JAMA

doi: 10.1001/jama.298.14.1605pmid: N/A

Topiramate for Alcohol Dependence Previous studies have found that treatment with oral topiramate is associated with reductions in drinking behavior and alcohol craving among alcohol-dependent persons. In this issue, Johnson and colleagues Article report results from a randomized multisite clinical trial in which adults with alcohol dependence were assigned to receive topiramate or placebo and participated in weekly brief adherence counseling sessions. The authors found that persons who received topiramate reported significantly fewer heavy drinking days, fewer drinks per day, and more days abstinent and had lower laboratory-confirmed levels of alcohol consumption compared with persons who received a placebo. In an editorial, Willenbring Article discusses alcohol dependence and strategies for its effective treatment. Job Strain and Risk of Recurrent CHD Events Some evidence suggests that jobs with high psychological demands and low decision latitude—components related to job strain—increase the risk of a first coronary heart disease (CHD) event. However, whether job strain is associated with recurrent CHD events is not clear. Aboa-Éboulé and colleagues Article assessed this relationship in a prospective cohort study of persons who returned to work after a first myocardial infarction. The authors found that persons who reported high job strain at 6 weeks and 2 years following their return to work had a significantly increased risk of a new CHD event compared with persons who did not report high job strain at 1 or both interviews. In an editorial, Orth-Gomér Article discusses the evidence linking job and personal stress to adverse health consequences. Maintenance Treatment of Childhood Weight Loss Weight maintenance following weight loss is a significant challenge for patients. In a 4-month extension of a family-based behavioral weight-loss treatment program for children, Wilfley and colleagues Article assessed the short-term and long-term efficacy of 2 weight maintenance approaches—one emphasizing behavioral skills and the other social facilitation. The authors found that children who were randomly assigned to either weight maintenance intervention had greater success maintaining their weight loss at 4 months than children who were randomly assigned to a control group with no further intervention. Successful weight maintenance waned during the 20-month follow-up, particularly among children with social problems. In an editorial, Rhodes and Ludwig Article discuss unique features of childhood obesity and its management. Quality of Care in Medicaid Managed Care Plans To examine the quality of care received by Medicaid beneficiaries vs commercial populations in managed care plans, Landon and colleagues analyzed national quality of care data for 11 quality indicators from the Healthcare Effectiveness Data and Information Set. The authors found that among Medicaid enrollees in managed care plans, performance measures were comparable for Medicaid-only plans and Medicaid/commercial plans that serve large numbers of both types of enrollees. Similarly, among commercial enrollees, there was no difference in quality of care in plans that served primarily commercial enrollees vs Medicaid/commercial plans. However, in comparisons of Medicaid beneficiaries with commercially insured persons, performance measures for commercial populations exceeded those for Medicaid populations. Article A Piece of My Mind “Was my failure to respond to a fellow human being who was balanced precariously on life's precipice a sign of my own arrogance?” From “The Book.” Article Medical News & Perspectives Factors behind the severe shortage of nurses in the United States. Article Clinician's corner An appraisal of the likely contribution of genomics to personalized medicine. Article Stress and Disease The role of stress in depression, cardiovascular disease, HIV/AIDS, and cancer. Article Petroleum and Public Health Implications of petroleum scarcity for medical care and public health. Article Readers Respond Submit your views on the diagnostic or treatment options for a patient at a medical crossroads. Your response may be selected for online publication with the article. Go to www.jama.com on October 3 to read the first case. Submission deadline is October 31. Article JAMA Patient Page For your patients: Information about chronic stress and the heart. Article

Quaranta, Kristen M.

