illness/Blackwell Publishing Ltd.
From Rotterdam: PSA screening test: 2-year or 4-year interval?
http://www.ncbi.nlm.nih.gov/pubmed/21840117
Eur Urol. 2011 Aug 11. [Epub ahead of print]
Toward an Optimal Interval for Prostate Cancer Screening.
van Leeuwen PJ, Roobol MJ, Kranse R, Zappa M, Carlsson S, Bul M, Zhu X, Bangma CH, Schröder FH, Hugosson J.
Source
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Abstract
BACKGROUND:
The rate of decrease in advanced cancers is an estimate for determining prostate cancer (PCa) screening program effectiveness.
OBJECTIVE:
Assess the effectiveness of PCa screening programs using a 2- or 4-yr screening interval.
DESIGN, SETTING, AND PARTICIPANTS:
Men aged 55-64 yr were participants at two centers of the European Randomized Study of Screening for Prostate Cancer: Gothenburg, Sweden (2-yr screening interval, n=4202), and Rotterdam, the Netherlands (4-yr screening interval, n=13 301). We followed participants until the date of PCa, the date of death, or the last follow-up at December 31, 2008, or up to a maximum of 12 yr after initial screening. Potentially life-threatening (advanced) cancer was defined as cancer with at least one of following characteristics: clinical stage ≥T3a, M1, or N1; serum prostate-specific antigen (PSA) >20.0 ng/ml; or Gleason score ≥8 at biopsy.
INTERVENTION:
We compared the proportional total (advanced) cancer incidence (screen-detected and interval cases), defined as the ratio of the observed number of (advanced) cancers to the expected numbers of (advanced) cancers based on the control arm of the study.
MEASUREMENTS:
The proportional cancer incidence from the second screening round until the end of observation was compared using a 2- or 4-yr screening interval.
RESULTS AND LIMITATIONS:
From screening round 2 until the end of observation, the proportional cancer incidence was 3.64 in Gothenburg and 3.08 in Rotterdam (relative risk [RR]: 1.18; 95% confidence interval [CI], 1.04-1.33; p=0.009). The proportional advanced cancer incidence was 0.40 in Gothenburg and 0.69 in Rotterdam (RR: 0.57; 95% CI, 0.33-0.99; p=0.048); the RR for detection of low-risk PCa was 1.46 (95% CI, 1.25-1.71; p<0.001). This study was limited by the assumption that PSA testing in the control arm was similar in both centers.
CONCLUSIONS:
A 2-yr screening interval significantly reduced the incidence of advanced PCa; however, the 2-yr interval increased the overall risk of being diagnosed with (low-risk) PCa compared with a 4-yr interval in men aged 55-64 yr. Individualized screening algorithms must be improved to provide the strategy for this issue.
Eur Urol. 2011 Aug 11. [Epub ahead of print]
Toward an Optimal Interval for Prostate Cancer Screening.
van Leeuwen PJ, Roobol MJ, Kranse R, Zappa M, Carlsson S, Bul M, Zhu X, Bangma CH, Schröder FH, Hugosson J.
Source
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands.
Abstract
BACKGROUND:
The rate of decrease in advanced cancers is an estimate for determining prostate cancer (PCa) screening program effectiveness.
OBJECTIVE:
Assess the effectiveness of PCa screening programs using a 2- or 4-yr screening interval.
DESIGN, SETTING, AND PARTICIPANTS:
Men aged 55-64 yr were participants at two centers of the European Randomized Study of Screening for Prostate Cancer: Gothenburg, Sweden (2-yr screening interval, n=4202), and Rotterdam, the Netherlands (4-yr screening interval, n=13 301). We followed participants until the date of PCa, the date of death, or the last follow-up at December 31, 2008, or up to a maximum of 12 yr after initial screening. Potentially life-threatening (advanced) cancer was defined as cancer with at least one of following characteristics: clinical stage ≥T3a, M1, or N1; serum prostate-specific antigen (PSA) >20.0 ng/ml; or Gleason score ≥8 at biopsy.
INTERVENTION:
We compared the proportional total (advanced) cancer incidence (screen-detected and interval cases), defined as the ratio of the observed number of (advanced) cancers to the expected numbers of (advanced) cancers based on the control arm of the study.
MEASUREMENTS:
The proportional cancer incidence from the second screening round until the end of observation was compared using a 2- or 4-yr screening interval.
RESULTS AND LIMITATIONS:
From screening round 2 until the end of observation, the proportional cancer incidence was 3.64 in Gothenburg and 3.08 in Rotterdam (relative risk [RR]: 1.18; 95% confidence interval [CI], 1.04-1.33; p=0.009). The proportional advanced cancer incidence was 0.40 in Gothenburg and 0.69 in Rotterdam (RR: 0.57; 95% CI, 0.33-0.99; p=0.048); the RR for detection of low-risk PCa was 1.46 (95% CI, 1.25-1.71; p<0.001). This study was limited by the assumption that PSA testing in the control arm was similar in both centers.
CONCLUSIONS:
A 2-yr screening interval significantly reduced the incidence of advanced PCa; however, the 2-yr interval increased the overall risk of being diagnosed with (low-risk) PCa compared with a 4-yr interval in men aged 55-64 yr. Individualized screening algorithms must be improved to provide the strategy for this issue.
From NYU: Baseline PSA testing at a "young" age?
http://www.ncbi.nlm.nih.gov/pubmed/21862205
Eur Urol. 2011 Aug 10. [Epub ahead of print]
Baseline Prostate-Specific Antigen Testing at a Young Age.
Loeb S, Carter HB, Catalona WJ, Moul JW, Schroder FH.
Source
Department of Urology, New York University School of Medicine, New York, NY, USA.
Abstract
CONTEXT:
Prostate cancer screening is highly controversial, including the age to begin prostate-specific antigen (PSA) testing. Several studies have evaluated the usefulness of baseline PSA measurements at a young age.
OBJECTIVE:
Review the literature on baseline PSA testing at a young age (≤60 yr) for the prediction of prostate cancer risk and prognosis.
EVIDENCE ACQUISITION:
PubMed was searched for English-language publications on baseline PSA and prostate cancer for the period ending April 2011.
EVIDENCE SYNTHESIS:
In most published series, median PSA levels in the general male population range from approximately 0.4 to 0.7 ng/ml in men in their 40s and from approximately 0.7 to 1.0 ng/ml in men in their 50s. Evidence from both nonscreening and screening populations has demonstrated the predictive value of a single baseline PSA measurement for prostate cancer risk assessment. Specifically, men with baseline PSA levels above the age-group-specific median have a greater risk of prostate cancer diagnosis during the next 20-25 yr. Additional studies confirmed that higher baseline PSA levels at a young age are also associated with a greater risk of aggressive disease, metastasis, and disease-specific mortality many years later.
CONCLUSIONS:
Baseline PSA measurements at a young age are significant predictors of later prostate cancer diagnosis and disease-specific outcomes. Thus baseline PSA testing may be used for risk stratification and to guide screening protocols.
Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Eur Urol. 2011 Aug 10. [Epub ahead of print]
Baseline Prostate-Specific Antigen Testing at a Young Age.
Loeb S, Carter HB, Catalona WJ, Moul JW, Schroder FH.
Source
Department of Urology, New York University School of Medicine, New York, NY, USA.
Abstract
CONTEXT:
Prostate cancer screening is highly controversial, including the age to begin prostate-specific antigen (PSA) testing. Several studies have evaluated the usefulness of baseline PSA measurements at a young age.
OBJECTIVE:
Review the literature on baseline PSA testing at a young age (≤60 yr) for the prediction of prostate cancer risk and prognosis.
EVIDENCE ACQUISITION:
PubMed was searched for English-language publications on baseline PSA and prostate cancer for the period ending April 2011.
EVIDENCE SYNTHESIS:
In most published series, median PSA levels in the general male population range from approximately 0.4 to 0.7 ng/ml in men in their 40s and from approximately 0.7 to 1.0 ng/ml in men in their 50s. Evidence from both nonscreening and screening populations has demonstrated the predictive value of a single baseline PSA measurement for prostate cancer risk assessment. Specifically, men with baseline PSA levels above the age-group-specific median have a greater risk of prostate cancer diagnosis during the next 20-25 yr. Additional studies confirmed that higher baseline PSA levels at a young age are also associated with a greater risk of aggressive disease, metastasis, and disease-specific mortality many years later.
CONCLUSIONS:
Baseline PSA measurements at a young age are significant predictors of later prostate cancer diagnosis and disease-specific outcomes. Thus baseline PSA testing may be used for risk stratification and to guide screening protocols.
Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
From Tokyo: PSA screening test recommendations
http://www.ncbi.nlm.nih.gov/pubmed/21948815
Ann Oncol. 2011 Sep 23. [Epub ahead of print]
Optimal prostate-specific antigen screening interval for prostate cancer.
Kobayashi D, Takahashi O, Fukui T, Glasziou PP.
Source
Department of Medicine, Division of General Internal Medicine, St Luke's International Hospital, Tokyo.
Abstract
BACKGROUND:
To identify the optimal interval for repeat prostate-specific antigen (PSA) testing to screen for prostate cancer in healthy adults.
PATIENTS AND METHODS:
A retrospective cohort study was conducted on 7332 healthy males without prostate cancer at baseline from 2005 to 2008. Participants underwent annual health checkups including PSA testing at the Center for Preventive Medicine in Japan. Participants with high PSA (≥4.0 ng/ml) underwent further examination for prostate cancer. A subgroup analysis was conducted age group (<50 years, ≥50 years). RESULTS: Mean age was 50 years. Mean PSA at baseline was 1.2 ng/ml. In over 50-year group, for those with initial PSA of <1.0, 1.0-1.9, 2.0-2.9, and 3.0-3.9 ng/ml at baseline, the 3-year cumulative incidence of prostate cancer was 0%, 0.1%, 0.3%, and 5.7%, respectively. No prostate cancer was identified in those <50 years, regardless of PSA level. CONCLUSIONS: If PSA screening is recommended, males >50 years with PSA of 3.0-3.9 ng/ml at baseline should undergo rescreening at 2 years. For men with PSA <3.0 ng/ml, PSA rescreening at intervals of ≥3 years is appropriate. PSA screening may not be indicated in males of <50 years of age.
Ann Oncol. 2011 Sep 23. [Epub ahead of print]
Optimal prostate-specific antigen screening interval for prostate cancer.
Kobayashi D, Takahashi O, Fukui T, Glasziou PP.
Source
Department of Medicine, Division of General Internal Medicine, St Luke's International Hospital, Tokyo.
Abstract
BACKGROUND:
To identify the optimal interval for repeat prostate-specific antigen (PSA) testing to screen for prostate cancer in healthy adults.
PATIENTS AND METHODS:
A retrospective cohort study was conducted on 7332 healthy males without prostate cancer at baseline from 2005 to 2008. Participants underwent annual health checkups including PSA testing at the Center for Preventive Medicine in Japan. Participants with high PSA (≥4.0 ng/ml) underwent further examination for prostate cancer. A subgroup analysis was conducted age group (<50 years, ≥50 years). RESULTS: Mean age was 50 years. Mean PSA at baseline was 1.2 ng/ml. In over 50-year group, for those with initial PSA of <1.0, 1.0-1.9, 2.0-2.9, and 3.0-3.9 ng/ml at baseline, the 3-year cumulative incidence of prostate cancer was 0%, 0.1%, 0.3%, and 5.7%, respectively. No prostate cancer was identified in those <50 years, regardless of PSA level. CONCLUSIONS: If PSA screening is recommended, males >50 years with PSA of 3.0-3.9 ng/ml at baseline should undergo rescreening at 2 years. For men with PSA <3.0 ng/ml, PSA rescreening at intervals of ≥3 years is appropriate. PSA screening may not be indicated in males of <50 years of age.
From Cleveland Clinic: How to address a rising PSA level and a negative prostate biopsy
http://www.ncbi.nlm.nih.gov/pubmed/21344195
Curr Urol Rep. 2011 Jun;12(3):197-202.
Management of rising prostate-specific antigen after a negative biopsy.
Levy DA, Jones JS.
Source
Cleveland Clinic, Department of Regional Urology, Glickman Urological Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Levyd3@ccf.org.
Abstract
Prostate biopsy remains one of the most commonly performed urologic office procedures. A significant percentage of men with a negative result may have unrecognized disease. Inadequate biopsy strategies or findings of high-grade prostatic intraepithelial neoplasia or atypia increase this likelihood. The term "negative biopsy" may be misleading. Traditional sextant biopsy is inaccurate and extended- or saturation-biopsy protocols miss small cancers. A rising prostate-specific antigen (PSA) after a negative prostate biopsy may indicate undiagnosed cancer. Magnetic resonance imaging (MRI) and template-guided biopsy have been proposed as diagnostic adjuncts in this setting. Medical manipulation has met with limited acceptance in this setting. In the presence of a rising PSA after a negative biopsy a low threshold for repeat biopsy should be entertained. Saturation biopsy increases cancer detection, especially in patients with more than two prior biopsies. Adjuncts to improve cancer detection, such as administration of 5-α-reductase inhibitors and MRI, are promising.
Curr Urol Rep. 2011 Jun;12(3):197-202.
Management of rising prostate-specific antigen after a negative biopsy.
Levy DA, Jones JS.
Source
Cleveland Clinic, Department of Regional Urology, Glickman Urological Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Levyd3@ccf.org.
Abstract
Prostate biopsy remains one of the most commonly performed urologic office procedures. A significant percentage of men with a negative result may have unrecognized disease. Inadequate biopsy strategies or findings of high-grade prostatic intraepithelial neoplasia or atypia increase this likelihood. The term "negative biopsy" may be misleading. Traditional sextant biopsy is inaccurate and extended- or saturation-biopsy protocols miss small cancers. A rising prostate-specific antigen (PSA) after a negative prostate biopsy may indicate undiagnosed cancer. Magnetic resonance imaging (MRI) and template-guided biopsy have been proposed as diagnostic adjuncts in this setting. Medical manipulation has met with limited acceptance in this setting. In the presence of a rising PSA after a negative biopsy a low threshold for repeat biopsy should be entertained. Saturation biopsy increases cancer detection, especially in patients with more than two prior biopsies. Adjuncts to improve cancer detection, such as administration of 5-α-reductase inhibitors and MRI, are promising.
The PSA test and the family physician
http://www.ncbi.nlm.nih.gov/pubmed/21501547
Can J Urol. 2011 Apr;18 Suppl:20-3.
PSA and the family physician.
Barkin J.
Source
Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada.
Abstract
The need for men to undergo screening for prostate cancer is controversial. Urologists are concerned about finding many men with minimal disease who may not require therapy or may be over-treated, while conversely missing men with clinically significant prostate cancer that could be treated and cured if found at an early enough stage. Most men today present to the physician with some symptoms attributable to the prostate, and then have a prostate-specific antigen (PSA) test to screen for prostate cancer. PSA is still the most effective test to suggest that there may be underlying prostate cancer. In addition to measuring total PSA, other measures such as PSA density, age-related PSA, or PSA velocity can provide further justification that a patient should undergo a prostate biopsy to detect possible cancer. The American Urological Association has developed new guidelines for screening for prostate cancer in men who are not at risk. The key is to use one of the PSA tools to help diagnose prostate cancer at an early stage and then offer aggressive curative therapy, if appropriate, while still providing the best quality of life and least chance of failure, in the right patient at the right time.
Can J Urol. 2011 Apr;18 Suppl:20-3.
PSA and the family physician.
Barkin J.
Source
Humber River Regional Hospital, University of Toronto, Toronto, Ontario, Canada.
Abstract
The need for men to undergo screening for prostate cancer is controversial. Urologists are concerned about finding many men with minimal disease who may not require therapy or may be over-treated, while conversely missing men with clinically significant prostate cancer that could be treated and cured if found at an early enough stage. Most men today present to the physician with some symptoms attributable to the prostate, and then have a prostate-specific antigen (PSA) test to screen for prostate cancer. PSA is still the most effective test to suggest that there may be underlying prostate cancer. In addition to measuring total PSA, other measures such as PSA density, age-related PSA, or PSA velocity can provide further justification that a patient should undergo a prostate biopsy to detect possible cancer. The American Urological Association has developed new guidelines for screening for prostate cancer in men who are not at risk. The key is to use one of the PSA tools to help diagnose prostate cancer at an early stage and then offer aggressive curative therapy, if appropriate, while still providing the best quality of life and least chance of failure, in the right patient at the right time.
PSA testing: Medical studies' "incongruent results" add to the controversy
http://www.ncbi.nlm.nih.gov/pubmed/21717898
Oncology (Williston Park). 2011 May;25(6):452-60, 463.
Screening for prostate cancer with PSA testing: current status and future directions.
Croswell JM, Kramer BS, Crawford ED.
