Kaiser Permanente Franklin Medical Offices

The aim of this study was to compare the efficacy of a peer learning program to score-based peer review in a radiology department. Our score-based peer review program was transitioned to an open, inclusive, education- and improvement-oriented peer learning program. Program performance was evaluated by learning opportunity submissions, program participation, number of learning opportunity distributions to radiologists, number of practice improvement projects resulting from program, and radiologist survey results before and after interventions. Outcomes for the score-based peer review program compared with those of the peer learning program were as follows. The mean number of radiologists participating monthly increased from 5.0 to 35.2 (p < 0.01); submissions increased from 3.0 discrepancies per month to 36.0 learning opportunities per month (p < 0.01); the mean monthly learning opportunity distributions to radiologists increased from 18 to 352 (p < 0.01); improvement projects performed during the study periods increased from 5 to 61 (p < 0.01); and mean monthly continuing medical education credits earned by radiologists increased from 7.7 to 50.6 (p < 0.01). Radiologists felt peer learning accomplished goals better than did score-based peer review. In transitioning our score-based peer review program to a peer learning program, our radiologists identified, discussed, and converted more learning opportunities into practice improvement and perceived peer learning to be of higher value than score-based peer review.

To review the pharmacology, pharmacokinetics, clinical trial data, and safety profile of tocilizumab, a new biologic agent targeting the interleukin-6 cytokine receptor. A systematic search of MEDLINE (1998-June 2008) and International Pharmaceutical Abstracts (1970-June 2008) was performed to identify published clinical trials and review articles. Key search terms were tocilizumab, MRA, interleukin-6/receptors, interleukin-6/immunology, and rheumatoid arthritis. The search was limited to studies in humans that were published in the English language. References from articles located during this search were evaluated for other relevant citations. Abstracts from national and international rheumatology meetings (American College of Rheumatology and European League Against Rheumatism) and from unpublished Phase 3 clinical trials in progress (using www.clinicaltrials.gov) were also reviewed. All available human studies describing the pharmacology, pharmacokinetics, efficacy, safety, and adverse effects of tocilizumab were included. At doses greater than 4 mg/kg, tocilizumab use has resulted in significant improvement in clinical outcomes, including the American College of Rheumatology parameters indicating a patient's level of improvements and disease remission. Improvements were noted when tocilizumab was used as monotherapy or in combination with methotrexate or other disease-modifying antirheumatic drugs. The most effective dose of tocilizumab appears to be 8 mg/kg, which has shown significant improvements in radiographic measures of joint damage. The most common adverse effects have included abnormal results of liver function tests, hyperlipidemia, neutropenia, infections, nasopharyngitis, gastrointestinal complaints, musculoskeletal disorders, headache, rash, and pruritus. Tocilizumab represents a promising new treatment for rheumatoid arthritis. Additional research is warranted to confirm its radiographic benefits, clarify its safely profile, and identify its place in rheumatoid arthritis treatment relative to current biologic agents.

To review the data examining hormone replacement therapy (HRT) in the treatment of lipoprotein disorders in women. A MEDLINE search (1975-1995) of the English-language literature was performed to identify pertinent primary literature and review articles. Articles were also identified through bibliographies of selected articles. Controlled and uncontrolled studies evaluating the effects of lipoprotein concentrations or coronary risk and the effects of estrogen and HRT on coronary heart disease and lipoprotein concentrations in women were evaluated. Trials pertaining to adverse effects of therapy were also examined. Emphasis was placed on recent clinical trials. The National Cholesterol Education Program's (NCEP's) 1993 report recommends estrogen replacement therapy as a treatment option in postmenopausal women with hyperlipidemia. Recent trials suggesting that triglycerides and highly-density lipoproteins are more closely related to coronary risks in women necessitate an improved understanding of estrogen and progestin's effects of lipoprotein concentrations. A recent trial has clarified the lipoprotein effects of HRT in women with normal lipid concentrations and suggests that beneficial effects on low-density lipoproteins are maintained, although progestins attenuate beneficial changes in high-density lipoproteins and triglyceride elevations persist. The few trials evaluating estrogen use in women with hyperlipidemia suggest a beneficial effect as well. In the absence of contraindications, postmenopausal women with hyperlipidemia should be offered estrogen replacement therapy as conjugated equine estrogen of 0.625 mg/D. Pending further information. NCEP's recommendations should be followed regarding goals of therapy.