Quality Assessment of Online Complementary and Alternative Medicine Information Resources Relevant to Cancer.

BACKGROUND: Complementary and alternative medicine (CAM) is often used by cancer patients and survivors in the US. Many people turn to the internet as their first source of information. Health information seeking through the internet can be useful for patients to gain a better understanding of specific CAM treatments to discuss with their healthcare team, but only if the information is comprehensive, high quality, and reliable. The aim of this article is to examine the content, writing/vetting processes, and visibility of cancer CAM online informational resources. METHODS: Online CAM resources were identified by Google and PubMed searches, literature reviews, and through sources listed on various websites. The websites were analyzed through a modified online health information evaluation tool, DISCERN (score range = 1-5). The website's features relevant to the quality assessment were described. RESULTS: Eleven CAM websites were chosen for analysis. The DISCERN analysis showed a range of quality scores from 3.6 to 4.9. Lower DISCERN scores were generally due to deficiencies in describing the writing, editing, and updating processes. A lack of transparency with authorship and references was commonly present. CONCLUSION: Cancer patients interested in CAM need unbiased, evidence-based, reliable, high-quality, easily accessible educational materials. Individuals should use the guidelines followed in this analysis (including DISCERN and Medline Plus) to find reliable sources. Website developers can use CAM Cancer (NAFKAM), Beyond Conventional Cancer Therapies, Memorial Sloan Kettering Cancer Center, breastcancer.org, Office of Dietary Supplements, National Center for Complementary and Integrative Health, and Cancer.gov as models for trustworthy content.

The NCI library of traditional Chinese medicinal plant extracts - Preliminary assessment of the NCI-60 activity and chemical profiling of selected species.

Botanical-based natural products are an important resource for medicinal drug discovery and continue to provide diverse pharmacophores with therapeutic potential against cancer and other human diseases. A prototype Traditional Chinese Medicine (TCM) plant extract library has been established at the US National Cancer Institute, which contains both the organic and aqueous extracts of 132 authenticated medicinal plant species that collectively represent the potential therapeutic contents of most commonly used TCM herbal prescriptions. This library is publicly available in 96- and 384- well plates for high throughput screening across a broad array of biological targets, as well as in larger quantities for isolation of active chemical ingredients. Herein, we present the methodology used to generate the library and the preliminary assessment of the anti-proliferative activity of this crude extract library in NCI-60 human cancer cell lines screen. Particularly, we report the chemical profiling and metabolome comparison analysis of four commonly used TCM plants, namely Brucea javanica, Dioscorea nipponica, Cynanchum atratum, and Salvia miltiorrhiza. Bioassay-guided isolation resulted in the identification of the active compounds, and different extraction methods were compared for their abilities to extract cytotoxic compounds and to concentrate biologically active natural products.

The rise, fall, and future direction of computer-assisted personalized sedation.

PURPOSE OF REVIEW: The first computer-assisted personalized sedation (CAPS) device was developed to address the growing demand for routine endoscopy procedures in the United States in the early 2000s. This review will describe the environment that gave rise to CAPS and summarize the design of that first device. It will then discuss the market forces that led to the fall of CAPS, with sales of the device ending 2 years after commercialization. RECENT FINDINGS: CAPS was initially conceived as a means to enable proceduralists to administer conscious sedation with propofol safely. In the nearly 20 years since its conception, the expectations of patients and proceduralists for endoscopy sedation, have evolved from conscious sedation to deep. Due to the increased risk inherent in deep sedation, future CAPS devices should be tools for anesthesiologists, not proceduralists. SUMMARY: Over $2 billion are spent annually for anesthesia services in routine endoscopic procedures for low-risk patients; a spending rate that is not sustainable. CAPS, in an 'anesthesia oversight' model similar to medical supervision, has a future as a cost-efficient means for anesthesia services to provide sedation in endoscopy and other nonoperating room venues. Anesthesiologists should work with medical device companies and payers to develop a CAPS 'anesthesia oversight' model.

Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

PURPOSE OF REVIEW: In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients. RECENT FINDINGS: A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not. SUMMARY: A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.

