Communication about chronic critical illness

BACKGROUND

Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met.

METHODS

In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3-7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items.

RESULTS

Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively.

CONCLUSIONS

Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.

Reduced oxidant stress and extended lifespan in mice exposed to a low glycotoxin diet: association with increased AGER1 expression

Aging is accompanied by increased oxidative stress (OS) and accumulation of advanced glycation end products (AGEs). AGE formation in food is temperature-regulated, and ingestion of nutrients prepared with excess heat promotes AGE formation, OS, and cardiovascular disease in mice. We hypothesized that sustained exposure to the high levels of pro-oxidant AGEs in normal diets (Reg(AGE)) contributes to aging via an increased AGE load, which causes AGER1 dysregulation and depletion of anti-oxidant capacity, and that an isocaloric, but AGE-restricted (by 50%) diet (Low(AGE)), would decrease these abnormalities. C57BL6 male mice with a life-long exposure to a Low(AGE) diet had higher than baseline levels of tissue AGER1 and glutathione/oxidized glutathione and reduced plasma 8-isoprostanes and tissue RAGE and p66(shc) levels compared with mice pair-fed the regular (Reg(AGE)) diet. This was associated with a reduction in systemic AGE accumulation and amelioration of insulin resistance, albuminuria, and glomerulosclerosis. Moreover, lifespan was extended in Low(AGE) mice, compared with Reg(AGE) mice. Thus, OS-dependent metabolic and end organ dysfunction of aging may result from life-long exposure to high levels of glycoxidants that exceed AGER1 and anti-oxidant reserve capacity. A reduced AGE diet preserved these innate defenses, resulting in decreased tissue damage and a longer lifespan in mice.

PRO 2000 elicits a decline in genital tract immune mediators without compromising intrinsic antimicrobial activity

OBJECTIVE

Vaginal microbicides should protect against infection without disrupting the mucosal environment or its mediators of host defense. The objective of this study was to examine the effect of 14 daily applications of 0.5% PRO 2000 or placebo gel on mediators of mucosal immunity and intrinsic antimicrobial activity.

DESIGN AND METHODS

A randomized, prospective, double-blind, placebo-controlled study was conducted among 24 healthy, abstinent women. Levels of cytokines, chemokines, defensins, and other protective factors and intrinsic antimicrobial activity were determined in cervicovaginal lavage samples collected on study days 0, 7, 14, and 21.

RESULTS

No increase in pro-inflammatory cytokines was observed. Rather cytokines and protective factors including interleukin (IL)-1 receptor antagonist, immunoglobulins and human beta-defensin 2 were lower in the drug compared with the placebo group. All of the mediators returned towards baseline on day 21. Women who were cycling had lower levels of most proteins on study days 7 and/or 14 compared with women on oral contraceptives; however, the magnitude of decline was greater in women who received PRO 2000 compared with placebo gel. The reduction in protective factors was not associated with a loss in the intrinsic anti-viral (HIV or herpes simplex virus) activity or anti-bacterial activity (Escherichia coli or Staphylococcus aureus).

CONCLUSION

In contrast to experience with nonoxynol-9, PRO 2000 did not trigger an inflammatory response in cervicovaginal secretions. There was a modest reduction in mucosal immune mediators, but this loss was not associated with a reduction in intrinsic antimicrobial activity.

Comparison of statistical models for analyzing genotype, inferred haplotype, and molecular haplotype data

This report compares statistical models based on molecular and inferred haplotypes of the human paraoxonase-1 gene (PON1). In a study of 402 women comprising three race/ethnicities, 137 women had ambiguous inferred haplotypes. The inferred haplotypes (the one with highest posterior probability) for 20 of these women differed from molecular haplotypes, while based on the posterior distribution from the imputation method, 30 discrepancies were expected. We examined the proportion of the variance in PON1 enzymatic activity (phenotype) explained by genotype, and by inferred and molecular haplotype information. For Caucasians, there was an improvement in adjusted R(2) from 16% for the genotype count model, to 29% for imputed haplotypes, and a further improvement to 33% for molecular haplotypes. For Hispanics and African-Americans, there was no indication that haplotypes helped in explaining PON1 activity, and the imputed model gave essentially the same R(2) as the molecular model. For African-Americans, none of the models had adjusted R(2) that exceeded 4%, while for Hispanics they were all about 21-22%. We propose a new parsimonious model which uses all the genotype information and selected haplotype information. For PON1, this model achieves essentially the same adjusted R(2) as the all-haplotype model, with a potential cost savings and without giving the extreme predictions for uncommon haplotype combinations that the all-haplotype models provides.