Source
Agency for Healthcare Research and Quality, Rockville, Maryland 20850, USA. jennifer.croswell@ahrq.hhs.gov
Abstract
The ultimate utility of the serum prostate specific antigen (PSA) assay as a screening test for reducing prostate cancer mortality has been an area of intense controversy since its introduction. PSA testing was not initially envisioned as a screening tool, but as a way to evaluate treatment responses in men with prostate cancer. Far in advance of evidence from randomized trials, the rapid and widespread uptake of PSA screening into US practice was initially driven by the intuitively logical assumption that the earlier one detects a malignancy, the more likely treatment is to be curative while minimizing associated harms. However, a growing body of observational evidence began to point to a substantial burden of associated overdiagnosis and overtreatment triggered by PSA testing. The interim results of several randomized clinical trials specifically designed to evaluate the impact of PSA testing on prostate cancer mortality have recently become available, but their incongruent results seem to have added fuel to the debate. This article presents a review of the literature on screening for prostate cancer with PSA testing; we include a detailed discussion of potential explanations for the contradictory results of the two largest randomized trials as well as reflections on the future of prostate cancer screening.
Oncology (Williston Park). 2011 May;25(6):452-60, 463.
Screening for prostate cancer with PSA testing: current status and future directions.
Croswell JM, Kramer BS, Crawford ED.
Source
Agency for Healthcare Research and Quality, Rockville, Maryland 20850, USA. jennifer.croswell@ahrq.hhs.gov
Abstract
The ultimate utility of the serum prostate specific antigen (PSA) assay as a screening test for reducing prostate cancer mortality has been an area of intense controversy since its introduction. PSA testing was not initially envisioned as a screening tool, but as a way to evaluate treatment responses in men with prostate cancer. Far in advance of evidence from randomized trials, the rapid and widespread uptake of PSA screening into US practice was initially driven by the intuitively logical assumption that the earlier one detects a malignancy, the more likely treatment is to be curative while minimizing associated harms. However, a growing body of observational evidence began to point to a substantial burden of associated overdiagnosis and overtreatment triggered by PSA testing. The interim results of several randomized clinical trials specifically designed to evaluate the impact of PSA testing on prostate cancer mortality have recently become available, but their incongruent results seem to have added fuel to the debate. This article presents a review of the literature on screening for prostate cancer with PSA testing; we include a detailed discussion of potential explanations for the contradictory results of the two largest randomized trials as well as reflections on the future of prostate cancer screening.
From Sydney Morning Herald: No PSA test? Not so fast, says Australia
http://www.smh.com.au/national/men-urged-to-persist-with-disputed-prostate-test-20111007-1ldno.html
Men urged to persist with disputed prostate test
Julie Robotham
October 8, 2011
AUSTRALIA should not follow a forthcoming US recommendation against testing apparently healthy men for possible prostate cancer, experts say, but concentrate instead on ensuring those who do receive the test are treated with scientific rigour.
In a move set to inflame already polarised debate on the question, the influential United States Preventive Services Task Force is expected to say next week that men should not undergo the prostate specific-antigen blood test, which measures a protein secreted by the gland. ''Unfortunately, the evidence now shows that this test does not save men's lives," Virginia Moyer, the chairwoman of the task force, told The New York Times. "This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does."
Read more: http://www.smh.com.au/national/men-urged-to-persist-with-disputed-prostate-test-20111007-1ldno.html#ixzz1a6UegnTr
Men urged to persist with disputed prostate test
Julie Robotham
October 8, 2011
AUSTRALIA should not follow a forthcoming US recommendation against testing apparently healthy men for possible prostate cancer, experts say, but concentrate instead on ensuring those who do receive the test are treated with scientific rigour.
In a move set to inflame already polarised debate on the question, the influential United States Preventive Services Task Force is expected to say next week that men should not undergo the prostate specific-antigen blood test, which measures a protein secreted by the gland. ''Unfortunately, the evidence now shows that this test does not save men's lives," Virginia Moyer, the chairwoman of the task force, told The New York Times. "This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does."
Read more: http://www.smh.com.au/national/men-urged-to-persist-with-disputed-prostate-test-20111007-1ldno.html#ixzz1a6UegnTr
From MSNBC: PSA test - Throwing the baby out with the bath water?
http://www.msnbc.msn.com/id/44815299/ns/health-mens_health/#.To8Cd5sg-k4
No prostate test: 'Throwing baby out with bath water'
Medical groups say recommendation against routine screening will increase cancer deaths in men
"An influential panel's recommendation against routine prostate cancer screening in healthy men has prompted worries the move will increase cancer deaths.
The U.S. Preventive Services Task Force, the same group that recommended doctors scale back on mammograms for women, is thinking of recommending against use of the prostate-specific antigen or PSA test."
No prostate test: 'Throwing baby out with bath water'
Medical groups say recommendation against routine screening will increase cancer deaths in men
"An influential panel's recommendation against routine prostate cancer screening in healthy men has prompted worries the move will increase cancer deaths.
The U.S. Preventive Services Task Force, the same group that recommended doctors scale back on mammograms for women, is thinking of recommending against use of the prostate-specific antigen or PSA test."
From the NYT: Answering questions about the PSA test
http://well.blogs.nytimes.com/2011/10/06/answering-questions-about-the-p-s-a-test/
"News that an influential panel of experts is advising healthy men not to be screened for prostate cancer with a widely used test is certain to cause confusion and anxiety among men and their doctors, and reignites a debate about the benefits and risks of screening tests.
The recommendations, to be officially announced on Tuesday by the United States Preventive Services Task Force, affect more than 44 million men age 50 and older who typically are candidates for a simple blood screen call the prostate-specific antigen (P.S.A.) test.
The panel, which already recommends against P.S.A. screening for men age 75 and older, will cite recent research suggesting that the testing does not save lives but does lead to unnecessary treatments that can cause impotence, incontinence and a number of other complications.
Here are some answers to common questions about P.S.A. testing and what the task force recommendations mean for men."
"News that an influential panel of experts is advising healthy men not to be screened for prostate cancer with a widely used test is certain to cause confusion and anxiety among men and their doctors, and reignites a debate about the benefits and risks of screening tests.
The recommendations, to be officially announced on Tuesday by the United States Preventive Services Task Force, affect more than 44 million men age 50 and older who typically are candidates for a simple blood screen call the prostate-specific antigen (P.S.A.) test.
The panel, which already recommends against P.S.A. screening for men age 75 and older, will cite recent research suggesting that the testing does not save lives but does lead to unnecessary treatments that can cause impotence, incontinence and a number of other complications.
Here are some answers to common questions about P.S.A. testing and what the task force recommendations mean for men."
"Prostate test does not save lives"
http://www.medpagetoday.com/HematologyOncology/ProstateCancer/28929
USPSTF: Prostate Test Does Not Save Lives
By Charles Bankhead, Staff Writer, MedPage Today
Published: October 06, 2011
"Healthy men do not need prostate cancer screening with prostate specific antigen (PSA) because the test does not save lives and often leads to unnecessary testing, interventions, and treatment, the United States Preventive Services Task Force (USPSTF) is expected to recommend in an update to its prostate cancer screening guidelines.
According to a report in the New York Times, the recommendation will be announced Tuesday and is based on a USPSTF-commissioned study, which failed to show a clear benefit from prostate cancer screening with PSA."
USPSTF: Prostate Test Does Not Save Lives
By Charles Bankhead, Staff Writer, MedPage Today
Published: October 06, 2011
"Healthy men do not need prostate cancer screening with prostate specific antigen (PSA) because the test does not save lives and often leads to unnecessary testing, interventions, and treatment, the United States Preventive Services Task Force (USPSTF) is expected to recommend in an update to its prostate cancer screening guidelines.
According to a report in the New York Times, the recommendation will be announced Tuesday and is based on a USPSTF-commissioned study, which failed to show a clear benefit from prostate cancer screening with PSA."
Wednesday, September 28, 2011
From NY Review of Books: Hemingway
http://www.nybooks.com/articles/archives/2011/oct/13/finest-life-you-ever-saw/?pagination=false
"Hemingway’s declining health and psychological problems were more serious at the end of the 1950s. He had shock treatments at the Mayo Clinic and believed the FBI was following him. (In fact FBI agents had compiled a large file on him.) He was delusional and slurring his speech. It was kept from the public. He was unable to write as much as a single sentence. In chilling detail Hendrickson gives the almost step-by-step account of his final hour when he rose early one morning in Ketchum, Idaho, put on his slippers, and went quietly past the master bedroom where his wife was sleeping. The suicide could be seen as an act of weakness, even moral weakness, a sudden revelation of it in a man whose image was of boldness and courage, but Hendrickson’s book is testimony that it was not a failure of courage but a last display of it.
Hemingway’s Boat is a book written with the virtuosity of a novelist, hagiographic in the right way, sympathetic, assiduous, and imaginative. It does not rival the biographies but rather stands brilliantly beside them—the sea, Key West, Cuba, all the places, the life he had and gloried in. His commanding personality comes to life again in these pages, his great charm and warmth as well as his egotism and aggression.
'Forgive him anything,' as George Seldes’s wife said in the early days, 'he writes like an angel.'”
"Hemingway’s declining health and psychological problems were more serious at the end of the 1950s. He had shock treatments at the Mayo Clinic and believed the FBI was following him. (In fact FBI agents had compiled a large file on him.) He was delusional and slurring his speech. It was kept from the public. He was unable to write as much as a single sentence. In chilling detail Hendrickson gives the almost step-by-step account of his final hour when he rose early one morning in Ketchum, Idaho, put on his slippers, and went quietly past the master bedroom where his wife was sleeping. The suicide could be seen as an act of weakness, even moral weakness, a sudden revelation of it in a man whose image was of boldness and courage, but Hendrickson’s book is testimony that it was not a failure of courage but a last display of it.
Hemingway’s Boat is a book written with the virtuosity of a novelist, hagiographic in the right way, sympathetic, assiduous, and imaginative. It does not rival the biographies but rather stands brilliantly beside them—the sea, Key West, Cuba, all the places, the life he had and gloried in. His commanding personality comes to life again in these pages, his great charm and warmth as well as his egotism and aggression.
'Forgive him anything,' as George Seldes’s wife said in the early days, 'he writes like an angel.'”
From Kevin Leslie and colleagues: Bird Fancier's Lung!
http://www.ncbi.nlm.nih.gov/pubmed/21870048
Clin Rev Allergy Immunol. 2011 Aug 26. [Epub ahead of print]
Bird Fancier's Lung: A State-of-the-Art Review.
Chan AL, Juarez MM, Leslie KO, Ismail HA, Albertson TE.
Source
Division of Pulmonary, Critical Care and Sleep Medicine, University of California at Davis, School of Medicine and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA, 95817, USA, andrew.chan@ucdmc.ucdavis.edu.
Abstract
Bird fancier's lung (BFL) resulting from avian antigen exposure is a very common form of hypersensitivity pneumonitis. Its pathogenesis is modified by genetic polymorphisms located within the major histocompatibility complex, and also by smoking, which may decrease serum antibody response to inhaled antigen. Acute, subacute, and chronic presentations of BFL are recognized, but often overlap clinically. Continued antigen exposure in the chronic phase portends a worse prognosis. Chronic bronchitis symptoms may be part of the BFL clinical spectrum, and rhinitis may suggest an allergic component. The diagnosis of BFL is enhanced by a high index of suspicion of exposure to avian antigen, recurrent symptomatic episodes occurring 4-8 h after exposure, inspiratory "velcro" crackles on auscultation, weight loss, and positive IgG precipitins to the antigen. Characteristic findings on high-resolution computed tomography of the chest include centrilobular nodules, ground-glass opacification, and mosaicism due to air trapping. Bronchoalveolar lavage will classically show >25% lymphocytosis, a CD4/CD8 ratio of <1.0 and >1% mast cells in the acute phase. Lung biopsies, if obtained in the subacute phase of the disease, typically show loosely formed granulomas, giant cells, a lymphoplasmacytic interstitial infiltrate, and possibly some degree of fibrosis. In some patients, usual interstitial pneumonia or fibrotic non-specific interstitial pneumonia patterns may be seen on surgical biopsy. Skin testing, serological testing, and bronchial provocation tests for BFL frequently suffer from a lack of standardization. Effective treatment for BFL consists mainly of antigen avoidance, as corticosteroids likely do not alter long-term prognosis. Lung transplantation can be considered for progressive chronic disease refractory to medical measures.
Clin Rev Allergy Immunol. 2011 Aug 26. [Epub ahead of print]
Bird Fancier's Lung: A State-of-the-Art Review.
Chan AL, Juarez MM, Leslie KO, Ismail HA, Albertson TE.
Source
Division of Pulmonary, Critical Care and Sleep Medicine, University of California at Davis, School of Medicine and VA Northern California Health Care System, 4150 V Street, Suite 3400, Sacramento, CA, 95817, USA, andrew.chan@ucdmc.ucdavis.edu.
Abstract
Bird fancier's lung (BFL) resulting from avian antigen exposure is a very common form of hypersensitivity pneumonitis. Its pathogenesis is modified by genetic polymorphisms located within the major histocompatibility complex, and also by smoking, which may decrease serum antibody response to inhaled antigen. Acute, subacute, and chronic presentations of BFL are recognized, but often overlap clinically. Continued antigen exposure in the chronic phase portends a worse prognosis. Chronic bronchitis symptoms may be part of the BFL clinical spectrum, and rhinitis may suggest an allergic component. The diagnosis of BFL is enhanced by a high index of suspicion of exposure to avian antigen, recurrent symptomatic episodes occurring 4-8 h after exposure, inspiratory "velcro" crackles on auscultation, weight loss, and positive IgG precipitins to the antigen. Characteristic findings on high-resolution computed tomography of the chest include centrilobular nodules, ground-glass opacification, and mosaicism due to air trapping. Bronchoalveolar lavage will classically show >25% lymphocytosis, a CD4/CD8 ratio of <1.0 and >1% mast cells in the acute phase. Lung biopsies, if obtained in the subacute phase of the disease, typically show loosely formed granulomas, giant cells, a lymphoplasmacytic interstitial infiltrate, and possibly some degree of fibrosis. In some patients, usual interstitial pneumonia or fibrotic non-specific interstitial pneumonia patterns may be seen on surgical biopsy. Skin testing, serological testing, and bronchial provocation tests for BFL frequently suffer from a lack of standardization. Effective treatment for BFL consists mainly of antigen avoidance, as corticosteroids likely do not alter long-term prognosis. Lung transplantation can be considered for progressive chronic disease refractory to medical measures.
Lung cancer: "major breakthrough", "paradigm shift", "fantastic development"
http://www.medscape.com/viewarticle/748990
"Paul Bunn, MD, professor of medicine and James Dudley Chair in Cancer Research at the University of Colorado School of Medicine, in Aurora, who was on the panel, noted that the approval of crizotinib is part of a paradigm shift in the care and management of lung cancer."
"Mark G. Kris, MD, chief of the thoracic oncology service at Memorial Sloan-Kettering Cancer Center in New York City, noted that this is a 'fantastic development.' 'I see this as a delivery on the promise of personalized medicine and genomic medicine,' he said during the panel discussion. 'Clinical trials have shown that virtually every patient with an ALK fusion who received crizotinib has had some benefit. It is very effective.'"
"Paul Bunn, MD, professor of medicine and James Dudley Chair in Cancer Research at the University of Colorado School of Medicine, in Aurora, who was on the panel, noted that the approval of crizotinib is part of a paradigm shift in the care and management of lung cancer."
"Mark G. Kris, MD, chief of the thoracic oncology service at Memorial Sloan-Kettering Cancer Center in New York City, noted that this is a 'fantastic development.' 'I see this as a delivery on the promise of personalized medicine and genomic medicine,' he said during the panel discussion. 'Clinical trials have shown that virtually every patient with an ALK fusion who received crizotinib has had some benefit. It is very effective.'"
From Investor's Business Daily: Health care costs continue to rise
http://www.investors.com/NewsAndAnalysis/Article/586229/201109271842/Obama-Trauma.htm
"Until now, many of the fears about ObamaCare have been theoretical. But this year's 9% spike in premiums is concrete evidence of the substantial harm it's already doing to our health care system.
As soon as the Kaiser Family Foundation's annual report on insurance premiums was released, ObamaCare defenders dismissed its most troubling finding: Insurance premiums for family coverage shot up an average $1,482 this year."
"Until now, many of the fears about ObamaCare have been theoretical. But this year's 9% spike in premiums is concrete evidence of the substantial harm it's already doing to our health care system.
As soon as the Kaiser Family Foundation's annual report on insurance premiums was released, ObamaCare defenders dismissed its most troubling finding: Insurance premiums for family coverage shot up an average $1,482 this year."
From Florida State U: Background music and stereotypes
http://www.ncbi.nlm.nih.gov/pubmed/21938892
J Music Ther. 2011 Summer;48(2):208-25.
