Routine Prophylactic Cardioprotective Therapy Should Not Be Given to All Recipients of Potentially Cardiotoxic Cancer Chemotherapy

With growing recognition of the associations between cancer therapy and cardiotoxicity, attention has increasingly focused on the prevention of cancer therapy-related cardiovascular disease. Various strategies for cardioprotection have been proposed, including routine administration of therapies such as inhibitors of the renin-angiotensin-aldosterone system and β-blockers. We argue this approach is unsupported by the evidence and will be associated with a high likelihood of adverse effects. We highlight alternate strategies for managing this emerging issue, which focus on a targeted approach to primary prevention driven by early identification of cardiotoxicity and selective prophylaxis of patients at increased risk for developing cardiotoxicity.

Outcomes after heart transplantation for amyloid cardiomyopathy in the modern era

We conducted a review of patients undergoing heart transplantation (HT) at our institution for amyloid cardiomyopathy (ACM) between 2008 and 2013. Complete follow-up was available for all patients. Nineteen patients with ACM underwent HT during the study period, accounting for 9.4% of all HT performed at our institution during this period. Amyloid subtype was light chain (AL) in 9 patients and transthyretin (ATTR) in 10 (2 wild-type, 7 familial, 1 unknown). Eight of nine patients with AL amyloidosis began chemotherapy prior to HT, six have resumed chemotherapy since HT, and five have undergone autologous stem cell transplantation. Most recent free light chain levels in AL patients decreased by a median of 85% from peak values. Only one patient developed recurrent graft amyloidosis, occurring at 3.5 years post-HT and asymptomatic. After a median follow-up of 380 days, 17 (89.5%) patients are alive. To our knowledge, this is the largest single-center series reported of ACM patients undergoing HT in the modern era. Our results suggest that acceptable outcomes following HT can be achieved in the short-to-intermediate term and that this is a feasible option for end-stage ACM with careful patient selection and aggressive control of amyloidogenic light chains in AL patients.

Short-term mechanical circulatory support for recovery from acute right ventricular failure: clinical outcomes

BACKGROUND

Acute right ventricular failure (ARVF) refractory to optimal medical management may require rescue therapy with mechanical circulatory support (MCS). The RV exhibits a greater capacity for rapid recovery than the left ventricle, making devices designed specifically for temporary RV MCS attractive. We report our experience with the Impella Right Direct (RD) and Right Peripheral (RP) temporary ventricular assist devices (Abiomed, Danvers, MA) in patients with ARVF.

METHODS

We conducted a retrospective cohort study examining the clinical outcomes of consecutive patients supported with the Impella RD or RP at 2 institutions during a 6-year period.

RESULTS

During the study period, 18 patients (67% men; mean age 57 ± 10 years) received MCS, 15 with the Impella RD and 3 with the Impella RP. Before RV MCS, all patients required intravenous inotropes, 7 (39%) required inhaled nitric oxide, 7 (39%) required intra-aortic balloon counterpulsation, and 2 (11%) had experienced a cardiac arrest. Device implantation resulted in an improvement in cardiac index (2.1 ± 0.1 liters/min/m(2) pre-implant vs 2.6 ± 0.2 liters/min/m(2) post-implant, p = 0.04) and reduced central venous pressure (22 ± 5 vs 15 ± 4 mm Hg, p < 0.01). Fourteen (78%) patients recovered sufficient RV function to facilitate device explanation after 7 days (range, 2-19 days) of support, and 4 (22%) patients died on support after 6 days (range 1-11 days). Survival to 30 days was 72% and to 1 year was 50%. At 1-year follow-up, the mean New York Heart Association functional classification was 1.3 ± 0.5, and only 1 patient demonstrated severe RV dysfunction on echocardiography.

CONCLUSIONS

Most patients with ARVF rapidly recover sufficient RV function to facilitate device explantation, highlighting an expanding role for minimally invasive temporary RV assist devices optimized for the treatment of recoverable ARVF.