doi: 10.1001/jama.298.14.1609pmid: 17925505

Twentieth-century American painter, social realist, and social activist Philip Evergood (1901-1973) forged his own artistic style. It was a style that was not easily categorized, a style that did not conform to popular agenda, yet a style that was always intended for a specific end. The painter's responsibility, he believed, was to express social consciousness and to take a stand on the contentious issues affecting the common man. Evergood's paintings were not meant for frivolity, entertainment, or beauty; his aim was of a higher sort. This was evident as his convictions materialized into the recordings of social plights illustrating inequality, the tragedy of war, and the subjugation of the working class. Some examples of his realistic expressions of consciousness are Pink Dismissal Slip (1937) and Don't Cry Mother (1938). Evergood's style, although unique, was grounded in his education, his mentors' techniques, and his professional associations. He was educated in London at the Slade School of Fine Art and studied in Paris with André Lhote. Soon after, Evergood traveled to Spain. Here he further developed his individualistic and eclectic style through the influences of El Greco and Goya, which resulted in his use of bright colors and dynamic brushstrokes. Evergood was also impressed by his friendship with John Sloan, whose urban realism he incorporated and personalized into his own technique of chronicling social realities. Additionally, Evergood was a faculty member of the American Artists School, which advocated a creation of art that was socially and politically mindful. As an activist for the Artists Union, he also lobbied to generate federal funds for downtrodden artists. These alliances further fueled Evergood's natural inclinations to bring about a more equitable society. Evergood's ideas were manifested in real-life illustrations of the two world wars and the Great Depression. This turmoil greatly affected his and other artists' livelihoods until President Roosevelt formulated the Federal Art Project as part of the New Deal. An example of a work he created from a newspaper article to express his contempt for war is Boy From Stalingrad (1943), which depicts a youth guarding the dead bodies of a thousand Germans. Although he based it on an actual scene, Evergood was not interested in painting forms or events that were true in perspective, harmony, or proportion. Instead, he surrendered balance, proportion, and harmony to gain a greater emotional impact. In his renditions, Evergood also commonly expressed complex ideas in the simplest manner. His execution, albeit straightforward, was always intended to raise awareness of a sensitive issue and to produce a particular effect. As he wrote in a note (March 1966), “Technical brilliance . . . [is] secondary to the fervor, the heat of desire to say something meaningful, strong, urgent, timely.” Despite his resultant obstacles to popular acceptance and the disapprovals from some art critics, he devoutly followed his personal artistic instincts, not those of the establishment. In the late 1940s, Evergood continued to create meaningful works of art with representation of the basic elements of his style, yet his interest in social satire seemed to recede. Thereafter, his works became more visionary, self-reflective, personal, and surrealistic, although still purposeful. In 1952, Evergood settled in Connecticut, where he painted in this freer style. One example is Self-portrait (cover ), which portrays himself as a farmhand working in a wheat field. His typical use of color to evoke emotion is evident in this painting with the vibrant ambers, oranges, and reds of the fields that are replicated in the face and hair of the figure. The disproportionate, exaggerated, almost cartoonish nature of the man's hands and feet and the simplistic expression on his face exemplify the surrealistic quality and Evergood's common disregard for proportion. The unrefined overall appearance of the work contrasts, as always, with Evergood's sophisticated intent: to equate himself to an oppressed worker whose product is a commodity and, like any other worker’s, is produced through hard work and toil. Philip Evergood (1901-1973), Self-portrait, 1960, American. Oil on canvas. 38.7 × 28.9 cm. Courtesy of the University of Kentucky Art Museum (http://www.uky.edu/artmuseum/), Lexington; gift in memory of Robert B. Mayer by his wife and children, 1976.23.1. Tragically, Evergood's artistic and social passions were halted when he died in a home fire in Bridgewater, Connecticut. Though his life ended suddenly, the power of his convictions persist through his artistic representations. Back to top Article Information Editor's Note: This week's writer is Kristen M. Quaranta, assistant editor, Department of Medical Humanities, JAMA.

Savoie, John

doi: 10.1001/jama.298.14.1610pmid: N/A

Memory believes before knowing remembers. —William Faulkner, Light in August Grassy earth bulges above. Branches stretch away, twig and fade in leaves dim with the other side of light lapping underneath, then all forever to fall. He tastes the salt, feels the heat sliding up his back, gritty bark runging curled knees. The sun, unseen, throbs at the center of things. Face flushed with gravity of blood, he senses again in voices ringing up- side down, outside in, the presence like a breathing closer than his own. Shade tightens in a dome. He scrunches to that first curious pose then flings himself swinging like a bell's pounding tongue and calls out to the only one he cares to show— “Hey Mo-o-o-o-om!” Through the dark glint of her glasses she smiles, then shouts from sunlight, “I see you, I see you!” The child's spine shivers in wonder, terror, joy, as though separate threads silver, gold, and black— the void from self to soul— were now woven into one.

Campbell, Bruce H.

