Chronomodulated chemotherapy: clinical value and possibilities for dissemination in the United States

Modern medicine has been relatively slow to apply chronotherapeutic principles to standard oncologic practice. Despite the impressive body of evidence supporting the use of chronochemotherapy, with only a rare exception most oncology clinics in the United States lack the expertise and capability to implement it. At the same time, American medicine has increasingly come to recognize the importance of toxicity mitigation, cytoprotection, and quality of life for patients undergoing cancer treatment. However, toxicity mitigation strategies such as chronomodulated infusional chemotherapy and novel cytoprotective agents are not widely embraced by U.S. physicians. This article explores some reasons why this situation exists, including the influence of non-medical biases that may affect management decisions on the application of chemotherapy. The author conducted a survey of U.S. companies representing the three private insurance payers available (HMO, PPO, Indemnity) as well as representatives of Medicare and Medicaid. Responses to the survey confirmed that U.S. insurers do not at present officially reimburse for chronotherapy; however, changes will come about through educational efforts aimed at increasing awareness among insurers as to the clinical benefits and cost-effectiveness of this mode of treatment. At this juncture, the outlook for cancer chronotherapy as a first-line approach to the treatment of metastatic cancer in the United States remains uncertain. Under the current method of insurance reimbursement, the advancement of chronotherapy in the United States is threatened despite evidence that such treatment is both therapeutically sound and cost-effective.     

Chronomodulated chemotherapy: clinical value and possibilities for dissemination in the United States

Modern medicine has been relatively slow to apply chronotherapeutic principles to standard oncologic practice. Despite the impressive body of evidence supporting the use of chronochemotherapy, with only a rare exception most oncology clinics in the United States lack the expertise and capability to implement it. At the same time, American medicine has increasingly come to recognize the importance of toxicity mitigation, cytoprotection, and quality of life for patients undergoing cancer treatment. However, toxicity mitigation strategies such as chronomodulated infusional chemotherapy and novel cytoprotective agents are not widely embraced by U.S. physicians. This article explores some reasons why this situation exists, including the influence of non-medical biases that may affect management decisions on the application of chemotherapy. The author conducted a survey of U.S. companies representing the three private insurance payers available (HMO, PPO, Indemnity) as well as representatives of Medicare and Medicaid. Responses to the survey confirmed that U.S. insurers do not at present officially reimburse for chronotherapy; however, changes will come about through educational efforts aimed at increasing awareness among insurers as to the clinical benefits and cost-effectiveness of this mode of treatment. At this juncture, the outlook for cancer chronotherapy as a first-line approach to the treatment of metastatic cancer in the United States remains uncertain. Under the current method of insurance reimbursement, the advancement of chronotherapy in the United States is threatened despite evidence that such treatment is both therapeutically sound and cost-effective.     

Hospital bed utilisation in the NHS,Kaiser Permanente,and the US Medicare programme: analysis of routine data

Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California.Design Analysis of routinely available data from 2000 and 2001 on inpatient admissions, lengths of stay, and bed days in populations aged over 65 for 11 leading causes of use of acute beds.Setting Comparison of NHS data with data from Kaiser Permanente in California and the Medicare programme in California and the United States; interviews with Kaiser Permanente staff and visits to Kaiser facilities.Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaiser''s standardised rate, almost twice that of the Medicare California''s standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a “California effect” as well as a “Kaiser effect” in hospital utilisation.Conclusion The NHS can learn from Kaiser''s integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.     

Osteopathic research: elephants, enigmas, and evidence

Background

The growth and acceptance of osteopathic physicians as conventional medical practitioners in the United States has also raised questions about the distinctive aspects of osteopathic medicine. Although the use of osteopathic manipulative treatment (OMT) and a focus on primary care are most often cited as rationales for the uniqueness of osteopathic medicine, an osteopathic professional identity remains enigmatic.

Discussion

The fledgling basic osteopathic research efforts of the early and mid-twentieth century have not been sustained and expanded over time. Thus, there is presently a scarcity of basic mechanistic and translational research that can be considered to be uniquely osteopathic. To be sure, there have been advances in osteopathic clinical trials, particularly those involving OMT for low back pain. Meta-analysis of these low back pain trials has provided evidence that: (1) OMT affords greater pain reduction than active or placebo control treatments; (2) the effects of OMT are comparable regardless of whether treatment is provided by fully-licensed osteopathic physicians in the United States or by osteopaths in the United Kingdom; and (3) the effects of OMT increase over time. However, much more clinical research remains to be done. The planning and implementation of a large longitudinal study of the natural history and epidemiology of somatic dysfunction, including an OMT component, represents a much-needed step forward. Osteopathic medicine's use of OMT and its focus on primary care are not mutually exclusive aspects of its uniqueness. The intersection of these fundamental aspects of osteopathic medicine suggests that the profession may successfully adopt a generic strategy of "focused differentiation" to attain a competitive advantage in the health care arena. While there are both requisite demands and risks for the osteopathic profession in adopting such a strategy, these are reasonable in relation to the potential rewards to be attained. To help promote an osteopathic identity, "omtology" and its derivative terms are recommended in referring to the study of OMT.