Clinically significant placebo analgesic response in a pilot trial of botulinum B in patients with hand pain and carpal tunnel syndrome

OBJECTIVE

We conducted a pilot trial to assess the effect of botulinum toxin B on palmar pain and discomfort in carpal tunnel syndrome (CTS) patients. Design. Randomized, double-blind, placebo-controlled.

PATIENTS

Twenty ambulatory CTS patients. Intervention. Botulinum toxin B or placebo injections into three hypothenar muscles anatomically linked or attached to the carpal tunnel and its tentorium, that is, the Opponens Digiti Minimi and Flexor Digiti Minimi, located with electromyography (EMG), and the Palmaris Brevis Muscle, anatomically located without EMG.

SETTING

New York City hospital.

OUTCOME MEASURES

Outcomes were measured with numeric ratings, with higher scores indicating worse outcomes. Daily, subjects recorded their 0-10 numeric ratings of overall pain levels and pain-related sleep disturbances. During weekly telephone calls, they reported their 0-10 ratings for overall pain, pain-related sleep disturbance, and CTS-related tingling during the night and day as experienced over the preceding 24 hours. For each of four clinic visits, we averaged each subject's ratings of nine quality of life indicators from the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), each measured on a 0-6 numeric scale.

RESULTS

Over the 13-week trial, compared to baseline scores, the following outcomes predominantly showed decreases of statistical significance (P < or = 0.050) or borderline significance (0.050 < P < or = 0.10) for weeks 2 through 8: overall pain per daily diary entries and per weekly telephone reports, and pain-related sleep disturbance in the placebo group per phone report and in the botulinum toxin B group per diary report. CTS painful night tingling and day tingling, as well as the average scores of the WHYMPI quality of life indicators, showed improvements with statistical or borderline significance for almost each follow-up week. Between-group analyses, however, demonstrated that at each follow-up week, there was no statistically significant difference between the two study groups regarding changes from baseline in any study outcome.

CONCLUSION

Botulinum toxin B is not dramatically superior to placebo for the relief of CTS symptoms. Possible explanations of the improvements in each study group are explored.

Temporal surveillance using scan statistics

We describe two classes of statistics for testing an arbitrary model of disease incidence over time against an alternative model involving a spike (pulse) superimposed on this background. The statistics are each based on taking the maximum of some function comparing observed and expected numbers of events in a window of width w. One approach applies p-values for scan statistics calculated for a constant background rate to this more general problem. For a fixed window, w, the approach gives a simple formula to determine p-values for retrospective analysis, or to sound an alarm for either continuous or grouped prospective data. The latter application involves a new approximation for the distribution of the maximum number of cases in w consecutive intervals. The second approach based on generalized likelihood ratio tests (GLRTs), sounds an alarm for a higher than anticipated rate of events in a scanning window of fixed length, or for window sizes that lie in a region. GLRTs are constructed for continuous observations, for grouped data, or for a sequence of trials. As for GLRTs used in retrospective evaluations, simulation is required to implement the prospective procedure. For grouped surveillance data, we compare by simulation, operating characteristics of the P-scan with fixed windows (both correctly specified and not), the fixed-window GLRT, the variable-window GLRT, and a variant of the CUSUM. The simulations demonstrate a very high correlation between the P-scan and corresponding fixed-window GLRT.

