Mechanisms of alcohol-associated cancers: introduction and summary of the symposium.

Chronic alcohol consumption is associated with an increased risk for cancers of many organs, such as oral cavity, pharynx, larynx, and esophagus; breast; liver; ovary; colon; rectum; stomach; and pancreas. An understanding of the underlying mechanisms by which chronic alcohol consumption promotes carcinogenesis is important for development of appropriate strategies for prevention and treatment of alcohol-associated cancers. The National Institute on Alcohol Abuse and Alcoholism, Office of Dietary Supplements, Office of Rare Diseases, National Cancer Institute, National Institute on Drug Abuse, and National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, sponsored an international symposium on Mechanisms of Alcohol-Associated Cancers in Bethesda, Maryland, USA, October 2004. The following is a summary of the symposium. Chronic ethanol consumption may promote carcinogenesis by (1) production of acetaldehyde, which is a weak mutagen and carcinogen; (2) induction of cytochrome P450 2E1 and associated oxidative stress and conversion of procarcinogens to carcinogens; (3) depletion of S-adenosylmethionine and, consequently, induction of global DNA hypomethylation; (4) induction of increased production of inhibitory guanine nucleotide regulatory proteins and components of extracellular signal-regulated kinase-mitogen-activated protein kinase signaling; (5) accumulation of iron and associated oxidative stress; (6) inactivation of the tumor suppressor gene BRCA1 and increased estrogen responsiveness (primarily in breast); and (7) impairment of retinoic acid metabolism. Nicotine may promote carcinogenesis through activation of extracellular signal-regulated kinase/cyclooxygenase-2/vascular endothelial growth factor signaling pathway.     

Evaluation of the relationship between a chronic disease care management program and california pay-for-performance diabetes care cholesterol measures in one medical group

BACKGROUND: Pay for performance (P4P) is a business model in which health plans pay provider organizations (medical groups) financial incentives based on attainment of clinical quality, patient experience, and use of information technology. The California P4P program is the largest P4P program in the united states and represents a potential revenue source for all participating medical groups. The clinical specifications for the California P4P program are based on the national Committee for Quality assurance (NCQA), Health Plan Employer Data, and information set (HEDIS), and each clinical measure has its own benchmark. in 2005, participating medical groups were paid on the basis of 9 clinical measures that were evaluated in the 2004 measurement year. The cholesterol testing measure represented 4.44%-7.14% of the total P4P dollars available to participating medical groups from the health plans. OBJECTIVES: To (1) compare the percentage of medical group members aged 18 to 75 years with diabetes (type 1 or type 2) who received a low-density lipoprotein cholesterol (LDL-C) test and attained LDL-C control (<130 mg per dl) after enrolling in a chronic disease care management (CDCM) program with similar members managed by routine care, and to (2) assess the potential effect of CDCM on the quality performance ranking and financial reimbursement of a medical group reporting these measures in the 2004 California P4P measurement year. METHODS: This is a retrospective database review of electronic laboratory (lab) values, medical and hospital claims, and encounter data collected between january 1, 2003 and December 31, 2004 at 1 California medical group comprising 160 multispecialty providers. Requirements were continuous patient enrollment in 1 of the 7 health plans participating in P4P during the measurement year (2004) with no more than 1 gap in enrollment of up to 45 days. Patients aged 18 to 75 years were included in the diabetes cholesterol measure (denominator) if they had at least 2 outpatient encounters coded for a primary, secondary, or tertiary diagnosis of diabetes (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.xx, 357.2, 362.0, 366.41, 648.0) or 1 acute inpatient (Diagnosis Related Group code 294 or 295) or emergency room visit for diabetes. Lab values were obtained from multiple sources, including archived lab databases during the same measurement period (numerator). The CDCM program provided education and recommendations for diet, lifestyle, and medication modification delivered by a multidisciplinary team of nurses, pharmacists, and dieticians, and this intervention was compared with routine care for patients not enrolled in the CDCM program. RESULTS: Of the 54,000 health plan members enrolled in this medical group under capitated reimbursement, 1,859 patients (3.4%) met the California P4P specifications for eligibility for the diabetes cholesterol measures and were evaluated. Of these, 8.9% (165/1,859) were followed by the CDCM program and 91.1% (1,694/1,859) by routine care. The LDL-C lab testing rate for patients in the CDCM program was 91.5% (151/165), and the LDL-C goal rate was 78.2% (129/165) compared with 67.8% (1,148/1,694) and 55.7%, respectively, for routine care (P < 0.001 for both comparisons). if the LDL-C lab testing and goal attainment rates for the CDCM group were compared with rates for peer medical groups, this medical group would have scored in the 75th and 90th percentiles, respectively, corresponding to an annual revenue potential of $28,512 for this medical group if the total incentive payment from the health plan was $1 per member per month (PMPM), or $57,024 if the total incentive P4P payment was $2 PMPM. CONCLUSIONS: Preliminary data from 165 patients with diabetes managed in a CDCM program in a medical group operating under a small P4P financial incentive showed higher rates of LDL-C lab testing and goal attainment than from patients managed by routine care. Had these rates of LDL-C testing and goal attainment achieved in the CDCM program been extended to the entire P4P population with diabetes, this medical group would have generated incentive payments under the P4P program and ranked higher in publicly available quality scores.     

