Preserved muscle oxidative metabolic phenotype in newly diagnosed non-small cell lung cancer cachexia.

BACKGROUND: Cachexia augments cancer-related mortality and has devastating effects on quality of life. Pre-clinical studies indicate that systemic inflammation-induced loss of muscle oxidative phenotype (OXPHEN) stimulates cancer-induced muscle wasting. The aim of the current proof of concept study is to validate the presence of muscle OXPHEN loss in newly diagnosed patients with lung cancer, especially in those with cachexia. METHODS: Quadriceps muscle biopsies of comprehensively phenotyped pre-cachectic (n = 10) and cachectic (n = 16) patients with non-small cell lung cancer prior to treatment were compared with healthy age-matched controls (n = 22). OXPHEN was determined by assessing muscle fibre type distribution (immunohistochemistry), enzyme activity (spectrophotometry), and protein expression levels of mitochondrial complexes (western blot) as well as transcript levels of (regulatory) oxidative genes (quantitative real-time PCR). Additionally, muscle fibre cross-sectional area (immunohistochemistry) and systemic inflammation (multiplex analysis) were assessed. RESULTS: Muscle fibre cross-sectional area was smaller, and plasma levels of interleukin 6 were significantly higher in cachectic patients compared with non-cachectic patients and healthy controls. No differences in muscle fibre type distribution or oxidative and glycolytic enzyme activities were observed between the groups. Mitochondrial protein expression and gene expression levels of their regulators were also not different. CONCLUSION: Muscle OXPHEN is preserved in newly diagnosed non-small cell lung cancer and therefore not a primary trigger of cachexia in these patients.

Expanding the safety net of specialty care for the uninsured: a case study.

OBJECTIVE: To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured. STUDY SETTING: Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access-New Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation. STUDY DESIGN: Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations. PRINCIPAL FINDINGS: Implementation relied on the application of core principles from community-based participatory research (CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings. CONCLUSIONS: Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations.

Project Access-New Haven: improving access to specialty care for patients without insurance.

BACKGROUND: Poor access to specialty care among uninsured adults threatens the delivery of quality health care and may contribute to the misuse and overuse of emergency departments and hospitals. INTERVENTION: We sought to improve access to specialty care through a program called Project Access-New Haven (PA-NH),which engages specialty physicians and hospitals to volunteer in a coordinated-care model for the uninsured. Patient navigators guide patients through the health-care network and help to alleviate administrative obstacles. RESULTS: Project Access-New Haven has been operational since August 2010. With >200 specialty physicians volunteering and strong commitments from local hospitals, comprehensive specialty care has been provided to 78 patients. Average wait-time for appointments is 17 days. CONCLUSION: PA-NH provides timely medical care and patient navigation foruninsured patientswith specialty-care needs. In the process, more physicians are participating in the care of vulnerable populations. Further data are needed to assess the potential cost-savings of PA-NH.

Predictors of compliance with free endoscopic colorectal cancer screening in uninsured adults.

BACKGROUND: National guidelines endorse colonoscopy as the only colorectal cancer (CRC) screening test which prevents CRC and evaluates the entire large bowel. However, little is known regarding patient compliance with a screening program that exclusively uses colonoscopy, particularly in an underserved population. The Connecticut Department of Public Health provided funds for the total cost of colonoscopies, patient navigators and education of staff and primary care providers. With cost and provider barriers removed, we were able to examine patient related factors influencing compliance with colonoscopy in an ethnically diverse sample of underinsured adults. OBJECTIVE: To determine what patient related factors are predictors of compliance with screening colonoscopy. DESIGN: Cross sectional retrospective study. PARTICIPANTS: Underinsured patients (50-64 years) visiting nine Connecticut community health centers (CHCs) were evaluated for medical eligibility for screening; eligible patients were offered a free colonoscopy. MAIN MEASURES: Patients were deemed non-compliant if they refused, canceled or did not show for the colonoscopy. Obesity (Body Mass Index ≥ 30), educational attainment, gender, race, ethnicity, previous screening and social ties were examined as primary risk factors for compliance. KEY RESULTS: Of 424 uninsured patients (62% female, 21% White, 26% Black, 53% Hispanic), 354 were eligible for colonoscopy. Among eligible patients, 263 (74.3%) were compliant. Obese patients were more likely than non-obese patients to be non-compliant with colonoscopy (adjusted odds ratio = 2.16; 95% Confidence interval = 1.20-3.89). A high school education was positively correlated with increased compliance social ties such as having a spouse, significant other, family or friend also increased compliance. CONCLUSIONS: In an ethnically diverse, uninsured population, obese patients and patients with lower educational attainment were less likely to comply with free colonoscopy. These patients require special attention in colonoscopy-based CRC screening efforts.

Isolated gastric malakoplakia: a case report and review of the literature.

A 62-year-old African American woman presented with weight loss and dyspepsia. She did not have any clinical evidence of immunodeficiency. Upper gastrointestinal endoscopy revealed multiple small polypoid lesions in the gastric body and fundus that appeared larger and more erythematous than usual fundic gland polyps. Examination of biopsy specimens revealed an infiltrate of large histiocytes with eosinophilic granular cytoplasm located in the lamina propria and containing Michaelis-Gutmann bodies. These histologic findings were diagnostic of gastric malakoplakia. Gastrointestinal malakoplakia is uncommon, and exclusive gastric involvement is extremely rare. Because occult bacterial infection has been postulated as the underlying cause of malakoplakia, the presence of Helicobacter pylori infection was investigated using immunohistochemical and serologic techniques, and the presence of Yersinia enterocolitica or Yersinia pseudotuberculosis infection was investigated by polymerase chain reaction assay. There was no evidence of H pylori, Y enterocolitica, or Y pseudotuberculosis in these biopsy specimens, and there was no evidence of malakoplakia or concurrent malignancy at any other site. Follow-up examination 12 months later revealed no endoscopic or histologic improvement.