The effect of background music on the perception of personality and demographics.
Lastinger DL 5th.
Source
The Florida State University, FL, USA.
Abstract
This study seeks to discover stereotypes people may have about different music genres and if these stereotypes are projected onto an individual. Also, the study investigates if music therapy students are more or less biased than non-music majors in this regard. Subjects (N=388) were comprised of student members of the American Music Therapy Association (N=182) and students from a college in the southeastern United States who were not music majors (N=206). Subjects were asked to listen to a recording and complete a short survey. Subjects assigned to the control condition heard only a person reading a script. Subjects assigned to one of the four experimental conditions heard the same recording mixed with background music and ambient crowd noise, intended to simulate a live performance. Subjects were asked to rate the person in the recording on personality descriptors and predict demographic information in the survey. Many of the survey responses were significantly affected by the genre of music. For example, it was shown that when in the presence of rap or country music, all subjects rated the personality of the person in the recording significantly more negative than when in the presence of classical, jazz, or no music. There were no significant differences between the groups for any variable or condition when comparing survey responses between college students and AMTA student members.
J Music Ther. 2011 Summer;48(2):208-25.
The effect of background music on the perception of personality and demographics.
Lastinger DL 5th.
Source
The Florida State University, FL, USA.
Abstract
This study seeks to discover stereotypes people may have about different music genres and if these stereotypes are projected onto an individual. Also, the study investigates if music therapy students are more or less biased than non-music majors in this regard. Subjects (N=388) were comprised of student members of the American Music Therapy Association (N=182) and students from a college in the southeastern United States who were not music majors (N=206). Subjects were asked to listen to a recording and complete a short survey. Subjects assigned to the control condition heard only a person reading a script. Subjects assigned to one of the four experimental conditions heard the same recording mixed with background music and ambient crowd noise, intended to simulate a live performance. Subjects were asked to rate the person in the recording on personality descriptors and predict demographic information in the survey. Many of the survey responses were significantly affected by the genre of music. For example, it was shown that when in the presence of rap or country music, all subjects rated the personality of the person in the recording significantly more negative than when in the presence of classical, jazz, or no music. There were no significant differences between the groups for any variable or condition when comparing survey responses between college students and AMTA student members.
From LERES-France: Don't drink the water?
http://www.ncbi.nlm.nih.gov/pubmed/21912785
J Environ Monit. 2011 Sep 12. [Epub ahead of print]
Contamination levels of human pharmaceutical compounds in French surface and drinking water.
Mompelat S, Thomas O, Le Bot B.
Source
School of Advanced Studies in Public Health (EHESP), Laboratoire d'Etude et de Recherche en Environnement et Sante (LERES), Avenue Professeur Leon Bernard, 35043, Rennes Cedex, France. Barbara.Lebot@ehesp.fr.
Abstract
The occurrence of 20 human pharmaceutical compounds and metabolites from 10 representative therapeutic classes was analysed from resource and drinking water in two catchment basins located in north-west France. 98 samples were analysed from 63 stations (surface water and drinking water produced from surface water). Of the 20 human pharmaceutical compounds selected, 16 were quantified in both the surface water and drinking water, with 22% of the values above the limit of quantification for surface water and 14% for drinking water). Psychostimulants, non-steroidal anti-inflammatory drugs, iodinated contrast media and anxiolytic drugs were the main therapeutic classes of human pharmaceutical compounds detected in the surface water and drinking water. The results for surface water were close to results from previous studies in spite of differences in prescription rates of human pharmaceutical compounds in different countries. The removal rate of human pharmaceutical compounds at 11 water treatment units was also determined. Only caffeine proved to be resistant to drinking water treatment processes (with a minimum rate of 5%). Other human pharmaceutical compounds seemed to be removed more efficiently (average elimination rate of over 50%) by adsorption onto activated carbon and oxidation/disinfection with ozone or chlorine (not taking account of the disinfection by-products). These results add to the increasing evidence of the occurrence of human pharmaceutical compounds in drinking water that may represent a threat to human beings exposed to a cocktail of human pharmaceutical compounds and related metabolites and by-products in drinking water.
J Environ Monit. 2011 Sep 12. [Epub ahead of print]
Contamination levels of human pharmaceutical compounds in French surface and drinking water.
Mompelat S, Thomas O, Le Bot B.
Source
School of Advanced Studies in Public Health (EHESP), Laboratoire d'Etude et de Recherche en Environnement et Sante (LERES), Avenue Professeur Leon Bernard, 35043, Rennes Cedex, France. Barbara.Lebot@ehesp.fr.
Abstract
The occurrence of 20 human pharmaceutical compounds and metabolites from 10 representative therapeutic classes was analysed from resource and drinking water in two catchment basins located in north-west France. 98 samples were analysed from 63 stations (surface water and drinking water produced from surface water). Of the 20 human pharmaceutical compounds selected, 16 were quantified in both the surface water and drinking water, with 22% of the values above the limit of quantification for surface water and 14% for drinking water). Psychostimulants, non-steroidal anti-inflammatory drugs, iodinated contrast media and anxiolytic drugs were the main therapeutic classes of human pharmaceutical compounds detected in the surface water and drinking water. The results for surface water were close to results from previous studies in spite of differences in prescription rates of human pharmaceutical compounds in different countries. The removal rate of human pharmaceutical compounds at 11 water treatment units was also determined. Only caffeine proved to be resistant to drinking water treatment processes (with a minimum rate of 5%). Other human pharmaceutical compounds seemed to be removed more efficiently (average elimination rate of over 50%) by adsorption onto activated carbon and oxidation/disinfection with ozone or chlorine (not taking account of the disinfection by-products). These results add to the increasing evidence of the occurrence of human pharmaceutical compounds in drinking water that may represent a threat to human beings exposed to a cocktail of human pharmaceutical compounds and related metabolites and by-products in drinking water.
From the FDA: Feeding botanical supplements and teas to infants
http://www.ncbi.nlm.nih.gov/pubmed/21536609
Pediatrics. 2011 Jun;127(6):1060-6. Epub 2011 May 2.
Feeding of dietary botanical supplements and teas to infants in the United States.
Zhang Y, Fein EB, Fein SB.
Source
Office of Regulations, Policy and Social Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, Maryland, USA. Yuanting.zhang@fda.hhs.gov
Abstract
OBJECTIVES:
To describe the use of dietary botanical supplements and teas among infants, the characteristics of mothers who give them the specific botanical supplements and teas used, reasons for use, and sources of information.
METHODS:
We used data from the Infant Feeding Practices Study II, a longitudinal survey of women studied from late pregnancy through their infant's first year of life conducted by the US Food and Drug Administration and the Centers for Disease Control and Prevention between 2005 and 2007. The sample was drawn from a nationally distributed consumer opinion panel and was limited to healthy mothers with healthy term or near-term singleton infants. The final analytical sample included 2653 mothers. Statistical techniques include frequencies, χ² tests, and ordered logit models.
RESULTS:
Nine percent of infants were given dietary botanical supplements or teas in their first year of life, including infants as young as 1 month. Maternal herbal use (P < .0001), longer breastfeeding (P < .0001), and being Hispanic (P = .016) were significantly associated with giving infants dietary botanical supplements or teas in the multivariate model. Many supplements and teas used were marketed and sold specifically for infants. Commonly mentioned information sources included friends or family, health professionals, and the media.
CONCLUSIONS:
A substantial proportion of infants in this sample was given a wide variety of supplements and teas. Because some supplements given to infants may pose health risks, health care providers need to recognize that infants under their care may be receiving supplements or teas.
Pediatrics. 2011 Jun;127(6):1060-6. Epub 2011 May 2.
Feeding of dietary botanical supplements and teas to infants in the United States.
Zhang Y, Fein EB, Fein SB.
Source
Office of Regulations, Policy and Social Sciences, Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, Maryland, USA. Yuanting.zhang@fda.hhs.gov
Abstract
OBJECTIVES:
To describe the use of dietary botanical supplements and teas among infants, the characteristics of mothers who give them the specific botanical supplements and teas used, reasons for use, and sources of information.
METHODS:
We used data from the Infant Feeding Practices Study II, a longitudinal survey of women studied from late pregnancy through their infant's first year of life conducted by the US Food and Drug Administration and the Centers for Disease Control and Prevention between 2005 and 2007. The sample was drawn from a nationally distributed consumer opinion panel and was limited to healthy mothers with healthy term or near-term singleton infants. The final analytical sample included 2653 mothers. Statistical techniques include frequencies, χ² tests, and ordered logit models.
RESULTS:
Nine percent of infants were given dietary botanical supplements or teas in their first year of life, including infants as young as 1 month. Maternal herbal use (P < .0001), longer breastfeeding (P < .0001), and being Hispanic (P = .016) were significantly associated with giving infants dietary botanical supplements or teas in the multivariate model. Many supplements and teas used were marketed and sold specifically for infants. Commonly mentioned information sources included friends or family, health professionals, and the media.
CONCLUSIONS:
A substantial proportion of infants in this sample was given a wide variety of supplements and teas. Because some supplements given to infants may pose health risks, health care providers need to recognize that infants under their care may be receiving supplements or teas.
From U Utah: Increased ER admits for pneumonia showed no reduced mortality
http://www.ncbi.nlm.nih.gov/pubmed/21907451
Ann Emerg Med. 2011 Sep 8. [Epub ahead of print]
Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department.
Dean NC, Jones JP, Aronsky D, Brown S, Vines CG, Jones BE, Allen T.
Source
Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT.
Abstract
STUDY OBJECTIVE:
We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.
METHODS:
We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.
RESULTS:
Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.
CONCLUSION:
We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.
Ann Emerg Med. 2011 Sep 8. [Epub ahead of print]
Hospital Admission Decision for Patients With Community-Acquired Pneumonia: Variability Among Physicians in an Emergency Department.
Dean NC, Jones JP, Aronsky D, Brown S, Vines CG, Jones BE, Allen T.
Source
Pulmonary and Critical Care Medicine Division at Intermountain Medical Center and the University of Utah, Salt Lake City, UT.
Abstract
STUDY OBJECTIVE:
We examine variability among emergency physicians in rate of hospitalization for patients with pneumonia and the effect of variability on clinical outcomes.
METHODS:
We studied 2,069 LDS Hospital emergency department (ED) patients with community-acquired pneumonia who were aged 18 years or older during 1996 to 2006, identified by International Classification of Diseases, Ninth Revision coding and compatible chest radiographs. We extracted vital signs, laboratory and radiographic results, hospitalization, and outcomes from the electronic medical record. We defined "low severity" as PaO(2)/FiO(2) ratio greater than or equal to 280 mm Hg, predicted mortality less than 5% by an electronic version of CURB-65 that uses continuous and weighted elements (eCURB), and less than 3 Infectious Disease Society of America-American Thoracic Society 2007 severe pneumonia minor criteria. We adjusted hospitalization decisions and outcomes for illness severity and patient demographics.
RESULTS:
Initial hospitalization rate was 58%; 10.7% of patients initially treated as outpatients were secondarily hospitalized within 7 days. Median age of admitted patients was 63 years; median eCURB predicted mortality was 2.65% (mean 6.8%) versus 46 years and 0.93% for outpatients. The 18 emergency physicians (average age 44.9 [standard deviation 7.6] years; years in practice 8.4 [standard deviation 6.9]) objectively calculated and documented illness severity in 2.7% of patients. Observed 30-day mortality for inpatients was 6.8% (outpatient mortality 0.34%) and decreased over time. Individual physician admission rates ranged from 38% to 79%, with variability not explained by illness severity, time of day, day of week, resident care in conjunction with an attending physician, or patient or physician demographics. Higher hospitalization rates were not associated with reduced mortality or fewer secondary hospital admissions.
CONCLUSION:
We observed a 2-fold difference in pneumonia hospitalization rates among emergency physicians, unexplained by objective data.
From Weill Cornell: Current status of Pseudomonas vaccines for Cystic Fibrosis patients
http://www.ncbi.nlm.nih.gov/pubmed/21941090
Hum Vaccin. 2011 Oct 1;7(10). [Epub ahead of print]
Recent developments for Pseudomonas vaccines.
Sharma A, Worgall S.
Source
Department of Genetic Medicine and Department of Pediatrics, Weill Medical College of Cornell University, New York, NY USA.
Abstract
Infections with Pseudomonas aeruginosa are a major health problem for immune-compromised patients and individuals with cystic fibrosis. A vaccine against: P. aeruginosa has long been sought after, but is so far not available. Several vaccine candidates have been assessed in experimental animals and humans, which include sub-cellular fractions, capsule components, purified and recombinant proteins. Unique characteristics of the host and the pathogen have complicated the vaccine development. This review summarizes the current state of vaccine development for this ubiquitous pathogen, in particular to provide mucosal immunity against infections of the respiratory tract in susceptible individuals with cystic fibrosis.
Hum Vaccin. 2011 Oct 1;7(10). [Epub ahead of print]
Recent developments for Pseudomonas vaccines.
Sharma A, Worgall S.
Source
Department of Genetic Medicine and Department of Pediatrics, Weill Medical College of Cornell University, New York, NY USA.
Abstract
Infections with Pseudomonas aeruginosa are a major health problem for immune-compromised patients and individuals with cystic fibrosis. A vaccine against: P. aeruginosa has long been sought after, but is so far not available. Several vaccine candidates have been assessed in experimental animals and humans, which include sub-cellular fractions, capsule components, purified and recombinant proteins. Unique characteristics of the host and the pathogen have complicated the vaccine development. This review summarizes the current state of vaccine development for this ubiquitous pathogen, in particular to provide mucosal immunity against infections of the respiratory tract in susceptible individuals with cystic fibrosis.
Sarcopenia and postmenopausal osteoporosis
http://www.ncbi.nlm.nih.gov/pubmed/21904688
J Osteoporos. 2011;2011:536735. Epub 2011 Aug 28.
Similarities in acquired factors related to postmenopausal osteoporosis and sarcopenia.
Sirola J, Kröger H.
Source
Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, 70211 Kuopio, Finland.
Abstract
Postmenopausal population is at increased risk of musculoskeletal impairments. Sarcopenia and osteoporosis are associated with significant morbidity and social and health-care costs. These two conditions are uniquely linked with similarities in pathophysiology and diagnostic methods. Uniform diagnostic criteria for sarcopenia are still evolving. Postmenopausal sarcopenia and osteoporosis share many environmental risk- and preventive factors. Moreover, geriatric frailty syndrome may result from interaction of osteoporosis and sarcopenia and may lead to increased mortality. The present paper reviews the factors in evolution of postmenopausal sarcopenia and osteoporosis.
J Osteoporos. 2011;2011:536735. Epub 2011 Aug 28.
Similarities in acquired factors related to postmenopausal osteoporosis and sarcopenia.
Sirola J, Kröger H.
Source
Department of Orthopedics, Traumatology and Hand Surgery, Kuopio University Hospital, 70211 Kuopio, Finland.
Abstract
Postmenopausal population is at increased risk of musculoskeletal impairments. Sarcopenia and osteoporosis are associated with significant morbidity and social and health-care costs. These two conditions are uniquely linked with similarities in pathophysiology and diagnostic methods. Uniform diagnostic criteria for sarcopenia are still evolving. Postmenopausal sarcopenia and osteoporosis share many environmental risk- and preventive factors. Moreover, geriatric frailty syndrome may result from interaction of osteoporosis and sarcopenia and may lead to increased mortality. The present paper reviews the factors in evolution of postmenopausal sarcopenia and osteoporosis.
Physicians, get ready to "adapt"
http://www.ncbi.nlm.nih.gov/pubmed/21934512
Health Care Manage Rev. 2011 Sep 19. [Epub ahead of print]
The cultural complexity of medical groups.
Nembhard IM, Singer SJ, Shortell SM, Rittenhouse D, Casalino LP.
Source
Ingrid M. Nembhard, PhD, MS*, is Assistant Professor, Yale School of Public Health and Yale School of Management, Yale University, New Haven, Connecticut. E-mail: ingrid.nembhard@yale.edu. Sara J. Singer, PhD, MBA*, is Assistant Professor, Harvard School of Public Health and Harvard Medical School, Boston, Massachusetts. E-mail: ssinger@hsph.harvard.edu. Stephen M. Shortell, PhD, MPH, MBA, is Blue Cross of California Distinguished Professor of Health Policy and Management, School of Public Health, Haas School of Business, and is Dean, School of Public Health, University of California, Berkeley. E-mail: shortell@berkeley.edu. Diane Rittenhouse, MD, MPH, is Associate Professor, Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. E-mail: Rittenhouse@fcm.ucsf.edu. Lawrence P. Casalino, MD, PhD, is Chief of the Division of Outcomes and Effectiveness Research and The Livingston Farrand Associate Professor of Public Health, Department of Public Health, Weill Cornell Medical College, New York, New York. E-mail: lac2021@med.cornell.edu.