Biophysical and economic implications for agriculture of +1.5° and +2.0°C global warming using AgMIP Coordinated Global and Regional Assessments.

This study presents results of the Agricultural Model Intercomparison and Improvement Project (AgMIP) Coordinated Global and Regional Assessments (CGRA) of +1.5° and +2.0°C global warming above pre-industrial conditions. This first CGRA application provides multi-discipline, multi-scale, and multi-model perspectives to elucidate major challenges for the agricultural sector caused by direct biophysical impacts of climate changes as well as ramifications of associated mitigation strategies. Agriculture in both target climate stabilizations is characterized by differential impacts across regions and farming systems, with tropical maize Zea mays experiencing the largest losses, while soy Glycine max mostly benefits. The result is upward pressure on prices and area expansion for maize and wheat Triticum aestivum, while soy prices and area decline (results for rice Oryza sativa are mixed). An example global mitigation strategy encouraging bioenergy expansion is more disruptive to land use and crop prices than the climate change impacts alone, even in the +2.0°C scenario which has a larger climate signal and lower mitigation requirement than the +1.5°C scenario. Coordinated assessments reveal that direct biophysical and economic impacts can be substantially larger for regional farming systems than global production changes. Regional farmers can buffer negative effects or take advantage of new opportunities via mitigation incentives and farm management technologies. Primary uncertainties in the CGRA framework include the extent of CO2 benefits for diverse agricultural systems in crop models, as simulations without CO2 benefits show widespread production losses that raise prices and expand agricultural area.

A New Method of Assessing the Impact of Evidence-Based Medicine on Claim Outcomes.

OBJECTIVE: The objective of this study is to develop a method of quantifying compliance with Evidence-Based Medicine (EBM) guidelines as a means of assessing the relationship between the use of EBM guidelines and illness absence and costs in workers' compensation. METHODS: A total of 45,951 indemnity claims with two years of development filed between 2008 and 2013 were utilized to develop the methodology. RESULTS: The newly developed methodology adequately assessed the relationship between claim outcomes (duration and medical incurred) and adherence to EBM guidelines, controlling for medical complexity, distinct number of International Classification of Diseases (ICD)-9 codes, and other confounding factors. CONCLUSIONS: The compliance score described in this paper may be a useful tool for determining the impact of worker's compensation treatment guidelines on claim outcomes.

Using Research to Improve College Readiness: A Research Partnership Between the Los Angeles Unified School District and the Los Angeles Education Research Institute.

The Los Angeles Unified School District (LAUSD) serves a large majority of socioeconomically disadvantaged students who are struggling academically and are underprepared for high school graduation and college. This article describes the partnership between LAUSD and the Los Angeles Education Research Institute, and how this collaboration endeavors to produce accessible and high-quality research to inform pressing problems of practice. The article also presents findings from an ongoing partnership research project analyzing a district policy focused on improving college readiness by aligning high school graduation and college-eligibility requirements. In a cohort that went through high school before the policy became mandatory for all students, less than 1/5 of all students (and 30% of graduates) met the college eligibility criteria. Our findings indicate that academic and behavioral indicators from 8th and 9th grade can help identify for possible intervention students who are not on track to meet these new graduation requirements.

Effect of physician-dispensed medication on workers' compensation claim outcomes in the state of Illinois.

OBJECTIVE: To evaluate differences between physician-dispensed and non-physician-dispensed medication with regard to lost time, prescription volume, and pharmaceutical, medical, indemnity costs in the Illinois workers' compensation system. METHODS: We studied a sample of 6824 workers' compensation indemnity claims that were opened and closed between January 1, 2007, and December 31, 2012, by Accident Fund Holdings in the State of Illinois. RESULTS: The number of prescriptions per claim and pharmaceutical, medical, and indemnity costs, as well as time out from work, were significantly higher in claims where a pharmaceutical was dispensed by the physician within 90 days of injury than in claims where physician dispensing did not occur. These differences persisted controlling for age, sex, attorney involvement, and injury complexity. CONCLUSION: Physician dispensing is associated with higher costs and more lost time than pharmacy-dispensed medications in workers' compensation claims.

