Person: Komaroff, Anthony
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Komaroff
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Komaroff, Anthony
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Publication The Dysuria-Pyuria Syndrome(Massachusetts Medical Society, 1980-08-21) Komaroff, Anthony; Friedland, GeraldPublication Efficiency and Cost of Primary Care by Nurses and Physician Assistants(Massachusetts Medical Society, 1978-02-09) Greenfield, Sheldon; Komaroff, Anthony; Pass, Theodore M.; Anderson, Hjalmar; Nessim, SharonWe conducted a prospective study in a prepaid primary-care practice (health-maintenance organization) of a system in which nurses and physician assistants used protocols, and compared the efficiency and costs of this "new-health-practitioner" protocol system to a physician-only nonprotocol system. In five months, we studied 472 patients with any of four common acute complaints — respiratory infections, urinary and vaginal infections, headache, and abdominal pain; a subset of 203 patients was randomly allocated between the two systems. In the new-health-practitioner system physician time per patient was reduced by 92 per cent, from 11.8 to 0.9 minutes, and average visit costs — including practitioner time and charges for laboratory tests and medications — were 20 per cent less (P = 0.01). We conclude that this protocol system saves physician time and reduces costs. (N Engl J Med 298:305–309, 1978)Publication Inflammation correlates with symptoms in chronic fatigue syndrome(Proceedings of the National Academy of Sciences, 2017) Komaroff, AnthonyIt is not unusual for patients who say they are sick to have normal results on standard laboratory testing. The physician often concludes that there is no “real” illness and that the patients’ symptoms likely stem from a psychological disorder. An alternative conclusion, often honored in the breach, is that the standard laboratory tests are measuring the wrong things. Chronic fatigue syndrome (CFS)―also called myalgic encephalomyelitis/chronic fatigue syndrome―is such an illness. Often, the condition begins suddenly, following an “infectious-like” illness. For years, patients do not return to full health. The illness waxes and wanes, and at its worst leads patients to be bedridden or unable to leave their homes. A report from the National Academies estimates that CFS affects up to 2.5 million people in the United States and generates direct and indirect expenses of $17–24 billion annually (1). The most widely used case definition (2) consists only of symptoms. This, along with typically normal results on standard laboratory tests, has raised the question of whether there are any “real” objective, biological abnormalities in CFS. In PNAS, Montoya et al. (3) report the latest evidence that there are such abnormalities. Indeed, research over the past 30 y has discovered pathology involving the central nervous system (CNS) and autonomic nervous system (ANS), energy metabolism (with associated oxidative and nitrosative stress), and the immune system, as described in a detailed review (4). This Commentary will briefly summarize the evidence, providing citations only to work published since this review. I will then place the report by Montoya et al. (3) in context, and speculate about the pathophysiology of the illness.Publication Gene Editing Using CRISPR(American Medical Association (AMA), 2017) Komaroff, AnthonyThe gene-editing technique known as CRISPR (clustered regularly interspaced short palindromic repeats) is only 5 years old, yet it has galvanized biomedical research and raised important ethical questions. What is it, how does it work, and how could it change medical practice? Biomedical scientists have been “editing” (or, at least, altering) genes for many years. Recombinant DNA technology allowed particular genes to be inserted into a plasmid (a circle of DNA) or into a virus: bacterial and yeast cells now could produce therapeutically useful human proteins, and viral vectors could perform gene therapy in humans. Gene targeting and RNA interference allowed the knockout of particular genes and the insertion of a healthy gene at the site of a defective gene. Zinc finger proteins and transcription activator-like effector nucleases (TALENs) precisely altered specific genes. Then came CRISPR. Compared with these previous technologies, CRISPR is easier, faster, less expensive, and more powerful.Publication The Microbiome and Risk for Atherosclerosis(American Medical Association (AMA), 2018) Komaroff, AnthonyPublication Regional Medical Programs in Search of a Mission(Massachusetts Medical Society, 1971-04-08) Komaroff, AnthonyCreated five years ago, the Regional Medical Programs now have established organizations that cover the entire country. Private medicine is involved to a degree unparalleled in any other federal health program. In many cases the Programs have served to bring together elements of the health-care delivery system that have previously been isolated from one another. In other cases they have promoted the extension of recent