Snake oil, ethics, and the first amendment: what's a profession to do?

This article considers the appropriate legal and ethical response to those whose advocacy of "alternative" or unvalidated therapies places people at risk of harm. What are our professional responsibilities with respect to such advocacy, and what sorts of harm will justify government intervention?     

Liver function tests during treatment with antipsychotic drugs: a case series of 23 patients

Atypical antipsychotics represent a new class of medication for the treatment of schizophrenia and their use is associated with a reduction of neurological side effects. This article reports the result of the systematic clinical and biological supervision of hepatic enzymes on 23 schizophrenic inpatients treated by atypical antipsychotic during 2 weeks at Days 1 (D1), 7 (D7), and 14 (D14) in a naturalistic study during 6 months. The drug administrated was limited to four medications—risperidone, amisulpride, olanzapine, and clozapine—but other psychotropic agents were prescribed. Six cases of biological cytolytic hepatitis were observed. Due to the numerous risk factors and the frequency of “routine” conditions, careful supervision of the hepatic function is needed to prevent this kind of side effect.     

Culturally competent dietary education for southern rural African Americans with diabetes

PURPOSE: The purpose of this article is to describe a culturally competent, dietary self-management intervention designed to improve physiological outcomes, diabetes self-management, and costs of care for high-risk African Americans with type 2 diabetes. METHODS: A longitudinal, quasi-experimental design was used to evaluate the effectiveness of the intervention for 23 adult African Americans from a physician practice group in rural South Carolina. The intervention consisted of 4 low-fat dietary education classes, 6 discussion groups, and follow-up. Intervention sessions were provided by a dietitian and nurse case managers and framed as social events; families were encouraged to participate. RESULTS: Data suggest that the intervention significantly improved fat-related dietary habits, A1C values, fasting blood glucose, and frequency of acute care visits. A trend in reduction of lipids and weight also was observed. CONCLUSIONS: Culturally competent dietary self-management provides a meaningful approach to focused diabetes education for rural African Americans. Integrating nursing case management provides an innovative method of addressing the more global issues of delivery of care to underserved rural populations and decreasing the high costs of care.     

Tetrofosmin imaging in the detection of myocardial viability in patients with previous myocardial infarction: comparison with sestamibi and tl-201 scintigraphy

BACKGROUND: Technetium 99m tetrofosmin has been introduced as a myocardial perfusion agent, providing similar results to those of thallium 201 and sestamibi in the identification of patients with coronary artery disease. No data are available comparing tetrofosmin and sestamibi imaging in the identification of reversible left ventricular (LV) dysfunction in the same patients. This study compared the results of tetrofosmin, thallium, and sestamibi single photon emission computed tomography at rest in detection of myocardial viability in patients with previous myocardial infarction. METHODS AND RESULTS: Seventeen patients with previous myocardial infarction who were undergoing coronary revascularization were studied. Echocardiography was performed at baseline and 3 months after revascularization to evaluate recovery of LV function. The optimal threshold cutoffs to separate reversible from irreversible dysfunction, as determined by receiver operating characteristic analysis, were 55% of peak activity for both tetrofosmin and sestamibi and 60% for thallium. In all asynergic segments (n = 77) analyzed, tetrofosmin uptake correlated with both sestamibi (r = 0.90, P <.0001) and thallium (r = 0.85, P <.0001) activity. The sensitivity and specificity for reversible dysfunction were, respectively, 70% and 70% for tetrofosmin, 70% and 66% for sestamibi, and 60% and 68% for thallium imaging (all P = not significant). The areas under the receiver operating characteristic curves constructed for tetrofosmin, thallium, and sestamibi activity were 0.74 +/- 0.06 (mean +/- SD), 0.75 +/- 0.06, and 0.74 +/- 0.06, respectively (all P = not significant). Concordance for detecting myocardial viability between tetrofosmin and thallium imaging was found in 67 regions (87%) (kappa = 0.74), and concordance between tetrofosmin and sestamibi imaging was found in 69 regions (90%) (kappa = 0.79). CONCLUSIONS: The diagnostic performance of quantitative rest tetrofosmin single photon emission computed tomography in predicting functional recovery after revascularization is comparable to that of both thallium and sestamibi scintigraphy in patients with myocardial infarction and chronic LV dysfunction.     

Biomarkers in breast cancer

Breast cancer is one of the most frequently diagnosed cancers among women in the western world. Due to the aggressive behaviour of some specific types and the possibility of an early diagnosis, breast cancer has been constantly studied. Tumour size, histological type, cellular and nuclear characteristics, mitotic index, vascular invasion, hormonal receptors and axillary lymph node status are biomarkers routinely used. However, these parameters are not enough to predict the course of this disease. Molecular biology advances have made it possible to find new markers, which have already been incorporated to the clinical practice. Their ultimate goal is to reduce mortality by identifying women at risk for the development of this disease, help diagnosis, determine prognosis, detect recurrences, monitor and guide treatment, and in particular cancers they are suited for general screening. Tumour markers in breast cancer were ranked in categories reflecting their clinical utility, according to the American College of Pathologists. This article focuses on traditional and new molecular markers stratifying them into categories and emphasizing their relevance in the routine evaluation of patients with breast cancer.     