Evaluation of practice patterns in the treatment of atrial fibrillation among the commercially insured.

OBJECTIVE: The management of atrial fibrillation (AF) involves two choices: (1) rate control versus rhythm control, and (2) anticoagulation treatment based upon risk of stroke. The objective of the study was to describe practice patterns in both of these treatment areas in patients with newly diagnosed AF among a commercially insured population. METHODS: This retrospective administrative claims analysis included patients with ≥2 AF claims between 1 January 2008 and 30 September 2010. Patients with AF claims within a year prior to the index date (i.e., the first AF diagnosis date) were excluded. The primary outcome was the proportion of patients treated with rate control (i.e., beta blockers, calcium channel blockers, digoxin) versus rhythm control (i.e., electrical cardioversion, left atrial catheter ablation [LACA], and/or surgical ablation) and the use of anticoagulants stratified by risk of stroke based on CHADS2 score. RESULTS: Of 48,814 patients with a diagnosis of AF, 38,502 (78.9%) received treatment. Of those treated, the majority received only pharmacologic treatment (73.4%), of which beta blockers were predominantly used in the initial regimen (66.7%). Antiarrhythmic drugs were used in 23.9% of patients, but within the initial regimen in only 11.7% of patients. Direct current cardioversion occurred in 18.2% of patients, with the majority being either first-line (8.5%) or second-line (9.1%) therapy. LACA was used in only 5.2% of patients and was typically reserved for use after pharmacologic treatment or direct current cardioversion. Of 1924 patients who received LACA, 14.6% received a repeat procedure and 53.4% of the repeat procedures occurred within 6 months of the initial one. A little more than half of all patients (57.0%) received anticoagulant therapy (predominantly warfarin); of those at high risk for stroke, 63.8% with a CHADS2 score ≥2 received anticoagulants. KEY LIMITATIONS: It is a retrospective analysis using administrative claims data from a commercially insured population only. Identification of the first episode of AF may be inaccurate, and we cannot differentiate between paroxysmal and persistent AF. CONCLUSIONS: Debate continues regarding whether the preferred management of most patients with AF is through rate control or restoration of normal sinus rhythm. Our retrospective study found that treatments to restore normal heart rhythm, including LACA, which could be considered aggressive initial treatment, were typically reserved as second- or third-line alternatives. Initial standard of care for the majority patients was beta blockers. Though use of anticoagulation may be higher than other observational studies, opportunities exist to increase treatment in high risk patients.

The effect of opioid use on workers' compensation claim cost in the State of Michigan.

OBJECTIVE: To investigate the association between opioid utilization and catastrophic claim (≥$100,000) cost. METHOD: A total of 12,226 workers' compensation indemnity claims that were opened and closed from January 1, 2006 to February 28, 2010 in the State of Michigan were selected for multivariate logistic regression analyses. RESULT: Controlling for sex, age, claim duration, number of distinct International Classification of Diseases-Ninth Revision codes per claim, and legal involvement, the presence of short-acting opioids on a claim were 1.76 (95% confidence interval: 1.23 to 2.51) and long-acting opioids 3.94 (95% confidence interval: 2.35 to 6.89) more likely to have a final cost $100,000 or more than a claim without any prescription. CONCLUSION: The use of opioid medications, particularly long-acting opioid medications, is an independent risk factor for the development of catastrophic claims.

Direct healthcare costs of osteoporosis-related fractures in managed care patients receiving pharmacological osteoporosis therapy.