Abstract
BACKGROUND:
Organizational culture is an important driver of organizational performance. However, little is known about the cultures of medical groups, which play an important role in health care.
PURPOSE:
We sought to characterize the cultures of medical groups and identify factors that influence these cultures.
METHODOLOGY:
We conducted a qualitative study of the organizational cultures of 8 U.S. multispecialty medical groups, using data collected during site visits and in-depth interviews with clinical and administrative staff (N = 69). Groups were randomly selected from those that participated in the second National Study of Physician Organizations using stratified sampling along three dimensions (i.e., ownership type, use of care management practices, and outcome performance). We analyzed the data to assess the presence of seven culture types-group, hierarchical, rational, developmental, quality oriented, patient centered, and physician centered-using the constant comparative method.
FINDINGS:
We found that a multiplicity and diversity of cultures exist within and across multispecialty medical groups, with a dominance of patient-centered, physician-centered, rational, or quality-oriented cultures and less emphasis on group, developmental, and hierarchical cultures. Culture types that may seem antithetical, for example, patient-centered and physician-centered cultures, often coexisted within the same group. Across culture types, we found that six factors influenced medical group culture: financial, people, leadership, structural, processes, and environmental.
PRACTICE IMPLICATIONS:
As medical groups adapt to changes under health care reform, their success likely depends on their having cultures that facilitate collaboration with other organizations (e.g., hospitals) that possess different cultures and adaptation to changes in payment and regulation. Our study suggests that some groups may not have the developmental and group cultures needed to adapt. Our study identifies six categories of levers they can use to alter their culture as desired.
Health Care Manage Rev. 2011 Sep 19. [Epub ahead of print]
The cultural complexity of medical groups.
Nembhard IM, Singer SJ, Shortell SM, Rittenhouse D, Casalino LP.
Source
Ingrid M. Nembhard, PhD, MS*, is Assistant Professor, Yale School of Public Health and Yale School of Management, Yale University, New Haven, Connecticut. E-mail: ingrid.nembhard@yale.edu. Sara J. Singer, PhD, MBA*, is Assistant Professor, Harvard School of Public Health and Harvard Medical School, Boston, Massachusetts. E-mail: ssinger@hsph.harvard.edu. Stephen M. Shortell, PhD, MPH, MBA, is Blue Cross of California Distinguished Professor of Health Policy and Management, School of Public Health, Haas School of Business, and is Dean, School of Public Health, University of California, Berkeley. E-mail: shortell@berkeley.edu. Diane Rittenhouse, MD, MPH, is Associate Professor, Department of Family and Community Medicine, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco. E-mail: Rittenhouse@fcm.ucsf.edu. Lawrence P. Casalino, MD, PhD, is Chief of the Division of Outcomes and Effectiveness Research and The Livingston Farrand Associate Professor of Public Health, Department of Public Health, Weill Cornell Medical College, New York, New York. E-mail: lac2021@med.cornell.edu.
Abstract
BACKGROUND:
Organizational culture is an important driver of organizational performance. However, little is known about the cultures of medical groups, which play an important role in health care.
PURPOSE:
We sought to characterize the cultures of medical groups and identify factors that influence these cultures.
METHODOLOGY:
We conducted a qualitative study of the organizational cultures of 8 U.S. multispecialty medical groups, using data collected during site visits and in-depth interviews with clinical and administrative staff (N = 69). Groups were randomly selected from those that participated in the second National Study of Physician Organizations using stratified sampling along three dimensions (i.e., ownership type, use of care management practices, and outcome performance). We analyzed the data to assess the presence of seven culture types-group, hierarchical, rational, developmental, quality oriented, patient centered, and physician centered-using the constant comparative method.
FINDINGS:
We found that a multiplicity and diversity of cultures exist within and across multispecialty medical groups, with a dominance of patient-centered, physician-centered, rational, or quality-oriented cultures and less emphasis on group, developmental, and hierarchical cultures. Culture types that may seem antithetical, for example, patient-centered and physician-centered cultures, often coexisted within the same group. Across culture types, we found that six factors influenced medical group culture: financial, people, leadership, structural, processes, and environmental.
PRACTICE IMPLICATIONS:
As medical groups adapt to changes under health care reform, their success likely depends on their having cultures that facilitate collaboration with other organizations (e.g., hospitals) that possess different cultures and adaptation to changes in payment and regulation. Our study suggests that some groups may not have the developmental and group cultures needed to adapt. Our study identifies six categories of levers they can use to alter their culture as desired.
Med mal in the UK
http://www.ncbi.nlm.nih.gov/pubmed/21923926
Head Neck Oncol. 2011 Sep 17;3(1):41. [Epub ahead of print]
English Law for the Surgeon I: Consent, Capacity and Competence.
Jerjes W, Mahil J, Upile T.
Abstract
ABSTRACT: Traditionally, in the United Kingdom and Europe the surgeon was generally not troubled by litigation from patients presenting as elective as well as emergency cases, but this aspect of custom has changed. Litigation by patients now significantly affects surgical practice and vicarious liability often affects hospitals. We discuss some fundamental legal definitions, a must to know for a surgeon, and highlight some interesting cases.
Head Neck Oncol. 2011 Sep 17;3(1):41. [Epub ahead of print]
English Law for the Surgeon I: Consent, Capacity and Competence.
Jerjes W, Mahil J, Upile T.
Abstract
ABSTRACT: Traditionally, in the United Kingdom and Europe the surgeon was generally not troubled by litigation from patients presenting as elective as well as emergency cases, but this aspect of custom has changed. Litigation by patients now significantly affects surgical practice and vicarious liability often affects hospitals. We discuss some fundamental legal definitions, a must to know for a surgeon, and highlight some interesting cases.
Lung cancer treatment: Third CECOG concensus
http://www.ncbi.nlm.nih.gov/pubmed/21940784
Ann Oncol. 2011 Sep 22. [Epub ahead of print]
Third CECOG consensus on the systemic treatment of non-small-cell lung cancer.
Brodowicz T, Ciuleanu T, Crawford J, Filipits M, Fischer JR, Georgoulias V, Gridelli C, Hirsch FR, Jassem J, Kosmidis P, Krzakowski M, Manegold C, Pujol JL, Stahel R, Thatcher N, Vansteenkiste J, Minichsdorfer C, Zöchbauer-Müller S, Pirker R, Zielinski CC; for the Central European Cooperative Oncology Group (CECOG).
Source
Clinical Division of Oncology, Comprehensive Cancer Center, Medical University Vienna-General Hospital, Vienna, Austria.
Abstract
The current third consensus on the systemic treatment of non-small-cell lung cancer (NSCLC) builds upon and updates similar publications on the subject by the Central European Cooperative Oncology Group (CECOG), which has published such consensus statements in the years 2002 and 2005 (Zielinski CC, Beinert T, Crawford J et al. Consensus on medical treatment of non-small-cell lung cancer-update 2004. Lung Cancer 2005; 50: 129-137). The principle of all CECOG consensus is such that evidence-based recommendations for state-of-the-art treatment are given upon which all participants and authors of the manuscript have to agree (Beslija S, Bonneterre J, Burstein HJ et al. Third consensus on medical treatment of metastatic breast cancer. Ann Oncol 2009; 20 (11): 1771-1785). This is of particular importance in diseases in which treatment options depend on very particular clinical and biologic variables (Zielinski CC, Beinert T, Crawford J et al. Consensus on medical treatment of non-small-cell lung cancer-update 2004. Lung Cancer 2005; 50: 129-137; Beslija S, Bonneterre J, Burstein HJ et al. Third consensus on medical treatment of metastatic breast cancer. Ann Oncol 2009; 20 (11): 1771-1785). Since the publication of the last CECOG consensus on the medical treatment of NSCLC, a series of diagnostic tools for the characterization of biomarkers for personalized therapy for NSCLC as well as therapeutic options including adjuvant treatment, targeted therapy, and maintenance treatment have emerged and strongly influenced the field. Thus, the present third consensus was generated that not only readdresses previous disease-related issues but also expands toward recent developments in the management of NSCLC. It is the aim of the present consensus to summarize minimal quality-oriented requirements for individual patients with NSCLC in its various stages based upon levels of evidence in the light of a rapidly expanding array of individual therapeutic options.
Ann Oncol. 2011 Sep 22. [Epub ahead of print]
Third CECOG consensus on the systemic treatment of non-small-cell lung cancer.
Brodowicz T, Ciuleanu T, Crawford J, Filipits M, Fischer JR, Georgoulias V, Gridelli C, Hirsch FR, Jassem J, Kosmidis P, Krzakowski M, Manegold C, Pujol JL, Stahel R, Thatcher N, Vansteenkiste J, Minichsdorfer C, Zöchbauer-Müller S, Pirker R, Zielinski CC; for the Central European Cooperative Oncology Group (CECOG).
Source
Clinical Division of Oncology, Comprehensive Cancer Center, Medical University Vienna-General Hospital, Vienna, Austria.
Abstract
The current third consensus on the systemic treatment of non-small-cell lung cancer (NSCLC) builds upon and updates similar publications on the subject by the Central European Cooperative Oncology Group (CECOG), which has published such consensus statements in the years 2002 and 2005 (Zielinski CC, Beinert T, Crawford J et al. Consensus on medical treatment of non-small-cell lung cancer-update 2004. Lung Cancer 2005; 50: 129-137). The principle of all CECOG consensus is such that evidence-based recommendations for state-of-the-art treatment are given upon which all participants and authors of the manuscript have to agree (Beslija S, Bonneterre J, Burstein HJ et al. Third consensus on medical treatment of metastatic breast cancer. Ann Oncol 2009; 20 (11): 1771-1785). This is of particular importance in diseases in which treatment options depend on very particular clinical and biologic variables (Zielinski CC, Beinert T, Crawford J et al. Consensus on medical treatment of non-small-cell lung cancer-update 2004. Lung Cancer 2005; 50: 129-137; Beslija S, Bonneterre J, Burstein HJ et al. Third consensus on medical treatment of metastatic breast cancer. Ann Oncol 2009; 20 (11): 1771-1785). Since the publication of the last CECOG consensus on the medical treatment of NSCLC, a series of diagnostic tools for the characterization of biomarkers for personalized therapy for NSCLC as well as therapeutic options including adjuvant treatment, targeted therapy, and maintenance treatment have emerged and strongly influenced the field. Thus, the present third consensus was generated that not only readdresses previous disease-related issues but also expands toward recent developments in the management of NSCLC. It is the aim of the present consensus to summarize minimal quality-oriented requirements for individual patients with NSCLC in its various stages based upon levels of evidence in the light of a rapidly expanding array of individual therapeutic options.
Thursday, September 22, 2011
From Cancer: Radiotherapy for lung cancer
http://www.ncbi.nlm.nih.gov/m/pubmed/21935913/?i=1&from=lung%20cancer
Predicting the need for palliative thoracic radiation after first-line chemotherapy for advanced nonsmall cell lung carcinoma.
AuthorsHigginson DS, et al.
Cancer. 2011 Sep 20. doi: 10.1002/cncr.26495. [Epub ahead of print]
Affiliation
Department of Radiation Oncology, Division of Hematology and Oncology, University of North Carolina, Chapel Hill, North Carolina. dhiggins@unch.unc.edu, daniel.higginson@gmail.com.
Abstract
BACKGROUND: The objective of this secondary analysis was to identify patients with selected stage IIIB/IV nonsmall cell lung carcinoma and good performance status who were at high risk for requiring subsequent palliative thoracic radiotherapy after initial treatment with first-line chemotherapy.
METHODS: The authors conducted a pooled analysis of patients at a single institution who enrolled onto 10 prospective phase 2 and 3 clinical trials that involved first-line, platinum-based chemotherapy. Baseline lung-related characteristics before trial enrollment were analyzed as possible prognostic factors for freedom from pulmonary events (defined either as subsequent thoracic radiation or as a new collapsed lung, which is an indication for thoracic radiation).
RESULTS: Of 244 consecutive patients who were reviewed, 42 patients received a palliative course of thoracic radiation, 40 exhibited evidence of new lobar collapse on follow-up chest imaging, and 14 received thoracic radiation for lobar collapse. On univariable analysis, pulmonary symptoms (P = .043) or pneumonia at presentation (P = .0001), increasing size of hilar disease (P < .0001), and evidence of obstruction of major bronchi or vessels (P = .0003) were associated with subsequent pulmonary events. On multivariable analysis, hilar disease measuring >3 cm (hazard ratio, 1.8; P = .003) and prechemotherapy pneumonia (hazard ratio, 2.1; P = .009) were associated with pulmonary events; patients who had both risk factors or hilar disease >5 cm in greatest dimension exhibited a >50% risk of subsequent events.
CONCLUSIONS: Patients with bulky hilar disease and a history of pneumonia at presentation were at high risk for requiring palliative thoracic radiation. The authors propose studying these patients to determine whether early thoracic radiation may be beneficial by preserving quality of life and performance status. Cancer 2011. © 2011 American Cancer Society.
Copyright © 2011 American Cancer Society.
Predicting the need for palliative thoracic radiation after first-line chemotherapy for advanced nonsmall cell lung carcinoma.
AuthorsHigginson DS, et al.
Cancer. 2011 Sep 20. doi: 10.1002/cncr.26495. [Epub ahead of print]
Affiliation
Department of Radiation Oncology, Division of Hematology and Oncology, University of North Carolina, Chapel Hill, North Carolina. dhiggins@unch.unc.edu, daniel.higginson@gmail.com.
Abstract
BACKGROUND: The objective of this secondary analysis was to identify patients with selected stage IIIB/IV nonsmall cell lung carcinoma and good performance status who were at high risk for requiring subsequent palliative thoracic radiotherapy after initial treatment with first-line chemotherapy.
METHODS: The authors conducted a pooled analysis of patients at a single institution who enrolled onto 10 prospective phase 2 and 3 clinical trials that involved first-line, platinum-based chemotherapy. Baseline lung-related characteristics before trial enrollment were analyzed as possible prognostic factors for freedom from pulmonary events (defined either as subsequent thoracic radiation or as a new collapsed lung, which is an indication for thoracic radiation).
RESULTS: Of 244 consecutive patients who were reviewed, 42 patients received a palliative course of thoracic radiation, 40 exhibited evidence of new lobar collapse on follow-up chest imaging, and 14 received thoracic radiation for lobar collapse. On univariable analysis, pulmonary symptoms (P = .043) or pneumonia at presentation (P = .0001), increasing size of hilar disease (P < .0001), and evidence of obstruction of major bronchi or vessels (P = .0003) were associated with subsequent pulmonary events. On multivariable analysis, hilar disease measuring >3 cm (hazard ratio, 1.8; P = .003) and prechemotherapy pneumonia (hazard ratio, 2.1; P = .009) were associated with pulmonary events; patients who had both risk factors or hilar disease >5 cm in greatest dimension exhibited a >50% risk of subsequent events.
CONCLUSIONS: Patients with bulky hilar disease and a history of pneumonia at presentation were at high risk for requiring palliative thoracic radiation. The authors propose studying these patients to determine whether early thoracic radiation may be beneficial by preserving quality of life and performance status. Cancer 2011. © 2011 American Cancer Society.
Copyright © 2011 American Cancer Society.
Wednesday, September 21, 2011
Miliary mesothelioma?
http://www.ncbi.nlm.nih.gov/pubmed/21918389
J Thorac Oncol. 2011 Oct;6(10):1753-6.
Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy.
Purek L, Laroumagne S, Dutau H, Maldonado F, Astoul P.
Source
*Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, University of the Mediterranean, Marseille, France; and †Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
Abstract
Malignant pleural mesothelioma is usually a fatal disease and is considered a locally aggressive tumor. Consequently, distant metastases are very rare and a diffuse involvement of the lung is seldom reported. However, due to more efficient chemotherapy protocols and aggressive management strategies including induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation therapy, so called trimodality therapy, survival is prolonged in selected patients. Therefore, new presentations of the disease are appearing with new diagnostic and therapeutic challenges. Herein, we report two cases of treated mesothelioma patients who developed a miliary mesothelioma in the remaining lung 36 and 41 months after undergoing multimodal therapy. Diagnostic assessment and therapeutic strategy are discussed taking into account the different evolutions of each patient.
J Thorac Oncol. 2011 Oct;6(10):1753-6.
Miliary mesothelioma: a new clinical and radiological presentation in mesothelioma patients with prolonged survival after trimodality therapy.
Purek L, Laroumagne S, Dutau H, Maldonado F, Astoul P.
