Gaining Physician Buy-In for Disease Management Initiatives

Achieving the support of physicians is perhaps the most difficult challenge to successfully implementing a disease management programme. Most physicians are sceptical of disease management initiatives. Many perceive these programmes to be a threat to their professional autonomy or an unreasonable demand on their limited time with patients. Nonetheless, failure to achieve high levels of physician support results in suboptimal levels of patient identification, enrolment and effectiveness of interventions. Therefore, it is impossible to achieve good outcomes across a large population without achieving physician buy-in.Leaders of organisations implementing disease management programmes can use 5 core strategies to achieve physician buy-in for disease management programmes. These are: education, enlisting champions, ‘creating a box’, building on success, and sharing the gains. Providing education corrects misconceptions many physicians have about disease management. Champions are respected clinicians who are willing to share their positive views of a disease management programme. ‘Creating a box’ sets clear goals and expectations for physicians who consider building a disease management programme. Building on success involves demonstrating that a relatively easy programme works before attempting a more complex or controversial programme. Finally, sharing the gains means that physicians should be rewarded for their time and effort supporting disease management programmes.     

The involvement of the fractalkine receptor in the transmigration of neuroblastoma cells through bone-marrow endothelial cells

Transendothelial migration (TEM) of tumor cells is a crucial step in metastasis formation. The prevailing paradigm is that the mechanism underlying TEM of tumor cells is similar to that of leukocytes involving adhesion molecules and chemokines. Fractalkine (CX3CL1) is a unique membrane-bound chemokine that functions also as an adhesion molecule. CX3CL1 can be cleaved to a soluble fragment, capable of attracting fractalkine receptor (CX3CR1)-expressing cells. In the present study, we asked if CX3CR1 is involved in the TEM of neuroblastoma cells. We demonstrated that biologically functional CX3CR1 is expressed by several neuroblastoma cell lines. Most importantly, CX3CR1-expressing neuroblastoma cells were stimulated by CX3CL1 to transmigrate through human bone-marrow endothelial cells. A dose dependent phosphorylation of ERK1/2 and AKT was induced in CX3CR1-expressing neuroblastoma cells by soluble CX3CL1. In addition to CX3CR1, neuroblastoma cells also express the CX3CL1 ligand. Membrane CX3CL1 expression was downregulated and the shedding of soluble CX3CL1 was upregulated by PKC activation. Taken together, the results of this study indicate that CX3CR1 plays a functional role in transmigration of neuroblastoma cells through bone-marrow endothelium. These results led us to hypothesize that the CX3CR1-CX3CL1 axis takes part in bone-marrow metastasis of neuroblastoma.     

Generalized hypercementosis

The case of an elderly female patient with a long-standing history of generalized hypercementosis is described. A thorough review of the literature indicates that this may be one of the most extensive cases of hypercementosis to be reported. Possible etiologic factors--including heredity, systemic disorders, chronic periapical infection, and abnormal occlusal trauma--are discussed.     

Utilization of prealbumin as a nutritional parameter

The response of prealbumin was compared to that of albumin and transferrin in 16 patients following 7 days of metabolic/nutritional support. Baseline values were compared to day 7 results to assess the degree of change. Prealbumin demonstrated a significant increase in the mean serum concentration (13.0 vs 19.6 mg/100 ml) in the presence of a positive nitrogen balance. Transferrin exhibited a similar significant response (168.8 vs 223.7 mg/100 ml). Albumin, body weight, and serum iron concentration did not change significantly during the 7-day period. Prealbumin effectively demonstrated an anabolic response in the study sample and could possibly be used as an early indicator of visceral protein anabolism in patients receiving metabolic/nutritional support.     

Multicentric familial squamous odontogenic tumor

Three cases of multicentric squamous odontogenic tumor, one of which was previously reported, are presented in three black siblings. A review of the literature indicates that 5 of the 26 previously recorded cases arose in multiple sites, but no evidence of familial history has been suggested. Although squamous odontogenic tumor has been described as a relatively rare, benign odontogenic neoplasm, the multicentric familial nature of our present cases suggests this represents either a reactive hyperplasia or hamartoma of residual odontogenic epithelium within the periodontal tissues. Management of previous cases has varied from simple curettage to maxillectomy with only one case of recurrence.     