Validation Study of an Automated Electronic Acute Lung Injury Screening Tool

Objective

The authors designed an automated electronic system that incorporates data from multiple hospital information systems to screen for acute lung injury (ALI) in mechanically ventilated patients. The authors evaluated the accuracy of this system in diagnosing ALI in a cohort of patients with major trauma, but excluding patients with congestive heart failure (CHF).

Design

Single-center validation study. Arterial blood gas (ABG) data and chest radiograph (CXR) reports for a cohort of intensive care unit (ICU) patients with major trauma but excluding patients with CHF were screened prospectively for ALI requiring intubation by an automated electronic system. The system was compared to a reference standard established through consensus of two blinded physician reviewers who independently screened the same population for ALI using all available ABG data and CXR images. The system's performance was evaluated (1) by measuring the sensitivity and overall accuracy, and (2) by measuring concordance with respect to the date of ALI identification (vs. reference standard).

Measurements

One hundred ninety-nine trauma patients admitted to our level 1 trauma center with an initial injury severity score (ISS) ≥ 16 were evaluated for development of ALI in the first five days in an ICU after trauma.

Main Results

The system demonstrated 87% sensitivity (95% confidence interval [CI] 82.3-91.7) and 89% specificity (95% CI 84.7-93.4). It identified ALI before or within the 24-hour period during which ALI was identified by the two reviewers in 87% of cases.

Conclusions

An automated electronic system that screens intubated ICU trauma patients, excluding patients with CHF, for ALI based on CXR reports and results of ABGs is sufficiently accurate to identify many early cases of ALI.     

Chloride conductance contributes to period determination of a neuronal circadian pacemaker

The isolated eye ofBulla gouldiana, a marine mollusc, is a circadian pacemaker. Previous studies have shown that membrane potential changes of neurons at the base of theBulla retina play a critical role in the expression of the circadian rhythm and that the free-running period can be modified by chronic alteration of the resting membrane potential. We now report that treatments which inhibit Cl⁻ conductance shorten the free-running period. Substitution of Cl⁻ with the anions SO₄²⁻, isethionate and glutamate significantly shorten the period of the ocular rhythm in vitro. Furthermore, addition of the Cl⁻ channel blocker 9-anthracene-carboxylic acid (9-AC) is also effective at shortening the period of the circadian rhythm. These data suggest that a Cl⁻ conductance participates in determining the free-running period of the circadian pacemaker cells. This is the first report of Cl⁻ conductance involvement in a circadian system and the effect is remarkable in that few treatments are known which reliably shorten the period of circadian clocks.     

Treatment of seasonal allergic rhinitis using homeopathic preparation of common allergens in the southwest region of the US: a randomized, controlled clinical trial

BACKGROUND: Studies using homeopathy have reported beneficial effects from treating allergy-related conditions. OBJECTIVE: To investigate the effects of a homeopathic drug prepared from common allergens (tree, grass, weed species) specific to the Southwest region of the US. METHODS: A 4-week, double-blind clinical trial comparing homeopathic preparations with placebo was conducted in the Phoenix metropolitan area during the regional allergy season from February to May. Participants included 40 men and women, 26-63 years of age, diagnosed with moderate to severe seasonal allergic rhinitis symptoms. Study outcomes included allergy-specific symptoms using the rhinoconjunctivitis quality-of-life questionnaire (RQLQ), functional quality of life using the Medical Outcomes Study Short Form-36 (MOS SF-36), and the work productivity and activity impairment (WPAI) questionnaire. RESULTS: Scales from the RQLQ, MOS SF-36, and WPAI questionnaire showed significant positive changes from baseline to 4 weeks in the homeopathic group compared with the placebo group (p < 0.05). Subjects reported no adverse effects during the intervention period. CONCLUSIONS: These preliminary findings indicate potential benefits of the homeopathic intervention in reducing symptoms and improving quality of life in patients with seasonal allergic rhinitis in the Southwestern US.     

Frequently asked questions (FAQ)

As Americans use botanical medicines in ever-increasing numbers, they are moving beyond capsules and tinctures, and turning to assorted preparations that will complete their herbal medicine chest. According to The Arthritis Foundation, almost 45% of patients apply ointments or rubs for osteoarthritis. Topical preparations have a long history in traditional herbal medicine systems, and make up a significant proportion of the armamentarium of indigenous practitioners. Although contemporary patients are often resistant to the inconvenience of topical preparations, they often will become compliant after a notable success. The nomenclature of these topical preparations, as one would expect, is murky. There are no clear and consistent definitions for the assorted terms, and different sources will use different terms for the same material or process.     

Effects of metoprolol on heart rate in patients with digitalis treated chronic atrial fibrillation

Adequate control of ventricular rate in patients with chronic atrial fibrillation (AF) may not be achieved with digitalis alone. In the present study the additional effect of two different doses (50 mg and 50 + 50 mg) of oral metoprolol, a new selective β-blocking agent, on ventricular rate in patients with longstanding AF has been studied. A decrease in the mean ventricular rate during rest and during exercise at various work loads was observed after both doses. The effect was more pronounced at the highest work load of 80 W, both after 50 mg (p < 0.002) and after 50 + 50 mg (p < 0.01) of the drug. A high initial heart rate at rest or during exercise was reduced more by the drug than a lower one. Exercise tolerance was reduced in 2 patients. These results suggest that patients with AF in whom satisfactory control of heart rate cannot be achieved with digitalis alone may benefit from addition of individualized metoprolol therapy.