doi: 10.1001/jama.298.14.1613pmid: 17925506

Had he been born at a different time or in a different place, he might have been a character actor in the movies, a regular in the chorus on the Shakespearean stage, or a traveling troubadour. As it was, he was just barely bumping along at the margins, cheerful as could be. His outward appearance was startling: His face was disproportionately large, and his mop of dark hair was always wild. In conversation, you had to choose which of his eyes to engage. His animated limbs were gangly and their final resting places unpredictable. His high-pitched voice did not seem to fit his long, lean body. When he folded himself into the examination room chair, his hand shot out in greeting, an innocent smile washed over his face, and he squeaked, “Hi, Doc!” He was, safe to say, a memorable character. My first encounter with him came immediately after he noticed “a little trouble swallowing.” When I examined his throat, I found the largest, most extensive cancer I had ever seen involving someone's tongue, tonsil, palate, larynx, and pharyngeal wall. His treatment options were extremely limited. After a workup and discussion at our clinic's weekly tumor conference, he was scheduled for what we assumed would be a marginally effective short course of high-dose-per-fraction palliative radiation. Surprisingly, he had a brisk and encouraging early response. After the first few radiation sessions, his regimen was switched to a standard curative course. His tumor continued to melt. I assumed that he would never swallow again, given the amount of scar tissue that normally develops after such treatment. Wrong again. He recovered steadily and resumed his previous life not long after treatment was completed. No scars, no significant adverse effects. He had a little pain that was completely controlled by a mild narcotic. He was one of our “miracles,” and we told him this. He was delighted that he had surprised us by being cured and by staying alive. At every visit, he would laugh, “You really didn't think I would make it, did you, Doc?” Although my involvement in his treatment had been very limited—after all, my only task had been to refer him on to the radiation oncologists—he always greeted me warmly and thanked me profusely. The miraculous cure held up over time. We settled into a follow-up routine that required fewer and less-frequent visits. He called occasionally for refills of his pain medication, but there was no up-tick in the pill count, so we would contact the pharmacy with authorizations. With every call, he would tell our administrative assistant, who by this time was new and had never met him, what a great surgeon I was. As she relayed each message, I always smiled, assuming that the compliments had more to do with making certain he was able to get timely prescription refills than any personal feeling for me. Several years later, I received a package from him. Inside was a used book with a torn dust jacket, bent corners, and a price tag that read “25¢.” It was a biography of Dr Tom Dooley, published in the early 1960s. Along with the book, my patient had enclosed a handwritten note, written in pencil, thanking me for “being the best doctor I know.” No other explanation. I wondered at the gesture, shook my head, and set the book aside, unread. I recall now that I had always intended to respond to the gift, but I did not. A thank-you note would have taken just a few seconds. Of course, I rationalized that he might not even receive the note because of the transient nature of his lifestyle. Perhaps, though, I was uncertain of the meaning of the gift. I left note-writing for another day, perhaps hoping to eventually find the right words. Before long, preparing a response dropped entirely off my mental priority to-do list. Winters in Wisconsin can be harsh. A couple of years later, when the snows finally started to thaw in March, some kids discovered his partially submerged body in a park lagoon across the road from where he had last lived. The newspaper, in a one-paragraph story, noted that his roommate had reported him missing late that December. There was no further information other than that he had no known relatives. I was stunned and abashed. Now that he was gone, I finally retrieved the book. Tom Dooley, it turns out, had established a network of charity health facilities for the poor people of Vietnam, Laos, and Cambodia in the 1950s. In 1960, a Gallup Poll identified him as one of America's Ten Most Admired Men. Dooley had known Albert Schweitzer, and Dooley's work was credited with inspiring the birth of the Peace Corps. When Dr Dooley developed malignant melanoma and died in 1961 at the age of 34, the world mourned his short but incredibly productive life. As I breathed in the musty pages, I wondered: Had my patient read this book before he sent it to me? Had I really reminded him of this dynamic, virtuous, unselfish physician who improved the lives of thousands of people? Or was the book meant to inspire me to approximate Dooley's character? I would be left to forever ponder these questions. Before long, I had deliberately recycled the note and given away the book because the gift that had, until then, barely stirred me now made me feel unworthy. His gift had been a simple act of grace. My inability to celebrate his gesture resurfaced and burned in me anew when I later read Robert Coles' introduction to William Carlos Williams' The Doctor Stories. Dr Coles writes: “Presumptuousness and self-importance are the wounds this life imposes upon those privy to the wounds of others. The busy, capable doctor, well aware of all the burdens he must carry, and not in the least inclined to shirk his duties, may stumble badly in those small moral moments that constantly press upon him or her—the nature of a hello or good-bye, the tone of voice as a question is asked or answered, the private thoughts one has, and the effect they have on our face, our hands as they do their work, our posture, our gait.” Was my failure to respond to a fellow human being who was balanced precariously on life's precipice a sign of my own arrogance? Perhaps. I know it's far too late in coming (and I really do apologize for that) but, Jack, my friend, thanks for the book. And rest in peace.

Kuehn, Bridget M.