PRO 2000 Gel Inhibits HIV and Herpes Simplex Virus Infection Following Vaginal Application: A Double‐Blind Placebo‐Controlled Trial

BACKGROUND

Microbicides used to prevent the transmission of human immunodeficiency virus (HIV) are advancing to clinical trials on the basis of activity observed in vitro and in animal models. However, no data demonstrate activity of microbicides after application in humans. This study was designed to determine the antiviral activity in cervicovaginal lavage (CVL) samples collected after intravaginal application of 0.5% PRO 2000 gel (Indevus).

METHODS

A randomized, double-blind study was conducted to assess the anti-HIV and anti-herpes simplex virus (HSV) activity of PRO 2000 in CVL samples obtained at screening (48 hours before) and 1 hour after application of study or placebo gel. HeLa cells or human macrophages were inoculated with CVL samples spiked with replication-defective HIV containing a luciferase indicator gene and pseudotyped with an R5 envelope. Human cervical epithelial cells were inoculated with CVL samples and challenged with HSV-2(G), and the virus titer was then determined.

RESULTS

CVL samples obtained after application of PRO 2000 gel significantly inhibited HIV and HSV infection by at least 1000-fold, compared with CVL samples obtained at screening (P < .001). There were no differences in cytokine levels between the drug and placebo groups.

CONCLUSIONS

PRO 2000 gel (0.5%) is sufficiently bioavailable and retains substantial antiviral activity after intravaginal application. This strategy provides a mechanism for testing the efficacy of a microbicide before embarking on large-scale clinical trials.

Cervicovaginal secretions contribute to innate resistance to herpes simplex virus infection

Defining and preserving the innate antiviral activity found in cervicovaginal secretions is critical. Cervicovaginal lavage (CVL) samples were obtained from 20 healthy women and evaluated for anti-herpes simplex virus (HSV) activity. CVL samples reduced HSV-2 yields by 23-fold (median), and the anti-HSV activity of CVL samples correlated with the concentration of human neutrophil peptides (HNP)-1-3. Both CVL samples and HNP-1-3 interacted with virus and prevented entry after binding. Substantially less protective activity was observed in CVL samples obtained from 20 human immunodeficiency virus--infected subjects, but the addition of CVL samples from healthy subjects enhanced the antiviral activity. The significance of the innate activity was further demonstrated by showing that CVL samples prevented murine genital herpes. Fourteen of 15 mice were protected from genital herpes if they were challenged with HSV-2 pretreated with CVL samples from healthy subjects. In contrast, all 15 mice challenged with untreated HSV-2 died. These findings are evidence that cervicovaginal secretions contribute to innate resistance to HSV-2 and identify defensins as contributors to this activity.

Autoimmune disease is a risk factor for the development of non-Hodgkin's lymphoma

OBJECTIVE

To investigate the relationship of prior autoimmune disease to the development of non-Hodgkin's lymphoma (NHL).

METHODS

Patients with NHL (n = 278) seen from 1993 to 2002 were compared with a group of patients with other hematological disorders (controls, n = 317) seen at the same time. All patients were questioned about prior autoimmune disease. Comparisons between NHL patients and controls were based on analysis of a 2 2 table of counts using Fisher's exact test. Analysis of the effect of autoimmune disease on NHL status, controlling for other risk factors, was performed using logistic regression.

RESULTS

Thirty-six (13%) NHL patients had a prior autoimmune disease compared to 5% of controls (p = 0.001). Sixty-nine percent of NHL patients with a prior autoimmune disease were female compared to 43% without a prior autoimmune disease, and this was similar in control patients, 69% and 48%, respectively. Twenty percent of all women with NHL had a history of autoimmune disease compared to 7% of women in the control group (p = 0.001). Nineteen of the NHL patients with autoimmune disease (56%) received immunosuppressive treatment compared to 5 (38%) in the controls.

CONCLUSION

Autoimmune disease may account in part for the increase in NHL, especially in women.

Efficacy and tolerability of anti-asthma herbal medicine intervention in adult patients with moderate-severe allergic asthma

BACKGROUND

Chinese herbal medicine has a long history of human use. A novel herbal formula, anti-asthma herbal medicine intervention (ASHMI), has been shown to be an effective therapy in a murine model of allergic asthma.