Source
*Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, Hôpital Nord, University of the Mediterranean, Marseille, France; and †Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
Abstract
Malignant pleural mesothelioma is usually a fatal disease and is considered a locally aggressive tumor. Consequently, distant metastases are very rare and a diffuse involvement of the lung is seldom reported. However, due to more efficient chemotherapy protocols and aggressive management strategies including induction chemotherapy followed by extrapleural pneumonectomy and adjuvant high-dose hemithoracic radiation therapy, so called trimodality therapy, survival is prolonged in selected patients. Therefore, new presentations of the disease are appearing with new diagnostic and therapeutic challenges. Herein, we report two cases of treated mesothelioma patients who developed a miliary mesothelioma in the remaining lung 36 and 41 months after undergoing multimodal therapy. Diagnostic assessment and therapeutic strategy are discussed taking into account the different evolutions of each patient.
From Nature: The evolution of overconfidence
http://www.ncbi.nlm.nih.gov/pubmed/21921915
Nature. 2011 Sep 14;477(7364):317-20. doi: 10.1038/nature10384.
The evolution of overconfidence.
Johnson DD, Fowler JH.
Source
Politics and International Relations, University of Edinburgh, Edinburgh EH8 9LD, UK. dominic.johnson@ed.ac.uk
Abstract
Confidence is an essential ingredient of success in a wide range of domains ranging from job performance and mental health to sports, business and combat. Some authors have suggested that not just confidence but overconfidence--believing you are better than you are in reality--is advantageous because it serves to increase ambition, morale, resolve, persistence or the credibility of bluffing, generating a self-fulfilling prophecy in which exaggerated confidence actually increases the probability of success. However, overconfidence also leads to faulty assessments, unrealistic expectations and hazardous decisions, so it remains a puzzle how such a false belief could evolve or remain stable in a population of competing strategies that include accurate, unbiased beliefs. Here we present an evolutionary model showing that, counterintuitively, overconfidence maximizes individual fitness and populations tend to become overconfident, as long as benefits from contested resources are sufficiently large compared with the cost of competition. In contrast, unbiased strategies are only stable under limited conditions. The fact that overconfident populations are evolutionarily stable in a wide range of environments may help to explain why overconfidence remains prevalent today, even if it contributes to hubris, market bubbles, financial collapses, policy failures, disasters and costly wars.
Nature. 2011 Sep 14;477(7364):317-20. doi: 10.1038/nature10384.
The evolution of overconfidence.
Johnson DD, Fowler JH.
Source
Politics and International Relations, University of Edinburgh, Edinburgh EH8 9LD, UK. dominic.johnson@ed.ac.uk
Abstract
Confidence is an essential ingredient of success in a wide range of domains ranging from job performance and mental health to sports, business and combat. Some authors have suggested that not just confidence but overconfidence--believing you are better than you are in reality--is advantageous because it serves to increase ambition, morale, resolve, persistence or the credibility of bluffing, generating a self-fulfilling prophecy in which exaggerated confidence actually increases the probability of success. However, overconfidence also leads to faulty assessments, unrealistic expectations and hazardous decisions, so it remains a puzzle how such a false belief could evolve or remain stable in a population of competing strategies that include accurate, unbiased beliefs. Here we present an evolutionary model showing that, counterintuitively, overconfidence maximizes individual fitness and populations tend to become overconfident, as long as benefits from contested resources are sufficiently large compared with the cost of competition. In contrast, unbiased strategies are only stable under limited conditions. The fact that overconfident populations are evolutionarily stable in a wide range of environments may help to explain why overconfidence remains prevalent today, even if it contributes to hubris, market bubbles, financial collapses, policy failures, disasters and costly wars.
Chronic diseases and anxiety
http://www.ncbi.nlm.nih.gov/pubmed/21908055
Gen Hosp Psychiatry. 2011 Sep 9. [Epub ahead of print]
Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults.
El-Gabalawy R, Mackenzie CS, Shooshtari S, Sareen J.
Source
Department of Psychology, University of Manitoba, Winnipeg, MB Canada R3E 3N4.
Abstract
OBJECTIVE:
The primary objectives of this study were to examine the likelihood of anxiety disorders among respondents with common physical health conditions and to explore the associations between this comorbidity and older adults' perceived mental and physical health.
METHOD:
The sample consisted of older adults from the Canadian Community Health Survey 1.2 (n=12,792). Trained lay interviewers assessed psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Physical health conditions were based on self-reported diagnoses by health professionals. Multiple logistic regressions examined whether suffering from a physical health condition increased the odds of any assessed anxiety disorder (panic, agoraphobia, social phobia and posttraumatic stress disorder). Multiple linear regressions examined associations between self-rated health and comorbid physical health conditions and anxiety.
RESULTS:
After adjusting for confounding variables, the presence of chronically painful conditions (i.e., arthritis, back pain and migraine) and of other commonly occurring diseases (i.e., allergies, cataracts and gastrointestinal, lung and heart disease) were positively associated with anxiety. The comorbidity of anxiety with allergies, cataracts, arthritis and lung disease resulted in poorer self-rated physical and/or mental health after adjusting for confounding variables.
CONCLUSION:
Health problems in older adults are associated with increased odds of anxiety, and this comorbidity is associated with poorer self-reported health than medical problems or anxiety alone. These findings have important clinical implications for health professionals.
Copyright © 2011 Elsevier Inc. All rights reserved.
Gen Hosp Psychiatry. 2011 Sep 9. [Epub ahead of print]
Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults.
El-Gabalawy R, Mackenzie CS, Shooshtari S, Sareen J.
Source
Department of Psychology, University of Manitoba, Winnipeg, MB Canada R3E 3N4.
Abstract
OBJECTIVE:
The primary objectives of this study were to examine the likelihood of anxiety disorders among respondents with common physical health conditions and to explore the associations between this comorbidity and older adults' perceived mental and physical health.
METHOD:
The sample consisted of older adults from the Canadian Community Health Survey 1.2 (n=12,792). Trained lay interviewers assessed psychiatric disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Physical health conditions were based on self-reported diagnoses by health professionals. Multiple logistic regressions examined whether suffering from a physical health condition increased the odds of any assessed anxiety disorder (panic, agoraphobia, social phobia and posttraumatic stress disorder). Multiple linear regressions examined associations between self-rated health and comorbid physical health conditions and anxiety.
RESULTS:
After adjusting for confounding variables, the presence of chronically painful conditions (i.e., arthritis, back pain and migraine) and of other commonly occurring diseases (i.e., allergies, cataracts and gastrointestinal, lung and heart disease) were positively associated with anxiety. The comorbidity of anxiety with allergies, cataracts, arthritis and lung disease resulted in poorer self-rated physical and/or mental health after adjusting for confounding variables.
CONCLUSION:
Health problems in older adults are associated with increased odds of anxiety, and this comorbidity is associated with poorer self-reported health than medical problems or anxiety alone. These findings have important clinical implications for health professionals.
Copyright © 2011 Elsevier Inc. All rights reserved.
The Framingham Heart Study and chronic kidney disease
http://www.ncbi.nlm.nih.gov/pubmed/21931075
Hypertension. 2011 Sep 19. [Epub ahead of print]
Fatty Kidney, Hypertension, and Chronic Kidney Disease: The Framingham Heart Study.
Foster MC, Hwang SJ, Porter SA, Massaro JM, Hoffmann U, Fox CS.
Source
Framingham Heart Study, Framingham, MA; Division of Intramural Research and the Center for Population Studies, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Department of Epidemiology, Harvard School of Public Health, Boston, MA; Division of Endocrinology and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Boston University School of Public Health, Boston, MA; Department of Radiology, Massachusetts General Hospital, Boston, MA.
Abstract
Ectopic fat depots may mediate local and systemic disease. Animal models of diet-induced obesity demonstrate increased fat accumulation in the renal sinus. The association of renal sinus fat with hypertension, chronic kidney disease, and other metabolic disorders has not been studied in a large, community-based sample. Participants from the Framingham Heart Study (n=2923; mean age: 54 years; 51% women) underwent quantification of renal sinus fat area using computed tomography. High renal sinus fat ("fatty kidney") was defined using sex-specific 90th percentiles in a healthy referent subsample. Multivariable linear and logistic regression was used to model metabolic risk factors as a function of fatty kidney and log-transformed renal sinus fat. Multivariable models were adjusted for age, sex, and outcome-specific covariates and then additionally adjusted for body mass index or abdominal visceral adipose tissue. The prevalence of fatty kidney was 30.1% (n=879). Individuals with fatty kidney had a higher odds ratio (OR) of hypertension (OR: 2.12; P<0.0001), which persisted after adjustment for body mass index (OR: 1.49; P<0.0001) or visceral adipose tissue (OR: 1.24; P=0.049). Fatty kidney was also associated with an increased OR for chronic kidney disease (OR: 2.30; P=0.005), even after additionally adjusting for body mass index (OR: 1.86; P=0.04) or visceral adipose tissue (OR: 1.86; P=0.05). We observed no association between fatty kidney and diabetes mellitus after adjusting for visceral adipose tissue. In conclusion, fatty kidney is a common condition that is associated with an increased risk of hypertension and chronic kidney disease. Renal sinus fat may play a role in blood pressure regulation and chronic kidney disease.
Hypertension. 2011 Sep 19. [Epub ahead of print]
Fatty Kidney, Hypertension, and Chronic Kidney Disease: The Framingham Heart Study.
Foster MC, Hwang SJ, Porter SA, Massaro JM, Hoffmann U, Fox CS.
Source
Framingham Heart Study, Framingham, MA; Division of Intramural Research and the Center for Population Studies, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Department of Epidemiology, Harvard School of Public Health, Boston, MA; Division of Endocrinology and Metabolism, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Biostatistics, Boston University School of Public Health, Boston, MA; Department of Radiology, Massachusetts General Hospital, Boston, MA.
Abstract
Ectopic fat depots may mediate local and systemic disease. Animal models of diet-induced obesity demonstrate increased fat accumulation in the renal sinus. The association of renal sinus fat with hypertension, chronic kidney disease, and other metabolic disorders has not been studied in a large, community-based sample. Participants from the Framingham Heart Study (n=2923; mean age: 54 years; 51% women) underwent quantification of renal sinus fat area using computed tomography. High renal sinus fat ("fatty kidney") was defined using sex-specific 90th percentiles in a healthy referent subsample. Multivariable linear and logistic regression was used to model metabolic risk factors as a function of fatty kidney and log-transformed renal sinus fat. Multivariable models were adjusted for age, sex, and outcome-specific covariates and then additionally adjusted for body mass index or abdominal visceral adipose tissue. The prevalence of fatty kidney was 30.1% (n=879). Individuals with fatty kidney had a higher odds ratio (OR) of hypertension (OR: 2.12; P<0.0001), which persisted after adjustment for body mass index (OR: 1.49; P<0.0001) or visceral adipose tissue (OR: 1.24; P=0.049). Fatty kidney was also associated with an increased OR for chronic kidney disease (OR: 2.30; P=0.005), even after additionally adjusting for body mass index (OR: 1.86; P=0.04) or visceral adipose tissue (OR: 1.86; P=0.05). We observed no association between fatty kidney and diabetes mellitus after adjusting for visceral adipose tissue. In conclusion, fatty kidney is a common condition that is associated with an increased risk of hypertension and chronic kidney disease. Renal sinus fat may play a role in blood pressure regulation and chronic kidney disease.
Off label drug use, the FDA, and law
http://www.ncbi.nlm.nih.gov/pubmed/21847881
Am J Law Med. 2011;37(2-3):258-77.
Commercial speech and off-label drug uses: what role for wide acceptance, general recognition and research incentives?
Gilhooley M.
Source
Seton Hall Law School, USA.
Abstract
This article provides an overview of how the constitutional protections for commercial speech affect the Food and Drug Administration's (FDA) regulation of drugs, and the emerging issues about the scope of these protections. A federal district court has already found that commercial speech allows manufacturers to distribute reprints of medical articles about a new off-label use of a drug as long as it contains disclosures to prevent deception and to inform readers about the lack of FDA review. This paper summarizes the current agency guidance that accepts the manufacturer's distribution of reprints with disclosures. Allergan, the maker of Botox, recently maintained in a lawsuit that the First Amendment permits drug companies to provide "truthful information" to doctors about "widely accepted" off-label uses of a drug. While the case was settled as part of a fraud and abuse case on other grounds, extending constitutional protections generally to "widely accepted" uses is not warranted, especially if it covers the use of a drug for a new purpose that needs more proof of efficacy, and that can involve substantial risks. A health law academic pointed out in an article examining a fraud and abuse case that off-label use of drugs is common, and that practitioners may lack adequate dosage information about the off-label uses. Drug companies may obtain approval of a drug for a narrow use, such as for a specific type of pain, but practitioners use the drug for similar uses based on their experience. The writer maintained that a controlled study may not be necessary to establish efficacy for an expanded use of a drug for pain. Even if this is the case, as discussed below in this paper, added safety risks may exist if the expansion covers a longer period of time and use by a wider number of patients. The protections for commercial speech should not be extended to allow manufacturers to distribute information about practitioner use with a disclosure about the lack of FDA approval. Distributions of information about unapproved uses should not be acceptable unless experts consider the expanded use to be generally recognized as safe and effective based on adequate studies. The last part of this paper considers the need to develop better research incentives to encourage more testing and post-market risk surveillance by drug makers on off-label uses of their drugs. Violations of the Federal Food Drug and Cosmetic Act (FFDCA) can be considered violations of the False Claims Act, which opens the way to fraud and abuse suits. The scale of penalties involved in these suits may lead to more examination of the scope of FDA regulation and commercial speech protections. Thus this symposium's consideration of these issues is timely and important.
Am J Law Med. 2011;37(2-3):258-77.
Commercial speech and off-label drug uses: what role for wide acceptance, general recognition and research incentives?
Gilhooley M.
Source
Seton Hall Law School, USA.
Abstract
This article provides an overview of how the constitutional protections for commercial speech affect the Food and Drug Administration's (FDA) regulation of drugs, and the emerging issues about the scope of these protections. A federal district court has already found that commercial speech allows manufacturers to distribute reprints of medical articles about a new off-label use of a drug as long as it contains disclosures to prevent deception and to inform readers about the lack of FDA review. This paper summarizes the current agency guidance that accepts the manufacturer's distribution of reprints with disclosures. Allergan, the maker of Botox, recently maintained in a lawsuit that the First Amendment permits drug companies to provide "truthful information" to doctors about "widely accepted" off-label uses of a drug. While the case was settled as part of a fraud and abuse case on other grounds, extending constitutional protections generally to "widely accepted" uses is not warranted, especially if it covers the use of a drug for a new purpose that needs more proof of efficacy, and that can involve substantial risks. A health law academic pointed out in an article examining a fraud and abuse case that off-label use of drugs is common, and that practitioners may lack adequate dosage information about the off-label uses. Drug companies may obtain approval of a drug for a narrow use, such as for a specific type of pain, but practitioners use the drug for similar uses based on their experience. The writer maintained that a controlled study may not be necessary to establish efficacy for an expanded use of a drug for pain. Even if this is the case, as discussed below in this paper, added safety risks may exist if the expansion covers a longer period of time and use by a wider number of patients. The protections for commercial speech should not be extended to allow manufacturers to distribute information about practitioner use with a disclosure about the lack of FDA approval. Distributions of information about unapproved uses should not be acceptable unless experts consider the expanded use to be generally recognized as safe and effective based on adequate studies. The last part of this paper considers the need to develop better research incentives to encourage more testing and post-market risk surveillance by drug makers on off-label uses of their drugs. Violations of the Federal Food Drug and Cosmetic Act (FFDCA) can be considered violations of the False Claims Act, which opens the way to fraud and abuse suits. The scale of penalties involved in these suits may lead to more examination of the scope of FDA regulation and commercial speech protections. Thus this symposium's consideration of these issues is timely and important.
More on Cystic Fibrosis and Pseudomonas infection
http://www.ncbi.nlm.nih.gov/pubmed/21930755
Infect Immun. 2011 Sep 19. [Epub ahead of print]
Genotypic and phenotypic variation in P. aeruginosa reveals signatures of secondary infection and mutator activity in certain CF patients with chronic lung infections.
Warren AE, Boulianne-Larsen CM, Chandler CB, Chiotti K, Kroll E, Miller SR, Taddei F, Sermet-Gaudelus I, Ferroni A, McInnerney K, Franklin MJ, Rosenzweig F.
Source
Division of Biological Sciences, The University of Montana, Missoula, Montana.