Conclusion

The osteopathic profession should adopt a coherent strategy for developing and promoting its identity. Failure to do so will likely ensure that osteopathic medicine remains "stuck in the middle."     

Medicine's Role in Health Care Cost Containment

During the 20th century, medicine has confronted a series of problems threatening health care delivery in the United States. Historically, crises developed related first to quality of care, later to access and finally to the current issue of cost. Factors responsible for the large increases in health care expenditures in the United States during the last decade include increased medical care costs, population and demand for care. Additionally, economy-wide inflation, advanced medical technologies, an aging population, the growth of health care facilities, expansion of third-party payment systems including Medicare and Medicaid and rising incomes per capita have occurred. Programs now exist, and others are being planned, through which physicians, individually in private practice and collectively through organized medicine, may confront this major challenge now threatening the very foundations of health care delivery in the United States.     

Health,illness, and immigration. East Indians in the United States.

East Indian immigrants to the United States represent the diversity in religion, language, and culture that exists in India, so it is difficult to make unequivocal statements about their health beliefs and behaviors. Despite the diversity, an understanding of Ayurvedic humoral concepts of health and illness provides a key to some pervasive and persistent ideas and practices. India has a pluralistic medical system in which Western medicine, which is increasingly popular for some ailments, is one option among many. Even those who are familiar with the "Western" medical system in India may find American medicine alien.     

Geographic Access to High Capability Severe Acute Respiratory Failure Centers in the United States

Objective

Optimal care of adults with severe acute respiratory failure requires specific resources and expertise. We sought to measure geographic access to these centers in the United States.

Design

Cross-sectional analysis of geographic access to high capability severe acute respiratory failure centers in the United States. We defined high capability centers using two criteria: (1) provision of adult extracorporeal membrane oxygenation (ECMO), based on either 2008–2013 Extracorporeal Life Support Organization reporting or provision of ECMO to 2010 Medicare beneficiaries; or (2) high annual hospital mechanical ventilation volume, based 2010 Medicare claims.

Setting

Nonfederal acute care hospitals in the United States.

Measurements and Main Results

We defined geographic access as the percentage of the state, region and national population with either direct or hospital-transferred access within one or two hours by air or ground transport. Of 4,822 acute care hospitals, 148 hospitals met our ECMO criteria and 447 hospitals met our mechanical ventilation criteria. Geographic access varied substantially across states and regions in the United States, depending on center criteria. Without interhospital transfer, an estimated 58.5% of the national adult population had geographic access to hospitals performing ECMO and 79.0% had geographic access to hospitals performing a high annual volume of mechanical ventilation. With interhospital transfer and under ideal circumstances, an estimated 96.4% of the national adult population had geographic access to hospitals performing ECMO and 98.6% had geographic access to hospitals performing a high annual volume of mechanical ventilation. However, this degree of geographic access required substantial interhospital transfer of patients, including up to two hours by air.

Conclusions

Geographic access to high capability severe acute respiratory failure centers varies widely across states and regions in the United States. Adequate referral center access in the case of disasters and pandemics will depend highly on local and regional care coordination across political boundaries.     

ACMC: past,present and future.

In this article, the president of the Association of Canadian Medical Colleges (ACMC) and its director of research review the issues that have confronted ACMC since its inception: the founding of ACMC; development of the clinical teaching unit; creation of the Medical Research Council and expansion of the research mission; the Royal Commission on Health Services and the founding of new faculties of medicine; ACMC''s in-house research program; accreditation and ACMC''s links with medical education in the United States; and French-language medical education in Canada. The review points out the perennial nature of many of these issues, and how often perceived solutions to the problems later become problems themselves. It ends on the optimistic note that ACMC can successfully meet the challenges of the future.     

Male versus female genital alteration: Differences in legal,medical, and socioethical responses

The different legal, social, and medical approaches to ritually based male and female genital circumcision in the United States are highlighted in this article. The religious and historical origins of these practices are briefly examined, as well as the effect of changing policy statements by American medical associations on the number of circumcisions performed. Currently, no state or federal laws single out male circumcision for regulation. The tolerant attitudes toward male circumcision in law, medicine, and societal opinion stand in striking contrast to the attitudes of those disciplines toward even the least invasive form of female genital alteration. US law tacitly condones male circumcision by providing exemptions that are not available for other medical procedures, while criminalizing any similar or even less extensive procedure on females. The increase in immigration, over the past few decades, of people from countries in which female genital alteration is a cultural tradition has brought the issue to the United States. The medical profession's changing approach over time toward male circumcision is primarily responsible for such different legal and societal reactions toward female genital alteration.     

Structural Competency in the U.S. Healthcare Crisis: Putting Social and Policy Interventions Into Clinical Practice

This symposium of the Journal of Bioethical Inquiry illustrates structural competency: how clinical practitioners can intervene on social and institutional determinants of health. It will require training clinicians to see and act on structural barriers to health, to adapt imaginative structural approaches from fields outside of medicine, and to collaborate with disciplines and institutions outside of medicine. Case studies of effective work on all of these levels are presented in this volume. The contributors exemplify structural competency from many angles, from the implications of epigenetics for environmental intervention in personalized medicine to the ways clinicians can act on fundamental causes of disease, address abuses of power in clinical training, racially desegregate cities to reduce health disparities, address the systemic causes of torture by police, and implement harm-reduction programs for addiction in the face of punitive drug laws. Together, these contributors demonstrate the unique roles that clinicians can play in breaking systemic barriers to health and the benefit to the U.S. healthcare system of adopting innovations from outside of the United States and outside of clinical medicine.     