Cardiac resynchronization therapy in the cardiorenal syndrome

The cardiorenal syndrome (CRS) is a complex clinical syndrome in which dysfunction of either the heart or the kidneys affects the functioning of the other organ system. Many therapies used in heart failure have further detrimental effects on renal function. Cardiac resynchronization therapy (CRT) is a relatively new form of device therapy that reduces morbidity and mortality in patients with heart failure. This review will discuss the effects of CRT on renal function in patients with CRS, the impact of baseline renal function on response to CRT, and potential risks associated with CRT in this unique population.

Adalimumab for the treatment of Crohn-like colitis and enteritis in glycogen storage disease type Ib

Glycogen storage disease (GSD) type Ib is a congenital disorder of glycogen metabolism that is associated with neutropenia, neutrophil dysfunction, and an inflammatory bowel disease that mimics a Crohn phenotype. Gastrointestinal inflammation in GSD Ib has been successfully treated with 5-aminosalicylic acid and granulocyte colony-stimulating factor (G-CSF). However, therapeutic options for patients not responding to traditional therapies have been limited owing to untoward effects of glucocorticoids and immunomodulators in this metabolic disorder. Adalimumab is a monoclonal antibody targeting tumour necrosis factor-α that has shown promise for the treatment of patients with Crohn disease. Due to the limited options for treating GSD-associated inflammatory bowel disease, use of adalimumab was attempted in a case unresponsive to aminosalicylate, G-CSF, and antibiotic therapy. Significant clinical and histological improvement was observed in our patient, and the medication was well tolerated.

Persistence and efficacy of termiticides used in preconstruction treatments to soil in Mississippi

Laboratory and field studies were conducted to determine the persistence and efficacy of termiticides used as preconstruction treatments against subterranean termites. Bifenthrin (0.067%), chlorpyrifos (0.75%), and imidacloprid (0.05%) ([AI]; wt:wt) were applied to soil beneath a monolithic concrete slab at their minimum labeled rates. Soil samples were taken from three depths (0-2.5, 2.6-7.6, and 7.7-15.2 cm) at six sampling times (0, 3, 6, 9, 12 and 48 mo) from sites in Harrison and Oktibbeha counties in Mississippi. Residue analyses were conducted on the 0-2.5- and 2.6-7.5-cm depths, and bioassays were conducted using all three depths. In field studies, significant termiticide degradation occurred between sampling times 0 and 48 mo for all termiticides. At all sampling times, the top 2.5 cm of soil contained more termiticide than the other depths. Time to 50% dissipation of termiticide in the 0-2.5-cm depth was 9, 6, and 2 mo for bifenthrin, chlorpyrifos, and imidacloprid, respectively. Termite mortalities in contact bioassays remained high for bifenthrin and chlorpyrifos throughout the 48-mo sampling period; however, mortality of termites exposed to imidacloprid-treated soil dropped after the initial sampling. Termites readily penetrated all termiticide-treated soil in bioassays of 52-mm soil cores at 48 mo. Percentage of mortality in these bioassays was 15, 43, and 13 for bifenthrin, chlorpyrifos, and imidacloprid respectively.

Bone chemical structure response to mechanical stress studied by high pressure Raman spectroscopy

While the biomechanical properties of bone are reasonably well understood at many levels of structural hierarchy, surprisingly little is known about the response of bone to loading at the ultrastructural and crystal lattice levels. In this study, our aim was to examine the response (i.e., rate of change of the vibrational frequency of mineral and matrix bands as a function of applied pressure) of murine cortical bone subjected to hydrostatic compression. We determined the relative response during loading and unloading of mineral vs. matrix, and within the mineral, phosphate vs. carbonate, as well as proteinated vs. deproteinated bone. For all mineral species, shifts to higher wave numbers were observed as pressure increased. However, the change in vibrational frequency with pressure for the more rigid carbonate was less than for phosphate, and caused primarily by movement of ions within the unit cell. Deformation of phosphate on the other hand, results from both ionic movement as well as distortion. Changes in vibrational frequencies of organic species with pressure are greater than for mineral species, and are consistent with changes in protein secondary structures such as alterations in interfibril cross-links and helix pitch. Changes in vibrational frequency with pressure are similar between loading and unloading, implying reversibility, as a result of the inability to permanently move water out of the lattice. The use of high pressure Raman microspectroscopy enables a deeper understanding of the response of tissue to mechanical stress and demonstrates that individual mineral and matrix constituents respond differently to pressure.

