Two transitions in daughters' caregiving careers

Daughters and daughters-in-law of presently unmarried elders were studied longitudinally, and the data were analyzed to determine how two transitions in caregiving status affected the women of the younger generation. One transition compared noncaregivers who had become caregivers 1 year later ("caregiving entrants," n = 33) with continuing noncaregivers (n = 56) and with veteran continuing caregivers (n = 78) over the same period. The second transition followed Time 1 new caregivers as they became "new veteran" caregivers (n = 69), comparing them with "old veteran" caregivers (n = 189) over the same year. The transition to caregiving was marked by a decrease in the care receiver's competence and an increase in the amount of care received, but caregiving entrants' quality of life did not change significantly over 1 year, as compared with either continuing noncaregivers or veteran caregivers. Although longitudinal study shows little positive evidence for the wear-and-tear model of caregiving, methodological improvements are needed before discarding the hypothesis that caregiving erodes mental health.

Diabetic patients have a decreased incidence of acute respiratory distress syndrome

OBJECTIVE

Our ability to predict which critically ill patients will develop acute respiratory distress syndrome (ARDS) is imprecise. Based on the effects of diabetes mellitus on the inflammatory cascade, we hypothesized that a history of diabetes might alter the incidence of ARDS.

DESIGN

A prospective multicenter study.

SETTING

Intensive care units at four university medical centers.

PATIENTS

One hundred thirteen consecutive patients with septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

All patients were prospectively followed during their intensive care course for the development of ARDS. A history of diabetes was identified in 28% (32/113) of the patients. In this study, nondiabetics were more likely to develop septic shock from a pulmonary source (48%, 39/81) compared with diabetics (25%, 8/32) (p = .02). Forty-one percent (46/113) of the patients with septic shock developed ARDS. Forty-seven percent of the nondiabetic patients developed ARDS compared with only 25% of those with diabetes (p = .03, relative risk = 0.53, 95% confidence interval = 0.28-0.98). In a multivariate logistic regression analysis, when we adjusted for several variables including source of infection, the effect of diabetes on the incidence of ARDS remained significant (p = .03, odds ratio = 0.33, 95% confidence interval = 0.12-0.90).

CONCLUSIONS

In patients with septic shock, a history of diabetes is associated with a lower risk of developing ARDS compared with nondiabetics.

Use of structural magnetic resonance imaging to predict who will get Alzheimer's disease

We used magnetic resonance imaging (MRI) measurements to determine whether persons in the prodromal phase of Alzheimer's disease (AD) could be accurately identified before they developed clinically diagnosed dementia. Normal subjects (n = 24) and those with mild memory difficulty (n = 79) received an MRI scan at baseline and were then followed annually for 3 years to determine which individuals subsequently met clinical criteria for AD. Patients with mild AD at baseline were also evaluated (n = 16). Nineteen of the 79 subjects with mild memory difficulty "converted" to a diagnosis of probable AD after 3 years of follow-up. Baseline MRI measures of the entorhinal cortex, the banks of the superior temporal sulcus, and the anterior cingulate were most useful in discriminating the status of the subjects on follow-up examination. The accuracy of discrimination was related to the clinical similarity between groups. One hundred percent (100%) of normal subjects and patients with mild AD could be discriminated from one another based on these MRI measures. When the normals were compared with the individuals with memory impairments who ultimately developed AD (the converters), the accuracy of discrimination was 93%, based on the MRI measures at baseline (sensitivity = 0.95; specificity = 0.90). The discrimination of the normal subjects and the individuals with mild memory problems who did not progress to the point where they met clinical criteria for probable AD over the 3 years of follow-up (the "questionables") was 85% and the discrimination of the questionables and converters was 75%. The apolipoprotein E genotype did not improve the accuracy of discrimination. The specific regions selected for each of these discriminations provides information concerning the hierarchical fashion in which the pathology of AD may affect the brain during its prodromal phase.

