High Quality Care and Ethical Pay-for-Performance: A Society of General Internal Medicine Policy Analysis

BACKGROUND: Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain. OBJECTIVE: The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation. RESULTS: We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients. CONCLUSION: We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality

31st Annual Meeting and Associated Programs of the Society for Immunotherapy of Cancer (SITC 2016) : part two

Background The immunological escape of tumors represents one of the main ob- stacles to the treatment of malignancies. The blockade of PD-1 or CTLA-4 receptors represented a milestone in the history of immunotherapy. However, immune checkpoint inhibitors seem to be effective in specific cohorts of patients. It has been proposed that their efficacy relies on the presence of an immunological response. Thus, we hypothesized that disruption of the PD-L1/PD-1 axis would synergize with our oncolytic vaccine platform PeptiCRAd. Methods We used murine B16OVA in vivo tumor models and flow cytometry analysis to investigate the immunological background. Results First, we found that high-burden B16OVA tumors were refractory to combination immunotherapy. However, with a more aggressive schedule, tumors with a lower burden were more susceptible to the combination of PeptiCRAd and PD-L1 blockade. The therapy signifi- cantly increased the median survival of mice (Fig. 7). Interestingly, the reduced growth of contralaterally injected B16F10 cells sug- gested the presence of a long lasting immunological memory also against non-targeted antigens. Concerning the functional state of tumor infiltrating lymphocytes (TILs), we found that all the immune therapies would enhance the percentage of activated (PD-1pos TIM- 3neg) T lymphocytes and reduce the amount of exhausted (PD-1pos TIM-3pos) cells compared to placebo. As expected, we found that PeptiCRAd monotherapy could increase the number of antigen spe- cific CD8+ T cells compared to other treatments. However, only the combination with PD-L1 blockade could significantly increase the ra- tio between activated and exhausted pentamer positive cells (p= 0.0058), suggesting that by disrupting the PD-1/PD-L1 axis we could decrease the amount of dysfunctional antigen specific T cells. We ob- served that the anatomical location deeply influenced the state of CD4+ and CD8+ T lymphocytes. In fact, TIM-3 expression was in- creased by 2 fold on TILs compared to splenic and lymphoid T cells. In the CD8+ compartment, the expression of PD-1 on the surface seemed to be restricted to the tumor micro-environment, while CD4 + T cells had a high expression of PD-1 also in lymphoid organs. Interestingly, we found that the levels of PD-1 were significantly higher on CD8+ T cells than on CD4+ T cells into the tumor micro- environment (p < 0.0001). Conclusions In conclusion, we demonstrated that the efficacy of immune check- point inhibitors might be strongly enhanced by their combination with cancer vaccines. PeptiCRAd was able to increase the number of antigen-specific T cells and PD-L1 blockade prevented their exhaus- tion, resulting in long-lasting immunological memory and increased median survival

Music Listening Behavior, Health, Hearing and Otoacoustic Emission Levels

This study examined the relationship between hearing levels, otoacoustic emission levels and listening habits related to the use of personal listening devices (PLDs) in adults with varying health-related fitness. Duration of PLD use was estimated and volume level was directly measured. Biomarkers of health-related fitness were co-factored into the analyses. 115 subjects ages 18–84 participated in this study. Subjects were divided into two sub-groups; PLD users and non-PLD users. Both groups completed audiological and health-related fitness tests. Due to the mismatch in the mean age of the PLD user versus the non-PLD user groups, age-adjusted statistics were performed to determine factors that contributed to hearing levels. Age was the most significant predictor of hearing levels across listening and health-related fitness variables. PLD user status did not impact hearing measures, yet PLD users who listened less than 8 hours per week with intensities of less than 80 dBA were found to have better hearing. Other variables found to be associated with hearing levels included: years listening to PLD, number of noise environments and use of ear protection. Finally, a healthy waist-to-hip ratio was a significant predictor of better hearing, while body mass index approached, but did not reach statistical significance

College students’ personal listening device usage and knowledge

<div><p></p><p><i>Objective:</i> To determine the usage and knowledge of safe limits on personal listening devices (PLD) among college students. <i>Design:</i> First, information on health history was collected. Second, microphone in real ear techniques determined eardrum to free-field correction factors. Third, hearing levels were evaluated and information gathered about knowledge of safe listening behaviors. <i>Study sample:</i> 180 college students participated in a one-hour session using their PLDs and earphones set to their personal preference. <i>Results:</i> Virtually all participants reported knowledge of hearing loss risk due to PLD use and accurately recognized their own PLD listening levels (<i>p</i> = .01) as either within or exceeding safe sound limits. Forty-four subjects listened at greater than 80-dBA free-field equivalent levels. Only 7% of these participants were aware of these hazardous levels and 15% of participants’ exposure surpassed free-field equivalent levels normalized to eight hours. <i>Conclusions:</i> Despite reported knowledge of hearing loss risk due to PLD use in virtually all college students, 1 in 4 were found to listen to their PLDs at free-field equivalent levels greater than 80-dBA, with 94% unaware of their potential risk. Further research is needed to provide accurate PLD listening information and evaluate the possibility of long term PLD intensities that surpass recommended safety levels on hearing loss in adults over time.</p></div