Improving completeness, accuracy & timeliness of HIV voluntary counseling & testing client data in Malawi using touchscreen computers

A real-time data collection system can mitigate problems of data completeness, accuracy and timeliness often experienced using paper-based data collection and subsequent data entry. The Client Management Information System developed for the Malawi AIDS Counseling and Resource Organization employs touchscreen computers to collect client information during voluntary counseling and testing sessions. A user-friendly interface allows counselors with low levels of computer literacy to electronically capture client data in real-time without compromising the quality of counseling.

Smoke alarm ownership and installation: a comparison of a rural and a suburban community in Georgia

As part of a smoke alarm giveaway and installation program (The Get-Alarmed Campaign), a total of 454 households were surveyed in two counties in Georgia, one metropolitan and one nonmetropolitan. The targeted communities in these counties had a high prevalence of low-income and minority populations and thus were at high risk of house fire-related morbidity and mortality. The objectives of the program were to determine the prevalence of and predictors for installed, functioning smoke alarms, and to install at least one smoke alarm and/or smoke alarm batteries in 100% of participating homes in need. Characteristics associated with smoke alarm ownership included home ownership, having a higher income, and having a central heating source, factors which should be considered in targeting future intervention strategies. At onset, 159/454 households (35.0%) had no smoke alarms installed and 56/275 households with existing smoke alarms (20.4%) had none that were functional. Regardless of ownership status, a free smoke alarm was installed in the household of 93.8% of participants and new batteries were installed in existing smoke alarms for 31.7% of participants. This project illustrates the usefulness of a door-to-door campaign in increasing smoke alarm ownership in both a rural and a suburban community with a high concentration of residents at high risk of house fire-related morbidity and mortality.

To help or hinder: Which is more important in explaining a physician's willingness to recommend a health plan?

PURPOSE

To examine how specific health plan practices contribute to physicians' willingness to recommend a health plan to a patient, and whether the relative importance of plan practices is viewed differently when patients are seriously ill.

METHODS

The Physician's Evaluation of Health Plans Project has surveyed 1,757 generalist physicians in 16 health plans in 5 areas nationwide. Each physician reported on one plan. Three multi-item scales assessed physicians' perceptions of health plan activities that facilitated or impeded high-quality care in the plans and the clinical capabilities of plan physicians. Regression analyses were used to explore relations between facilitators, barriers, and clinical capabilities, and two global physician judgments (the physician's willingness to recommend a plan and their judgment that a plan provided lower quality for sicker patients).

RESULTS

A physician's willingness to recommend a health plan is more highly related to what plans do to facilitate care than to the barriers created by plans in managing care. However, barriers to care were substantially more important when evaluating health plan quality for sicker patients.

CONCLUSIONS

From the physician's perspective, the relative importance of plan strategies to manage care is different for typical patients and patients who are more seriously ill. Efforts to collect information on health plan quality should separately evaluate care for sicker patients, in addition to evaluating the overall performance of the health plan.

Measuring the physician perspective on quality of care in health plans

Physicians provide one source of information about the quality of care in health plans, but concerns exist that physicians cannot distinguish quality from financial considerations or other underlying attitudes. We examined whether physicians can (a) distinguish different domains of health plan quality and (b) distinguish health plan quality from their underlying attitudes. We analyzed data on 419 generalist physicians from four health plans. Three scales assessed physicians' perceptions of facilitators and barriers to high-quality care in the plans and the clinical capabilities of plan physicians. Structural equation modeling indicated that physicians could distinguish domains of health plan quality. Physicians could also distinguish plan quality from their attitudes toward the plan, but plan quality was more highly correlated with general managed care attitudes than expected. These data suggest that physicians can provide information about health plan quality, but it will be important to validate these measures against patient outcomes.

