Joel W. Adelson

Improving Asthma-Related Health Outcomes Among Low-Income, Multiethnic, School-aged Children: Results of a Demonstration Project That Combined Continuous Quality Improvement and Community Health Worker Strategies

OBJECTIVE. The purpose of this work was to improve asthma-related health outcomes in an ethnically and geographically disparate population of economically disadvantaged school-aged children by using a team-based approach using continuous quality improvement and community health workers. PATIENTS AND METHODS. A demonstration project was conducted with 7 community clinics treating ∼3000 children with asthma 5 to 18 years of age. The overall clinic population with asthma was assessed for care-process changes through random cross-sectional chart reviews at baseline and 24 months (N = 560). A subset of patients with either moderate or severe persistent asthma or poorly controlled asthma (N = 405) was followed longitudinally for specific asthma-related clinical outcomes, satisfaction with care, and confidence managing asthma by family interview at baseline and at 12 or 24 months. Patient-centered and care-process outcomes included patient/parent assessment of quality of care and confidence in self-management, asthma action plan review, and documentation of guideline-based indicators of quality of care. Direct clinical outcomes included daytime and nighttime symptoms, use of rescue medications, acute care and emergency department visits, hospitalizations, and missed school days. Each clinic sites degree of adherence to the intervention model was evaluated and ranked to examine the correlation between model adherence and outcomes. RESULTS. Cross-sectional data showed clinic-wide improvements in the documentation of asthma severity, review of action plans, health services use, and asthma symptoms. At follow-up in the longitudinal sample, fewer patients reported acute visits, emergency department visits, hospitalizations, frequent daytime and nighttime symptoms, and missed school days compared with baseline. More patients reported excellent or very good quality of care and confidence in asthma self-management. Linear regression analysis of the clinical sites’ model adherence ranks against site-level combined scores estimating overall outcomes, clinical outcomes, and improvements in clinical care processes showed significant linear correlations with R2 ≥ 0.60. CONCLUSIONS. The demonstration produced major improvements in asthma-related care processes and clinical outcomes. Closer adherence to the demonstration model was directly associated with better outcomes.

Pitfalls in Predicting Resting Energy Requirements in Critically Ill Children: A Comparison of Predictive Methods to Indirect Calorimetry

BACKGROUND Critical illness in children is thought to have profound effects on nutritional status. It is essential to avoid complications associated with inadequate nutrition support and delivery of excess energy. OBJECTIVE To compare the results of several commonly used methods for predicting energy requirements in a group of critically ill children indirect calorimetry was used to measure energy expenditure in these children. DESIGN Resting energy expenditures estimated by different prediction methods for energy were compared with measurements of actual resting energy expenditure obtained by indirect calorimetry in 52 children admitted to a pediatric intensive care unit. Agreement between each predictive method and indirect calorimetry was evaluated by Bland-Altman limits of agreement and by whether the methods met the predetermined criterion for accuracy of within 10% of the measured value. RESULTS None of the equations predicted individual values accurately. Each of the predictive equations gave a wide and variable scatter of predicted values around the median. The recommended dietary allowance for energy was the least accurate and differed significantly even from the other predictive methods, overestimating energy expenditure in 50 of 52 patients. None of the remaining methods stood out as being more precise. CONCLUSIONS Predictive methods commonly used to estimate energy expenditure in critically ill children are very imprecise and may lead to overprovision or underprovision of nutrition support. Resting energy expenditure should be measured by indirect calorimetry whenever possible.

Cystic fibrosis. Gastrointestinal complications and gene therapy.

The gastrointestinal and nutritional complications of cystic fibrosis are diverse. As longevity improves in patients with cystic fibrosis, management of these complications is becoming increasingly important . This article provides overviews of the molecular aspects of the pathogenesis of cystic fibrosis, the current status of gene therapy, and a review of the gastrointestinal manifestations and nutritional care.