doi: 10.1001/jama.298.14.1623pmid: 17925507

Despite projections that the ongoing shortage of nurses could grow to more than 1 million nurses by 2020, a bottleneck at US nursing schools caused more than 42 000 qualified applicants to be turned away in 2006-2007. With rising salaries and the promise of a bright long-term employment outlook, individuals are clamoring to enter nursing training programs. Hospitals and other health care facilities facing the prospect of a growing elder population and the simultaneous graying of the nurse workforce are eager to hire these would-be nurses. But nursing schools—pinched by a growing faculty shortage, a lack of facilities, too few clinical training placements, and limited funds—have not been able to keep pace with the demand. Falling behind Falling behind US nursing schools have boosted enrollment over the past several years, with an increase of 5% in 2006, 9.6% in 2005, 14.1% in 2004, 16.6% in 2003, according to the American Association of Colleges of Nursing (AACN) 2006 annual report on enrollment. But these increases are consistently declining over time and fall short of the 40% yearly increases in enrollment needed to meet the demand. Using data from a 2004 survey, a 2006 report from the Health Resources and Services Administration (HRSA) predicted that the shortage of nurses will grow steadily over the next several years, with a projected shortage of 218 800 nurses in 2005 and 1 million nurses in 2020 (http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/4.htm). The shortage of nurses in the United States is projected to grow to more than 1 million by 2020. This represents a roughly 36% shortfall of the nurses needed to cope with, among other things, an increasingly aged population and increasingly high-tech health care. (Photo credit: Christine Balderas/iStockphoto.com) Falling behind Other estimates paint a somewhat less dire picture. In 2000, Peter I. Buerhaus, PhD, RN, and colleagues estimated there would be deficit of about 800 000 nurses by 2020, in part because of declining numbers of individuals entering nursing schools in their early to mid 20s (Buerhaus PI et al. JAMA. 2000;283[22]:2948-2954). But the researchers recently revised this figure after observing that the number of working nurses actually grew by 300 000 between 2000 and 2005—nearly 6 times HRSA's estimate for growth during that period. They attributed this unexpectedly large increase in nurses to a greater number of individuals entering the profession in their late 20s and early 30s. Taking into account this trend, the researchers now estimate that there will be a shortage of 340 000 nurses in 2020 (Auerbach DI et al. Health Aff [Millwood]. 2007;26[1]:178-185). Falling behind Buerhaus cautioned that despite this positive development, the United States still faces serious consequences from the shortage. Falling behind “The hurricane has weakened from a 5 to 4,” he said. “But it's still right on shore and it's still not going to miss us.” Falling behind Hospitals are currently reporting a 6% to 8% vacancy rate in nursing positions, which Buerhaus classifies as a “mild” shortage. Even so, health care professionals are reporting that the inadequate number of nurses is having adverse effects on the quality of health care. An analysis of 3 national surveys (one of physicians, one of nurses, and one of hospitals' chief nursing officers and chief executive officers) found that all 3 groups agree that the shortage has seriously impaired communication between hospital staff members, patient-nurse relationships, hospital capacity, and patient-centered care (Buerhaus PI et al. Health Aff [Millwood]. 2007;26[3]:853-862). Schools squeezed Schools squeezed While nursing schools would like to increase enrollments to levels that would meet current needs, several factors limit their ability to do so. Schools squeezed Chief among these is a faculty shortage. An AACN survey of nursing programs with baccalaureate and graduate degree programs, released in July 2006, provides a snapshot of the problem. The 329 schools that responded said that to increase enrollment to meet student demand would require filling 637 faculty vacancies and creating 55 additional faculty positions. Schools squeezed The number of vacancies is expected to grow as the existing nursing faculty ages and eventually retires. An AACN report on nursing faculty salaries in 2006-2007 found that the average ages of PhD nursing professors, associate professors, and assistant professors were 58.6 years, 55.8 years, and 51.6 years, respectively. The average ages of instructors holding master's degrees were comparable, with professors, associate professors, and assistant professors averaging 56.5 years, 54.6 years, and 50.1 years, respectively. Schools squeezed Recruiting new nursing faculty is proving a daunting challenge as competition for the limited supply of nurses has forced hospitals to dramatically increase salaries for nurses. Schools squeezed “We have had to compensate nurses working in hospitals better, but the faculty salaries haven't kept pace,” said Karen B. Haller, PhD, RN, vice president of nursing at Johns Hopkins Hospital, in Baltimore. Schools squeezed For example, in the San Francisco Bay area, a nurse with a bachelor's degree can start out with a salary of $104 000, while a nurse practitioner or nurse anesthetist with a master's degree can earn $110 000 to $130 000, said Kathleen Dracup, RN, FNP, DNSc, dean of the School of Nursing, University of California, San Francisco (UCSF). By contrast, the salary for a nursing professor