Appropriate use of screening and diagnostic tests to foster high-value, cost-conscious care

Unsustainable rising health care costs in the United States have made reducing costs while maintaining high-quality health care a national priority. The overuse of some screening and diagnostic tests is an important component of unnecessary health care costs. More judicious use of such tests will improve quality and reflect responsible awareness of costs. Efforts to control expenditures should focus not only on benefits, harms, and costs but on the value of diagnostic tests-meaning an assessment of whether a test provides health benefits that are worth its costs or harms. To begin to identify ways that practicing clinicians can contribute to the delivery of high-value, cost-conscious health care, the American College of Physicians convened a workgroup of physicians to identify, using a consensus-based process, common clinical situations in which screening and diagnostic tests are used in ways that do not reflect high-value care. The intent of this exercise is to promote thoughtful discussions about these tests and other health care interventions to promote high-value, cost-conscious care.     

Konsenskonferenz 2014 der ISUP zur Gleason-Graduierung des Prostatakarzinoms

In 2005 the International Society of Urological Pathology (ISUP) held a concensus conference on Gleason grading in order to bring this grading system up to the current state of contemporary practice; however, it became clear that further modifications on the grading of prostatic carcinoma were necessary. The International Society of Urological Pathology therefore held a further consensus conference in 2014 to clarify these points. This article presents the essential results of the Chicago grading meeting.     

Biochemomechanics of Cerebral Vasospasm and its Resolution: II. Constitutive Relations and Model Simulations

Cerebral vasospasm is a poorly understood clinical condition that appears to result from complex biochemical and biomechanical processes that manifest as yet another example of vascular growth and remodeling. We submit that mathematical modeling holds great promise to help synthesize diverse types of data and thereby to increase our understanding of vasospasm. Toward this ultimate goal, we present constitutive relations and parametric studies that illustrate the potential utility of a new theoretical framework that combines information on wall mechanics, hemodynamics, and chemical kinetics. In particular, we show that chemical and mechanical mediators of cellular and extracellular matrix turnover can differentially dominate the progression and resolution of vasospasm. Moreover, based on our simulations, endothelial damage can significantly alter the time-course and extent of vasospasm as can impairment of autoregulation. Although the present results are consistent with salient features of clinically reported vasospasm, and thus provide some new insight, we suggest that most importantly they reveal areas of pressing need with regard to the collection of additional experimental data. Without appropriate data, our understanding of cerebral vasospasm will remain incomplete. Address correspondence to J. D. Humphrey, Department of Biomedical Engineering, Texas A&M University, 337 Zachry Engineering Center, 3120 TAMU, College Station, TX 77843-3120, USA. Electronic mail: jhumphrey@tamu.edu

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Biomechanics of the Porcine Basilar Artery in Hypertension

Hypertension is a significant risk factor for diverse cerebrovascular diseases ranging from stroke to arteriovenous malformations and saccular aneurysms. Our increasing understanding of vascular mechanobiology reveals that changes in mechanical stimuli, such as increased blood pressure, alter basic cellular functions including the production and degradation of extracellular matrix as well as proliferation, migration, and apoptosis. Understanding changes in the biomechanical properties of the vascular wall is fundamental to correlating mechanobiological responses with the altered loads. In this paper, we present the first biomechanical data on a large cerebral artery in terms of the time of development of hypertension in maturity. Specifically, we report rapid changes in both the structural and the material stiffness of the passive basilar artery in a novel aortic-coarctation model of hypertension in the mini-pig. Histological measurements reveal associated increases in fibrillar collagens in the media and adventitia as well as increased smooth muscle in the media. That such dramatic changes occur within 2 weeks of the initiation of hypertension in maturity necessitates a detailed study of the early changes as well as the potential to reverse these changes at later times.     