Sex and gender medicine in physician clinical training: results of a large,single-center survey

Background

“Sex and Gender Medicine” is a novel medical discipline that takes into account the effects of sex and gender on the health of women and men. The Institute of Medicine in the USA declared in its 2001 and 2010 statements that being a woman or a man significantly impacts the course of diseases, and therefore, this fact must be considered in diagnosis and therapy. We evaluated the representation of Sex and Gender Medicine in clinical training at Cedars-Sinai Medical Center, a large, tertiary, non-profit, academic medical training center in the Western United States.

Methods

Post-graduate physician trainees (residents and fellows) in all medical and surgical departments (medicine, surgery, OB-GYN, pediatrics, anesthesiology, pathology, urology, electrophysiology, pulmonary critical care, cardiology, women’s heart, medical genetics, radiology, neurosurgery, and radiation oncology) were surveyed online; 80 (55 and 45 % female and male residents, respectively) out of 890 physicians (9 % response rate) responded to questions regarding sex and gender-based medicine.

Results

Seventy percent of post-graduate physician trainees indicated that gender medicine concepts are never or only sometimes discussed/presented in their training program. Slightly greater than 70 % of the trainees indicated that gender concepts are never or only sometimes incorporated into didactic lectures or clinical teaching. However, more than 65 % felt that gender medicine concepts are important, and 60 % agreed that gender medicine curriculum should be implemented and taught in their clinical program.

Conclusions

Current physician trainees endorse both a current lack of and need for Sex and Gender Medicine clinical training.

     

分子影像:转化医学的重要工具和主要路径

随着基础医学与临床医学脱节现象的日益凸显,作为二者之间连接纽带和桥梁的转化医学越来越受到重视.近年来,转化医学在美、欧等西方国家迅速发展,在我国也正成为"十二五"期间医学领域的重要发展方向之一.分子影像作为现代分子生物学与先进医学影像技术相结合的产物,可以利用影像方法对活体内分子的生物化学过程进行定性和定量研究,是将基...     

Neutrons, magnets, and photons: a career in structural biology

The purpose of Reflections articles, it seems, is to give elderly scientists a chance to write about the "good old days," when everyone walked to school in the snow. They enjoy this activity so much that your editor, Martha Fedor, must have known that I would accept her invitation to write such an article, no matter how much I demurred at first. As everyone knows, flattery will get you everywhere. It may comfort the apprehensive reader to learn that there is not going to be much walking to school in the snow in this story. On the contrary, rather than thinking how hard I had it during my scientific career, I find it inconceivable that anyone could have had a smoother ride. At the time I began my career, science was an expanding enterprise in the United States that welcomed the young. Only in such an opportunity-rich environment would someone like me have stood a chance. The contrast between that world and the dog-eat-dog world young scientists confront today is stark.     

Reforming Women in the United States and Aotearoa/New Zealand: A Comparative Ethnography of Welfare Reform in Global Context

Historically, the United States and Aotearoa/New Zealand symbolize opposite poles of an individualist-collectivist welfare state continuum. Until recently, Aotearoa/New Zealand was known as a "cradle-to-grave" welfare state, with "universal" employment and coverage in health and education. U.S. history, in contrast, is marked by an unabashed individualism and a residualist approach to welfare. Recent neoliberal reforms, however, have engendered a convergence between the two countries in the conceptualization and organization of assistance for poor single mothers. Most notable are the "workfare" provisions of legislative changes made in 1996 in the two countries, which work to reconstitute poor mothers as potential able-bodied workers. In this article we analyze welfare reform in the United States and Aotearoa/New Zealand, with particular reference to how poor single mothers respond to, comply and cope with, or resist neoliberal strategies. Analysis is based on participant-observation, interviews, and focus groups conducted between 1989 and 1999. [welfare reform, neoliberalism, globalization, gender, the United States, Aotearoa/New Zealand]     

Medical malpractice in perspective. I--The American experience.

Concern over the possibility of an American style medical malpractice "crisis" in the United Kingdom has recently been voiced by members of both medical and legal professions. The validity of such fears is examined by reviewing the conditions that have given rise to the current American difficulties. It is argued that the rise in malpractice insurance premiums and associated restrictions in availability should be seen against the background of underwriting problems specific to medical liability in conjunction with a general decline in reinsurance cover. The evidence in relation to the clinical and resource implications of malpractice is analysed. In particular, arguments that increased litigation has influenced the practice of "defensive" medicine and the choice of specialty are critically examined. Medical malpractice claims and insurance are only part of a professional environment which is undergoing dramatic social and economic changes, many of which seem more plausible candidates to be treated as important influences on the nature and organisation of health care in the United States.