with a PhD at UCSF starts out at about $60 000, she said. She explained that many graduates of nursing PhD programs are in their 30s and 40s with mortgages, children, and student loans, so salary is an important factor in deciding whether to pursue a career in academia. Schools squeezed Less tangible elements also may draw nurses away from considering academic careers. Dracup explained nurses with advanced degrees now have many more options beyond working in a clinical setting or in academia, such as becoming a nurse practitioner or nurse anesthetist. The shortage of nurses in the United States is projected to grow to more than 1 million by 2020. This represents a roughly 36% shortfall of the nurses needed to cope with, among other things, an increasingly aged population and increasingly high-tech health care. Schools squeezed “There are many opportunities for nurses to advance their education, to earn more money, to be more intellectually challenged that don't include academia,” she said. Schools squeezed Other barriers to ending the shortage of faculty and students are that nursing schools lack the physical facilities and simulators needed to support an increased enrollment, as well as the limited number of available clinical placements for nursing students. Dracup explained that advances in medical care have meant that patients in the hospital are receiving more acute care and nursing students must be carefully supervised, so hospitals limit the number of students they will take on. Haller noted that in some departments, such as pediatrics and obstetrics, there are fewer clinical placements for nursing students because there are fewer beds than there were when she was training. For example, hospitals no longer need large pediatric wards to care for children with croup and most obstetric patients and their infants now leave the hospital in 24 to 48 hours instead of staying for a week. Seeking solutions Seeking solutions In an effort to overcome these challenges, nursing educational programs are seeking collaborations with hospitals, corporations and foundations, and other health professional training programs. Hospitals and some states also are stepping in with funding and creative solutions to boost the supply of nurses and to help nursing schools. Seeking solutions Many nursing schools are seeking partnerships with private entities. For example, UCSF received a $9.7 million grant from the Gordon and Betty Moore Foundation to establish the Betty Irene Moore Accelerated Doctoral Program in Nursing. The program will allow students to earn their nursing doctorate in 3 years. So far, 10 such students have been funded with a $60 000 fellowship for each of their 3 years of training in exchange for a promise to teach. Seeking solutions Schools also are partnering with other health care professional training programs to share facilities such as simulator laboratories, Dracup said. Such programs emphasizing interdisciplinary training of nurses, physicians, and other health care professionals also may have the added benefit of fostering better communication between disciplines, she said. Seeking solutions “We know from patient safety data that simulation training leads to better outcomes,” she said. Seeking solutions Hospitals also are stepping in to lend a hand to the schools. Many are providing nursing schools with funding to add faculty to their programs, said Jeanette Lancaster, PhD, RN, president of AACN and dean of the University of Virginia School of Nursing. Some, like Johns Hopkins Hospital, give staff with the appropriate level of training the option to teach part-time, Haller said. “It's in our vested interest to free up our staff who are qualified to teach to help,” she said. Lancaster added that many practicing nurses are excited to help educate the next generations so such programs also benefit hospitals by keeping highly skilled nurses engaged. Seeking solutions Other hospitals are making classroom space available to nursing educational programs. Many also are supporting staff who want to retrain to become nurses. Seeking solutions Many states are providing nursing schools with funding to help boost faculty salaries or are offering loan forgiveness to nurses with advanced degrees who teach, Lancaster said. Seeking solutions Nursing organizations such as the AACN are calling for more federal support for nursing education. Currently, Medicare provides some funding for physician residencies, but no such comparable support is available for nursing schools. Seeking solutions Dracup suggests that the government resurrect a nurse traineeship program it operated in the 1970s. The program was designed to encourage clinical nurses to go back to school for their PhDs and teach. Unlike existing federal grant and loan programs, the program paid the nurses' way through school and did not require them to take out loans. Dracup herself and many of her contemporaries on nursing school faculties went through the program. Seeking solutions Dracup also believes that individual philanthropy could also help ease the burden on nursing schools. She explained that traditionally, individuals and physicians have donated generously to medical schools, but nursing schools have been left out. Seeking solutions “I’m hoping the American public, which is so generous, as it thinks about the nursing shortage and the kinds of work that nurse-scientists and nurse-clinicians do, will begin to think about having endowed chairs in nursing to support the science, and providing philanthropy for clinics managed by nursing schools,” she said.