BACKGROUND: Osteoporosis is a common condition and the economic burden of osteoporosis-related fractures is significant. While studies have reported the incremental or attributable costs of osteoporosis-related fracture, data on the economic impact of osteoporosis-related fractures in commercial health plan populations are limited. OBJECTIVE: To estimate the direct costs of osteoporosis-related fractures among pharmacologically treated patients in a large, commercially insured population between 2005 and 2008. METHODS: In this retrospective cohort study, patients were identified from a large, commercially insured population with integrated pharmacy and medical claims. Inclusion criteria were age 45-64 years; one or more osteoporosis medication claim(s) with first (index) claim between 1 January 2005 and 30 April 2008; and continuous insurance coverage for ≥12 months pre-index and ≥6 months post-index. Patients with pre-index Paget's disease or malignant neoplasm; skilled nursing facility stay; combination therapy at index; or fracture ≤6 months post-index were excluded. A generalized linear model compared differences in 6-month pre-/post-event costs for patients with and without fracture. Propensity score weighting was used to ensure comparability of fracture and non-fracture patients. Generalized estimating equations accounted for repeated measures. RESULTS: The study included 49,680 patients (2613 with fracture) with a mean (SD) age of 56.4 (4.7) years; 95.9% were female. Mean differences between pre- and post-event direct costs were $US14,049 (95% CI 7670, 20,428) for patients with vertebral fractures, $US16,663 (95% CI 11,690, 21,636) for patients with hip fractures, and $US7582 (95% CI 6532, 8632) for patients with other fractures. After adjusting for covariates, osteoporosis-related fractures were associated with an additional $US9996 (95% CI 8838, 11,154; p < 0.0001) in direct costs per patient across all fracture types during the 6 months following fracture. CONCLUSION: Patients with osteoporosis-related fractures were found to incur nearly $US10,000 in estimated additional direct healthcare costs in the 6 months post-fracture, compared with patients with no fracture. Reduced fracture risk may lower associated direct healthcare costs.

Physical activity in patients who are severely mentally ill: feasibility of assessment for clinical and research applications.

Few studies have examined physical activity in patients who are severely mentally ill. We assessed feasibility and validity of using standardized self-report and objective measures of physical activity in 20 community-dwelling veteran patients, most with psychotic disorders and substance abuse in remission. Test-retest reliability of a past week physical activity survey and the Community Healthy Activities Model Program for Seniors interview were evaluated with repeated interviews. RT3 accelerometer data provided objective physical activity data. Test-retest reliability and validity correlations for the self-report instruments were similar in magnitude to those reported for nonclinical adult samples. Some activity measures were correlated with cognitive status and quality of life. Results indicate that self-reported physical activity can provide valid information for clinical and research applications in mental health settings. Correlations between physical activity measures and psychiatric symptoms suggested interesting patterns for future study.

Exceptional disease courses after the use of CAM: selection, registration, medical assessment, and research. an international perspective.

OBJECTIVES: To describe the different approaches that investigators in several countries have used to obtain, register, assess, and research exceptional case histories after the use of complementary and alternative medicine (CAM). METHODS: Searches have been carried out currently in the databases PubMed and MEDLINE((R)) using the keywords: exceptional disease course/best and worst cases/best-case series + use of CAM. We have only found a few papers limited to best-case series and cancer. Furthermore, we have used the "snowball method" by contacting researchers in different countries starting with with the National Cancer Institute in the United States in order to get information about ongoing approaches to obtain, register, assess, and research exceptional case histories after the use of CAM. RESULTS: There appears to be a gap between "evidence-based" knowledge drawn from randomized controlled trials, systematic reviews, and meta-analyses and experience-based knowledge of treatment outcomes reported by patients and CAM providers. Several research groups in different countries have initiated studies on patients experiencing exceptional treatment outcomes after the use of CAM. Four different approaches to collecting and assessing such case histories have been identified. Three of the approaches collect histories from the treatment providers, whereas the fourth recruits case histories mainly from patients themselves. The medical assessments are generally similar, and seek to document whether the course of disease is different than would have been expected in a conventional treatment situation. CONCLUSIONS: Given differences in the current procedures, the establishment of an international formal collaboration for the recruitment, assessment, and study of exceptional patients is likely to take time. Comparative studies may, however, generate new knowledge about exceptional disease courses across disease categories, cultural contexts, and national boundaries. Our recommendations are that therapeutic approaches that show promising results should warrant prospective study and randomized clinical trials. In addition we recommend that there be (1) agreement on the definition of an exceptional patient, (2) agreement on the interpretation of treatment results, (3) agreement on content requirements of medical records, (4) more consideration of worst cases, (5) more international exchange of experience with registration procedures, and (6) more international exchange of experience with medical assessment procedures.