Influence of a rural primary care clerkship on medical students' intentions to practice in a rural community

The purpose of this study is to examine the relationship of a rural clerkship to medical students' interest in establishing careers in rural communities. The Association of American Medical Colleges Medical School Graduation Questionnaire (GQ) for years 1988 through 1997 was examined to compare the career plans of students graduating from Morehouse School of Medicine (MSM) with those of all students graduating from United States medical schools before the period 1988 through 1992 and after the period 1993 through 1997, after the inception of the rural clerkship at MSM. Select GQ data items examined include student demographics, medical school experiences, and career plans. Statistical analyses were used to compare pre- and post-clerkship responses for MSM students and to compare their responses with the national trends. Results indicate that, following a transition period, MSM students showed an increased preference for a future career in a rural community. A smaller upward trend in the national data was observed. There appears to be an association between the rural clerkship experience at MSM and the stated preferred career choices of the students.

Breastfeeding and chronic disease in childhood and adolescence

A growing body of research suggests that infant feeding practices influence the risk for several chronic diseases of childhood and adolescence. Increased risks for type 1 diabetes, celiac disease, some childhood cancers, and inflammatory bowel disease have been associated with artificial infant feeding and short-term breastfeeding. As genetic susceptibility is understood more completely and gene-environment interactions are elucidated, evidence to either confirm or refute these findings will be forthcoming.

Exteroceptive suppression periods and pericranial muscle tenderness in chronic tension-type headache: effects of psychopathology, chronicity and disability

We examined pericranial muscle tenderness and abnormalities in the second exteroceptive suppression period (ES2) of the temporalis muscle in chronic tension-type headache (CTTH; n = 245) utilizing a blind design and methods to standardize the elicitation and scoring of these variables. No ES2 variable differed significantly between CTTH sufferers and controls (all tests, P>0.05). We found no evidence that CTTH sufferers with daily or near daily headaches, a mood or an anxiety disorder, or high levels of disability exhibit abnormal ES2 responses (all tests, P>0.05). CTTH sufferers were significantly more likely than controls to exhibit pervasive tenderness in pericranial muscles examined with standardized (500 g force) manual palpation (P<0.005). Female CTTH sufferers exhibited higher levels of pericranial muscle tenderness than male CTTH sufferers at the same level of headache activity (P<0.0001). Elevated pericranial muscle tenderness was associated with a comorbid anxiety disorder. These findings provide further evidence of pericranial hyperalgesia in CTTH and suggest this phenomenon deserves further study. Basic research that better elucidates the biological significance of the ES2 response and the factors that influence ES2 assessments appears necessary before this measure can be of use in clinical research.

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

Child sexual abuse prevention programs: a meta-analysis

Conducted a meta-analytic evaluation of the effectiveness of school-based child abuse prevention programs. Literature searches identified 27 studies meeting inclusion criteria for use in this meta-analysis. The average effect size for all programs studied was 1.07, indicating that children who participated in prevention programs performed 1.07 SD higher than control group children on the outcome measures used in the studies. Analysis of moderator variables revealed significant effects for age, number of sessions, participant involvement, type of outcome measure, and use of behavioral skills training. Most important, programs presented over 4 or more sessions that allowed children to become physically involved produced the highest effect sizes. Although most often used only with younger children, findings suggest that active, long-term programs may be more effective for children of all ages.

Pathologic gambling

Pathologic gambling and problem gambling affect approximately 5 to 15 million Americans and are common in young people. The community-minded family physician is in a good position to identify and assist patients who have gambling-related problems and thereby prevent or treat the resultant personal, family and social disruptions. Provider and community education about the depth and breadth of this condition is crucial for the identification and treatment of a growing problem. As with many psychologic conditions, identification of the disorder and treatment of the patient by the family physician comprise the primary treatment. Screening tools, treatment programs and self-help groups provide additional resources for the family physician. An illustrative case report demonstrates the importance of heightened awareness of and screening for this common condition.