OBJECTIVE

This study was undertaken to compare the efficacy, safety, and immunomodulatory effects of ASHMI treatment in patients with moderate-severe, persistent asthma with prednisone therapy.

METHODS

In a double-blind trial, 91 subjects underwent randomization. Forty-five subjects received oral ASHMI capsules and prednisone placebo tablets (ASHMI group) and 46 subjects received oral prednisone tablets and ASHMI placebo capsules (prednisone group) for 4 weeks. Spirometry measurements; symptom scores; side effects; and serum cortisol, cytokine, and IgE levels were evaluated before and after treatment.

RESULTS

Posttreatment lung function was significantly improved in both groups as shown by increased FEV(1) and peak expiratory flow findings (P<.001). The improvement was slightly but significantly greater in the prednisone group (P<.05). Clinical symptom scores, use of beta(2)-bronchodilators, and serum IgE levels were reduced significantly, and to a similar degree in both groups (P<.001). T(H)2 cytokine levels were significantly reduced in both treated groups (P<.001) and were lower in the prednisone-treated group (P<.05). Serum IFN-gamma and cortisol levels were significantly decreased in the prednisone group (P<.001) but significantly increased in the ASHMI group (P<.001). No severe side effects were observed in either group.

CONCLUSION

Anti-asthma herbal medicine intervention appears to be a safe and effective alternative medicine for treating asthma. In contrast with prednisone, ASHMI had no adverse effect on adrenal function and had a beneficial effect on T(H)1 and T(H)2 balance.

Molecular haplotyping by linking emulsion PCR: analysis of paraoxonase 1 haplotypes and phenotypes

Linking emulsion PCR (LE-PCR) enables formation of minichromosomes preserving phase information of two polymorphic loci, hence the haplotype. Emulsion PCR confines two amplicons of two linked polymorphic sites on a single template molecule to one aqueous-phase droplet. Linking PCR uses biotinylated, overlapping linking primers to connect these amplicons in the droplet. After LE-PCR, unlinked amplicons are removed on streptavidin-coated magnetic beads and single-stranded runoff products are capped by primer extension. Quantitative ASPCR can then be used to ascertain the haplotypes of the two polymorphic loci on the minichromosomes. Using LE-PCR, we determined the human paraoxonase-1 [PON1] molecular haplotypes at three loci (−909g>c, L55M, Q192R) in women who were compound heterozygotes for −909g>c/L55M (n = 89), −909g>c/Q192R (n = 77) and L55M/Q192R (n = 68). We observed a strong association between PON1 substrate specificity (paraoxon/phenylacetate substrate activity ratios) and −909g>c/Q192R haplotype. We have demonstrated here a powerful molecular haplotyping technology that can be applied in population studies.

Haplotype-Phenotype Relationships of Paraoxonase-1

Paraoxonase 1 (PON1) is an enzyme with multiple activities, including detoxification of organophosphates. It is believed to be important in preventing neurotoxic damage and has also been implicated in atherosclerosis. The PON1 gene contains five common polymorphisms, three in the promoter (-909G > C, -162A > G, -108C > T) and two in the coding region (M55L, Q192R) with varying but incomplete linkage disequilibrium. Our previous study showed that functional polymorphisms in PON1 were strongly associated with enzymatic activity in both pregnant women [26-30 weeks of gestation] and neonates. However, there was substantial overlapping of enzyme activities between genotypes. In this study, we investigated whether haplotype (genotype + phase) information would strengthen the genotype-phenotype relationship for PON1. The study consisted of a multiethnic population of 402 mothers and 229 neonates. Haplotypes were imputed by two widely used programs, PHASE and tagSNPs, which yielded very similar results. There were seven haplotypes with a frequency of 5% or higher in at least one ethnic group of the study population. Haplotype composition varied substantially with respect to ethnicity. Haplotypes in Caucasians and African-Americans showed the largest difference, and Caribbean Hispanics seemed to be a mixture of Caucasian and African ancestry. Collectively, the genetic (genotype or haplotype) contribution to PON1 enzymatic activity (measured as phenylacetate hydrolysis) was greater in neonates compared with mothers. Specifically, 16.6% of PON1 variability was explained by genotypes in mothers compared with 30.9% in neonates. Haplotype information offered a slightly increased power in predicting PON1 activity; they explained 35.5% and 19.3% of PON1 variability in neonates and mothers, respectively.

