Publications

Growth hormone (GH) is an underappreciated but important regulator of T cell development that can reverse age-related declines in thymopoiesis in rodents. Here, we report findings of a prospective randomized study examining the effects of GH on the immune system of HIV-1-infected adults. GH treatment was associated with increased thymic mass. In addition, GH treatment enhanced thymic output, as measured by both the frequency of T cell receptor rearrangement excision circles in circulating T cells and the numbers of circulating naive and total CD4(+) T cells. These findings provide compelling evidence that GH induces de novo T cell production and may, accordingly, facilitate CD4(+) T cell recovery in HIV-1-infected adults. Further, these randomized, prospective data have shown that thymic involution can be pharmacologically reversed in humans, suggesting that immune-based therapies could be used to enhance thymopoiesis in immunodeficient individuals.

PURPOSE OF REVIEW

To review the recent literature examining quality of care for several prevalent rheumatic conditions, including rheumatoid arthritis, osteoarthritis, gout and osteoporosis, and to summarize quality measurement and improvement initiatives relevant to rheumatology in the USA.

RECENT FINDINGS

In recent years, research has identified a significant gap between ideal and actual clinical practice in the USA. Consistent with trends seen in the US healthcare system as a whole, research suggests deficits in healthcare quality for populations with rheumatic conditions. We review the growing literature on quality of care for rheumatoid arthritis, osteoarthritis, gout and glucocorticoid-induced osteoporosis.

SUMMARY

Existing evidence suggests suboptimal healthcare quality for four common rheumatic conditions, a finding that parallels trends in the healthcare system as a whole.

Breast cancer incidence and mortality vary among different populations. African-American, Hispanic, Asian and Native American women have lower incidence but higher mortality compared with non-Hispanic white women. Explanations for the observed variation include social and economic factors such as education, income level, health insurance coverage, use of mammography, parity, breastfeeding and diet. Breast cancer may be a heterogeneous disease with different subtypes of tumors having different genetic and environmental risk factors. The difference in frequency of particular tumor subtypes between populations may explain some of the differences in incidence and mortality. Known genetic variants explain a small fraction of breast cancer cases, and so far there are no susceptibility genes that explain population differences in incidence and mortality. Studies evaluating the risk for particular tumor subtypes combining genetic and environmental variables and analyzing cases from different populations are needed to understand population differences in the severity of breast cancer.

OBJECTIVE

National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend that health professionals educate children with asthma and their caregivers about self-management. We conducted a meta-analysis to estimate the effects of pediatric asthma education on hospitalizations, emergency department visits, and urgent physician visits for asthma.

PATIENTS AND METHODS

Inclusion criteria included enrollment of children aged 2 to 17 years with a clinical diagnosis of asthma who resided in the United States. Pooled standardized mean differences and pooled odds ratios were calculated. Random-effects models were estimated for all outcomes assessed.

RESULTS

Of the 208 studies identified and screened, 37 met the inclusion criteria. Twenty-seven compared educational interventions to usual care, and 10 compared different interventions. Among studies that compared asthma education to usual care, education was associated with statistically significant decreases in mean hospitalizations and mean emergency department visits and a trend toward lower odds of an emergency department visit. Education did not affect the odds of hospitalization or the mean number of urgent physician visits. Findings from studies that compared different types of asthma education interventions suggest that providing more sessions and more opportunities for interactive learning may produce better outcomes.

CONCLUSIONS

Providing pediatric asthma education reduces mean number of hospitalizations and emergency department visits and the odds of an emergency department visit for asthma, but not the odds of hospitalization or mean number of urgent physician visits. Health plans should invest in pediatric asthma education or provide health professionals with incentives to furnish such education. Additional research is needed to determine the most important components of interventions and compare the cost-effectiveness of different interventions.

OBJECTIVES

To highlight areas of pharmacogenetics in which pharmacists may play a role and to describe those roles in the context of specific examples from a major academic medical center.

DATA SOURCES

Literature search (PubMed) and personal interviews for the University of California at San Francisco case examples.

DATA SYNTHESIS

The field of pharmacogenetics presents a wide range of opportunities for pharmacists. Specific roles for pharmacists are likely to fall within three major domains: developing research methodologies and setting research directions, establishing the value of pharmacogenetic testing in clinical practice, and participating in education and infrastructure development that moves pharmacogenetic technologies toward implementation.

CONCLUSION

As drug therapy experts, pharmacists are in a unique position to push the frontiers of pharmacogenetics in both the research and clinical practice environments.

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) infection is increasingly common worldwide and causes considerable morbidity and mortality. Of concern, community-associated MRSA infections are often recurrent and are highly transmissible to close contacts. The traditional tenet of pathogenesis is that MRSA colonization precedes infection. This has prompted persons involved in efforts to prevent community-associated MRSA infection to incorporate the use of intranasal topical antibiotics for nasal decolonization. However, data from outbreaks of community-associated MRSA infection suggest that skin-skin and skin-fomite contact represent important and common alternative routes of acquisition of the infecting strain. Furthermore, strain characteristics of the most successful community-associated MRSA strain, USA300, may contribute to a distinct pathogenesis. As we develop strategies to prevent community-associated MRSA infection, we must reconsider the pathogenesis of S. aureus. Reliance on models of health care-associated MRSA transmission for prevention of community-associated MRSA infection may result in the development of flawed strategies that attenuate our ability to prevent this serious and potentially deadly infection.