Selective Pancreatic Enzyme Secretion due to a New Peptide Called Chymodenin

Chymodenin, a peptide newly isolated from porcine duodenum, elicited a rapid threefold increase in secretion of chymotrypsinogen while increasing secrelion of total protein by only, about 40 percent; lipase secretion was unaffected. The pancreas appears able, under chymodenin stimulation, to rapidly alter the transport of an individual enzyme as opposed to producing en masse secretion of enzyme.

Fundamental cellular heterogeneity of the exocrine pancreas.

Homogeneity in structure and function are broadly assumed to be characteristics of the acinar pancreatic digestive enzyme-secreting tissue. In recent years, physiological studies have shown that the pancreas stores the digestive enzymes in heterogeneously composed pools and releases them from these pools in a cyclic and secretagoguec fashion. The cellular basis for pancreatic heterogeneity is unknown; classical light and electron microscopic preparations appear homogeneous. We applied a panel of biotinylated lectins to pancreatic tissue sections; acinar cell glycoconjugates were localized in situ with peroxidase and fluorescent techniques and lectin-gold complexes. The lectin-binding properties of both fasting rabbit and rat pancreas revealed extensive and specific heterogeneity of the acinar cell population. Light and electron microscopy demonstrated highly heterogeneous labeling of the zymogen granule contents of specific acinar cells with the lectins Ulex europaeus agglutinin (UEA) and Erythrina cristagalli (ECA), which also showed preferential labeling of peri-insular acini. Other lectins also demonstrated heterogeneous binding to specific cellular regions. The striking acinar cell heterogeneity confirms earlier predictions, and may eventually prove to be the cellular basis for the secretion of different enzyme mixtures from heterogeneous sources within the pancreas.

California’s Digital Divide: Clinical Information Systems For The Haves And Have-Nots

Strong barriers prevent the financing of clinical information systems (CIS) in health care delivery system organizations in market segments serving disadvantaged patients. These segments include community health centers, public hospitals, unaffiliated rural hospitals, and some Medicaid-oriented solo and small-group medical practices. Policy interventions such as loans, grants, pay-for-performance and other reimbursement changes, and support services assistance will help lower these barriers. Without intervention, progress will be slow and worsen health care disparities between the advantaged and disadvantaged populations.

The California Stem Cell Initiative: Persuasion, Politics, and Public Science

The California Institute for Regenerative Medicine (CIRM) was created by a California ballot initiative to make stem cell research a constitutional right, in response to Bush administration restrictions on stem cell research. The initiative created a taxpayer-funded, multibillion-dollar institution, intended to advance public health by developing cures and treatments for diabetes, cancer, paralysis, and other conditions. The initiative has been highly controversial among stakeholders and watchdog groups concerned with organizational transparency, accountability, and the ethics of stem cell research. We interviewed major stakeholders-both supporters and opponents-and analyzed documents and meeting notes. We found that the CIRM has overcome start-up challenges, been selectively influenced by criticism, and adhered to its core mission.

Clinical commentary: Medical ethics and the ramifications of equipoise in clinical research. Is a confirmatory trial using a non-bevacizumab containing arm feasible in patients with recurrent cervical cancer?

controlled trials (RCTs) represent the gold standard of methodology in clinical research and maximize the validity of scientific data through eliminating systematic biases. However, for clinical investigators one of the major ethical weaknesses is the act of randomization itself [1]. Clinical-researchers face the dilemma of reconciling their duty as physicians to provide the best care for their patients with the preeminent scientific process of assigning research participants to competing therapies by chance alone. The concept of ‘clinical equipoise’has been utilized by ethicists and researchers to overcome this crisis of professional responsibility. The reigning definition was described by Freedman as “an ethically necessary condition in all cases of clinical research... [that exists when] there is no consensus within the expert clinical community about the comparative merits of the alternatives to be tested” [2]. Since the 1970s equipoise has been challenged, deconstructed, and reformulated in the ethics literature, and it remains open for interpretation. Contemporary ethicists caution against relying on equi-