ATM sequence variants are predictive of adverse radiotherapy response among patients treated for prostate cancer

PURPOSE

To examine whether the presence of sequence variants in the ATM (mutated in ataxia-telangiectasia) gene is predictive for the development of radiation-induced adverse responses resulting from (125)I prostate brachytherapy for early-stage prostate cancer.

MATERIALS AND METHODS

Thirty-seven patients with a minimum of 1-year follow-up who underwent (125)I prostate brachytherapy of early-stage prostate cancer were screened for DNA sequence variations in all 62 coding exons of the ATM gene using denaturing high-performance liquid chromatography. The clinical course and postimplant dosimetry for each genetically characterized patient were obtained from a database of 2,020 patients implanted at Mount Sinai Hospital after 1990.

RESULTS

Twenty-one ATM sequence alterations located within exons, or in short intronic regions flanking each exon, were found in 16 of the 37 patients screened. For this group, 10 of 16 (63%) exhibited at least one form of adverse response. In contrast, of the 21 patients who did not harbor an ATM sequence variation, only 3 of 21 (14%) manifested radiation-induced adverse responses (p = 0.005). Nine of the patients with sequence alterations specifically possessed missense mutations, which encode for amino acid substitutions and are therefore more likely to possess functional importance. For this group, 7 of 9 (78%) exhibited at least one form of adverse response. In contrast, of the 28 patients who did not have a missense alteration, only 6 of 28 (21%) manifested any form of adverse response to the radiotherapy (p = 0.004). Of the patients with missense variants, 5 of 9 (56%) exhibited late rectal bleeding vs. 1 of 28 (4%) without such alterations (p = 0.002). Of those patients who were at risk for developing erectile dysfunction, 5 of 8 (63%) patients with missense mutations developed prospectively evaluated erectile dysfunction as opposed to 2 of 20 (10%) without these sequence alterations (p = 0.009).

CONCLUSIONS

Possession of sequence variants in the ATM gene, particularly those that encode for an amino acid substitution, is predictive for the development of adverse radiotherapy responses among patients treated with (125)I prostate brachytherapy.

The Chinese herbal medicine formula FAHF-2 completely blocks anaphylactic reactions in a murine model of peanut allergy

BACKGROUND

Peanut allergy is potentially life threatening. There is no curative therapy for this disorder. We previously found that an herbal formula, food allergy herbal formula (FAHF)-1, blocked peanut-induced anaphylaxis in a murine model when challenged immediately posttherapy.

OBJECTIVE

To test whether FAHF-2, an improved herbal formula, from which 2 herbs, Zhi Fu Zi (Radix Lateralis Aconiti Carmichaeli Praeparata) and Xi Xin (Herba Asari), were eliminated, is equally effective to FAHF-1, and if so, whether protection persists after therapy is discontinued.

METHODS

Mice allergic to peanut treated with FAHF-2 for 7 weeks were challenged 1, 3, or 5 weeks posttherapy. Anaphylactic scores, core body temperatures, vascular leakage, and plasma histamine levels after peanut challenge were determined. Serum peanut-specific antibody levels and splenocyte cytokine profiles were also measured.

RESULTS

After challenges, all sham-treated mice developed severe anaphylactic signs, significant decrease in rectal temperatures, significantly increased plasma histamine levels, and marked vascular leakage. In contrast, no sign of anaphylactic reactions, decrease in rectal temperatures, or elevation of plasma histamine levels was observed in FAHF-2-treated mice in 5 separate experiments. IgE levels were significantly reduced by FAHF-2 treatment and remained significantly lower as long as 5 weeks posttherapy. Splenocytes from FAHF-2-treated mice showed significantly reduced IL-4, IL-5, and IL-13, and enhanced IFN-gamma production to recall peanut stimulation in vitro .