Abstract
Evolutionary adaptation of Pseudomonas aeruginosa to the cystic fibrosis lung is limited by genetic variation, which depends on rates of horizontal gene transfer and mutation supply. Because each may increase following secondary infection or mutator emergence we sought to ascertain incidence of secondary infection and genetic variability in populations containing or lacking mutators. Forty-nine strains collected over three years from sixteen patients were phenotyped for antibiotic resistance and mutator status, and genotyped by rep-PCR, PFGE, and MLST. Though phenotypic and genetic polymorphisms were widespread and clustered more strongly within rather than between longitudinal series, their distribution revealed instances of secondary infection. Sequence data, however, indicated that inter-lineage recombination predated initial strain isolation. Mutator series were more likely to be multiply antibiotic-resistant, but not necessarily more variable in their nucleotide sequences than non-mutators. One mutator and one non-mutator series were sequenced at mismatch repair loci and analyzed for gene content using DNA microarrays. Both were wild-type with respect to mutL, but mutators encoded an 8-bp mutS deletion causing a frameshift mutation. Both series lacked 126 genes encoding pilins, siderophores and virulence factors whose inactivation has been linked to adaptation during chronic infection. Mutators exhibited loss of several-fold more genes having functions related to mobile elements, motility and attachment. A 105kb, 86-gene deletion was observed in one non-mutator that resulted in loss of virulence factors related to pyoverdine synthesis and elements of the multi-drug efflux regulon. Diminished DNA repair activity may facilitate but not be absolutely required for rapid evolutionary change.
Infect Immun. 2011 Sep 19. [Epub ahead of print]
Genotypic and phenotypic variation in P. aeruginosa reveals signatures of secondary infection and mutator activity in certain CF patients with chronic lung infections.
Warren AE, Boulianne-Larsen CM, Chandler CB, Chiotti K, Kroll E, Miller SR, Taddei F, Sermet-Gaudelus I, Ferroni A, McInnerney K, Franklin MJ, Rosenzweig F.
Source
Division of Biological Sciences, The University of Montana, Missoula, Montana.
Abstract
Evolutionary adaptation of Pseudomonas aeruginosa to the cystic fibrosis lung is limited by genetic variation, which depends on rates of horizontal gene transfer and mutation supply. Because each may increase following secondary infection or mutator emergence we sought to ascertain incidence of secondary infection and genetic variability in populations containing or lacking mutators. Forty-nine strains collected over three years from sixteen patients were phenotyped for antibiotic resistance and mutator status, and genotyped by rep-PCR, PFGE, and MLST. Though phenotypic and genetic polymorphisms were widespread and clustered more strongly within rather than between longitudinal series, their distribution revealed instances of secondary infection. Sequence data, however, indicated that inter-lineage recombination predated initial strain isolation. Mutator series were more likely to be multiply antibiotic-resistant, but not necessarily more variable in their nucleotide sequences than non-mutators. One mutator and one non-mutator series were sequenced at mismatch repair loci and analyzed for gene content using DNA microarrays. Both were wild-type with respect to mutL, but mutators encoded an 8-bp mutS deletion causing a frameshift mutation. Both series lacked 126 genes encoding pilins, siderophores and virulence factors whose inactivation has been linked to adaptation during chronic infection. Mutators exhibited loss of several-fold more genes having functions related to mobile elements, motility and attachment. A 105kb, 86-gene deletion was observed in one non-mutator that resulted in loss of virulence factors related to pyoverdine synthesis and elements of the multi-drug efflux regulon. Diminished DNA repair activity may facilitate but not be absolutely required for rapid evolutionary change.
From Archer Daniels Midland Co.: No association between fructose and metabolic syndrome.
http://www.ncbi.nlm.nih.gov/pubmed/21889564
Food Chem Toxicol. 2011 Aug 25. [Epub ahead of print]
Fructose and non-fructose sugar intakes in the US population and their associations with indicators of metabolic syndrome.
Sun SZ, Anderson GH, Flickinger BD, Williamson-Hughes PS, Empie MW.
Source
Office of Compliance and Ethics, Archer Daniels Midland Company, 1001 North Brush College Road, Decatur, IL 62521, USA.
Abstract
BACKGROUND:
Relationships of sugar intakes with indicators of metabolic syndrome are important concerns for public health and safety. For individuals, dietary intake data for fructose and other sugars are limited.
METHOD:
Descriptive statistics. The data from 25,506 subjects, aged 12-80yr, contained in the NHANES 1999-2006 databases were analyzed for sugar intakes and health parameters.
RESULTS:
Dietary fructose was almost always consumed with other sugars. On average, fructose provided 37% of total simple sugar intake and 9% of energy intake. In more than 97% of individuals studied, fructose caloric contribution was lower than that of non-fructose sugars. Fructose and non-fructose sugar intakes had no positive association with blood concentrations of TG, HDL cholesterol, glycohemoglobin, uric acid, blood pressure, waist circumference, and BMI in the adults studied (aged 19 to 80yr, n=17,749).
CONCLUSION:
Daily fructose intakes with the American diet averaged approximately 37% of total sugars and 9% of daily energy. Fructose was rarely consumed solely or in excess over non-fructose sugars. Fructose and non-fructose sugar ordinary consumption was not positively associated with indicators of metabolic syndrome, uric acid and BMI.
Copyright © 2011 Elsevier Ltd. All rights reserved.
Food Chem Toxicol. 2011 Aug 25. [Epub ahead of print]
Fructose and non-fructose sugar intakes in the US population and their associations with indicators of metabolic syndrome.
Sun SZ, Anderson GH, Flickinger BD, Williamson-Hughes PS, Empie MW.
Source
Office of Compliance and Ethics, Archer Daniels Midland Company, 1001 North Brush College Road, Decatur, IL 62521, USA.
Abstract
BACKGROUND:
Relationships of sugar intakes with indicators of metabolic syndrome are important concerns for public health and safety. For individuals, dietary intake data for fructose and other sugars are limited.
METHOD:
Descriptive statistics. The data from 25,506 subjects, aged 12-80yr, contained in the NHANES 1999-2006 databases were analyzed for sugar intakes and health parameters.
RESULTS:
Dietary fructose was almost always consumed with other sugars. On average, fructose provided 37% of total simple sugar intake and 9% of energy intake. In more than 97% of individuals studied, fructose caloric contribution was lower than that of non-fructose sugars. Fructose and non-fructose sugar intakes had no positive association with blood concentrations of TG, HDL cholesterol, glycohemoglobin, uric acid, blood pressure, waist circumference, and BMI in the adults studied (aged 19 to 80yr, n=17,749).
CONCLUSION:
Daily fructose intakes with the American diet averaged approximately 37% of total sugars and 9% of daily energy. Fructose was rarely consumed solely or in excess over non-fructose sugars. Fructose and non-fructose sugar ordinary consumption was not positively associated with indicators of metabolic syndrome, uric acid and BMI.
Copyright © 2011 Elsevier Ltd. All rights reserved.
From Mayo Clinic: Vitamin D and sarcopenia--any link?
http://www.ncbi.nlm.nih.gov/pubmed/21915904
J Bone Miner Res. 2011 Sep 13. doi: 10.1002/jbmr.510. [Epub ahead of print]
Is vitamin D a determinant of muscle mass and strength?
Marantes I, Achenbach SJ, Atkinson EJ, Khosla S, Melton LJ 3rd, Amin S.
Source
Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Hygiene and Epidemiology, OPorto Medical School, Portugal.
Abstract
BACKGROUND:
There remains little consensus on the link between vitamin D levels and muscle mass or strength. We therefore investigated the association of serum 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)(2) D), and parathyroid hormone (PTH) levels with skeletal muscle mass and strength.
METHODS:
We studied 311 men (mean age, 56 yrs; range, 23-91 yrs) and 356 women (mean age, 57 yrs; range, 21-97 yrs) representing an age-stratified, random sample of community adults. Multivariate linear regression models were used to examine the association of skeletal muscle mass (by total body dual-energy x-ray absorptiometry) and strength (handgrip force and isometric knee extension moment) with each of 25(OH)D, 1,25(OH)(2) D and PTH quartiles, adjusted for age, physical activity, fat mass and season.
RESULTS:
We found no consistent association between 25(OH)D or PTH and any of our measurements of muscle mass or strength, in either men or women. However, in subjects younger than 65 years, there was a statistically significant association between low 1,25(OH)(2) D levels and low skeletal mass in both men and women and low isometric knee extension moment and force in women, after adjustment for potential confounders.
CONCLUSION:
Modestly low 25(OH)D or high PTH levels may not contribute significantly to sarcopenia or muscle weakness in community adults. The link between low 25(OH)D and increased fall risk reported by others may be due to factors that affect neuromuscular function rather than muscle strength. The association between low 1,25(OH)(2) D and low skeletal mass and low knee extension moment, particularly in younger people, needs further exploration. © 2011 American Society for Bone and Mineral Research.
J Bone Miner Res. 2011 Sep 13. doi: 10.1002/jbmr.510. [Epub ahead of print]
Is vitamin D a determinant of muscle mass and strength?
Marantes I, Achenbach SJ, Atkinson EJ, Khosla S, Melton LJ 3rd, Amin S.
Source
Division of Epidemiology, Department of Health Sciences Research, College of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Hygiene and Epidemiology, OPorto Medical School, Portugal.
Abstract
BACKGROUND:
There remains little consensus on the link between vitamin D levels and muscle mass or strength. We therefore investigated the association of serum 25-hydroxyvitamin D (25(OH)D), 1,25-dihydroxyvitamin D (1,25(OH)(2) D), and parathyroid hormone (PTH) levels with skeletal muscle mass and strength.
METHODS:
We studied 311 men (mean age, 56 yrs; range, 23-91 yrs) and 356 women (mean age, 57 yrs; range, 21-97 yrs) representing an age-stratified, random sample of community adults. Multivariate linear regression models were used to examine the association of skeletal muscle mass (by total body dual-energy x-ray absorptiometry) and strength (handgrip force and isometric knee extension moment) with each of 25(OH)D, 1,25(OH)(2) D and PTH quartiles, adjusted for age, physical activity, fat mass and season.
RESULTS:
We found no consistent association between 25(OH)D or PTH and any of our measurements of muscle mass or strength, in either men or women. However, in subjects younger than 65 years, there was a statistically significant association between low 1,25(OH)(2) D levels and low skeletal mass in both men and women and low isometric knee extension moment and force in women, after adjustment for potential confounders.
CONCLUSION:
Modestly low 25(OH)D or high PTH levels may not contribute significantly to sarcopenia or muscle weakness in community adults. The link between low 25(OH)D and increased fall risk reported by others may be due to factors that affect neuromuscular function rather than muscle strength. The association between low 1,25(OH)(2) D and low skeletal mass and low knee extension moment, particularly in younger people, needs further exploration. © 2011 American Society for Bone and Mineral Research.
Quality and efficiency in US health care
http://www.ncbi.nlm.nih.gov/pubmed/21916090
Int J Health Care Qual Assur. 2011;24(5):366-88.
Examining quality and efficiency of the U.S. healthcare system.
Kumar S, Ghildayal NS, Shah RN.
Source
Opus College of Business, University of St. Thomas, Minneapolis, Minnesota, USA. skumar@stthomas.edu
Abstract
PURPOSE:
The fundamental concern of this research study is to learn the quality and efficiency of U.S. healthcare services. It seeks to examine the impact of quality and efficiency on various stakeholders to achieve the best value for each dollar spent for healthcare. The study aims to offer insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change shaped by the Federal healthcare fiscal policy and to recommend the improvement objective by comparing the U.S. healthcare system with those of other developed nations.
DESIGN/METHODOLOGY/APPROACH:
The US healthcare system is examined utilizing various data on recent trends in: spending, budgetary implications, economic indicators, i.e., GDP, inflation, wage and population growth. Process maps, cause and effect diagrams and descriptive data statistics are utilized to understand the various drivers that influence the rising healthcare cost. A proposed cause and effect diagram is presented to offer potential solutions, for significant improvement in U.S. healthcare.
FINDINGS:
At present, the US healthcare system is of vital interest to the nation's economy and government policy (spending). The U.S. healthcare system is characterized as the world's most expensive yet least effective compared with other nations. Growing healthcare costs have made millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical practices and reimbursement policies, technology-induced costs and consumer behavior.
PRACTICAL IMPLICATIONS:
Reviewing many articles, congressional reports, internet websites and related material, a simplified process map of the US healthcare system is presented. The financial process map is also created to further understand the overall process that connects the stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and effect diagram to further simplify the complexities of healthcare. This tool can also be used as a guide to improve efficiency by removing the "waste" from the system. Trend analyses are presented that display the crucial relationship between economic growth and healthcare spending.
ORIGINALITY/VALUE:
There are many articles and reports published on the US healthcare system. However, very few articles have explored, in a comprehensive manner, the links between the economic indicators and measures of the healthcare system and how to reform this system. As a result of the US healthcare system's complex structure, process map and cause-effect diagrams are utilized to simplify, address and understand. This study linked top-level factors, i.e., the societal, government policies, healthcare system comparison, potential reformation solutions and the enormity of the recent trends by presenting serious issues associated with U.S. healthcare.
Int J Health Care Qual Assur. 2011;24(5):366-88.
Examining quality and efficiency of the U.S. healthcare system.
Kumar S, Ghildayal NS, Shah RN.
Source
Opus College of Business, University of St. Thomas, Minneapolis, Minnesota, USA. skumar@stthomas.edu
Abstract
PURPOSE:
The fundamental concern of this research study is to learn the quality and efficiency of U.S. healthcare services. It seeks to examine the impact of quality and efficiency on various stakeholders to achieve the best value for each dollar spent for healthcare. The study aims to offer insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change shaped by the Federal healthcare fiscal policy and to recommend the improvement objective by comparing the U.S. healthcare system with those of other developed nations.
DESIGN/METHODOLOGY/APPROACH:
The US healthcare system is examined utilizing various data on recent trends in: spending, budgetary implications, economic indicators, i.e., GDP, inflation, wage and population growth. Process maps, cause and effect diagrams and descriptive data statistics are utilized to understand the various drivers that influence the rising healthcare cost. A proposed cause and effect diagram is presented to offer potential solutions, for significant improvement in U.S. healthcare.
FINDINGS:
At present, the US healthcare system is of vital interest to the nation's economy and government policy (spending). The U.S. healthcare system is characterized as the world's most expensive yet least effective compared with other nations. Growing healthcare costs have made millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical practices and reimbursement policies, technology-induced costs and consumer behavior.
PRACTICAL IMPLICATIONS:
Reviewing many articles, congressional reports, internet websites and related material, a simplified process map of the US healthcare system is presented. The financial process map is also created to further understand the overall process that connects the stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and effect diagram to further simplify the complexities of healthcare. This tool can also be used as a guide to improve efficiency by removing the "waste" from the system. Trend analyses are presented that display the crucial relationship between economic growth and healthcare spending.
ORIGINALITY/VALUE:
There are many articles and reports published on the US healthcare system. However, very few articles have explored, in a comprehensive manner, the links between the economic indicators and measures of the healthcare system and how to reform this system. As a result of the US healthcare system's complex structure, process map and cause-effect diagrams are utilized to simplify, address and understand. This study linked top-level factors, i.e., the societal, government policies, healthcare system comparison, potential reformation solutions and the enormity of the recent trends by presenting serious issues associated with U.S. healthcare.
From Lung Cancer: A smell test for mesothelioma?
http://www.ncbi.nlm.nih.gov/pubmed/21924516
Lung Cancer. 2011 Sep 14. [Epub ahead of print]
An electronic nose distinguishes exhaled breath of patients with Malignant Pleural Mesothelioma from controls.
Dragonieri S, van der Schee MP, Massaro T, Schiavulli N, Brinkman P, Pinca A, Carratú P, Spanevello A, Resta O, Musti M, Sterk PJ.
Source
Department of Respiratory Diseases, University of Bari, Bari, Italy; Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
Abstract
BACKGROUND:
Malignant Pleural Mesothelioma (MPM) is a tumour of the surface cells of the pleura that is highly aggressive and mainly caused by asbestos exposure. Electronic noses capture the spectrum of exhaled volatile organic compounds (VOCs) providing a composite biomarker profile (breathprint).
OBJECTIVE:
We tested the hypothesis that an electronic nose can discriminate exhaled air of patients with MPM from subjects with a similar long-term professional exposure to asbestos without MPM and from healthy controls.
METHODS:
13 patients with a histology confirmed diagnosis of MPM (age 60.9±12.2 year), 13 subjects with certified, long-term professional asbestos exposure (age 67.2±9.8), and 13 healthy subjects without asbestos exposure (age 52.2±16.2) participated in a cross-sectional study. Exhaled breath was collected by a previously described method and sampled by an electronic nose (Cyranose 320). Breathprints were analyzed by canonical discriminant analysis on principal component reduction. Cross-validated accuracy (CVA) was calculated.
RESULTS:
Breathprints from patients with MPM were separated from subjects with asbestos exposure (CVA: 80.8%, sensitivity 92.3%, specificity 85.7%). MPM was also distinguished from healthy controls (CVA: 84.6%). Repeated measurements confirmed these results.
CONCLUSIONS:
Molecular pattern recognition of exhaled breath can correctly distinguish patients with MPM from subjects with similar occupational asbestos exposure without MPM and from healthy controls. This suggests that breathprints obtained by electronic nose have diagnostic potential for MPM.
Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Lung Cancer. 2011 Sep 14. [Epub ahead of print]
An electronic nose distinguishes exhaled breath of patients with Malignant Pleural Mesothelioma from controls.