Hampton, Tracy

doi: 10.1001/jama.298.14.1625pmid: 17925508

The health of the environment is currently on many people’s minds, as scientists study it, politicians argue about it, and others try to do their part by adopting environmentally friendly practices at home and in the workplace. Some of the latter include individuals charged with making businesses and organizations—like hospitals—run. Health care administrators say that clinics are an obvious place to implement “green” initiatives, from reducing the quantity and toxicity of health care waste to integrating sustainable design and building techniques. “We should be doing everything we can to make sure that the environment in health care facilities and the impact they have on surrounding communities are healthy,” said Anna Gilmore Hall, RN, executive director of Health Care Without Harm, an international coalition of more than 500 hospitals, medical professionals, labor unions, environmental organizations, community groups, and other organizations that are working to reduce pollution in the health care industry. Raising awareness Raising awareness A variety of organizations and coalitions are coming on the scene to help the growing number of hospitals and clinics that are adopting ways to become more efficient and less detrimental to the environment. Significant outreach efforts are being made by Hospitals for a Healthy Environment, which was jointly founded by the American Hospital Association, the US Environmental Protection Agency, Health Care Without Harm, and the American Nurses Association. The not-for-profit organization is educating health care workers about pollution prevention opportunities and providing useful tools and resources to facilitate the industry's movement toward environmental sustainability. Its resources include a peer-to-peer listserv that allows health care professionals to ask technical questions and receive advice and feedback; monthly teleconferences; and model pollution prevention plans for medical waste minimization, mercury elimination, and reducing other pollutants. A variety of clinics and hospitals are adopting ways to become more efficient and less detrimental to the environment. Raising awareness According to Hospitals for a Healthy Environment, most hospitals are not aware of the amounts of waste they generate or how much they spend annually on disposal, not to mention its environmental impact. But there are practical solutions to many of these issues. For example, when staff throw away noncontaminated waste into regulated medical waste bins, facilities are needlessly paying for specialized disinfection and disposal. Institutions that have reduced the volume of regulated waste save 40% to 70% on waste disposal, according to Hospitals for a Healthy Environment. Raising awareness “It's well known that in hospitals, there's no time, no space, no money, so we're here to help implement programs in really cost-effective and efficient ways,” said Laura Brannen, ED, Hospitals for a Healthy Environment's executive director. She added that hospitals that adopt these programs have found that their efforts can save a significant amount of money. “If you're not watching the back door and the trash dock, you're tossing resources,” she said. Those resources include medical supplies—many unopened and unused materials are thrown out simply because they were in a room with a patient. Raising awareness A growing number of hospitals may call on Brannen and her staff for advice as federal and state governments continue to reshape regulations related to health care facilities. Since 1995, 95% of the medical waste incinerators in the United States have been closed because they could not meet environmental standards. In addition, hospitals are experiencing compliance problems across all environmental statutes, with the majority of violations involving hazardous waste management. Green efforts Green efforts At its Environmental Excellence Summit held earlier this spring, Hospitals for a Healthy Environment honored 128 hospitals, health care facilities, and other organizations. It also inaugurated an Environmental Leadership Circle to recognize groups that have won awards repeatedly over the years, commit to an exceptional standard of green efforts, and share their knowledge with other facilities. Green efforts One such leader is the University of Michigan Hospitals and Health Centers, in Ann Arbor. In 2006, its facilities recycled more than 1350 kg of compression sleeves (an effort that saved more than $236 000) and more than 7600 L of formalin, xylene, and alcohol. Other creative waste-reduction efforts included the collection of 40 500 kg of worn and surplus linen for sale to the local automotive industry and a paperless employment system that has saved substantial quantities of paper. Green efforts Environmental concerns also are evident in the university's plans for the building of the replacement facility for the C.S. Mott Children's Hospital and Women's Hospital. For the project, scheduled to open in 2011, the university is following the Green Guide for Health Care, Health Care Without Harm's and the Center for Maximum Potential Building Systems' design tool kit for integrating environmental and health principles and practices into the planning, design, construction, operations, and maintenance of health care facilities (http://www.gghc.org/). Green efforts Kaiser Permanente, headquartered in Oakland, Calif, is also following the Green Guide for Health Care and has won numerous awards for its environmental efforts. In the past 5 years, the organization has chosen ecologically sustainable materials for 2.7 million square meters in new construction, prevented 70 billion pounds of air pollutants each year, eliminated the purchase and disposal of 40 tons of hazardous chemicals, saved more than $10 million per year through energy conservation strategies, and installed more than 50 acres of reflective roofing. It also makes a concerted effort to buy food and products locally. Green efforts “Some hospitals import marble from Italy and deforest part of Africa for wood, but we try to use local renewable resources in our buildings and we serve organic food grown nearby,” said Christine Malcolm, Kaiser Permanente's senior vice president for hospital strategy and national facilities. Malcolm added that Kaiser Permanente's buildings abide by strict green standards and cost 5% less to build than other hospitals in California. Green efforts Dartmouth-Hitchcock Medical Center, in Lebanon, NH, is another environmental leader, with a recycling rate consistently exceeding 30%. Xylene and alcohol recycling saves at least $48 000 per year in avoided hazardous waste disposal fees and avoided chemical purchases. Dartmouth-Hitchcock also has launched a pilot project to switch to intravenous bags that do not contain polyvinyl chloride (PVC) and has begun using biodiesel fuel in its diesel fleet and grounds vehicles. Since 1990, the medical center has followed a formal environmental program that includes standard recycling programs for common items like paper and plastic, as well as procedures for recycling batteries, fluorescent bulbs, and chemicals. The facility's builders incorporated an environmentally friendly building design, including energy-efficient glass, compact fluorescent lighting, and highly efficient and programmable heating and cooling systems. Green efforts For hospitals that wish to get on the environmental bandwagon, small initial steps can have a big impact, said Gail Dahlstrom, Dartmouth-Hitchcock's vice president for facilities management. “Behavioral issues, like making an effort to recycle, are simple things,” she said. “Also, look into your housekeeping department and really assess the materials and agents that you use,” she advised. Community impact Community impact Hospitals and physicians also have the power to promote change outside the health care realm. Brannen points to hospitals' lead in eliminating mercury as the impetus for getting rid of mercury in all thermometers sold to the public. “This is a perfect example of how the community became educated because we were making changes in health care,” she said. Community impact The market also can be affected by decisions made in the clinic. “The hospital sector can really make dramatic social change by leveraging its purchasing power,” said Hall, noting that the health care industry represents 15% of the gross national product of the United States. “If we come together and exercise our purchasing power, we can change not only health care but the US economy,” said Malcolm. Hall pointed to recent demands by Kaiser Permanente for new carpeting that did not have PVC backing. “As a result of their insistence on that kind of product, you and I can now go to the store and buy carpet for our homes that doesn't have PVC backing,” she said. Community impact Physicians also have an important role. “It will be very difficult for environmentalists to move a market without broad physician involvement,” said Brannen. She said clinicians can take a number of steps, from choosing reusable gowns to limiting surplus supplies in operating rooms. Community impact To accelerate efforts, Kaiser Permanente and other health care organizations, architectural and engineering firms, academia, industry, nonprofit groups, and governmental organizations are embarking on a program called Healthcare's Global Health and Safety Initiative. The goals of this effort include establishing open source sharing of best practices that improve patient, workplace, and environmental health and safety; guidelines for group purchasing to transform the market and lead to safer and more environmentally sensitive products at competitive prices; and research to document benefits and cost-effectiveness of various interventions. Community impact While environmental experts would like to see even greater involvement from the health care community, they are encouraged by the various incremental steps that are being made on many fronts. “We really think the health care industry is at a tipping point,” said Hall. Helping Health Care Go Green Helping Health Care Go Green The Green Guide for Health Care. This tool kit, developed by Health Care Without Harm and the Center for Maximum Potential Building Systems, gives information on integrating environmental practices into the design, construction, operations, and maintenance of health care facilities (http://www.gghc.org/). Health Care Without Harm. The mission of this global coalition of organizations and groups is reducing pollution in the health care industry (http://www.noharm.org). Hospitals for a Healthy Environment. This organization educates health care professionals about pollution prevention and provides resources to help the industry move toward environmentally sound practices (http://www.h2e-online.org/).