CONCLUSION

FAHF-2 treatment completely eliminated anaphylaxis in mice allergic to peanut challenged as long as 5 weeks posttherapy. This result was associated with downregulation of T H 2 responses. FAHF-2 may be a potentially effective and safe therapy for peanut allergy.

The natural history of type B Niemann-Pick disease: results from a 10-year longitudinal study

OBJECTIVES

Type B Niemann-Pick disease (NPD-B) caused by acid sphingomyelinase deficiency is a rare, autosomal recessive, lysosomal storage disorder with a broad range of disease severity. The objectives of this study were to document the natural history of the disease in a large, clinically heterogeneous patient population that was followed for a period of 10 years and to determine how genotype influences phenotype.

METHODS

Twenty-nine patients with NPD-B had serial evaluations at least 9 months apart. Organ volumes, hematologic indices, lipid concentrations, pulmonary function, and hepatic activity were studied, and individual phenotypic severity was compared with genotype.

RESULTS

All patients with intact spleens had splenomegaly (mean value: 12.7 multiples of normal [MN]; range: 4.5-27.3 MN), and all but 1 had hepatomegaly (mean volume: 1.91 MN; range: 0.93-3.21 MN). At initial visit, 39% had thrombocytopenia and 3% had leukopenia. At final visit, the percentages increased to 54% and 34%, respectively. Mean annual decreases in platelet count and leukocyte count were 7 x 10(3) and 0.2 x 10(3) per mm3, respectively. The typical atherogenic lipid profile was worse in older patients. A total of 69% of patients had low diffusion capacity for carbon monoxide, and more than one third had low forced expiratory volume in 1 second, forced vital capacity, and forced expiratory volume in 1 second/forced vital capacity at initial visit. All measurements of pulmonary function showed a gradual deterioration over time. Liver dysfunction was characterized by stable elevation of hepatic transaminases and bilirubin. Homozygotes for DeltaR608, P323A, and P330R had milder disease than patients with all other genotypes.

CONCLUSIONS

The natural history of NPD-B is characterized by hepatosplenomegaly with progressive hypersplenism, worsening atherogenic lipid profile, gradual deterioration in pulmonary function, and stable liver dysfunction.

The incremental value of troponin-I testing in patients with intermediate risk unstable angina

BACKGROUND

Classification of patients with unstable angina (UA) by Agency for Health Care Policy and Research (AHCPR) guidelines in the emergency department reliably stratifies risk of death or myocardial infarction (MI) for triage to outpatient evaluation (low-risk), hospitalization (high-risk), or additional testing (intermediate-risk). Cardiac troponin-I elevation may identify patients at higher risk, but the incremental value may vary with AHCPR clinical risk.

HYPOTHESIS

The objective of this study was to determine whether cardiac troponin-I had any additional value beyond triage based upon history, physical examination, and electrocardiogram, in the evaluation of patients with UA.

METHODS

In all, 212 consecutive patients with UA and normal serum creatine kinase (CK)-MB levels and elevated troponin-I were risk stratified by AHCPR guidelines to evaluate the incremental value of adding routine troponin-I measurements to our current model for risk stratification.

RESULTS

Primary events (death/nonfatal MI) occurred in 35% of high-risk, 15% of intermediate-risk, and 0% of low-risk patients (p < 0.001 by chi-square for trend). High troponin-I (> or =2.0 ng/dl) occurred in 48% of high-risk, 21% of intermediate-risk, and 19% of low-risk patients. The remaining patients in each risk group had indeterminate troponin-I levels (> or =0.4 < 2 ng/dl). Of those with high troponin-I, a primary event occurred in 36, 42, and 0% in the respective high-, intermediate-, and low-risk groups (p < 0.001). High troponin-I levels corresponded with a statistically significant increased rate of primary events only in patients at AHCPR intermediate risk: 42.4 vs. 7.3%, p < 0.001.