Adverse Reactions to Isosulfan Blue During Selective Sentinel Lymph Node Dissection in Melanoma

Background: Selective sentinel lymph node (SLN) dissection can spare about 80% of patients with primary melanoma from radical lymph node dissection. This procedure identifies the SLN either visually by injecting isosulfan blue dye around the primary melanoma site or by handheld gamma probe after radiocolloid injection.Methods: During selective SLN mapping, 1 to 5 ml of isosulfan blue was injected intradermally around the primary melanoma. From November 1993, to August 1998, 406 patients underwent intraoperative lymphatic mapping with the use of both isosulfan blue and radiocolloid injection. Three cases of selective SLN dissection, in which adverse reactions to isosulfan blue occurred, were reviewed.Results: We report three cases of anaphylaxis after intradermal injection with isosulfan blue of 406 patients who underwent intraoperative lymphatic mapping by using the procedure as described above. The three cases we report vary in severity from treatable hypotension with urticaria and erythema to severe cardiovascular collapse with or without bronchospasm or urticaria.Conclusions: In our series, the incidence of anaphylaxis to isosulfan blue was approximately 1%. Anaphylaxis can be fatal if not recognized and treated rapidly. Operating room personnel who participate in intraoperative lymphatic mapping where isosulfan blue is used must be aware of the potential consequences and be prepared to treat anaphylaxis.     

Inter- and Intrajudge Reliability for Videofluoroscopic Swallowing Evaluation Measures

Interjudge reliability for videofluoroscopic (VFS) swallowing evaluations has been investigated, and results have, for the most part, indicated that reliability is poor. While previous studies are well-designed investigations of interjudge reliability, few reports of intrajudge reliability are available for VFS measures derived from frame-by-frame analysis that clinicians typically employ. The purpose of this study was to examine the inter- and intrajudge reliability of VFS examination measures commonly used to assess swallowing functions. No training to criteria occurred. VFS examinations were conducted on 20 patients who had suffered a stroke within six weeks and had no structural abnormalities or tracheostomies. Three clinical judges served as subjects and rated the VFS examinations from videotape using frame-by-frame analysis. A clinician's repeated review of measures employed in the 20 examinations indicated high intrajudge reliability for a number of measures, suggesting that an experienced clinician may employ consistent standards for rating certain VFS measures across patients and time. These standards appear to vary among clinicians and yield unacceptable interjudge reliability. The need to train clinicians to criteria to improve interjudge reliability is discussed.     

Gene expression in normal human bronchial epithelial (NHBE) cells following in vitro exposure to cigarette smoke condensate.

Cigarettes that burn tobacco produce a complex mixture of chemicals, including mutagens and carcinogens. Cigarettes that primarily heat tobacco produce smoke with marked reductions in the amount of mutagens and carcinogens and demonstrate reduced mutagenicity and carcinogenicity in a battery of toxicological assays. Chemically induced oxidative stress, DNA damage, and inflammation may alter cell cycle regulation and are important biological events in the carcinogenic process. The objective of this study was to characterize and compare the effects of smoke condensates from cigarettes that burn tobacco and those that primarily heat tobacco on gene expression in NHBE cells. For this comparison, we used quantitative RT/PCR and further evaluated the effects on cell cycling using flow cytometry. Cigarette smoke condensates (CSCs) were prepared from Kentucky 1R4F cigarettes (a tobacco-burning product designed to represent the average full-flavor, low "tar" cigarette in the US market) and Eclipse (a cigarette that primarily heats tobacco) using FTC machine smoking conditions. The CSC from 1R4F cigarettes induced statistically significant increases in the mRNA levels of genes responsive to DNA damage (GADD45) and involved in cell cycle regulation (p21;WAF1/CIP1), compared to the CSC from Eclipse cigarettes. In addition, genes coding for cyclooxygenase-2 (COX-2) and interleukin 8 (IL-8), which are associated with oxidative stress and inflammation, respectively, were increased statistically significantly more by CSC from 1R4F than by that from Eclipse. Furthermore, a dose-dependent increase in IL-8 protein secretion into cell culture media was stimulated by 1R4F exposure, whereas minimal IL-8 protein was secreted after Eclipse treatment. The biological relevance of the differential effect on gene expression was reflected in differential cell cycle regulation, as cells exposed to 1R4F CSC exhibited more significant S phase and G2 phase accumulation than cells exposed to Eclipse CSC. These data indicate that the simplified smoke chemistry of the tobacco-heating Eclipse cigarette yields statistically significant reductions in the expression of key genes involved in DNA damage, oxidative stress, inflammatory response, and cell cycle regulation in normal human bronchial epithelial cells compared to a representative tobacco-burning cigarette.