The effects of chronic alcohol abuse on pulmonary glutathione homeostasis

The incidence and severity of the acute respiratory distress syndrome (ARDS) is increased in critically ill patients with a prior history of chronic alcohol abuse; however, the specific mechanisms responsible for this association are unknown. Recently, we determined that chronic ethanol ingestion in rats decreased the alveolar epithelial lining fluid (ELF) concentration of the antioxidant glutathione (GSH), which is a characteristic finding in patients with ARDS. However, the effects of chronic alcohol abuse on the human alveolar epithelium are essentially unknown. Therefore, as a first step we asked if chronic alcohol abuse, independent of other comorbid conditions, decreases the concentration of GSH in the human lung. We determined that otherwise healthy chronic alcoholics had significantly decreased ELF concentrations of GSH compared with nonalcoholic control subjects (79 micromol [48 to 118 micromol] versus 576 micromol [493 to 728 mmol], p < 0.001). Furthermore, the percentage of GSH in the oxidized form was higher in the chronic alcoholics (9.8% [2.2 to 14.8%] versus 2.8% [0.4 to 4.0%] p = 0.05), indicative of increased utilization of GSH. This is the first report that chronic alcohol abuse alters GSH homeostasis in the human lung, and suggests a potential mechanism by which chronic alcohol abuse predisposes susceptible patients to develop ARDS.

Differences in the response times of pages originating from the ICU

STUDY OBJECTIVES

To determine whether the type of paging system causes significant differences in the response time by physicians to their pages in an ICU setting.

DESIGN AND SETTING

Prospective cohort study performed in the ICU of two university-affiliated hospitals. All pages were classified by several different variables, including the type of paging system: direct paging if a nurse or hospital operator could directly place the page, or indirect paging if a nurse or hospital operator was required to contact the physician's office or a private answering service who would then independently contact the physician. The main outcome measure was physicians' response time, in minutes, to pages originating from the ICU.

RESULTS

During a 100-day period, 402 pages were sent and answered by 166 different physicians (87 attending physicians and 79 housestaff/physician assistants). The median response time for all pages was 3 min with a 25 to 75% quartile of 1 to 8 min. Twenty-five percent of the pages placed through an indirect system were associated with a response time of >/= 29 min. In a multivariate model with the response time dichotomized at >/= 15 min ("slow") or < 15 min ("adequate"), pages placed through an indirect system were answered significantly more slowly than pages placed through a direct system (p < 0.001; odds ratio, 4.36; 95% confidence interval, 2.05 to 9.29). Pages answered in an adequate amount of time were also associated with a significantly higher degree of overall nursing satisfaction with the care delivered by the physician in response to the specific page when compared with pages answered in a "slow" manner (p < 0.001).

CONCLUSIONS

Physicians who use an indirect paging system are significantly slower in their response to ICU pages when compared with physicians who utilize a direct paging system. These results may lead to improvements in paging systems used by physicians who care for patients in an ICU setting.

Health, valuation of life, and the wish to live

This research investigated the relationship of an affective-cognitive schema, valuation of life (VOL), to older people's responses to a set of health utility (years of desired life) questions. Six hundred healthy and chronically ill elders aged 70 and older were interviewed to measure quality of life (QOL), mental health, and VOL. Valuation of life was significantly correlated with longer Years of Desired Life under 8 of 10 health conditions when background, health, QOL, and mental health states were controlled. We concluded that VOL is an internal representation of the many positive and negative features of the person and her everyday life that is necessary to comprehend how people may cling to life or welcome its end.

How to merge caregivers' corporate cultures

Mergers and acquisitions combine sets of employees, as well as corporate entities. These steps show how facilities can proactively address joining corporate cultures for a successful transition.

A transitional variant of Castleman's disease presenting as a chylous pleural effusion

Castleman's disease is an uncommon clinicopathologic entity that results in unregulated growth of lymphoid tissue. It may present as benign involvement of one lymph node group or as multicentric disease with serious systemic symptoms. Pleural effusions are an uncommon manifestation of Castleman's disease. We present a patient with Castleman's disease who initially presented with a chylous pleural effusion.

Topical antimicrobial therapy in the prevention of early childhood caries

PURPOSE

Early childhood caries (ECC) is microbiologically characterized by heavy infection of mutans streptococci (ms) on dental surfaces. Accordingly, it is reasonable to speculate that suppression of dental ms levels would decrease risk for ECC. On this basis, randomized double blind, placebo controlled pilot study was performed to test this concept.