CONCLUSION

The AHCPR guidelines risk stratify patients with UA. High troponin-I adds significant (p < 0.001) prognostic value in the patients at AHCPR intermediate risk and should be evaluated further in larger trials of such patients.

Scan statistics for temporal surveillance for biologic terrorism

INTRODUCTION

Intentional releases of biologic agents are often designed to maximize casualties before diagnostic detection. To provide earlier warning, syndromic surveillance requires statistical methods that are sensitive to an abrupt increase in syndromes or symptoms associated with such an attack.

OBJECTIVES

This study compared two different statistical methods for detecting a relatively abrupt increase in incidence. The methods were based on the number of observations in a moving time window.

METHODS

One class of surveillance techniques generates a signal based on values of the generalized likelihood ratio test (GLRT). This surveillance method is relatively well-known and requires simulation, but it is flexible and, by construction, has the appropriate type I error. An alternative surveillance method generates a signal based on the p-values for the conventional scan statistic. This test does not require simulation, complicated formulas, or use of specialized software, but it is based on approximations and thus can overstate or understate the probability of interest.

RESULTS

This study compared statistical methods by using brucellosis data collected by CDC. The methods provided qualitatively similar results.

CONCLUSIONS

Relatively simple modification of existing software should be considered so that when GLRTs are performed, the appropriate function will be maximized. When a health department has data that indicate an unexpected increase in rates but its staff lack experience with existing software for surveillance based on GLRTs, alternative methods that only require computing Poisson probabilities can be used.

Statistical analysis of wound-healing rates for pressure ulcers

To establish a functional model for determining wound-healing rates to use in the evaluation of efficacy of wound therapies, a review was conducted of statistical analysis methods from past wound-healing studies. Because most wounds do not usually close within the period of observation, that is, 12 weeks, evaluating time to 100% closure is not practical. Thus, a new, practical model for statistical analysis was formulated. A Gompertz-like function was applied to wound-healing rates of pressure ulcers, in the context of repeated measures for a nonlinear model. Photographing the wounds weekly, tracing their area with planimetry, and applying this new statistical model allows for the calculation of the expected rate of healing as a function of time. This approach yields a model useful for identifying prognostic factors, evaluating treatments, and improving our understanding of the variables that affect the wound-healing process.

Attitudes and psychosocial adjustment of unaffected siblings of patients with phenylketonuria

Sibling illness may contribute to an increased risk of adjustment problems in healthy siblings. Previous studies have reported a variety of effects on healthy individuals who have an ill sibling, but the psychosocial effects of treatable inherited disease on healthy siblings have not yet been investigated. We report the results of a survey study conducted in families with both unaffected and affected children with classic phenylketonuria (PKU), an inherited inborn error of metabolism. The survey included a knowledge test about PKU, and four previously validated instruments designed to assess psychosocial adjustment of unaffected siblings compared to age and sex matched norms. The responses revealed that unaffected adolescent and adult siblings had gaps in their knowledge about the genetic basis of PKU, and had evidence for the presence of adverse psychosocial sequelae. These findings suggest a role for genetic services providers, including genetic counselors, in assisting all members of a family adjust, when the diagnosis of an inborn error of metabolism has been made.

Opioid treatment for agitation in patients with advanced dementia

BACKGROUND

Some patients with advanced dementia cannot convey the experience of pain verbally and may react to pain with aggressive and agitated behaviors. We hypothesized that unrecognized pain could contribute to agitation and that low dose opioid therapy might reduce agitation by reducing pain. We therefore attempted to determine the effect of opioids on agitation in demented patients.

METHODS

We administered placebo for 4 weeks and a long-acting opioid for another 4 weeks to nursing home patients with advanced dementia and severe agitation despite treatment with psychotropic drugs. Patients and study nurses did not know if the medication administered was placebo or opioid. We measured the Cohen-Mansfield Agitation Inventory (CMAI) score at baseline and every two weeks.