Mitka, Mike

doi: 10.1001/jama.298.14.1629pmid: 17925509

Breastfeeding appears to provide many health benefits to newborn infants, but reducing their risk for developing certain allergies or asthma is not one of them, according to findings by researchers from Canada and Belarus. In a randomized controlled trial with an initial enrollment of 17 046 mother-infant pairs, the researchers found that 6.5 years after birth, children had the same risk for developing allergies or asthma whether or not they experienced prolonged or exclusive breastfeeding. The findings were published online by the British Medical Journal (Kramer MS et al. BMJ. doi:10.1136 /bmj.39304.464016.AE [published online ahead of print September 11, 2007]). However, the fact that breastfeeding does not appear to reduce allergy and asthma risk should not deter mothers from nursing their infants, said Michael S. Kramer, MD, lead author and professor of pediatrics, epidemiology, and biostatistics at McGill University, in Montreal. “There are plenty of other good reasons to breastfeed,” he said. The Promotion of Breastfeeding Intervention Trial (PROBIT) involved mother-infant pairs receiving care at 31 Belarusian maternity hospitals and their affiliated polyclinics. Belarus was chosen because, like many Eastern European countries in the 1990s (when the trial began), it did not aggressively promote breastfeeding as the preferred method of infant feeding. This allowed researchers to randomly assign the mother-infant pairs to either an experimental cohort, in which medical personnel were trained to teach better breastfeeding techniques and to encourage mothers to breastfeed for as long and as exclusively as possible, or a control cohort of traditional practices. As a result of the intervention, 72.7% of mothers in the experimental group were breastfeeding at 3 months, 49.8% at 6 months, 36.1% at 9 months, and 19.7% at 12 months. Of mothers in the traditional group, 60% were breastfeeding at 3 months, 36.1% at 6 months, 24.4% at 9 months, and 11.4% at 12 months. The researchers also found that 43.3% of mothers in the experimental group were exclusively breastfeeding at 3 months while only 6.4% in the control group did so. Both groups demonstrated substantial declines in breastfeeding at 6 months, with just 7.9% of mothers in the experimental group and 0.6% in the control group still exclusively breastfeeding. At 6.5 years follow-up, the researchers administered a questionnaire to parents of 13 889 children to elicit information about hay fever symptoms, eczema, and asthma. They also gave the children skin prick tests to determine sensitivity to dust mite, cat, birch pollen, mixed northern grasses, and Alternaria (fungi) allergens. No statistical differences between the experimental and control groups were found. Kramer said his team also hopes to publish 6.5-year outcomes data looking at whether breastfeeding affects obesity, blood pressure, intelligence, behavioral issues, and dental health. They also are planning an 11-year follow-up to assess possible diabetes and cardiovascular risks.