medical advances out from the medical centers, improving the care given by private practitioners and community hospitals. Yet confusion exists over the mission of the Regional Medical Programs, and the means by which to achieve that mission. Particularly at issue is their role in changing, rather than simply upgrading, the existing health-care delivery system. It remains to be seen whether they are faced with a golden opportunity or an insoluble dilemma.Publication Protocols for Physician Assistants — Management of Diabetes and Hypertension(Massachusetts Medical Society, 1974-02-07) Komaroff, Anthony; Black, W. L.; Flatley, Margaret; Knopp, Robert H.; Reiffen, Barney; Sherman, HerbertPhysician assistants used problem-oriented protocols in management of patients with diabetes and hypertension. The protocols directed the physician assistant in determining what data to collect, and whether the patients required a physician's care at that visit. Physicians verified the ability of the physician assistants to collect history and physical-examination data accurately, noting false-positive findings on 11 per cent of 381 visits, and false-negative findings on 1 per cent of visits. Subsequently, physicians selected certain patients as "suitable" to be managed by the physician assistants. "Suitable" patients were then randomly assigned to be seen by the physician assistants (experimental visits) or physicians (control visits) on return visits. On 37 percent of experimental visits over an 11-month period, the patients went home without seeing a physician. Physicians accepted the protocol disposition decision in 94 per cent of the cases. Patients accepted the system, as reflected by their attendance rate at the clinic.Publication Alternatives to Metronidazole(American Medical Association (AMA), 1976-05-10) Komaroff, Anthony; Cohen, Alan B.; McCue, Jack D.To the Editor.— The recent warning in The Medical Letter1 regarding the mutagenicity and possible carcinogenicity of metronidazole (Flagyl) raises the question of whether there is an alternative treatment of equal efficacy that is not equally suspect.The pharmacologic treatment options seem to include orally administered nitroimidazole drugs other than metronidazole, or topical agents available in vaginal-tablet or suppository form, such as furazolidone and nifuroxime (components of Tricofuron). None of the other nitroimidazoles are currently available in the United States, although tinidazole (Fasigyn) will apparently soon be released. Tinidazole2 and nimorazole are reported to have a better than 90% cure rate. However, the mutagenicity of nimorazole was demonstrated in the same study that implicated metronidazole,3 and subsequent research by the same group has apparently also demonstrated the mutagenic potential of tinidazole (C. E. Voogd, unpublished data).The efficacy of topically applied furazolidone, alone or in combination withPublication Roentgenograms in Primary Care Patients with Acute Low Back Pain: A Cost-Effectiveness Analysis(American Medical Association (AMA), 1982-06-01) Liang, Matthew; Komaroff, AnthonyFor patients visiting a primary care office practice for acute low back pain, we compared the benefits, risks, and costs of obtaining a roentgenogram of the lumbar spine routinely at the initial visit with performing a roentgenogram only if the patient's pain does not improve during and eight-week follow-up period. The cost-effectiveness analysis indicated that, to avert one day of physical suffering in a population of patients, the population would have to be subjected to the additional risk of 3,188 mrad of radiation and an additional cost of $2,072. While, in the individual case, circumstances might lead to a different conclusion, in general, the risks and costs of obtaining lumbar roentgenograms at the initial visit in patients with acute low back pain do not seem to justify the relatively small associated benefit.Publication Cost Effectiveness of Lead Screening(Massachusetts Medical Society, 1982-06-10) Berwick, Donald; Komaroff, AnthonyLead-screening programs may reduce childhood disabilities, but at what cost? Through a review of the literature, we performed a cost-effectiveness analysis in which the costs, savings, and health benefits of two lead-screening strategies — employing either a free erythrocyte protoporphyrin assay or blood lead measurement — were compared with each other and with a strategy of no screening in a population of three-year-old children. When the prevalence of lead poisoning among the children screened is 7 per cent or more, we estimate that free erythrocyte protoporphyrin screening averts morbidity and results In net savings: It is both better and cheaper than no screening. At prevalences below 7 per cent, the net positive costs from screening and early treatment must be weighed against the noneconomic benefits of improved quality of life and considered in relation to other investments that could be made to benefit society. At all prevalence rates, free erythrocyte protoporphyrin screening is more cost effective than blood lead screening.