METHODS

The study population consisted of 31 subjects (age: 12 to 19 mos; sex: 18F/13M) who were clients of a Women, Infants, and Children (WIC) clinic in Puerto Rico. Inclusion criteria included: (1) unremarkable medical history; (2) presence of 4 maxillary primary incisors (PMI) with no visible defects; (3) clinically caries free; (4) use of a nursing bottle at naptime and/or bedtime which contained a cariogenic substrate; (5) two consecutive ms positive cultures (utilizing Mitis-Salivarius-Bacitracin (MSB) agar) from pooled PMI plaque. The subjects were randomized into 2 groups. The 15 subjects in the experimental group and the 16 subjects in the control group were evaluated every 2 months during the study period. At each evaluation, the subjects had 10% povidone iodine (experimental group) or placebo (control group) applied to their dentition. The placebo was commercial instant tea (without lemon or sweetener) and deionized water. Treatment failure was defined as the appearance of a white spot lesion(s) on any of the PMI during the study period.

RESULTS

The mean duration of observation to treatment failure was 155 days; the mean duration of observation for treatment success was 217 days. Five of the 16 control subjects and 0 of the 15 experimental subjects experienced treatment failure (Fisher's exact test: P = 0.04). The Kaplan-Meier estimate for incidence of treatment failure in the placebo group was 48% over 357 days (P = 0.02).

CONCLUSION

These observations suggest that topical antimicrobial therapy reduces risk for the development of ECC in high-risk children.

Implementation and process evaluation of a school-based drug abuse prevention program: Project Towards No Drug Abuse

The present study provides an implementation, process, and immediate outcomes evaluation of the classroom component of Project Towards No Drug Abuse (TND). This project involves development and evaluation of a school-based drug abuse prevention curriculum for continuation high school youth, who are at relatively high risk for drug abuse. Three randomized conditions were evaluated: a standard care, classroom only, and classroom plus school-as-community. The latter condition was an enhanced school-based condition which involved outside-of-classroom meetings and activities. Implementation was high in both program conditions even though this was a higher risk context. Process evaluation data were favorable and did not vary between the two program conditions. Immediate outcomes data (knowledge) was higher in the two program conditions than in the standard care condition. Regarding the classroom program, addition of extra-classroom activities does not appear to alter the quality of delivery of the program.

Clinical outcomes for nursing caries treated using general anesthesia

This study did follow-up examinations of 84 Medicaid-eligible children with nursing caries after they received treatment for nursing caries utilizing general anesthesia. Results at six months suggest that parents are unresponsive to follow-up care and over half of the children seen had new smooth surface caries lesions. While results are preliminary, they suggest that major changes are needed in the tertiary care of children with nursing caries.

Circulating IL-1ra and IL-10 levels are increased but do not predict the development of acute respiratory distress syndrome in at-risk patients

Although numerous cytokines, including interleukin (IL)-1, IL-8, and tumor necrosis factor, circulate in critically ill patients at risk for acute respiratory distress syndrome (ARDS), none clearly predict the development of the syndrome. We hypothesized that cytokines, such as IL-1ra, IL-10, and IL-4, which modulate inflammation, might contribute to or reflect the development of acute lung injury. Accordingly, serial levels of IL-1ra and IL-10 were measured in 77 patients who were identifed as being at risk for the development of ARDS. Initial IL-1ra levels were significantly higher (p < 0.0001) in the patients (7.82 [2.29-38.01] ng/ml) than in normal control subjects (0.24 [0.24-0.34] ng/ml) but did not predict the development of ARDS. Initial IL-1ra levels, however, were greater (p = 0.038) in the patients who died (31.95 [3.02-65.06] ng/ml) compared with survivors (6.61 [1.86-29.33] ng/ml). Similarly, IL-10 levels were increased in patients (155 [53.75-318.75] ng/ml) compared with normal control subjects (0 ng/ml) but did not predict the development of ARDS. Like IL-1ra levels, initial IL-10 levels were significantly higher (p = 0.005) in patients who died compared with survivors. IL-4 was not detectable in any of the patient plasma samples measured. Thus, modulators of inflammation are increased in patients at risk for ARDS who die, but do not predict the development of the syndrome.