Mitka, Mike

doi: 10.1001/jama.298.14.1630pmid: N/A

A novel approach to creating 3-dimensional images of living cells and tissues will help scientists better understand how cells work and interact with each other. The technique, invented by researchers affiliated with the Massachusetts Institute of Technology (MIT), in Cambridge, and Harvard Medical School, in Boston, also might help the process of drug development by allowing researchers to see how various compounds affect specific cell types and components (Choi W et al. Nat Methods. 2007;4[9]:717-719). The group's research was funded by the National Institutes of Health, in Bethesda, Md, and Hamamatsu Corp, in Bridgewater, NJ. Going through a phase Going through a phase Traditional high-resolution light microscopy has important limitations for scientists studying cellular activity because cells do not absorb sufficient light. And adding contrast agents or fixing cells in place creates an unnatural environment that may inadvertently affect normal cell or tissue function. A new imaging technique can highlight changes in various organelles (such as the nucleoli [green] in this HeLA cell) in living cells (Nature Methods. 2007;4[9]:717-719). (Photo credit: Nature Publishing Group) Going through a phase But the new technique, called tomographic phase microscopy, allows researchers to create images of a living cell and its components by sidestepping these limitations. First, a 2-dimensional image is generated by passing helium-neon laser light through a cell and analyzing the changes in the speed of the light as it traverses the components of the cell, caused by a property known as its refractive index, which is characteristic of all matter. (The light is quite weak and has no effect on either the cell constituents or their environment.) Then, using an approach similar to computed tomography, this step is rapidly repeated from many different angles and sophisticated computer software synthesizes the collection of 2-dimensional images into a 3-dimensional image of the cell. Because each type of cellular component has a unique refractive index, intracellular size, shape, and composition can all be determined. Going through a phase “Biological cells have been studied for hundreds of years, but cells don't absorb light and when light passes through them; they're difficult to image, or see,” said Michael S. Feld, PhD, the lead researcher and professor of physics at MIT. “What does happen is that as the light travels through the cell, its interaction gives rise to a phase shift in the light wave—light speed changes as it passes through the parts of the cell.” Going through a phase Tomographic phase microscopy exploits the fact that every material in a cell has a distinct refractive index. Using a technique called interferometry that involves comparing 2 or more light waves—in this case, a light wave passing through a cell with a reference wave that does not go through the cell—the researchers captured information about the refractive indices of various parts of the cell to create a 2-dimensional image. They then combined 100 of these 2-dimensional images taken from various angles to assemble a 3-dimensional map of the refractive indices of the cell's organelles. The entire process took about 10 seconds and achieved an image resolution of 500 nm. The researchers have since reduced the imaging time to 0.1 second and they say they believe they will be able to achieve 150 nm in resolution. Practical applications Practical applications To explore tomographic phase microscopy's ability to detect physiological changes in living cells, the researchers beamed their laser into a culture of cervical cancer cells. Physicians sometimes apply acetic acid to areas of the cervix because the chemical—for unknown reasons—causes precancerous lesions to turn white. When the researchers added acetic acid to the culture, they observed that it changed the refractive index of a cell's nucleolus, suggesting changes favorable for cancer growth. Practical applications They then turned to multicellular imaging. Using the technique to examine Caenorhabditis elegans, a nematode that is an important model organism, they were able to view the individual cells of the entire 1-mm worm—about 1000 cells. Practical applications Feld expects a sea change in research once tomographic phase microscopy is perfected and scientists can study biological actions at the cellular level in real time and essentially make movies of cells in action. Practical applications Pathology, a system that processes biopsied tissues to extract cellular information used in diagnosis “is built on controlled artifacts, so when a pathologist looks at a slide of tissue, he or she is not looking at what the tissue is really like,” Feld said. But with the new technique, he added, “We can look at it in its unaltered state.”

Mitka, Mike

doi: 10.1001/jama.298.14.1631-bpmid: N/A

President George W. Bush announced on September 4 the withdrawal of the nomination of Charles W. Grim, DDS, MHSA, for a second 4-year term as director of the Indian Health Services. Charles W. Grim, DDS, MHSA, withdrew his nomination to serve a second 4-year term as director of the Indian Health Services. (Photo credit: Indian Health Services) Grim's confirmation was expected, but in published reports, he said he decided against another term to spend more time with his family. The withdrawal comes after eyebrows were raised during Grim's July 26 confirmation hearing before the Senate's Indian Affairs Committee. During testimony, Grim revealed that the White House's Office of Management and Budget had reviewed his planned remarks and excised comments referring to laws that some believe require the federal government to provide health care for American Indians. During the hearing, Committee Chairman Byron Dorgan (D, ND) tied the altered testimony to the administration's reluctance to endorse the Indian Health Care Improvement Act (S 1200 [http://thomas.loc.gov]), which has not been reauthorized for more than a decade. While some advocates for American Indian health care argue the act and the Snyder Act of 1921, along with various treaties, require the federal government to provide health care for all American Indians, the White House has argued such services must be tied to membership in recognized tribes and residence on reservations. Grim, a member of the Cherokee Nation, stated that he did not know the reason his testimony was altered.

Mitka, Mike

doi: 10.1001/jama.298.14.1631-dpmid: N/A

Kerry Weems, deputy chief of staff for Department of Health and Human Services Secretary Mike Leavitt, was named acting administrator of the Centers for Medicare & Medicaid Services (CMS) on September 5 by President George W. Bush. He replaces Leslie Norwalk, who left the CMS on July 20. Weems was nominated in May to become the permanent CMS administrator, and a confirmation hearing before the Senate Committee on Finance was held in July. But the Senate has yet to schedule a confirmation vote. Democratic senators used the hearing to express their frustrations at the White House and its handling of Medicare and Medicaid matters. “I am counting on Mr Weems to be fair and even-handed,” said committee chairman Max Baucus (D, Mont) during the hearing. “I do not believe that CMS has been putting beneficiaries' needs first recently. And that has to change.”