Dragonieri S, van der Schee MP, Massaro T, Schiavulli N, Brinkman P, Pinca A, Carratú P, Spanevello A, Resta O, Musti M, Sterk PJ.
Source
Department of Respiratory Diseases, University of Bari, Bari, Italy; Department of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
Abstract
BACKGROUND:
Malignant Pleural Mesothelioma (MPM) is a tumour of the surface cells of the pleura that is highly aggressive and mainly caused by asbestos exposure. Electronic noses capture the spectrum of exhaled volatile organic compounds (VOCs) providing a composite biomarker profile (breathprint).
OBJECTIVE:
We tested the hypothesis that an electronic nose can discriminate exhaled air of patients with MPM from subjects with a similar long-term professional exposure to asbestos without MPM and from healthy controls.
METHODS:
13 patients with a histology confirmed diagnosis of MPM (age 60.9±12.2 year), 13 subjects with certified, long-term professional asbestos exposure (age 67.2±9.8), and 13 healthy subjects without asbestos exposure (age 52.2±16.2) participated in a cross-sectional study. Exhaled breath was collected by a previously described method and sampled by an electronic nose (Cyranose 320). Breathprints were analyzed by canonical discriminant analysis on principal component reduction. Cross-validated accuracy (CVA) was calculated.
RESULTS:
Breathprints from patients with MPM were separated from subjects with asbestos exposure (CVA: 80.8%, sensitivity 92.3%, specificity 85.7%). MPM was also distinguished from healthy controls (CVA: 84.6%). Repeated measurements confirmed these results.
CONCLUSIONS:
Molecular pattern recognition of exhaled breath can correctly distinguish patients with MPM from subjects with similar occupational asbestos exposure without MPM and from healthy controls. This suggests that breathprints obtained by electronic nose have diagnostic potential for MPM.
Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
Lung and head & neck cancer and social stigma
http://www.ncbi.nlm.nih.gov/pubmed/21932417
Psychooncology. 2011 Sep 19. doi: 10.1002/pon.2063. [Epub ahead of print]
The psychosocial impact of stigma in people with head and neck or lung cancer.
Lebel S, Castonguay M, Mackness G, Irish J, Bezjak A, Devins GM.
Source
University of Ottawa, Ottawa, Ontario, Canada. slebel@uottawa.ca.
Abstract
BACKGROUND:
Lung and head and neck cancers are widely believed to produce psychologically destructive stigma because they are linked to avoidable risk-producing behaviors and are highly visible, but little research has tested these ideas. We examined cancer-related stigma, its determinants, and its psychosocial impact in lung (n = 107) and head and neck cancer survivors (n = 99) ≤3 years post-diagnosis. We investigated cancer site, self-blame, disfigurement, and sex as determinants, benefit finding as a moderator, and illness intrusiveness as a mediator of the relation between stigma and its psychosocial impact.
METHODS:
Prospective participants received questionnaire packages 2 weeks before scheduled follow-up appointments. They self-administered widely used measures of subjective well-being, distress, stigma, self-blame, disfigurement, illness intrusiveness, and post-traumatic growth.
RESULTS:
As hypothesized, stigma correlated significantly and uniquely with negative psychosocial impact, but contrary to common beliefs, reported stigma was comparatively low. Reported stigma was higher in (i) men than women, (ii) lung as compared with head and neck cancer, and (iii) people who were highly disfigured by cancer and/or its treatment. Benefit finding buffered stigma's deleterious effects, and illness intrusiveness was a partial mediator of its psychosocial impact.
CONCLUSIONS:
Stigma exerts a powerful, deleterious psychosocial impact in lung and head and neck cancers, but is less common than believed. Patients should be encouraged to remain involved in valued activities and roles and to use benefit finding to limit its negative effects. Copyright © 2011 John Wiley & Sons, Ltd.
Psychooncology. 2011 Sep 19. doi: 10.1002/pon.2063. [Epub ahead of print]
The psychosocial impact of stigma in people with head and neck or lung cancer.
Lebel S, Castonguay M, Mackness G, Irish J, Bezjak A, Devins GM.
Source
University of Ottawa, Ottawa, Ontario, Canada. slebel@uottawa.ca.
Abstract
BACKGROUND:
Lung and head and neck cancers are widely believed to produce psychologically destructive stigma because they are linked to avoidable risk-producing behaviors and are highly visible, but little research has tested these ideas. We examined cancer-related stigma, its determinants, and its psychosocial impact in lung (n = 107) and head and neck cancer survivors (n = 99) ≤3 years post-diagnosis. We investigated cancer site, self-blame, disfigurement, and sex as determinants, benefit finding as a moderator, and illness intrusiveness as a mediator of the relation between stigma and its psychosocial impact.
METHODS:
Prospective participants received questionnaire packages 2 weeks before scheduled follow-up appointments. They self-administered widely used measures of subjective well-being, distress, stigma, self-blame, disfigurement, illness intrusiveness, and post-traumatic growth.
RESULTS:
As hypothesized, stigma correlated significantly and uniquely with negative psychosocial impact, but contrary to common beliefs, reported stigma was comparatively low. Reported stigma was higher in (i) men than women, (ii) lung as compared with head and neck cancer, and (iii) people who were highly disfigured by cancer and/or its treatment. Benefit finding buffered stigma's deleterious effects, and illness intrusiveness was a partial mediator of its psychosocial impact.
CONCLUSIONS:
Stigma exerts a powerful, deleterious psychosocial impact in lung and head and neck cancers, but is less common than believed. Patients should be encouraged to remain involved in valued activities and roles and to use benefit finding to limit its negative effects. Copyright © 2011 John Wiley & Sons, Ltd.
Friday, September 16, 2011
Tumor necrosis factor, airway damage, and Cystic Fibrosis
http://www.ncbi.nlm.nih.gov/pubmed/21908587
Am J Physiol Lung Cell Mol Physiol. 2011 Sep 9. [Epub ahead of print]
Regulation of normal and cystic fibrosis airway epithelial repair processes by TNF{alpha} after injury.
Maille E, Trinh NT, Prive A, Bilodeau C, Bissonnette E, Grandvaux N, Brochiero E.
Source
1Centre de Recherche, CHUM-Hotel-Dieu.
Abstract
Chronic infection and inflammation have been associated with progressive airway epithelial damage in cystic fibrosis (CF) patients. However, the effect of inflammatory products on the repair capacity of respiratory epithelia is unclear. Our objective was to study the regulation of repair mechanisms by tumor necrosis factor-alpha (TNFα), a major component of inflammation in CF, in a model of mechanical wounding, in 2 bronchial cell lines, non-CF NuLi and CF CuFi. We observed that TNFα enhanced the NuLi and CuFi repair rates. Chronic exposure (24-48 h) to TNFα augmented this stimulation as well as the migration rate during repair. The cellular mechanisms involved in this stimulation were then evaluated. First, we discerned that TNFα induced metalloproteinase-9 release, EGF shedding and subsequent EGFR trans-activation. Second, TNFα-induced stimulation of the NuLi and CuFi wound closure rates was prevented by GM6001 (metalloproteinase inhibitor), EGF-Ab (to titrate secreted EGF) and EGFR tyrosine kinase inhibitors. Furthermore, we recently reported a relationship between the EGF response and K(+) channel function, both controlling bronchial repair. We now show that TNFα enhances KvLQT1 and K(ATP) currents, while their inhibition abolishes TNFα-induced repair stimulation. These results indicate that TNFα's effect is mediated, at least in part, through EGFR trans-activation and K(+) channel stimulation. In contrast, cell proliferation during repair was slowed by TNFα, suggesting that TNFα could exert contrasting actions on repair mechanisms of CF airway epithelia. Finally, the stimulatory effect of TNFα on airway wound repair was confirmed on primary airway epithelial cells, from non-CF and CF patients.
Am J Physiol Lung Cell Mol Physiol. 2011 Sep 9. [Epub ahead of print]
Regulation of normal and cystic fibrosis airway epithelial repair processes by TNF{alpha} after injury.
Maille E, Trinh NT, Prive A, Bilodeau C, Bissonnette E, Grandvaux N, Brochiero E.
Source
1Centre de Recherche, CHUM-Hotel-Dieu.
Abstract
Chronic infection and inflammation have been associated with progressive airway epithelial damage in cystic fibrosis (CF) patients. However, the effect of inflammatory products on the repair capacity of respiratory epithelia is unclear. Our objective was to study the regulation of repair mechanisms by tumor necrosis factor-alpha (TNFα), a major component of inflammation in CF, in a model of mechanical wounding, in 2 bronchial cell lines, non-CF NuLi and CF CuFi. We observed that TNFα enhanced the NuLi and CuFi repair rates. Chronic exposure (24-48 h) to TNFα augmented this stimulation as well as the migration rate during repair. The cellular mechanisms involved in this stimulation were then evaluated. First, we discerned that TNFα induced metalloproteinase-9 release, EGF shedding and subsequent EGFR trans-activation. Second, TNFα-induced stimulation of the NuLi and CuFi wound closure rates was prevented by GM6001 (metalloproteinase inhibitor), EGF-Ab (to titrate secreted EGF) and EGFR tyrosine kinase inhibitors. Furthermore, we recently reported a relationship between the EGF response and K(+) channel function, both controlling bronchial repair. We now show that TNFα enhances KvLQT1 and K(ATP) currents, while their inhibition abolishes TNFα-induced repair stimulation. These results indicate that TNFα's effect is mediated, at least in part, through EGFR trans-activation and K(+) channel stimulation. In contrast, cell proliferation during repair was slowed by TNFα, suggesting that TNFα could exert contrasting actions on repair mechanisms of CF airway epithelia. Finally, the stimulatory effect of TNFα on airway wound repair was confirmed on primary airway epithelial cells, from non-CF and CF patients.
Serving individual health care needs: Soon to be extinct?
http://www.ncbi.nlm.nih.gov/pubmed/21894536
Theor Med Bioeth. 2011 Sep 6. [Epub ahead of print]
Health care reform: Can a communitarian perspective be salvaged?
Callahan D.
Source
The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY, 10524, USA, callahan@thehastingscenter.org.
Abstract
The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of solidarity, which has been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups-that is, what people need at different stages of life.
Theor Med Bioeth. 2011 Sep 6. [Epub ahead of print]
Health care reform: Can a communitarian perspective be salvaged?
Callahan D.
Source
The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY, 10524, USA, callahan@thehastingscenter.org.
Abstract
The United States is culturally oriented more toward individual rights and values than to communitarian values. That proclivity has made it hard to develop a common good, or solidarity-based, perspective on health care. Too many people believe they have no obligation to support the health care of others and resist a strong role for government, higher taxation, or reduced health benefits. I argue that we need to build a communitarian perspective on the concept of solidarity, which has been the concept underlying European health care systems, by focusing not on individual needs, but rather, on those of different age groups-that is, what people need at different stages of life.
More on medical research integrity
http://www.ncbi.nlm.nih.gov/pubmed/21872111
J Vasc Surg. 2011 Sep;54(3 Suppl):22S-5S.
Shining the light on physician-pharmaceutical and medical device industry financial relationships.
Conn L, Vernaglia L.
Source
Foley & Lardner LLP, Boston, Mass.
Abstract
Long subject to legal scrutiny under the federal Anti-Kickback Statute, financial ties between physicians and drug manufacturers have recently come under additional pressure as a result of recently enacted state and federal disclosure laws and state gift restrictions, the latest coming in connection with the Federal Health Reform Law. These "sunshine" laws have been motivated by the concern that gifts and payments by manufacturers to physicians may lead to conflicts of interest and improperly influence physicians in their drug- or device-prescribing decisions. As a backdrop to these new laws, it is helpful to review prior guidance regarding manufacturer-physician financial relationships, both from the federal government and the industry itself. These laws do not prohibit physician involvement with industry in research and education, but they impose various new compliance requirements on these relationships, and also in many cases, require public disclosure of arrangements that previously were treated as confidential. It is still too early to tell if these laws will stifle innovation, but they do require a heightened degree of diligence to avoid, at a minimum, adverse publicity and embarrassment and, at worst, criminal and civil liability.
Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
J Vasc Surg. 2011 Sep;54(3 Suppl):22S-5S.
Shining the light on physician-pharmaceutical and medical device industry financial relationships.
Conn L, Vernaglia L.
Source
Foley & Lardner LLP, Boston, Mass.
Abstract
Long subject to legal scrutiny under the federal Anti-Kickback Statute, financial ties between physicians and drug manufacturers have recently come under additional pressure as a result of recently enacted state and federal disclosure laws and state gift restrictions, the latest coming in connection with the Federal Health Reform Law. These "sunshine" laws have been motivated by the concern that gifts and payments by manufacturers to physicians may lead to conflicts of interest and improperly influence physicians in their drug- or device-prescribing decisions. As a backdrop to these new laws, it is helpful to review prior guidance regarding manufacturer-physician financial relationships, both from the federal government and the industry itself. These laws do not prohibit physician involvement with industry in research and education, but they impose various new compliance requirements on these relationships, and also in many cases, require public disclosure of arrangements that previously were treated as confidential. It is still too early to tell if these laws will stifle innovation, but they do require a heightened degree of diligence to avoid, at a minimum, adverse publicity and embarrassment and, at worst, criminal and civil liability.
Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.
Standard of medical care during disasters
Confusing. Standard of care already takes into account circumstances surrounding an event.
http://www.ncbi.nlm.nih.gov/pubmed/21907452
Ann Emerg Med. 2011 Sep 8. [Epub ahead of print]
Altering the Standard of Care in Disasters-Unnecessary and Dangerous.
Schultz CH, Annas GJ.
Source
Center for Disaster Medical Sciences, Department of Emergency Medicine, UC Irvine School of Medicine, Orange, CA.
Abstract
After September 11, 2001, the United States began examining approaches to the delivery of medical care during disasters when demand exceeds available resources. One seemingly popular option is the creation of "crisis" or "altered" care standards meant to reduce the legal standard or duty of care for medical responders. However, evidence supporting the need for reduced care standards is lacking. Concern for liability exists but it is not evidence based. The actual risk for litigation is minimal, according to experience with multiple disasters during the last 15 years. Even if a lower legal standard or duty of care were to be adopted, it is unlikely this would reduce the risk of liability because violation of this lower standard could still result in an allegation of malpractice. Creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate, but altering the legal standard of care will not contribute to this process. Rather than inhibiting the creation of these protocols, the current legal standard of care helps guarantee that disaster policies are created in an ethical and transparent manner. Adoption of a lower legal care standard would encourage implementation of less effective approaches and could undermine the impetus to constantly improve the care of disaster victims. Once lowering the legal standard of care becomes accepted practice, it becomes unclear what will prevent this process from moving downward indefinitely. The most rational approach buttressed by evidence to date supports maintaining the current legal standard of care defined by the actions of reasonably prudent physicians under the same or similar circumstances.
http://www.ncbi.nlm.nih.gov/pubmed/21907452
Ann Emerg Med. 2011 Sep 8. [Epub ahead of print]
Altering the Standard of Care in Disasters-Unnecessary and Dangerous.
Schultz CH, Annas GJ.
Source
Center for Disaster Medical Sciences, Department of Emergency Medicine, UC Irvine School of Medicine, Orange, CA.
Abstract
After September 11, 2001, the United States began examining approaches to the delivery of medical care during disasters when demand exceeds available resources. One seemingly popular option is the creation of "crisis" or "altered" care standards meant to reduce the legal standard or duty of care for medical responders. However, evidence supporting the need for reduced care standards is lacking. Concern for liability exists but it is not evidence based. The actual risk for litigation is minimal, according to experience with multiple disasters during the last 15 years. Even if a lower legal standard or duty of care were to be adopted, it is unlikely this would reduce the risk of liability because violation of this lower standard could still result in an allegation of malpractice. Creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate, but altering the legal standard of care will not contribute to this process. Rather than inhibiting the creation of these protocols, the current legal standard of care helps guarantee that disaster policies are created in an ethical and transparent manner. Adoption of a lower legal care standard would encourage implementation of less effective approaches and could undermine the impetus to constantly improve the care of disaster victims. Once lowering the legal standard of care becomes accepted practice, it becomes unclear what will prevent this process from moving downward indefinitely. The most rational approach buttressed by evidence to date supports maintaining the current legal standard of care defined by the actions of reasonably prudent physicians under the same or similar circumstances.
Health Care Act, ACOs, PAs, and tort reform. Schizophrenia?
http://www.ncbi.nlm.nih.gov/pubmed/21910317
Ann Health Law. 2011 Summer;20(2):205-51, 5-6p preceding i.
The schizophrenia of physician extender utilization.
McLean TR.
