Basics of qualitative research: Grounded theory procedures and techniques

XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Disseminated intravascular coagulation is characterized by the widespread activation of coagulation, which results in the intravascular formation of fibrin and ultimately thrombotic occlusion of small and midsize vessels.1–3 Intravascular coagulation can also compromise the blood supply to organs and, in conjunction with hemodynamic and metabolic derangements, may contribute to the failure of multiple organs. At the same time, the use and subsequent depletion of platelets and coagulation proteins resulting from the ongoing coagulation may induce severe bleeding (Figure 1). Bleeding may be the presenting symptom in a patient with disseminated intravascular coagulation, a factor that can complicate decisions about . . .

Disseminated Intravascular Coagulation

The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm

Background: Inherited mutations in the BRCA1 gene may be responsible for almost half of inherited breast carcinomas. However, somatic (acquired) mutations in BRCA1 have not been reported, despite frequent loss of heterozygosity (LOH or loss of one copy of the gene) at the BRCA1 locus and loss of BRCA1 protein in tumors. To address whether BRCA1 may be inactivated by pathways other than mutations in sporadic tumors, we analyzed the role of hypermethylation of the gene's promoter region. Methods: Methylation patterns in the BRCA1 promoter were assessed in breast cancer cell lines, xenografts, and 215 primary breast and ovarian carcinomas by methylation-specific polymerase chain reaction (PCR). BRCA1 RNA expression was determined in cell lines and seven xenografts by reverse transcription-PCR. P values are two-sided. Results: The BRCA1 promoter was found to be unmethylated in all normal tissues and cancer cell lines tested. However, BRCA1 promoter hypermethylation was present in two breast cancer xenografts, both of which had loss of the BRCA1 transcript. BRCA1 promoter hypermethylation was present in 11 (13%) of 84 unselected primary breast carcinomas. BRCA1 methylation was strikingly associated with the medullary (67% methylated; P = .0002 versus ductal) and mucinous (55% methylated; P = .0033 versus ductal) subtypes, which are overrepresented in BRCA1 families. In a second series of 66 ductal breast tumors informative for LOH, nine (20%) of 45 tumors with LOH had BRCA1 hypermethylation, while one (5%) of 21 without LOH was methylated (P = .15). In ovarian neoplasms, BRCA1 methylation was found only in tumors with LOH, four (31%) of 13 versus none of 18 without LOH (P = .02). The BRCA1 promoter was unmethylated in other tumor types. Conclusion: Silencing of the BRCA1 gene by promoter hypermethylation occurs in primary breast and ovarian carcinomas, especially in the presence of LOH and in specific histopathologic subgroups. These findings support a role for this tumor suppressor gene in sporadic breast and ovarian tumorigenesis.

Promoter Hypermethylation and BRCA1 Inactivation in Sporadic Breast and Ovarian Tumors

Blood transfusion and blood conservation (techniques or strategies to avoid the need for blood) are complementary activities that constitute the clinical arena of transfusion medicine. Recent improvements in the safety of the blood supply and the increasing costs associated with transfusion therapies have led to a reevaluation of the clinical practices of blood transfusion and blood conservation. Among the issues that have been reevaluated are the threshold for transfusion at which the benefits outweigh the risks and the identification of patients most likely to benefit from blood conservation. This review summarizes recent developments in transfusion medicine that have affected the . . .

Transfusion medicine. First of two parts--blood transfusion.

Although the link between the BRCA1 tumour–suppressor gene and hereditary breast and ovarian cancer is established1,2,3,4,5, the role, if any, of BRCA1 in non–familial cancers is unclear BRCA1 mutations are rare in sporadic cancers6,7,8, but loss of BRCA1 resulting from reduced expression or incorrect subcellular localization9,10 is postulated to be important in non–familial breast and ovarian cancers Epigenetic loss, however, has not received general acceptance due to controversy regarding the subcellular localization of BRCA1 proteins, reports of which have ranged from exclusively nuclear11,12,13,14,15, to conditionally nuclear10, to the ER/golgi16, to cytoplasmic invaginations into the nucleus17 In an attempt to resolve this issue, we have comprehensively characterized 19 anti–BRCA1 antibodies These reagents detect a 220–kD protein localized in discrete nuclear foci in all epithelial cell lines, including those derived from breast malignancies Immunohistochemical staining of human breast specimens also revealed BRCA1 nuclear foci in benign breast, invasive lobular cancers and low–grade ductal carcinomas Conversely, BRCA1 expression was reduced or undetectable in the majority of high–grade, ductal carcinomas, suggesting that absence of BRCA1 may contribute to the pathogenesis of a significant percentage of sporadic breast cancers

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas

Preoperative Autologous Donation Preoperative autologous donation was rarely used before the recognition that HIV could be transmitted by blood transfusion. Fifteen years ago, fewer than 5 percent of eligible patients who were scheduled for elective surgery chose autologous blood donation.121 When public awareness of the possibility of transfusion-transmitted HIV became widespread, however, there was concern that too few patients were choosing autologous blood donation as an option. Several states, including California, passed legislation requiring that whenever it was “reasonably” likely that transfusion would be needed, a patient should be informed of all of the options regarding and alternatives to allogeneic . . .

Transfusion medicine. Second of two parts--blood conservation.

The American Recovery and Reinvestment Act identified secure patient-physician e-mail messaging as an objective of the meaningful use of electronic health records. In our study of 35,423 people with diabetes, hypertension, or both, the use of secure patient-physician e-mail within a two-month period was associated with a statistically significant improvement in effectiveness of care as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, the use of e-mail was associated with an improvement of 2.0–6.5 percentage points in performance on other HEDIS measures such as glycemic (HbA1c), cholesterol, and blood pressure screening and control.

Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients

AIM: To examine the demographic data on a large multi-ethnic population of patients with microscopic colitis (MC) in Southern California and to determine the association of MC with inflammatory bowel disease (IBD) and colorectal cancer.

METHODS: All patients diagnosed with MC by colonic biopsy from 1996-2005 were identified utilizing a pathology database. All biopsies were reviewed by experienced pathologists utilizing standard histologic criteria. Patients’ medical records were reviewed and data regarding patient age, co-morbidities, sex, ethnicity, and medications were analyzed. An age- and sex-matched standard control group was also generated. Chi-square test was used to evaluate the associations of co-morbidities between lymphocytic colitis (LC), collagenous colitis (CC) and the control group.

RESULTS: A total of 547 cases of MC were identified, 376 patients with LC and 171 patients with CC. The female/male ratio was 3:1 in CC and 2.7:1 in LC patients. Celiac disease (P < 0.001), irritable bowel syndrome (IBS) (P < 0.001), and thyroid diseases (P < 0.001) were found to have a higher occurrence in MC compared to the control group. No statistical differences in the occurrence of colorectal cancer, diabetes and IBD were found between the MC group and the control group.

CONCLUSION: This is the largest group of patients with MC known to the authors that has been studied to date. Conditions such as celiac disease, IBS, and thyroid diseases were found to be related to MC. Furthermore, neither an increased risk of colorectal cancer nor IBD was associated with MC in this study.

Michael H. Kanter

Papers

Transfusion medicine. First of two parts--blood transfusion.

Localization of human BRCA1 and its loss in high-grade, non-inherited breast carcinomas

Transfusion medicine. Second of two parts--blood conservation.

Improved Quality At Kaiser Permanente Through E-Mail Between Physicians And Patients

Microscopic colitis: a large retrospective analysis from a health maintenance organization experience.