Serum ferritin as a predictor of the acute respiratory distress syndrome

We investigated serum ferritin levels as a predictor of the acute respiratory distress syndrome (ARDS) because: (1) proinflammatory cytokines, which are implicated in ARDS, increase ferritin synthesis; and (2) oxidative stress in patients at risk for ARDS might liberate iron from ferritin, accelerating toxic hydroxyl radical (.OH) formation. Serum ferritin levels measured by radioimmunoassay (RIA) were greater in 75 patients at risk for ARDS (women, p < 0.0001; men, p < 0.0001) and 8 patients with ARDS (women, p = 0.001; men, p = 0.0009) than in healthy control subjects. Serum ferritin levels were also greater in female (p = 0.003) and male (p = 0.003) at-risk patients who developed ARDS than in patients who did not develop ARDS. In women, a value exceeding 270 ng/ml predicted ARDS with an 83% sensitivity, 71% specificity, 67% positive, and 86% negative predictive value. In men, a value exceeding 680 ng/ml predicted ARDS with a 60% sensitivity, 90% specificity, 75% positive, and 82% negative predictive value. Serum ferritin levels did not correlate with C-reactive protein levels, were not different in medical or surgical at-risk patients, and were not accounted for by liver disease. Evaluating serum ferritin levels in at-risk patients may help predict the development of ARDS and thereby improve study and treatment of ARDS. Elevated serum ferritin levels may also regulate the participation of iron in the oxidative responses that contribute to ARDS.

Endothelial cell activity varies in patients at risk for the adult respiratory distress syndrome

OBJECTIVE

The endothelial cell produces many bioactive compounds that are presumed to play important roles in the pathogenesis of the adult respiratory distress syndrome (ARDS). We postulated that individuals with sepsis and trauma-two at-risk diagnoses for the development of ARDS--might demonstrate differences in the degree of endothelial cell activity.

DESIGN

Prospective cohort study.

SETTING

Intensive care unit patients in a tertiary, university-affiliated, city hospital.

PATIENTS

Fifty-five intensive care unit patients (19 with sepsis and 36 trauma patients).

INTERVENTIONS

Plasma measurements of three endothelial cell products--von Willebrand factor antigen, soluble intercellular adhesion molecule-1 (ICAM-1), and soluble E-selectin-were performed within 8 hrs of patients meeting our inclusion criteria, and at the clinical onset of ARDS.

MEASUREMENTS AND MAIN RESULTS

Twenty-six percent of the septic patients and 25% of the trauma patients developed ARDS. The median (and 25% to 75% quartiles) concentrations of all three mediators measured in the sepsis patients (von Willebrand factor antigen 399% [375% to 452%], ICAM-1 573 ng/mL [470 to 980], and soluble E-selectin 180 ng/mL [81 to 340]) were significantly higher (p < .001 for each individual analysis) than in the trauma patients (von Willebrand factor antigen 256% [217% to 310%], ICAM-1 148 ng/mL [113 to 210], and soluble E-selectin 42 ng/mL [31 to 65 ng/ mL]). In addition, neither the ICAM-1 nor soluble E-selectin concentrations measured in the trauma patients were different (p = .17 and p = .24, respectively) from normal controls. In those patients who developed ARDS, the differences in the concentrations of all three endothelial cell mediators between the sepsis and trauma patients persisted (p = .008 for von Willebrand factor antigen, p = .003 for ICAM-1, and p = .003 for E-selectin).

CONCLUSION

These findings suggest that differences in endothelial cell activity exist between sepsis and trauma patients who are at risk for the development of ARDS.

Lupane derivatives from Lophopetalum wallichii with farnesyl protein transferase inhibitory activity

Chloroform-soluble extracts of the stems and of the mixed stems and stem bark of Lophopetalum wallichii were found to be inhibitory in a farnesyl protein transferase (FPTase) bioassay system. During the course of activity-guided fractionation, the known lupane-type triterpenes, ochraceolide A (1), ochraceolide B (2), betulin, and lupeol and the new lupane lactone, dihydro ochraceolide A (4), were isolated. The stereochemistry of the epoxide group of ochraceolide B (2) was determined by preparation of both epoxide isomers [2, and the new semisynthetic derivative, 20-epi-ochraceolide B (3)] from 1. The structure of 4 was established by reduction of 1 with sodium borohydride. Compounds 1 and 2 exhibited significant inhibitory activity in the FPTase assay (IC50 values of 1.0 and 0.7 microgram/mL, respectively). Lupeol was found to be weakly active (IC50 65.0 micrograms/mL) in this test system, whereas no significant inhibition was detected for betulin or compounds 3 or 4. When evaluated against a panel of human cancer cells in culture, compounds 1 and 4 were modestly cytotoxic. Compounds 2 and 3 were not active in the panel.