RESULTS

Among 47 patients who entered the study, 25 completed the two phases. The median age for the 25 patients was 85.5 years. Analyses of the data of these 25 patients and of the patients <85 years-old showed no significant differences in agitation level between the placebo and opioid phases. However, among the 13 patients who completed the study and were > or =85 years old, the agitation level at the end of the opioid phase was significantly lower than at the end of the placebo phase (mean change in CMAI score: -6.4; 95% confidence interval (CI): -10.96, -1.8). The decrease in agitation in the patients > or =85 years old persisted after adjusting for sedation. The results remained unchanged when we expanded the analyses to include four > or =85 patients who dropped out of the study after the second week of the opioid phase.

CONCLUSION

Low dose, long-acting opioids can lessen agitation that is difficult to control in very old (> or =85) patients with advanced dementia.

Characteristics of patients requesting and receiving physician-assisted death

BACKGROUND

Surveys have shown that physicians in the United States report both receiving and honoring requests for physician assistance with a hastened death. The characteristics of patients requesting and receiving physician aid in dying are important to the development of public policy.

OBJECTIVE

To determine patient characteristics associated with acts of physician-assisted suicide.

DESIGN

Physicians among specialties involved in care of the seriously ill and responding to a national representative prevalence survey on physician-assisted suicide and euthanasia were asked to describe the demographic and illness characteristics of the most recent patient whose request for assisted dying they refused as well as the most recent request honored.

RESULTS

Of 1902 respondents (63% of those surveyed), 379 described 415 instances of their most recent request refused and 80 instances of the most recent request honored. Patients requesting assistance were seriously ill, near death, and had a significant burden of pain and physical discomfort. Nearly half were described as depressed at the time of the request. The majority made the request themselves, along with family. In multivariate analysis, physicians were more likely to honor requests from patients making a specific request who were in severe pain (odds ratio, 2.4; 95% confidence interval, 1.01-5.7) or discomfort (odds ratio, 6.5; 95% confidence interval, 2.6-16.1), had a life expectancy of less than 1 month (odds ratio, 4.3; 95% confidence interval, 1.7-10.8), and were not believed to be depressed at the time of the request (odds ratio, 0.2; 95% confidence interval, 0.1-0.5).

CONCLUSION

Persons requesting and receiving assistance in dying are seriously ill with little time to live and a high burden of physical suffering.

Personnel standards and quality assurance practices of biochemical genetic testing laboratories in the United States

CONTEXT

It has been suggested that specific regulation of laboratories performing genetic testing may be needed to ensure standards and quality assurance, and to safeguard the rights of patients with regard to confidentiality and providing informed consent. Previously, a comprehensive analysis of current practices of molecular genetic testing laboratories was conducted, the results of which have assisted in the assessment of the need for regulation and its impact on access to testing. However, a study designed to determine clinical laboratory practices with regard to biochemical genetic testing has not been carried out.

OBJECTIVE

To collect and analyze data regarding availability of clinical biochemical genetic testing, personnel standards, and laboratory quality assurance practices.

DESIGN

A mail survey of biochemical genetic testing laboratory directors and assignment of a quality assurance score based on responses to genetic testing process items.

SETTING

Hospital-based, independent, and research-based biochemical genetic testing laboratories in the United States.

PARTICIPANTS

Directors of biochemical genetic testing laboratories (n = 133; response rate 68.5%).

MAIN OUTCOME MEASURE

Laboratory process quality assurance score based on the standards defined by the American College of Medical Genetics Laboratory Practice Committee.

RESULTS

Personnel qualifications varied, although all directors had doctoral degrees. The mean quality assurance score was 77% (range 28%-100%). Higher scores were associated with the following variables: test director having an MD degree versus PhD degree (P = .002), director board certification in biochemical genetics (P = .002), research and hospital laboratory versus independent laboratory setting (P < .001), and participation in a proficiency testing program (P = .03). Twelve percent of participants had a confidentiality policy, and 19% required informed consent before testing.

CONCLUSION

The finding that a number of laboratories had quality assurance scores that may reflect suboptimal laboratory practices, particularly with regard to reporting practices, suggests that personnel qualification and laboratory practice standards may be in need of improvement to ensure quality in clinical biochemical genetic testing laboratories, as well as the appropriate clinical use of the test results.