Increased plasma cell frequency and accumulation of abnormal syndecan-1plus T-cells in Igmu-deficient/lpr mice

The expression of muH chain is an important checkpoint in B cell development. In mice deficient for IgM transmembrane tail exons (muMT mice) B cell development is blocked at the pro-B stage. However, we showed that Fas-deficient muMT mice (muMT/lpr) develop a very small population of isotype-switched B cells and produce high titers of self-reactive serum antibodies. In addition, muMT/lpr mice develop severe lymphoproliferation and both pathologic processes occur at young ages. This may suggest that lack of Fas-Fas ligand signaling exacerbates murine lupus in B cell lymphopenic mice. To test this we analyzed antibody and plasma cell formation, and accumulation of abnormal T cells in muMT/lpr mice. Our results show that the muMT/lpr mouse is particularly permissive for the development and accumulation of antibody-producing cells, thereby explaining the high titers of serum antibodies in these mice. In addition, we found that accumulating cells in spleen and lymph nodes of muMT/lpr mice are alphabeta T cells expressing the abnormal B220+/CD3+ surface markers, a phenotype also described for other Fas-deficient mouse models. Strikingly, we found that accumulating cells in muMT/lpr mice express the membrane proteoglycan syndecan-1, a known plasma cell marker. Development of these cells is blocked in mice deficient for TCRbeta and TCRdelta. We also found that both antibody production and lymphoproliferation in muMT/lpr mice are Th1 regulated. Our results, therefore, suggest that in the muMT/lpr mouse model a small population of isotype-switched B cells is sufficient for the initiation and propagation of Th1-regulated murine lupus.     

From Patchwork to Package: Implementing Foundational Capabilities for State and Local Health Departments

Daily public health responses are threatened by the inadequate capacity of public health agencies. A 2012 Institute of Medicine report defined a package of foundational capabilities that support all programs and services within a health department. Standardizing foundational capabilities may help address the increasing disparity in health department performance nationally.During the Fall of 2013, we collected information on how much state and local health departments knew about foundational capabilities. To our knowledge, this was the first study to assess current health department infrastructure as it relates to foundational capabilities.The recent economic recession further destabilized the already fragile public health infrastructure in the United States.1 Nationally, local and state health departments have lost 10%–12% of their staff since 2008 as a direct result of budget reductions and cost-saving strategies.2,3 Although departments across the United States did not all experience losses equally, these workforce reductions exacerbated an existing disparity in public health funding, services, and staffing.4 The continued erosion of public health agencies’ capacity across the United States threatens their ability to deliver timely clinical and population-based services, as well as address day-to-day public health needs. Although public health services have been credited with providing 25 of the 30 years of increased life expectancy in the 20th century,5 the eroding public health infrastructure challenges our ability to maintain these gains and threatens our capacity to confront the mounting epidemics of chronic disease and emerging infectious disease.6In 2009, the Institute of Medicine (IOM) formed a committee to consider the structure, functions, and financing of the governmental public health system. The committee’s findings, published in the 2012 For the Public’s Health: Investing in a Healthier Future,7 recommended a “minimum package of public health programs and services” to complement and reinforce the minimum package of clinical health care services created by the Patient Protection and Affordable Care Act (ACA). A key part of the public health minimum package was a set of foundational capabilities; these are the cross-cutting skills essential to the governmental public health infrastructure needed everywhere for the governmental public health system to work anywhere, such as disease surveillance, communications, policy development, and financial management. In short, a public health response is only as robust as the individual health departments engaged in addressing a threat; therefore, all must have the requisite capacity and capabilities for the larger public health system to function effectively. Efforts to develop and maintain these capabilities in public health departments are often unfunded despite many ongoing initiatives dedicated to supporting them.Following the IOM report, national funders and public health organizations developed the concept of a minimum package of capabilities for public health agencies into the Foundational Public Health Services (FPHS) model (Figure 1). This model also incorporated the idea of “Foundational Areas,” which are core public health programs and activities.8 The states of Washington and Ohio led groundbreaking work to define and to determine the cost of the specific skills and services that would comprise a “package” of the FPHS.9,10 Despite the development of the foundational capability concept and FPHS model, little concrete information is available about the degree to which health departments are familiar with or are establishing or funding related services. In our study, we collected information about “how much” and “what” leaders of state and local health departments know about the concept of foundational capabilities in public health practice. These findings will be useful to policymakers and practitioners as they move from defining the concepts to securing sustainable funding for FPHS programs and services.Open in a separate windowFIGURE 1—Foundational Public Health Services model.Note. HD = health department; HR = human resources; IT = information technology; QI = quality improvement.     

Public health spending in 2008: on the challenge of integrating PHSSR data sets and the need for harmonization

In recent years, state and local public health department budgets have been cut, sometimes drastically. However, there is no systematic tracking of governmental public health spending that would allow researchers to assess these cuts in comparison with governmental public health spending as a whole. Furthermore, attempts to quantify the impact of public health spending are limited by the lack of good data on public health spending on state and local public health services combined. The objective of this article is to integrate self-reported state and local health department (LHD) survey data from 2 major national organizations to create state-level estimates of governmental public health spending. To create integrated estimates, we selected 1388 LHDs and 46 states that had reported requisite financial information. To account for the nonrespondent LHDs, estimates of the spending were developed by using appropriate statistical weights. Finally, funds from federal pass-through and state sources were estimated for LHDs and subtracted from the total spending by the state health agency to avoid counting these dollars in both state and local figures. On average, states spend $106 per capita on traditional public health at the state and local level, with an average of 42% of spending occurring at the local level. Considerable variation exists in state and local public health funding. The results of this analysis show a relatively low level of public health funding compared with state Medicaid spending and health care more broadly.