Entrepreneurial nurses and midwives in the United Kingdom: an integrative review

AIM: This paper is a report of an integrative literature review to investigate: (a) the extent of entrepreneurial activity by nurses, midwives and health visitors in the United Kingdom and (b) the factors that influenced these activities. BACKGROUND: Internationally, social and commercial entrepreneurial activity is regarded as important for economic growth and social cohesion. METHODS: Seventeen bibliographic databases were searched using single and combined search terms: 'entrepreneur$', 'business', 'private practice', 'self-employ$', 'intrapreneur$'social enterprise$'mutuals', 'collectives', 'co-op' and 'social capital' which were related to a second layer of terms 'Nurs$', 'Midwi$', 'Visit$'. 'Entrepreneur$' Private Midwi$, Independent Midwi$, and 'nursing workforce'. In addition, hand searches of non-indexed journals and grey literature searches were completed. The following inclusion criteria were: (a) describing nurses, midwife and/or health visitor entrepreneurship (b) undertaken in the UK, and (c) reported between January 1996 and December 2005. RESULTS: Of 154 items included only three were empirical studies; the remainder were narrative accounts. While quality of these accounts cannot be verified, they provide as complete an account as possible in this under-researched area. The numbers of nurses, midwives and health visitors acting entrepreneurially were very small and mirror international evidence. A categorization of entrepreneurial activity was inductively constructed by employment status and product offered. 'Push' and 'pull' influencing factors varied between types of entrepreneurial activity. CONCLUSION: Empirical investigation into the extent to which nurses and midwives respond to calls for greater entrepreneurialism should take account of the complex interplay of contextual factors (e.g. healthcare legislation), professional and managerial experience and demographic factors.     

Prolonged treatment of Salmonella enterica serovar Typhimurium with commercial disinfectants selects for multiple antibiotic resistance, increased efflux and reduced invasiveness

OBJECTIVES: To study how disinfectants affect antimicrobial susceptibility and phenotype of Salmonella enterica serovar Typhimurium SL1,344. METHODS: Wild-type strain SL1,344 and its isogenic gyrA mutant were passaged daily for 7 days in subinhibitory concentrations, and separately for 16 days in gradually increasing concentrations of a quaternary ammonium disinfectant containing formaldehyde and glutaraldehyde (QACFG), an oxidizing compound blend (OXC), a phenolic tar acids-based disinfectant (TOP) and triclosan. The MICs of antimicrobials and antibiotics for populations and representative isolates and the proportion of cells resistant to the MICs for the wild-type were determined. Expression of acrB gene, growth at 37 degrees C and invasiveness of populations in Caco-2 intestinal epithelial cells were assessed. RESULTS: QACFG and triclosan showed the highest selectivity for variants with reduced susceptibility to chloramphenicol, tetracycline, ampicillin, acriflavine and triclosan. Populations treated with the above biocides had reduced invasiveness in Caco-2 cells, and altered growth kinetics. Resistance to disinfectants was observed only after exposure to gradually increasing concentrations of triclosan, accompanied with a 2000-fold increase in its MIC. Growth in OXC and TOP did not affect the MICs of antibiotics, but resulted in the appearance of a proportion of cells resistant to the MIC of acriflavine and triclosan for the wild-type. Randomly selected stable variants from all populations, except the one treated with TOP, over-expressed acrB. CONCLUSIONS: In vitro exposure to QACFG and triclosan selects for Salmonella Typhimurium cells with reduced susceptibility to several antibiotics. This is associated with overexpression of AcrAB efflux pump, but accompanied with reduced invasiveness.     

Prognostic and predictive factors and reporting of prostate carcinoma in prostate needle biopsy specimens

The information provided in the surgical pathology report of a prostate needle biopsy of carcinoma has become critical in the subsequent management and prognostication of the cancer. The surgical pathology report should thus be comprehensive and yet succinct in providing relevant information consistently to urologists, radiation oncologists and oncologists and, thereby, to the patient. This paper reflects the current recommendations of the 2004 World Health Organization-sponsored International Consultation, which was co-sponsored by the College of American Pathologists. It builds on the existing work of several organizations, including the College of American Pathologists, the Association of Directors of Anatomic and Surgical Pathologists, the Royal Society of Pathologists, the European Society of Urologic Pathology and the European Randomized Study of Screening for Prostate Cancer.     

AH23848: a thromboxane receptor-blocking drug that can clarify the pathophysiologic role of thromboxane A2

Despite numerous suggestions in the literature that thromboxane A2 is involved in a variety of occlusive vascular diseases, no definitive evidence is available. Arguments have been presented to support the view that such evidence can only come from clinical studies with a highly specific thromboxane receptor-blocking drug. We have now identified such a drug, AH23848, in our laboratories. Preliminary experiments with AH23848, ([1 alpha (Z), 2 beta,5 alpha]-(+/-)-7-[5-[[(1,1'-biphenyl)-4-yl]methoxy]-2-(4-morpholin yl)-3-oxocyclopentyl]-4-heptenoic acid), show that it is a potent, specific thromboxane receptor-blocking drug that is orally active and has a long duration of action. It should be a valuable tool in elucidating any physiologic or pathologic role of thromboxane A2.