Review of the evidence for an association between infant feeding and childhood cancer

To assess the association between infant feeding and childhood cancer, a qualitative review of 9 published case-control studies was undertaken. The results of this synthesis suggest that children who are never breast-fed or are breast-fed short-term have a higher risk than those breast-fed for > or = 6 months of developing Hodgkin's disease (HD), but not non-Hodgkin's lymphoma or acute lymphoblastic leukemia. HD has features of a complex cellular immune disorder and of chronic infection. Human milk contains an extensive array of anti-microbial activity and appears to stimulate early development of the infant immune system. Artificially fed infants negotiate exposure to infectious agents without the benefits of this immunologic armament and do not do as well as breast-fed infants in resisting infection. Thus, human milk may make the breast-fed infant better able to negotiate future carcinogenic insults by modulating the interaction between infectious agents and the developing infant immune system or by directly affecting the long-term development of the infant immune system. Further research should attempt to confirm the association between infant feeding and HD in large, population-based, case-control studies. Improved measurement of infant feeding must be addressed if future studies are to advance our understanding of this association. In addition, studies of specific measures of immunity, particularly of cellular immune responses, should be conducted in populations of breast-fed and non-breast-fed young children.

Are all health plans created equal? The physician's view

CONTEXT

The health care market is demanding increasing amounts of information regarding quality of care in health plans. Physicians are a potentially important but infrequently used source of such information.

OBJECTIVE

To assess physicians' views on health plan practices that promote or impede delivery of high-quality care in health plans and to compare ratings between plans.

SETTING

Minneapolis-St Paul, Minn.

PARTICIPANTS

One hundred physicians in each of 3 health plans. Each physician rated 1 health plan.

MAIN OUTCOME MEASURES

Likert-type items that assessed health plan practices that promote or impede delivery of high-quality care.

RESULTS

A total of 249 physicians (84%) completed the survey. Fewer than 20% of all physicians gave plans the highest rating (excellent or strongly agree) for health plan practices that promote delivery of high-quality care (such as providing continuing medical education for physicians, identifying patients needing preventive care, and providing physicians feedback about practice patterns). Barriers to delivering high-quality care related to sufficiency of time to spend with patients, covered benefits and copayment structure, and utilization management practices. Ratings differed across health plans. For example, the percentage of physicians indicating that they would recommend the plan they rated to their own family was 64% for plan 1, 92% for plan 2, and 24% for plan 3 (P<.001 for all comparisons).

CONCLUSIONS

Physician surveys can highlight strengths and weaknesses in health plans, and their ratings differ across plans. Physician ratings of health plan practices that promote or impede delivery of high-quality care may be useful to consumers and purchasers of health care as a tool to evaluate health plans and promote quality improvement.

A comprehensive weight-loss program for soldiers

A weight-loss treatment program for active duty military personnel is discussed and evaluated. The Fat Loss and Exercise Program at U.S. Army Hospital, Bremerhaven, Germany, consisted of a 3-week inpatient treatment program and 6 months of weekly outpatient follow-up. The program combined a multidisciplinary team approach to the treatment of obesity--psychology, internal medicine, nursing, nutrition care, and physical therapy. Patients showed a significant weight and body fat loss [F(2,90) = 52.91 and 65.85, p < 0.001, respectively] from the initiation of treatment (mean = 205.9 pounds, 28.91%) to the end of the inpatient program (mean = 192.8 pounds, 25.97%) with maintenance over 6 months (mean = 190.4 pounds, 25.03%). Changes in cholesterol levels by treatment phase are also discussed. Results demonstrate positive increases in high-density lipoprotein at each phase. These results support a comprehensive, multidisciplinary inpatient treatment of obesity within the military.