Source
Third Millennium Consultants, LLC, Shawnee, KS, USA. tmclean@isp.com
Abstract
The Patient Protection and Affordable Care Act of 2010 provides incentives for healthcare to be delivered by Affordable Care Organizations (ACOs). The public face of many, if not most, ACOs is likely to be the Patient Centered Medical Home (PCMHs), a business structure that evolved from Retail Medical Clinics, which made greater use of physician extenders (PAs). Accordingly, this paper examines the evolution and structure of PCMHs as well as how the PCMH is regulated. As neither legal or market regulatory mechanisms are ideal for policing business structures that employ PAs, this paper concludes that the tort reform most appropriate for PCMHs is the introduction of either no-fault or enterprise liability coverage.
Ann Health Law. 2011 Summer;20(2):205-51, 5-6p preceding i.
The schizophrenia of physician extender utilization.
McLean TR.
Source
Third Millennium Consultants, LLC, Shawnee, KS, USA. tmclean@isp.com
Abstract
The Patient Protection and Affordable Care Act of 2010 provides incentives for healthcare to be delivered by Affordable Care Organizations (ACOs). The public face of many, if not most, ACOs is likely to be the Patient Centered Medical Home (PCMHs), a business structure that evolved from Retail Medical Clinics, which made greater use of physician extenders (PAs). Accordingly, this paper examines the evolution and structure of PCMHs as well as how the PCMH is regulated. As neither legal or market regulatory mechanisms are ideal for policing business structures that employ PAs, this paper concludes that the tort reform most appropriate for PCMHs is the introduction of either no-fault or enterprise liability coverage.
Lobectomies: Thorascopic vs. Open
Surg Endosc. 2011 Sep 5. [Epub ahead of print]
Lobectomy for early-stage lung carcinoma: a cost analysis of full thoracoscopy versus posterolateral thoracotomy.
Ramos R, Masuet C, Gossot D.
Source
Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, 75014, Paris, France.
Abstract
BACKGROUND:
Major pulmonary resections for early-stage non-small-cell lung cancer (NSCLC) are increasingly being performed by thoracoscopy, but there are economic concerns related to the use of many disposable items and increased operative time. We evaluated and compared the costs of thoracoscopic lobectomy versus open lobectomy.
METHODS:
Data from all patients who underwent lobectomy for clinical stage I NSCLC from January 1, 2007, to December 31, 2009 were reviewed. Two hundred eighty-seven major pulmonary resections (269 lobectomies and 18 anatomic segmentectomies) for NSCLC were performed: 98 cases via a totally endoscopic approach (TS) and 189 via a classical posterolateral thoracotomy (PLT). Direct medical costs [hospital stay, intensive care unit (ICU) stay, disposables, theatre time, laboratory, and radiology costs] were evaluated.
RESULTS:
Patient demographics were similar in both groups. The two groups did not differ in histology, pathologic stage, or type of lobectomy. There were no differences in postoperative complications or readmissions during the 30-day postoperative period; however, patients in the TS group had significantly fewer chest tube days and shorter hospital length of stay (p < 0.001). Theatre costs were significantly higher in the TS group [2,861 ± 458 vs. 2,260 ± 399 (p < 0.001)]. Mean cost for disposables for TS was 1,800 ± 560.46 vs. 901 ± 328 for PLT (p < 0.001). Thoracoscopic upper-right lobectomy and anatomic segmentectomy were more expensive than other thoracoscopic lobectomies. Mean costs for hospital stay, laboratory, and radiological services for TS were less than for PLT (p < 0.001), although mean ICU stay was similar in both groups. Finally, overall costs were significantly greater for the PLT group (14,145.57 ± 7,117.84) than for the TS group (11,934.13 ± 6,690.25) (p < 0.001).
CONCLUSION:
Thoracoscopic lobectomy was less expensive than open lobectomy for patients with early-stage NSCLC. Although thoracoscopic lobectomy has a higher initial cost, overall cost is less expensive due to a shorter hospital stay.
Lobectomy for early-stage lung carcinoma: a cost analysis of full thoracoscopy versus posterolateral thoracotomy.
Ramos R, Masuet C, Gossot D.
Source
Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, 75014, Paris, France.
Abstract
BACKGROUND:
Major pulmonary resections for early-stage non-small-cell lung cancer (NSCLC) are increasingly being performed by thoracoscopy, but there are economic concerns related to the use of many disposable items and increased operative time. We evaluated and compared the costs of thoracoscopic lobectomy versus open lobectomy.
METHODS:
Data from all patients who underwent lobectomy for clinical stage I NSCLC from January 1, 2007, to December 31, 2009 were reviewed. Two hundred eighty-seven major pulmonary resections (269 lobectomies and 18 anatomic segmentectomies) for NSCLC were performed: 98 cases via a totally endoscopic approach (TS) and 189 via a classical posterolateral thoracotomy (PLT). Direct medical costs [hospital stay, intensive care unit (ICU) stay, disposables, theatre time, laboratory, and radiology costs] were evaluated.
RESULTS:
Patient demographics were similar in both groups. The two groups did not differ in histology, pathologic stage, or type of lobectomy. There were no differences in postoperative complications or readmissions during the 30-day postoperative period; however, patients in the TS group had significantly fewer chest tube days and shorter hospital length of stay (p < 0.001). Theatre costs were significantly higher in the TS group [
CONCLUSION:
Thoracoscopic lobectomy was less expensive than open lobectomy for patients with early-stage NSCLC. Although thoracoscopic lobectomy has a higher initial cost, overall cost is less expensive due to a shorter hospital stay.
Octogenerians and the safety of lung surgery
http://www.ncbi.nlm.nih.gov/pubmed/21900023
Eur J Cardiothorac Surg. 2011 Sep 5. [Epub ahead of print]
Is it safe to include octogenarians at the start of a video-assisted thoracic surgery lobectomy programme?
Amer K, Khan AZ, Vohra H, Saad R.
Source
The Cardiovascular & Thoracic Unit, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
Abstract
Objective: The study aimed to investigate the safety of including patients ≥80 years of age at the start of a video-assisted thoracic surgery major pulmonary resection (VMPR) programme. Methods: Patients were considered for VMPR if the computed tomography/positron emission tomography (CT/PET) was suggestive of T1-3, N0-1 and M0 lesion. Age was not a criterion for exclusion at the very start of the programme. Data were collected prospectively and comparison made between two groups, (A) <80 years of age and (B) ≥80 years, in terms of preoperative risk factors, oncological and functional data, operative results, postoperative complications and survival. Results: Between April 2005 and January 2011, 200 consecutive patients were considered for VMPR. A total of 160 had non-small-cell lung cancer, of whom 136 were in group A, with a median age of 66.5 (range: 42.8-79.4 years) and 24 in group B with a median age of 82 (range: 80-85.5 years). In group B, 13 were men and 11 were women. Rate of conversion to thoracotomy was similar (3 (12.5%) in group B vs 17 (12.5%) in group A, p=0.65), and so was the mean hospital stay (5.8±3.3 days in group B vs 5.9±4.6 days in group A, p=0.899). Admission to intensive care unit and atrial fibrillation were significantly higher in octogenarians (six (25%) and six (25%) in group B vs eight (5.9%) and nine (6.6%) in group A, p=0.008 and p=0.012, respectively). There was significantly less mean days of air leak in octogenarians (0.06±0.3 days in group B vs 2.8±5.6 days in group A, p=0.000). Otherwise, there were no age-related differences in relation to morbidity, mortality and the 3-year survival rate. Conclusion: Octogenarians undergoing VMPR have a higher incidence of atrial fibrillation and admission to the intensive care unit for cardiopulmonary support but otherwise are no different from younger age groups when it comes to rate of conversion to thoracotomy, hospital stay, morbidity and mortality. Age should not be an excuse to deny the elderly curative VATS resection. In our experience, accepting octogenarians early in the VMPR programme did not compromise the outcome results.
Eur J Cardiothorac Surg. 2011 Sep 5. [Epub ahead of print]
Is it safe to include octogenarians at the start of a video-assisted thoracic surgery lobectomy programme?
Amer K, Khan AZ, Vohra H, Saad R.
Source
The Cardiovascular & Thoracic Unit, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK.
Abstract
Objective: The study aimed to investigate the safety of including patients ≥80 years of age at the start of a video-assisted thoracic surgery major pulmonary resection (VMPR) programme. Methods: Patients were considered for VMPR if the computed tomography/positron emission tomography (CT/PET) was suggestive of T1-3, N0-1 and M0 lesion. Age was not a criterion for exclusion at the very start of the programme. Data were collected prospectively and comparison made between two groups, (A) <80 years of age and (B) ≥80 years, in terms of preoperative risk factors, oncological and functional data, operative results, postoperative complications and survival. Results: Between April 2005 and January 2011, 200 consecutive patients were considered for VMPR. A total of 160 had non-small-cell lung cancer, of whom 136 were in group A, with a median age of 66.5 (range: 42.8-79.4 years) and 24 in group B with a median age of 82 (range: 80-85.5 years). In group B, 13 were men and 11 were women. Rate of conversion to thoracotomy was similar (3 (12.5%) in group B vs 17 (12.5%) in group A, p=0.65), and so was the mean hospital stay (5.8±3.3 days in group B vs 5.9±4.6 days in group A, p=0.899). Admission to intensive care unit and atrial fibrillation were significantly higher in octogenarians (six (25%) and six (25%) in group B vs eight (5.9%) and nine (6.6%) in group A, p=0.008 and p=0.012, respectively). There was significantly less mean days of air leak in octogenarians (0.06±0.3 days in group B vs 2.8±5.6 days in group A, p=0.000). Otherwise, there were no age-related differences in relation to morbidity, mortality and the 3-year survival rate. Conclusion: Octogenarians undergoing VMPR have a higher incidence of atrial fibrillation and admission to the intensive care unit for cardiopulmonary support but otherwise are no different from younger age groups when it comes to rate of conversion to thoracotomy, hospital stay, morbidity and mortality. Age should not be an excuse to deny the elderly curative VATS resection. In our experience, accepting octogenarians early in the VMPR programme did not compromise the outcome results.
From Keith Kerr: Lung cancer, personalized medicine, and new challenges
http://www.ncbi.nlm.nih.gov/pubmed/21916947
Histopathology. 2011 Sep 14. doi: 10.1111/j.1365-2559.2011.03854.x. [Epub ahead of print]
Personalized medicine for lung cancer: new challenges for pathology.
Kerr KM.
Source
Aberdeen University Medical School, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Abstract
Recent advances in non-small-cell lung cancer (NSCLC) therapy mean the relatively simple discrimination between small-cell and 'non-small-cell' carcinoma is insufficient to determine the best treatment for individual patients. Safety, efficacy and prescribing requirements mandate more specific subtyping of NSCLC for several new drugs: practice made difficult by the tumour heterogeneity combined with the paucity of tissue in most diagnostic samples. Immunohistochemical approaches have emerged as accurate predictors of probable tumour histotype. P63 and/or cytokeratins 5 and 6 and thyroid transcription factor 1 (TTF1) are among the best predictors, respectively, of squamous and adenocarcinoma histology. Molecular characteristics may predict response to both newer molecular targeted agents and traditional cytotoxic agents. Specific mutations in the epidermal growth factor receptor (EGFR) gene as predictors of response to EGFR tyrosine kinase inhibitors (erlotinib, gefitinib) is the first example of markers which predict response to targeted agents. Actual drug targets [e.g. thymidilate synthase (TS) - pemetrexed] or markers of the tumour's ability to repair cytotoxic drug-induced damage [e.g. excision repair cross-complementation group 1 (ERCC1) - cisplatin] may well also complement NSCLC diagnosis. This extended diagnostic requirement from increasingly limited material provided by minimally invasive biopsy techniques poses major challenges for pathology.
Histopathology. 2011 Sep 14. doi: 10.1111/j.1365-2559.2011.03854.x. [Epub ahead of print]
Personalized medicine for lung cancer: new challenges for pathology.
Kerr KM.
Source
Aberdeen University Medical School, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
Abstract
Recent advances in non-small-cell lung cancer (NSCLC) therapy mean the relatively simple discrimination between small-cell and 'non-small-cell' carcinoma is insufficient to determine the best treatment for individual patients. Safety, efficacy and prescribing requirements mandate more specific subtyping of NSCLC for several new drugs: practice made difficult by the tumour heterogeneity combined with the paucity of tissue in most diagnostic samples. Immunohistochemical approaches have emerged as accurate predictors of probable tumour histotype. P63 and/or cytokeratins 5 and 6 and thyroid transcription factor 1 (TTF1) are among the best predictors, respectively, of squamous and adenocarcinoma histology. Molecular characteristics may predict response to both newer molecular targeted agents and traditional cytotoxic agents. Specific mutations in the epidermal growth factor receptor (EGFR) gene as predictors of response to EGFR tyrosine kinase inhibitors (erlotinib, gefitinib) is the first example of markers which predict response to targeted agents. Actual drug targets [e.g. thymidilate synthase (TS) - pemetrexed] or markers of the tumour's ability to repair cytotoxic drug-induced damage [e.g. excision repair cross-complementation group 1 (ERCC1) - cisplatin] may well also complement NSCLC diagnosis. This extended diagnostic requirement from increasingly limited material provided by minimally invasive biopsy techniques poses major challenges for pathology.
From CDC: Lung cancer disparities. Need to study why. Just smoking rates?
http://www.ncbi.nlm.nih.gov/pubmed/21918961
Cancer. 2011 Sep 14. doi: 10.1002/cncr.26479. [Epub ahead of print]
Racial and regional disparities in lung cancer incidence.
Underwood JM, Townsend JS, Tai E, Davis SP, Stewart SL, White A, Momin B, Fairley TL.
Source
Centers for Disease Control and Prevention, Atlanta, Georgia; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service Officer assigned to the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. jmunderwood@cdc.gov.
Abstract
BACKGROUND:
Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the United States (US). We examined data from 2004 to 2006 for lung cancer incidence rates by demographics, including race and geographic region, to identify potential health disparities.
METHODS:
Data from cancer registries affiliated with the Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) were used for this study; representing 100% of the US population. Age-adjusted incidence rates and 95% confidence intervals for demographic (age, sex, race, ethnicity, and US Census region), and tumor (stage, grade, and histology) characteristics were calculated.
RESULTS:
During 2004 to 2006, 623,388 people (overall rate of 68.9 per 100,000) were diagnosed with lung cancer in the US. Lung cancer incidence rates were highest among men (86.2), Blacks (73.0), persons aged 70 to 79 years (431.1), and those living in the South (74.7). Among Whites, the highest lung cancer incidence rate was in the South (75.6); the highest rates among Blacks (88.9) and American Indians/Alaska Natives (65.4) in the Midwest, Asians/Pacific Islanders in the West (40.0), and Hispanics in the Northeast (40.3).
CONCLUSIONS:
Our findings of racial, ethnic, and regional disparities in lung cancer incidence suggest a need for the development and implementation of more effective culturally specific preventive and treatment strategies that will ultimately reduce the disproportionate burden of lung cancer in the US. Cancer 2011. © 2011 American Cancer Society.
Cancer. 2011 Sep 14. doi: 10.1002/cncr.26479. [Epub ahead of print]
Racial and regional disparities in lung cancer incidence.
Underwood JM, Townsend JS, Tai E, Davis SP, Stewart SL, White A, Momin B, Fairley TL.
Source
Centers for Disease Control and Prevention, Atlanta, Georgia; Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia; Epidemic Intelligence Service Officer assigned to the National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia. jmunderwood@cdc.gov.
Abstract
BACKGROUND:
Lung cancer is the second most commonly diagnosed cancer and the leading cause of cancer-related death in the United States (US). We examined data from 2004 to 2006 for lung cancer incidence rates by demographics, including race and geographic region, to identify potential health disparities.
METHODS:
Data from cancer registries affiliated with the Centers for Disease Control and Prevention's (CDC) National Program of Cancer Registries (NPCR), and the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results Program (SEER) were used for this study; representing 100% of the US population. Age-adjusted incidence rates and 95% confidence intervals for demographic (age, sex, race, ethnicity, and US Census region), and tumor (stage, grade, and histology) characteristics were calculated.
RESULTS:
During 2004 to 2006, 623,388 people (overall rate of 68.9 per 100,000) were diagnosed with lung cancer in the US. Lung cancer incidence rates were highest among men (86.2), Blacks (73.0), persons aged 70 to 79 years (431.1), and those living in the South (74.7). Among Whites, the highest lung cancer incidence rate was in the South (75.6); the highest rates among Blacks (88.9) and American Indians/Alaska Natives (65.4) in the Midwest, Asians/Pacific Islanders in the West (40.0), and Hispanics in the Northeast (40.3).
CONCLUSIONS:
Our findings of racial, ethnic, and regional disparities in lung cancer incidence suggest a need for the development and implementation of more effective culturally specific preventive and treatment strategies that will ultimately reduce the disproportionate burden of lung cancer in the US. Cancer 2011. © 2011 American Cancer Society.
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